Chapter 19: Vital Signs; week 4 Flashcards
Concept of Vital Signs
-suggests assessment of vital or critical physiological functions
-variations reflect a persons state of health and/or functional ability of the body systems
1. Temperature
2. pulse
3. respirations
4. BP
also,
5. pain
6. pulse oximetry
Normal Findings for Adults: Pulse
Normal: 60-100 beats/min
Average: 80 beats/min
Normal Findings for Adults: Respirations
Normal Range: 12-20 breaths/min
Normal Findings for Adults: BP
Normal Range: 110-119 mmhg systolic
60-80 mmhg diastolic
Prehypertensive: 120-139 mmhg systolic
80-89 mmhg diastolic
Average: 120/80
Core Temperature
adults normal internal temperature
Ranges: 97’ F to 100.8’ F
-typically 1 to 2 degrees higher than surface (skin) temperature
Adult Normal Finding: Temperature
Oral: 98’F
Rectal: 98.6’F (insert 1-1.5 inches)
- rectal + tympanic are for core temperatures
- oral + axillary are for surface temperature
Thermoregulation
- maintaining a stable temperature
- to keep the body temperature constant the body must balance heat production and heat loss
- balance is controlled by the hypothalamus; located between the cerebral hemispheres of the brain
Hypothalamus
- balance heat production + loss (thermoregulation)
- recognizes small changes in body temperature that are sent to it by sensory receptors in the skin (like a thermostat)
- heat production primarily caused by metabolism
- heat loss occurs through skin
Afebrile
without fever, normal body temperature
Febrile
(pyrexia, or fever)
-body temperature above normal
-usually caused by infection or response to tissue injury
>101’F (greater than)
>100’F (greater than)
-occurs in response to pyrogens (e.g bacteria)
-pyrogens induce secretion of substances (prostaglandins) that reset the hypothalmic thermostat at a higher temperature
Hyperthermia
core body temperature well above normal usually caused by exposure to extreme heat
103’F to 106’F
Hyperpyrexia
fever
>105.8’F
Hypothermia
core body temperature well below normal usually caused by exposure to extreme cold <95'F -shivering -cyanosis of lips and fingers -poor coordination -feels cold, then pain in extremities
Diaphoresis
visible perspiration which promotes heat loss and is common when fever breaks (sweating)
Sequence for taking BP
- Clean stethoscope with 70% alcohol
- Position client
- Fully expose patients arm
- Place cuff around clients bare upper arm
- Place stethoscope earpieces in ear
- Palpate brachial artery
- Inflate cuff
- Places stethoscope over brachial artery
- Deflates slowly
- Auscultates Korotkoff sounds
- Remove cuff
- Document findings
What you should look for with Respiratory Rate?
- Rate
- Rhythm
- Depth
- Effort
Decreasing Body Temperature
heat sensors in the hypothalamus are stimulated, they send out impulses to reduce body temperature
-activates compensatory mechanisms:
>peripheral vasodilation
>sweating
>inhibition of heat production
-Vasodilation (Increase diameter of blood vessels) diverts core-warmed blood to the body surface, where heat can be transferred to the surrounding environment
Increasing Body Temperature
sensors in the hypothalamus detect cold, send out impulses to increase heat production + reduce heat loss
-Produce heat:
> shivering
> release epinephrine, which increases metabolism
-Reduce Heat Loss:
> vasoconstriction (narrowing of blood vessels) converts heat by shunting blood away from the periphery (where heat is lost) to the core of the body (blood is warmed)
-piloerection: hairs standing on end
Pulse
the concept of perfusion refers to the continuous supply of oxygenated blood to all body cells
-Pulse–> rhythmic expansion of an artery produced when a bolus of oxygenated blood is forced into it by contraction of the heart
Body Produce and Regulate Pulse
the pulse “wave” begins when the left ventricle contracts and ends when the ventricle relaxes
-each contraction forces blood into the already-filled aorta, causing increased pressure within the arterial system
>Systole: peak of the wave, contraction of heart
>Diastole: trough or resting phase of heart
Characteristics of Pulse
- Rate: 60 to 100 bpm
- Rhythm: regular or irregular
- Strength: amplitude and quality; weak, thready, or strong and bounding
- Equality: equal on both sides of the body
Sites to Assess Pulse
- Apical: apex of heart (between 5th and 6th ICS)
- Carotid: between mid-line and side of neck
- Brachial: Medially in antecubital space (use with BP)
- Radial: laterally on anterior wrist
- Femoral: groin fold
- Popliteal: behind the knee
- Posterior Tibial: above ankle bone
- Dorsalis Pedis: foot
Pulse Quality (Strength)
assessed by determining the pulse volume and bilateral (both sides) equality of pulse
0- absent: cannot be felt
1- weak: (thready); barely felt, easily obliterated by pressing with the fingers
2- normal: easily palpated, not weak or bounding
3- full:easily felt with little pressure; not easily obliterated
4- bounding: forceful, obliterated by strong finger pressure
Respiration
pulmonary ventilation (breathing) that involves movement of air into lungs (inspiration) and out of the lungs (expiration)
-exchange of oxygen and carbon dioxide in the body
2 processes:
1. Mechanical
2. Chemical
Respiration: Mechanical Process
Active Breathing
- pulmonary ventilation; breathing
- active movement of air in and out of respiratory system
Respiration: Chemical Process
Gas Exchange
- exchange of oxygen + carbon dioxide
- transport of oxygen and carbon dioxide throughout the body
- exchange of gases between capillaries and tissues
How does the body regulate respirations?
- the respiratory center in the brain stem regulates the involuntary control of respirations
- ventilation is regulated by levels of CO2, O2, and pH in the arterial blood
- an increase in CO2 level causes respiratory control system in brain to increase the rate and depth of breathing
- excess CO2 is removed by the increased exhalation
Orthopnea
labored breathing when lying flat
-relieved by sitting up
Hyperventilation
more than normal amount of air is entering and leaving lungs
-rapid and deep breathing resulting in excess loss of CO2 (hypocapnea)
-complain of feeling light-headed and tingly
> 20 breaths/min (greater than)
Hypoventilation
less than normal amount of air is entering and leaving the lungs
-rate and depth of respirations are decreased
-CO2 is retained
< 12 breaths/ min (less than)
Cheyne-stokes Respirations
gradual increase then gradual decrease in depth of respirations followed by a period of apnea
What do Nurses Assess with Respiratory Rate?
- Rate: Tachypnea or Bradypnea
- Depth: shallow, normal, deep
- Rhythm: reg or irregular
- Effort: dyspnea, orthopnea
Breath Sounds: Wheeze
high-pitched continuous musical sounds
-usually heard on expiration
Breath Sounds: Rhonci
low-pitched continuous sounds
-caused by secretions in the large airways
Breath Sounds: Crackles
discontinuous sounds usually heard on inspiration
-may be:
>high-pitched popping sounds or
>low-pitched bubbling sounds
Breath Sounds: Stridor
a piercing, high-pitched sound heard primarily during inhalation
Breath Sounds: Stertor
labored breathing that produces a snoring sound
-“death rattle”
Pulse Oximetry
-non invasive method of monitoring respiratory status
-uses a external device that measures oxygen saturation; amount of oxygen being carried by the hemoglobin in the arterial blood
O2 stat—> 95%-100%
Oxygen Saturation
amount of oxygen being carried by the hemoglobin in the arterial blood
Arterial Blood Gases (ABGs)
arterial oxygen saturation
- directly measures the partial pressures of oxygen, carbon dixoide (CO2) and blood pH
- invasive blood draw
- directly measures the partial pressures of the gases in the arterial blood; O2, CO2 and blood pH
- method requires puncture of an artery followed by lab testing of sample
- provides comprehensive data, but is painful, time consuming, and expensive
Blood Pressure
pressure of the blood as it is forced against arterial walls during cardiac contraction
- force of blood against arterial wall
- blood pressure increases as ventricles contract (systole)
- blood pressure decreases when ventricles rest and fill (diastole)
Systolic Pressure
peak pressure exerted against arterial walls as the ventricles contract and eject blood
Diastolic Pressure
minimum pressure exerted against arterial walls between cardiac contractions when the heart is at rest
How does the body Regulate BP?
-cardiac function
-peripheral vascular resistance
-blood volume
the body constantly regulates and adjusts arterial pressure in order to supply blood to body tissues via perfusion of the capillary beds
Cardiac Output
the volume of blood pumped from the left ventricle throughout the circulation in one minute
When you Assess BP, what sounds are you listening for?
Korotkoff Sounds
1st Sound: as you deflate the BP cuff, a sound that occurs during systole
2nd Sound: further deflate, soft swishing sound caused by blood turbulence
3rd Sound: begins midway through BP, sharp rhythmic tapping sound
4th Sound: similar to 3rd, softer + fading
5th Sound: silence, diastole
Hypotension
low BP
Systolic BP <100mmhg (lower than 100 mmhg)
Hypertension
BP reading higher than normal
>140 mmhg systolic (greater than)
>90mmhg diastolic (greater than)
on two or more separate occasions
Nursing Interventions for: Diagnosed with High BP (hypertension)
- Monitor VS
- Monitor patients activity tolerance to determine activity tolerance (level of fatigue)
- Monitor I&O: fluid retention can increase blood volume and pressure
- Observe for edema: sign of fluid retention
- Monitor weight gain: indicate fluid retention or poor dietary/ activity compliance
- Assess clients attitude and beliefs about taking anti-hypertensive medications or lifestyle changes
Factors Influence Body Temperature
- developmental level or age
- gender
- level of consciousness
- amount of pain
- respiratory status
- concurrent treatments (O2, chemotherapy)
Factors Influencing Pulse Rates?
- exercise
- fever + heat
- hypothermia
- acute pain
- anxiety
- medications
- postural changes
- hemorrhage (bleeding out)
- pulmonary conditions
- age
- gender
Factors Influencing Respirations?
- age
- gender
- exercise
- acid-base balance
- brain lesions
- increased altitude
- respiratory disease
- anemia
- anxiety
- medications
- acute pain
- smoking
Factors that Influence BP
- as peripheral vascular resistance increases and arterial elasticity decreases, blood pressure increases
- as peripheral vascular resistance decreases and arteries dilate, blood pressure goes down
- increase in pulse rate will lower heart filling time causing BP to decrease
- if blood volume increases, more pressure is exerted on arterial walls and BP increases
- if blood volume decreases, less pressure is exerted on the arterial walls and BP decreases
Factors that affect BP
- developmental stage
- gender
- family history
- life style
- exercise
- stress
- pain
- race
- obesity
- medication
- diseases
What cuff size should i use for BP?
- bladder that encircles 80% of the arm
- wrap snuggly around the clients arm
- have client sit with feet flat on floor
- bladder will cover 2/3 of the length of upper arm
Describe Auscultating an apical pule for an average size adult
- left side of chest
- 5th ICS
- mid clavicular line
- listen for 1 full minute
Hypoxia
inadequate cellular oxygenation <95% (less than) -pallor -cyanosis -restlessness -confusion -dizziness -fatigued -tachycardia -tachypnea -apprehension
Nursing Interventions for: Alterations in pulse parameters
- dysrhythmia management
- vital signs monitoring
- activity tolerance
- collect lab data
- antidysrhythmic medications
- emotional support
Nursing Interventions for: Impaired Respiratory Status
- pulse oximetry
- Arterial blood gases (ABGs) sampling
