Chapter 30: Vital Signs Flashcards
List times when a patients vital signs are normally assessed:
A) On admission to a healthcare agency, to establish baselines
B) Part of a physical assessment
C) During an inpatient stay, as routine monitoring
Most frequent and routine measurements obtained by health care providers:
Temperature
Pulse
Blood pressure
Respiratory rate
Oxygen saturation
Average temperature range:
96.8-100.4 degrees F
Average oral/tympanic temperature
98.6 F
Average rectal temperature:
99.5 F
Average axillary temperature
97.7 F
Average pulse:
60 to 100 beats/min, deep and regular
Average adult respiration
12 to 20 breaths/min, deep and regular
Average blood pressure
Systolic <120
Diastolic <80
Average pulse pressure:
30-50 mm HG
Average core temperature for elderly
95-97 F as a result of decreased immunity
Lowest temperature is at ____ while highest temperature is at ____
Lowest: 6 am
Highest: 4 pm
Which part of brain controls body temperature?
Hypothalamus
Senses minor changes in body temperature
Anterior hypothalamus controls
heat loss
Posterior hypothalamus controls
heat production
When metabolism decreases,
less heat is produced.
Heat production occurs during
rest, voluntary movements, involuntary shivering and non shivering thermogenesis
7 factors that can cause an individual’s body temperature to change:
Age
- Newborn’s temp unstable baseline temp drops with age, infants and elderly more susceptible to environmental temp extremes
Exercise
-Increases body temperature
Hormonal fluctuations
-Women’s temp higher at ovulation
Circadian rhythms
- lowest temp: 6 am, highest 4pm
Stress
- levels of extreme temps affect core body temp
Environment
Smoking
-causes vasoconstriction that can decrease temp of skin
Factors influencing vital signs (9)
Infection
renal disease
Respiratory disease
Cardiovascular disease
Physical Environment
Emotional state of patient
Medications
Food and fluid intake
Activity level and tolerance
Pain SOCRATES meaning:
Site
Where is pain located?
Onset
When did pain start? gradual or sudden?
Character
Quality of pain? Stabbing, burning, aching in nature?
Radiation
Does pain radiate anywhere?
Associations
signs and symptoms associated with pain
Time Course
Any pattern to pain?
Exacerbating/relieving factors
What makes it worse or help it?
Severity
0-10 scale
Patterns of fever (SIRR)
Sustained: constant body temp that has little fluctuation
Intermittent: Fever spikes interspersed with usual temp levels. (Temp returns to acceptable value at least once in 24 hours)
Remittent: fever spikes and falls without a return to acceptable temperature levels
Relapsing: periods of febrile episodes and periods with acceptable temperature values (febrile episodes often longer than 24 hours)
Hyperthermia:
elevated body temperature 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
5 types of thermometers
Electric thermometer (oral/anus/axillary)
temporal artery thermometer (forehead of child typically)
tympanic thermometer (Ear)
disposable paper thermometers
temperature sensitive strips
5 sites commonly used to measure body temperature
Oral (most common)
-under tongue
Axillary
-frequently used for healthy newborns
Tympanic
Temporal
Rectal
Examples of nursing diagnoses for patients with body temperature alterations include (5)
Risk for imbalanced body temperature
hyperthermia
hypothermia
ineffective thermoregulation
risk for hypothermia
Pulse is the
palpable bounding of blood flow in a peripheral artery
Infant heart rate
120-160 beats/min
Toddler heart rate
90-140 beats/min
Preschooler heart rate
80-110 beats/min
School-age child heart rate
75-100 beats/min
Adolescent heart rate
60-90 beats/min
Adult heart rate
60-100 beats/min
Factors that influence pulse rate (7)
Exercise
Temperature
Emotions
Medications
Hemorrhage
Postural changes
Pulmonary conditions
Tachycardia:
an abnormally elected HR
ABOVE 100 beats/min in adults
Bradycardia:
Slow HR
Below 60 beats/min in adults
Document pulse strength as:
Bounding (4)
Full or strong (3)
Normal and expected (2)
Diminished or barely palpable (1)
Absent (0)
Respiration is the mechanism the body uses to:
exchange gases between the atmosphere and the blood and the blood and the cells
Respiration involves (3)
Ventilation (movement of gases in and out of the lungs)
Diffusion (movement of oxygen and carbon dioxide between the alveoli and the red blood cells)
Perfusion (distribution of red blood cells to and from the pulmonary capillaries)
Assess ventilation by determining…
respiratory rate, depth, rhythm and end-tidal carbon dioxide value
Assess diffusion and perfusion by
determining oxygen saturation
Hypoxemia:
low levels of arterial O2
A respiratory rate above ____ is an important risk factor for
27 breaths/min
cardiac arrest
Hypothermia:
low body temperature
-Frostbite results from exposure to subnormal temperatures
Hypotension- decreased blood pressure
Febrile
person with fever
Heat stroke
when prolonged exposure to high environmental temps overwhelms the body’s heat loss mechanisms
Heat exhaustion
when extreme or prolonged exposure to high environmental heat leads to profuse sweating and consequent water and electrolyte loss
Factors that cause pulse rate to vary:
Age
Gender
Fever
Stress
Medications
Hypovolemia
Pathology
Electrolyte balance
Hypoxia/hypoxemia
Dysrhythmia:
interval interrupted by an early or late beat or a missed beat indicates an abnormal rhythm or DYSRHYTHMIA
Factors influencing character of respirations (8)
Exercise
Acute pain
Anxiety
Smoking
Body position
Medications
Neurological injury
Hemoglobin function
Bradypnea:
rate of breathing is regular but abnormal slow (less than 12 breaths/min)
Tachypnea:
rate of breathing is regular but abnormally rapid (above 20 breaths/min)
Hyperpnea:
respirations are labored
increased in depth
increased in rate (greater than 20 breaths/min) (occurs normally during exercise)
Apnea:
respirations cease for several seconds. Persistent cessation results in respiratory arrest
Hyperventilation
rate and depth of respirations increase. Hypocarbia sometimes occurs
Hypoventilation
respiratory rate is abnormally low, and depth of ventilation is depressed
Hypercarbia sometimes occurs
Cheyne-Stokes respiration
respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation.
Respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth
pattern reverses…breathing slows and becomes shallow concluding as apnea before respiration resumes
Kussmaul’s respiration:
respirations are abnormally deep, regular and increased in rate
Biot’s respiration
respirations are abnormally shallow for 2-3 breaths, followed by irregular period of apnea
Factors affecting determination of pulse oxygen saturation (2)
Interference with light transmission
Interference with arterial pulsations
SaO2 normal range:
95% and 100%
Systolic pressure:
Contraction of the heart forces the blood under high pressure in the aorta
Peak of maximum pressure when ejection occurs
Diastolic pressure:
when the ventricles relax, the blood remaining in the arteries exerts a minimum or DIASTOLIC pressure
minimal pressure exerted against the arterial walls at all times
Pulse pressure:
difference between systolic and diastolic
Hypotension:
occurs when the systolic BP falls to 90 mm HG or below
Hematocrit:
% of red blood cells in blood, determines blood viscosity
When the hematocrit rises and blood flow slows, arterial BP increases
The heart contracts more forcefully to move the viscous blood through the circulatory system
Hypertension:
Asymptomatic
Diastolic readings greater than 90 mm Hg and systolic greater than 140 mm Hg
Orthostatic hypotension
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
Factors influencing Blood pressure:
Age
Stress
Ethnicity
Gender
Daily Variation
Medications
Activity and Weight
Smoking
Prehypertension:
Systolic 120-139
Diastolic 80-89
Stage 2 hypertension
Systolic >160
Diastolic >90
