Chapter 4 Vital Signs Flashcards
Vital Signs
Objective guideposts that provide measurement of essential life-sustaining functions, such as: Temperature, pulse, respiration, blood pressure, and pulse oximetry
TPR
Temperature, pulse, respiration
Symptoms
subjective evidence of a disease, such as pain or headache.
-Felt by the patient
Signs
objective evidence of a disease, can be measured by a physician, such as a fever
In which provinces of Canada are MLTs legally allowed to check, record or measure vital signs and ECG?
BC and ON
Vital Signs are usually checked during each office visit to establish….
- patient’s state of health
- baseline measurement
What is a baseline measurement?
The initial vital signs measurements of a patient that is healthy. This is used to compare future vital sign measurements
Guidelines for Measuring Vital Signs: (4)
- be familiar with normal ranges for vital signs
- make sure equipment is in proper working order
- eliminate or minimize factors that affect vital signs ie. exercise, emotional states
- use an organized approach when measuring vital signs ie. start with temperature, followed by pulse and etc.
Body temperature is regulated by which body part?
The hypothalamus AKA body thermostat in the brain which connects the pituitary gland to the nervous system.
- regulates our temperature by 1-2 degrees Fahrenheit only
how does the hypothalamus regulate body temperature?
Hypothalamus reduces temperature by sending a message to perspire.
What is the normal temperature range?
36.1-37.2 degrees Celsius or 97-99 degrees Fahrenheit
Remember infants and young children generally have higher temperature than adults because their thermoregulatory system not yet fully established
What are the most important baseline measurements?
blood pressure and pulse
Is the hypothalamus a gland?
no, it is a nerve tissue
Temperature is maintained by a balance of
heat lost from the body, and heat produced in the body
the most Heat in the body is produced by
voluntary muscle contractions (skeletal muscles) and involuntary muscle contractions (digestive system)
Other body heat is produced by:
cell metabolism, fever and strong emotional states
Heat is lost through these bodily functions:
urine and feces, moisture droplets from lungs, perspiration
Heat is also lost through:
Radiation, convection and conduction
Radiation
transfer of heat in form of waves to cooler surroundings
Convection
transfer of heat through air currents
Conduction
transfer of heat from one object to another by direct contact
Purpose of measuring body temperature:
- establish patients baseline
- check patient’s state of health
Average body temperature is
98.6 degrees Fahrenheit or 37 degrees Celsius
Baseline measurement
patient’s initial vital sign’s measurement used to compare future measurements
Fever pyrexia temperature
above 100.4 degrees Fahrenheit or above 38 degrees Celsius
Low grade fever temperature
99 to 100.4 degrees Fahrenheit or
37.2 -38 degrees Celsius
Hyperpyrexia Temperature
above 105.8 degrees Fahrenheit or 41 degrees Celsius
Generally fatal temperature
above 109.4 degrees Fahrenheit ( 43 degrees Celsius)
or
93.2 degrees Fahrenheit (34 degrees Celsius)
Hypothermia Temperature
below 97 degrees Fahrenheit or 36.1 degrees Celsius
aka subnormal
Where can we take the most accurate temperature in adults?
rectal
Variations in body temperature can be caused by:
environment, diurnal variations, extreme emotional states, exercise, patient’s normal body temperature, pregnancy
diurnal variation:
during sleep, body metabolism and muscle contractions slow down
Fever
common symptom of illness, particularly inflammation or infection, increased temperature above the normal range
-usually self-limiting- temperature goes back to normal when illness is over
Febrile
person who has a fever above 100.4 degrees Fahrenheit
Afebrile
person who doesn’t have a fever
pyrogen
any substance that produces fever; resets hypothalamus causes temperature to rise
onset fever
when temperature begins to rise
- may be slow or sudden
- causes coldness, chills, increase in pulse and respiration
Three patterns that describe the course of a fever:
continuous, intermittent and remittent
continuous fever
body temperature fluctuates minimally always remains elevated
ie. scarlet fever or pneumococcal pneumonia
intermittent fever
body temperature alternately rises and falls at times returns to normal or even becomes subnormal
ie. bacterial infections and viral infections
remittent fever
wide range of temperature fluctuations occurs - all or above normal
ie. influenza, pneumonia, endocarditis
Malaise
a vague sense of body discomfort, weakness and fatigue
Why do we try to avoid dehydration during a fever?
dehydration will affect electrolytes, we need electrolytes to keep the heart contracting and relaxing
subsiding stage
temperature returns to normal
Assessment sites of body temperature: (5)
mouth, axilla, rectum, ear and forehead
Qualifications of good temperature assessment sites:
- site should have abundant blood supply
- as closed as possible (prevents air from interfering)
- site depends on patient’s age, condition and state of consciousness
which temperature site is good for toddlers and preschoolers?
the axillary temperature
When recording temperature how do we indicate the axillary temperature was taken?
it should be marked with an “A” after temperature
If the axillary temperature measures 99 degrees Fahrenheit, what would the measurement of the oral temperature be?
99 degrees fahrenheit + 1 degree = 100 degrees Fahrenheit
-because the auxillary route measures 1 degree lower than the oral
Why is the rectal temperature the most accurate?
- rectum is highly vascular
- provides the most closed activity
- measures 1 degree higher than the oral route
If the rectal route measures 100 degrees Fahrenheit, what is the oral temperature?
100 degrees fahrenheit - 1 degree = 99 degrees fahrenheit
because the rectal route measures 1 degree higher than the oral route
Who is the rectal temperature recommended for?
infants, and young children, unconscious patients, mouth-breathing patients
never with newborns
Aural temperature is taken with a _____________________________ thermometer
tympanic membrane
The aural temperature is recommended for:
children under 6 years of age,
uncooperative patients, patients who can’t get oral temperature taken
When taking aural temperature what should be done for adults and children?
For adults hold top of ear up and back, for children hold bottom of ear down and back
Forehead temperature measures temperature along the __________________________
Temporal artery (major artery of head)
Forehead temperature compared to oral and axillary temperature?
forehead temperature is approximately 1 degree Fahrenheit higher than oral temperature
and is approximately 2 degree Fahrenheit higher than axillary temperature
note: why 2 Fahrenheit
There are four types of thermometers:
electronic, tympanic, temporal artery and chemical
What color probe for the oral, axillary and rectal thermometor?
oral and axillary thermometer have a blue probe and rectal thermometer have a red probe
How should disposable plastic probe covers be disposed?
in regular waste
What is the purpose of disposable plastic covers?
prevents transmission of microorganisms between patients, and protect the lens of the probe
Why are Mercury glass thermometers no longer used?
- breaks easily
- mercury can damage the nervous system
- harmful to wildlife
- many cities have banned use and sale of mercury
Where is the tympanic Membrane thermometer used?
in the aural site
Does the tympanic membrane thermometer measure the temperature of the blood?
NO, it measures the thermal energy of the tympanic membrane. ( the wave of the tympanic membrane)
When should we not use the tympanic membrane thermometer?
- patients with inflammation of external ear canal
- when the ear contains a discharge such as blood or pus
- excessive cerumen buildup that occludes the canal
How to place tympanic membrane thermometer in ear properly?
straighten the ear canal,
- for adults and children older than 3 years pull auricle upward and backward
- for children younger than 3 years, pull ear pinna downward and backward
Then insert probe tightly enough to seal opening of ear
When recording aural temperature what must be recorded?
- the temperature result and unit
- which ear was temperature taken, left or right
- normal reference range
- any additional notes
What is the procedure for measuring the temporal artery thermometer?
-scan button is continually depressed, probe is slowly moved across forehead
a falsely low temporal artery reading can be caused by:
- a dirty probe lens
- sweating of the forehead
- scanning the forehead too quickly
- not keeping the button pressed while scanning
Continuous Fever
body temperature fluctuates minimally but remains elevated
Remittent fever
Wide range of body temperature , but remains above normal
intermittent fever
body temperature rises and falls and at times returns to normal or becomes subnormal
How to clean lens of tympanic membrane thermometer?
- wipe lens with an antiseptic wipe
2. immediately wipe dry with a cotton swab
When taking a temporal artery temperature, how to avoid inaccurate results caused by a patient whose skin is clammy, sweat that isn’t visible or a fever that just broke?
After scanning the forehead, continue to scan temperature of neck area behind earlobe
do not take temporal temperature on patients with:
open sores or abrasions, scar tissue
a dirty probe lens, sweating of the forehead causes what in a temporal reading?
falsely low temperature
Which part of the body regulates the temperature?
hypothalamus
what is the hypothalamus attached to?
pituitary gland
the main source of body heat comes from?
skeletal muscles (voluntary and involuntary movement)
How can the body lose heat?
radiation, conduction and convection
What is the normal range of body temperature?
36.1 -37.2 degrees Celsius or 97-99 degrees Fahrenheit
Mechanism of the pulse
when the left ventricle of the heart contracts, blood is forced into the aorta, this creates a pulsating wave that travels from the aorta through the walls of the arterial system
We do not feel a pulse with veins. true or false
true, we feel the pulse in the arteries.
pulse rate
measured by counting the number of beats per minute
heart rate is determined by taking the _______
pulse
factors that affect pulse:
age, gender, physical activity, emotional states, metabolism, fever, medications
pulse is felt most strongly when ________________________________.
superficial artery is held against a firm tissue (bone).
Most common pulse site is
the radial artery, located in a groove on the inner aspect of the wrist just below the thumb
characteristics of the Apical (apex of the heart) pulse
stronger beat, more easily heard than other pulse sites.
- often used in infants and children under 3 years
- measured using a stethoscope
- location: fifth intercostal space at left midclavicular line
Should be taken if having difficulty feeling radial pulse, or if pulse is abnormally slow or rapid
Characteristics of the brachial (brachial artery)pulse
- located in antecubital space, front of the elbow, directly beneath basilic vein
- used to take bp, assess circulation to lower arm, measure pulse in infants during cardiac arrest
characteristics of ulnar pulse
- location: little finger on the side of the wrist
- used to assess circulation to the hand
characteristics of temporal pulse
location: front of ear just below eye level
- used when radial pulse is not accessible
- not easy to measure
characteristics of carotid pulse
location: anterior side of neck
- best site to find pulse quickly
- used to measure pulse in children and adults during cardiac arrest, monitor pulse during exercise
characteristics of femoral pulse
- location: middle of groin
- used to measure pulse in infants, children and adults during cardiac arrest, assess circulation to the lower legs
characteristics of the popliteal pulse
location: back of the knee
- used to measure BP when the brachial artery is not accessible, assess circulation to the lower leg
characteristics of posterior tibial pulse
location: inner space of ankle, posterior to ankle bone
- used to assess circulation to the foot
characteristics of the dorsalis pedis pulse
location: upper surface of foot between the first and second metatarsal bones
- used to assess circulation of the foot
Purpose of measuring pulse
- establish patient’s baseline pulse rate
- assess pulse following special procedures, medications or disease processes that affect the heart
how to locate pulse?
palpation; except for apical site
assessment of pulse includes:
pulse rate, rhythm, volume
ie. 61 bpm, rhythmic, strong
normal adult range of pulse
60-100 bpm
the average adult range of pulse
70-80 bpm
tachycardia
an abnormally fast heart rate of more than 100 bpm
-occurs during hemorrhaging, heart disease, vigorous exercise and strong emotional states
bradycardia
an abnormally slow rate falling below 60 bpm
-normally occurs during sleep and in a trained athlete
What to do if patient shows a bradycardic or tachycardic pulse?
take apical pulse
pulse rhythm
time interval between heartbeats
normal rhythm
same interval between beats
dysrhythmia
unequal or irregular intervals between beats, also termed arrhythmia
what will a physician order if the patient’s pulse is unequal or irregular?
apical-radial pulse, electrocardiogram, or holter monitoring
apical-radial pulse
performed to determine if a pulse deficit is present
-how? by measuring the apical pulse at the same time as the radial pulse for 1 full minute
why? for the pulse deficit
pulse deficit
radial pulse rate is less than the apical pulse rate
ie. one MA measures an apical pulse rate of 88, another MA measures the radial pulse of 76 bpm, therefore pulse deficit is 12 beats
which means not all heartbeats reach the peripheral arteries, caused by inefficient contraction of the heart, frequently occurs with atrial fibrillation
pulse volume
strength of the heartbeat
- should remain constant
- normal pulse feels strong and full
thready pulse
blood volume decreases, pulse feels weak
bounding pulse
blood volume increases, pulse feels extremely strong and full
Purpose of respiration
exchange of oxygen and carbon dioxide between the atmosphere and blood
Respiration is divided into 2 phases
inhalation (diaphragm descends, lungs expand, causes air containing O2 to move into lungs)
exhalation (diaphragm ascends, lungs return to original state, causes air containing CO2 to be expelled)
1 complete respiration is one inhalation and one exhalation
one complete respiration
one inhalation + one exhalation
external respiration
exchange of oxygen and carbon dioxide between alveoli and blood
alveoli
thin walled air sacs of the lungs in which the exchange of O2 and CO2 takes place
roles of capillaries in respiration
capillaries comes in contact with alveoli, picks up oxygen and carries it to the cells of the body
internal respiration
exchange of O2 and CO2 between body cells and blood
-oxygen is given off to the cells, carbon dioxide is picked up and transmitted as a waste product to lungs
involuntary respiration is controlled by the
medulla oblongata
buildup of CO2 sends message to medulla, triggers respiration to occur automatically
normal adult respiratory rate
12-20 rpm
ratio of respiration per pulse beat
1 respiration per 4 pulse
tachypnea
abnormal increase of more than 20 breaths/minute
bradypnea
abnormal decrease of fewer than 12 breaths/minute
factors that affect respiration
age, physical activity, medication, emotional state, fever
respiration rhythm should be
even and regular
respiration depth can be described as
normal, deep, shallow, determined by movement of chest
Eupnea
normal respiration, 12-20 rpm, rhythm, even and regular, depth is normal
hyperpnea
abnormal increase in rate and depth
- patient exhibits very deep, rapid and labored breathing
- occurs normally in exercise, fever and pain
-also occurs with inadequate oxygen supply in heart or lung disease
hypopnea
abnormal decrease in rate and depth, often occurs with sleep disorders
hyperventilation
abnormally fast and deep breathing
-usually associated with acute anxiety, causes dizziness and weakness
hypoxia
a reduction in the oxygen supply to the tissues, may cause cyanosis
cyanosis
bluish color of skin and mucous membranes
apnea
temporary absence of respirations, may occur during sleep
dyspnea
difficulty breathing or shortness of breath
orthopnea
the condition in which breathing is easier when an individual is in a sitting or standing position
blood pressure
measurement of force exerted by the blood on the walls of the arteries
systole
phase in the cardiac cycle in which the ventricles contract
systolic pressure
point of highest pressure on arterial walls
diastole
phase in cardiac cycle in which the heart (ventricles) relaxes between contraction
diastolic pressure
point of lesser pressure on arterial walls
hypertension stage 1
140/90
hypertension stage 2
160/100
hypotension
low blood pressure bp reading below 95/60
pulse pressure
difference between systolic and diastolic
normal range of pulse pressure
30-50
factors affecting blood pressure
age (as age increases bp increases), gender, diurnal variations, emotional states, physical activity, body position (sitting has higher diastolic pressure than standing), medications, pain, caffeine and smoking
equipment needed to measure blood pressure
stethoscope and sphygomomanometer
stethoscope
an instrument for amplifying and hearing sounds produced by the body
how does the cuff size of the sphygomomanometer affect bp reading
if cuff is too small falsely high, if cuff is too large falsely low
how to measure bp for obese patients if thigh cuff isn’t an option?
blood pressure can be measured at forearm using radial artery
korotkoff sounds
used to determine systolic and diastolic bp reading
