Chapter 29 Vital Signs Flashcards
Vital Signs:
indicators of health status, measures effectiveness of circulatory, respiratory, neural, endocrine body functions
body temperature =
heat produced -heat lost
core temperature:
middle body
relatively constant - temp of deep tissues
thermoregulation:
regulate the balance between heat lost and heat produced
BMR:
-Basal metabolic rate: depends on body surface area
Nonshivering thermogenesis:
occurs primarily in neonates (cannot shiver)
Diaphoresis:
visible perspiration primarily occurring on the forehead and upper thorax, although you can see it in other places on the body
Factors affecting body temperature:
age, exercise, hormone level, circadian rhythm, stress, environment, temperature alteration
Temperature Alterations:
fever, hyperthermia, heatstroke, heat exhaustion, hypothermia
fever
infection, based on several temperature readings at different times of the day
pyrexia:
occurs because heat-loss mechanisms are unable to keep pace with excessive heat production, resulting in an abnormal rise in body temperature
Pyrogens
bacteria/viruses elevate body temperature
febrile
pertaining to or characterized by an elevated body temperature
afebrile
when the fever “breaks” the patient
fever of unknown origin (FUO)
refers to fever with an undetermined cause
hyperthermia:
an elevated body temp related to the inability of the body to promote heat loss or reduce heat production
Malignant hyperthermia;
hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs
Heatstroke:
body temp of 40 C—prolonged exposure to the sun or high environmental temp
Heat exhaustion:
occurs when profuse diaphoresis results in excess water and electrolyte loss
Hypothermia
classified by core temp measurements – heat loss during prolonged exposure to cold overwhelms the ability of the body to produce heat
thermometers:
celsius and fahrenheit
Antipyretics:
medications that reduce fever
Cardiac output:
the volume of blood pumped by the heart during 1 minute
heart rate for
infant: 120-160
toddler: 90-140
preschooler: 80-110
school-aged children: 75-100
adolescent: 60-90
adult: 60-100
tachycardia
abnormally elevated HR
bradycardia
slow HR
pulse deficit
contraction of the heart that fails to transmit a pulse wave to the peripheral pulse
dysrhythmia
interval interrupted by an early or late beat or a missed beat indicates an abnormal rhythm
What vital signs are taken?
Main 4: Temperature, pulse, respiratory rate, blood pressure
Sometimes 5th sign is: Pain
Oxygen saturation also frequently measured (oxygenate organs and how well tissues are)
Vital signs are used to:
Monitor patient’s condition
Identify problems
Evaluate response to intervention
Guidelines for measuring vitals include:
Ensure that equipment is functional and is appropriate for the size and age of the patient.
Appropriately delegate measurement - have to follow up on them.
Be able to understand and interpret values.
Know the patient’s usual range of vital signs.
Determine the patient’s medical history, therapies, and prescribed medications.
Control or minimize environmental factors that affect vital signs.
Other Guidelines:
Use an organized, systematic approach when taking vital signs. (Pulse, respiration, BP, Temp)
Know the acceptable ranges for your patients before administering medications, and use vital sign measurements to determine indications for medication administration.
Communicate findings (new parameters)
Accurately document findings.
Analyze the results of vital sign measurement.
Instruct the patient or family caregiver in vital sign assessment and the significance of findings.
Goal of body temp
to obtain a representative average temp of core body tissues
acceptable temp range:
98.6° F to 100.4° F or 36° C to 38° C
no single temp is normal for all people
Surface temperature measurement sites
Skin - forehead
Oral cavity
Axilla -0.5 C lower than oral temp
Core temperature measurement sites
Tympanic membrane - ear
Urinary bladder
Rectal - 0.5 C higher than oral temp,
The nurse is checking the patient’s core temperature. Which site is the nurse using?
B. Tympanic membrane
electronic thermometer
rechargeable battery powered displayed unit: blue probe = oral and axillary, red probe = rectal
1.You have delegated vital signs to assistive personnel. The assistant informs you that the patient has just finished a bowl of hot soup. The nurse’s most appropriate advice would be to
D. Wait 30 minutes and take an oral temperature.
Goal of assessing radial pulse:
: to assess the integrity of the cardiovascular system
Which arteries are commonly used for a radial pulse?
radial and carotid arteries
Character of pulse:
rate, rhythm, strength, and equality
normal HR:
60-90 bpm
Respiration includes:
ventilation, diffusion, per-fusion, physiological control, mechanics, and rate
ventilation =
Movement of gases into and out of the lung.
diffusion =
Movement of oxygen and carbon monoxide between alveoli (deep lungs) and red blood cells
Perfusion =
Distribution of red blood cells to and from the pulmonary capillaries
Physiological control =
hypoxemia (low blood level of oxygen)
Mechanics of breathing =
eupnea (good breathing)
Normal rate of respiration
12-20
Measuring Oxygen Saturation (pulse oximetry)
Noninvasive measurement of arterial blood oxygen saturation
A probe with a light-emitting diode (LED) measures oxygenated hemoglobin molecules
Probes can be applied to the earlobe, finger, toe, bridge of nose, or forehead
Normal pulse oximetry (SpO2) is greater than 95%
Assessing Arterial BP
hypertension, hypotension, blood pressure equipment (sphygmomanometer and stethoscope)
hypertension =
prehypertension = 140/90
hypotension =
orthostatic (BP drops when you stand up)
normal rate for BP
130/80
Factors influencing BP:
Age, ethnicity (hispanics, african americans), stress, gender, daily variation (10a-10pm at highest, lowest is sleep and 3am), activity, weight, smoking, medications
Evidence Based Practice: Automatic BP machines =
Do not give the same results as manual methods (stethoscope/sphygmomanometer)
Systolic and diastolic values are lower
Used when frequent assessment is required
Critically ill/ potentially unstable patients
During/ after invasive procedures
Therapies requiring frequent monitoring
Patient Conditions Not Appropriate for Electronic Blood Pressure Measurement
Irregular heart rate
Peripheral vascular obstruction (e.g., clots, narrowed vessels)
Shivering
Seizures
Excessive tremors
Inability to cooperate
Blood pressure less than 90 mm Hg systolic
Benefits of electric BP measurement =
Detection of new problems (prehypertension)
Patients with hypertension can provide to their health care provider info about patterns of BP.
Self-monitoring helps adherence to therapy.
Disadvantages of electric BP measurement =
Improper use risks inaccurate readings.
Unnecessary alarming of patient
Patients may inappropriately adjust medications.
Recording Vital Signs
Record values on electronic or paper graphic.
Record in nurses’ notes any accompanying or precipitating symptoms.
Document interventions initiated on the basis of vital sign measurement.
If a vital sign is outside anticipated outcomes, write a variance note to explain, along with the nursing course of action.
Safety Guidelines for Skills:
Cleaning devices between patients decreases the risk for infection.
Rotating sites during repeated measurements of BP and pulse oximetry decreases the risk for skin breakdown.
Analyze trends for vital signs, and report abnormal findings.
Determine the appropriate frequency of measuring vital signs based on the patient’s condition.
pain is ….
subjective (whatever the patient says it is)
ALWAYS obtain
baseline vitals
When to take Vital signs: Box 5-1
- on admission to a health agency
2. routine schedule
temp drops when you
sleep
Advantages and disadvantages everything but temporal: box 5-3
Oral: easily accessible
newborns lose heat from their
head
puberty = unstable
temps
normal adults = temp
96.8F
women have greater fluctuations in
temp because of hormones, hot flashes
1am-4am =
body at lowest temp
maximum temp at
6 pm
Table 5-1: Pulse sites
temporal, apical, ulnar, femoral, popliteal
Factors influencing character of respiration
exercise, acute pain, anxiety, smoking, body position, medications, neurological injury, hemoglobin function (decreased level = anemia)
pg 91 5-2 classification of BP for adults 18 +
normal = systolic-
Diaphragm is used for
high pitch sounds
bell is used for
low pitched sounds
