Chapter 30: Vital Signs Flashcards
What are the vital signs?
- Temperature
- Pulse
- Respiration
- Oxygen Saturation
- Blood Pressure
- Pain
Vital Signs measure the effectiveness of:
- The circulatory system
- The respiratory system
- The neural system
- The endocrine system
What causes vital signs to change?
- Temperature of environment
- Physical Exertion
- Effects of Illness
What are the guidelines to taking vital signs?
- The RN is always responsible for the measurement of VS. (nurse analyzes and interpret the significance)
- Ensure the equipment is functional and appropriate for the patient.
- Know the patient baseline if possible.
- Know your patient therapies. (Certain medications and therapies can alter VS)
- Know the frequency at which it is essential to take VS. (according to unit policy and patient condition)
- Communicate significant changes!
- Patient and family teaching.
Body Temperature
Heat Produced - Heat Lost = Body Temperature aka Thermoregulation
Temperature Range for Adults: Average Temperature Range
36° to 38° C (96.8° to 100.4° F)
Temperature Range for Adults: Average oral/tympanic
37° C (98.6° F)
Temperature Range for Adults: Average rectal
37.5° C (99.5° F)
Temperature Range of Adults: Axillary
36.5° C (97.7° F)
Core temperature
Temperature of the deep tissues
Sites of Temperature Measurement
- Axillary
- Rectal
- Oral
- Tympanic membrane (core)
- Temporal artery
- Esophageal (core)
- Pulmonary artery (core)
- Bladder (core)
Body temperature is controlled by the
Hypothalamus (between cerebral hemispheres)
Anterior Hypothalamus controls
Heat loss.
- vasodilation-increased blood flow to skin and extremities-cooling.
- sweating
- inhibition of heat production
Posterior hypothalamus controls
Heat production.
- vasoconstriction-reduced blood to skin and extremities.
- muscle contraction stimulates heat production through shivering
Heat produced by the body is a by-product of
Metabolism, which is the chemical reaction in all body cells. Food is the primary fuel source.
BMR
Basal Metabolic Rate
What is BMR?
Heat produced by body at absolute rest.
BMR is affected by what?
The thyroid hormone, Testosterone by promoting the breakdown of glucose and fat.
Voluntary movements
Such as exercise (muscle contraction/sweating) increases metabolic rate/heat production. Also, increases heart rate and O2 demand.
Shivering
- Involuntary body response that can increase heat production 4-5 times that of the normal.
- increases energy expenditure up to 400%.
In vulnerable populations, shivering ….
Seriously drains energy resources, resulting in further physiological deterioration.
the heat produced by shivering …
helps equalize body temperature and the shivering ceases.
Forms of Heat Loss
- Radiation
- Conduction
- Convection
- Evaporation
Radiation
Heat transfer from the surface of one object to another without direct contact.
____ of the surface area of the human body radiates heat to the environment.
85%
Conduction
Transfer of heat from one object to another with direct contact.
Radiation increases as
The temperature difference between the objects increases.
What nursing actions can enhance heat loss during a fever?
By removing clothing or blankets?
Nursing considerations to minimize heat loss through radiation?
Covering the body with dark, closely woven clothing.
Nursing actions to decrease heat loss by conduction?
- Patient making contact with materials warmer than skin.
- Applying several layers of clothing.
Nursing actions that increase heat loss by conduction?
- Applying an ice pack or bathing a patient with a cool cloth.
Convection
Transfer of heat through air movement. Ex. Fans. Fans increase heat loss with moistened skin.
Evaporation
Liquid changed to gas. Approximately 600 to 900 ml/day lost due to evaporation.
Evaporation: Sensible loss
Sweating (diaphoresis)
Evaporation: Insensible loss
Respiration/lungs
Diaphoresis
Visible perspiration primarily occurring on the forehead and upper thorax.
What are the factors that affect body temperature?
- Age
- Exercise
- Hormone Levels
- Circadian Rhythm
- Stress
- Environment
A persons control over body temperature depends on:
- The degree of temperature extreme
- The person’s ability to sense feeling comfortable or uncomfortable
- Thought processes or emotions
A person’s mobility or ability to remove or add clothes.
Why do women generally experience greater fluctuations in body temperature than men?
Hormonal variations during the menstrual cycle cause body temperature fluctuations.
During the menstrual cycle,
Progesterone levels rise and fall cyclically. When they are low, the body temperature is a few tenth of a degree below the baseline level. The lower temperature persists until ovulation occurs.
During ovulation,
Greater amounts of progesterone enter the circulatory system and raise the body temperature to previous baseline levels or higher.
Body temperature changes in women during menopause
Periods of intense body heat and sweating lasting from 30 seconds to 5 minutes occur. Skin temperature can increase up to 4 degrees C, referred to as hot flashes. It is. A used by instability of the gasometer controls for vasodilation and vasoconstriction.
Circadian Rhythm
Normal Body Rhythms. Temperature is usually highest around 4pm and lowest in the early morning.
How does stress affect body temperature?
Physical and emotional stress can increase body temperature.
Why does our environment affect the body temperature of infants and older adults more?
Because the temperature regulating mechanisms of infants and older adults are less efficient.
Temperature Alterations
- Fever
- Hyperthermia
- Heatstroke
- Heat Exhaustion
- Hypothermia
Fever
(Pyrexia) caused by pyrogens (bacteria/viruses)
Stages of a Fever
Stage 1: chills, shivers and feels cold
Stage 2: The plateau: chills subside and body feels warm/dry
Stage 3: Heat loss responses: skin warm/flushed (vasodilation), diaphoresis
What happens during a fever?
You see an increase in cellular metabolism, oxygen consumption, body metabolism, Heart Rate and Respiratory Rate.
Body metabolism increases ____ for every ______ during a fever.
10% for every degree Celsius
Hyperthermia
Increased body temperature due to inability of the body to promote heat loss or reduce heat production.
Hyperthermia is caused by..
- Disease or trauma to the hypothalamus which impairs heat-loss mechanisms
- Malignant hyperthermia
Malignant hyperthermia
Hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs
Heatstroke
Body temperature of 40 degrees C (104 degrees F) or more.
Dangerous heat emergency
Heat depresses
Hypothalamic function
What are the signs/symptoms of heatstroke?
- HOT DRY SKIN (most important)
- confusion
- delirium
- nausea
- muscle cramps
Patients at risk for heatstroke include
- the very young and the very old
- those who have cardiovascular disease, hypothyroidism, diabetes or alcoholism.
Heat Exhaustion
When profuse diaphoresis results in fluid and electrolyte loss.
What is the prescription (RX) for Heat Exhaustion?
Restoring fluid and electrolytes and moving to a cooler environment
Hypothermia
Decreased body temperature. May be unintentional or intentional.
Mild Hypothermia
Core temperature: 34 to 36 degrees C
Moderate Hypothermia
Core temperature: 30 to 34 degrees C
Severe Hypothermia
Core temperature below 30 degrees C
Induced Hypothermia
Used in some surgical, emergency cardiac and neurological procedures to decrease metabolic demand. Ex) open heart surgery and ROSC (return of spontaneous circulation after cardiac arrest)
Frostbite
Ice crystals form in cells leading to permanent circulatory and tissue damage
What are the steps of the nursing process?
- Assess
- Nursing Diagnosis
- Plan
- Implement
- Evaluate
Assessing the Patient
Thoroughly assess each patient and critically analyze findings to ensure that you make patient-centered clinical decisions required for safe nursing care.
Diagnosis
After assessment, cluster defining characteristics to form a nursing diagnosis. Once diagnosis is determined, accurately select the related factor for problem-focused diagnosis.
Planning
Integrate knowledge gathered from assessment and patient history to develop an individualized plan of care. Match the patient needs with interventions that are supported and recommended.
Implementation
….
Evaluation
The effectiveness of your interventions.
Pulse
Indicator of circulatory status. Palpable bounding of blood flow in a peripheral artery.
Cardiac Output
The amount of blood pumped by the heart in one minute.
As HR increases…
There is less time for the heart to fill and leads to a decrease in blood pressure.
What are the most common locations for pulse assessment?
Radial and apical sites.
When a patient’s condition suddenly worsens, the ______ is recommended for quickly finding and assessing the pulse.
Carotid site
Why is the carotid recommended for assessing a pulse when a patient’s condition suddenly worsens?
The heart continues delivering blood through the carotid artery to the brain as long as possible. When cardiac output declines significantly, peripheral pulses weaken and are difficult to palpate.
When a patient takes a medication that affects HR, the _________ provides a more accurate assessment of heart function.
Apical pulse
What is the best site for assessing an infant or young child’s pulse?
Brachial or apical site because other peripheral pulses are deep and difficult to palpate accurately
Pulse deficit
The difference between the apical and radial pulse
Certain medications, such as digoxin, require an assessment of the ___
Apical pulse
The Bell of the Stethoscope is used for
Heart/valve sounds (low pitch sounds)
The Diaphragm of the Stethoscope is used for
Heart, bowel and lung sounds (high pitch sounds)
What are the Pulse Characters?
- Rate
- Rhythm
- Strength
- Equality
Pulse Rates
Normal: 60-100
Tachycardia: above or equal to 100 beats per minute
Bradycardia: <60 beats/min
Pulse Rhythm
- Regular/irregular
- Rhythms also have names: sinus, Afib, Aflutter, etc.
Pulse Strength
- 0 (absent)
- 1+ (weak)
- 2+ (normal)
- 3+ (strong)
- 4+ (bounding)
Pulse Equality
Bilaterally.
A pulse in one extremity is sometimes unequal in strength or absent in many disease states.
Tachycardia, bradycardia and dysrhythmias are defining characteristics of many nursing diagnoses, including the following:
- Activity Intolerance
- Anxiety
- Deficient/excess fluid volume
- Impaired Gas Exchange
- Acute Pain
The body’s survival depends on
O2 to body cells and CO2 to be removed from cells
Assess all symmetrical pulses simultaneously except for the _________
Carotid pulse
Dysrhythmias
Abnormal rhythm indicated by an interval interrupted by an early, late or missed beat
Respiration involves
- Diffusion
- Ventilation
- Perfusion
Ventilation
Movement of gases in and out of the lungs (RR).
Ventilation is driven by
Levels of oxygen, carbon dioxide and hydrogen ions
The most important factor in the control of ventilation (respiratory rate) is ..
The level of CO2 in the arterial blood
Diffusion
Movement of oxygen and CO2 between alveoli (lungs) and RBC’s
Perfusion
Distribution of RBC’s to and from the pulmonary capillaries
Hypoxemia
Low levels of arterial O2.
How does Hypoxemia help patients with chronic lung disease?
- Controls Ventilation.
- The chemoreceptors in the carotid artery and aorta of patients with chronic lung disease become sensitive to Hypoxemia.
- If the oxygen levels fall, these receptors signal the brain to increase the rate and depth of ventilation.
COPD
Bronchitis
Asthma
Emphysema
What would happen to a COPD patient who is given too much oxygen?
Is fatal for patients with chronic lung disease
Assessment of Ventilation
Easy to assess but most often the most casually measure.
Asses: Rate, Depth, Rhythm
Eupnea
Normal rate and depth of ventilation
Tachypnea
RR > 20 regular
Bradypnea
RR < 12 regular
Apnea
Absent reparations - respiratory arrest
Hyper/Hypoventilation
Leads to hyper/hypocarbia (CO2)
Cheyenne-Strokes
Irregular, usually ominous sign
Oxygen Saturation or Pulse Oxyimetry (SpO2)
Photo detection that detects the amount of O2 bound to hemoglobin molecules *however cannot differentiate O2 from CO in the presence of CO poisoning.
What is the normal oxygen saturation? SpO2
Normal between 95% - 100%
SpO2 is a reliable indicator of SaO2 when
Saturation is >70%.
SaO2
Arterial O2 saturation
SvO2
Returned venous saturation
An oxygen saturation of ____________ is a clinical emergency.
Less than 90%
Blood pressure
Force exerted on the walls of an artery by the pulsing blood under pressure from the heart.
A good indicator for cardiovascular health.
Systolic pressure
Maximum pressure created during systole (heart contraction)
Diastolic Pressure
Minimum pressure in the arteries at rest.
Normotensive BP
Around 120/70
Hypertensive BP
> 140/90
Hypotensive BP
<90/x
Cardiac Output
As heart rate increases, CO decreases and BP decreases
Peripheral Resistance
As PVR increases = BP increases (vascular tone)
Blood Volume
As volume increases, BP increases
Viscosity
As viscosity increases, BP increases (as does RBC and HCT)
Elasticity
Decrease elasticity = increase in BP
What factors influence blood pressure?
- Age (BP tends to rise with advancing age)
- Stress (increases)
- Ethnicity (increased hypertension in African Americans + twice the risk for complications: stoke and MI)
- Gender
- Daily Variation
- Medications
- Activity and Weight
- Smoking
How does gender influence blood pressure?
In men, increase in blood pressure after puberty.
In women, increase in blood pressure after menopause.
How does daily variation influence blood pressure?
Lower during sleep and higher as the day progresses.
How does medications influence blood pressure?
lower BP with Antihypertensive meds.
Increase BP with breathing treatments.
How does activity and weight influence BP?
Exercise overall lowers BP
Obesity increase risk for hypertension
How does smoking influence BP?
Causes vasoconstriction. Increases BP.
Hypertension
BP >140/90 Often asymptomatic (a lot of people don't have symptoms) : silent killer
Modifiable Risk Factors for Hypertension
- Obesity
- Cigarette smoking
- Alcohol consumption
- High sodium intake
- Sedentary lifestyle
- Continued exposure to stress
Hypotension
Systolic BP <90/x
Usually an abnormal finding associated with illness.
Causative Factors of Hypotension
- Dilation of arteries in vascular bed
- Loss of blood volume (hemorrhage)
- Failure of the heart muscle to adequately pump (MI)
Signs and Symptoms of hypotension
Pallor, skin mottling, clamminess, confusion, increased HR and decreased urine output.
Can be life-threatening so report immediately.
Orthostatic Hypotension
Aka postural hypotension.
Occurs when a normotensive person develops symptoms and a drop in systolic pressure by at least 20 mm Hg or a drop in diastolic pressure by at least 20 mm Hg within 3 minutes of rising to an upright position.
Orthostatic Hypotension is usually due to
A decrease in blood volume (dehydration, hemorrhage), prolonged bed rest, anemia
VS check for orthodontic hypotension is referred to as
Orthodontics. BP and Pulse taken lying, sitting, standing.
Self-Measurement of BP Advantages
- Elevated BP can be detected early
- Many home BP monitors can be applied over clothes
- Patterns of BP in pre-hypertensive patients may be discovered
- Allows for active participation in hypertensive treatment (helps with adherence to medications/treatments)
Self-Measurement of BP Disadvantages
- potential improper use of device/inaccurate readings
- inappropriately self-adjust medications
Patient Teaching for Self-Measurement of BP
- help patients understand the meaning and implication of readings
- teach proper use of equipment
- teach to record the time (same times of day preferable) and date of their readings to share with health care provider.
How often do you measure a patient’s vital signs?
….
How do hormone levels affect body temperature?
…..
Why are newborns and older adults more at risk when it comes to body temperature?
…
What would be the effect to patients with respiratory or cardiac problems?
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