II - Taking Vital Signs Flashcards
are body temperature, pulse, respiration, and blood pressure. Recently, many agencies have designated pain as a fifth vital sign.
The vital signs
Times to assess vital signs:
On admission to a health care agency to obtain baseline data
When a client has a change in health status or reports symptoms such as chest pain or feeling hot or faint
Before and after surgery or an invasive procedure
Before and/or after the administration of a medication that could affect the respiratory or cardiovascular systems; for example, before giving a digitalis preparation
Before and after any nursing intervention that could affect the vital signs (e.g., ambulating a client who has been on bed rest)
Purpose of taking vital signs
- To assess the health status of an individual
- To plan and implement nursing care
- To understand the effectiveness of the treatment
- To modify or change the mode of treatment
- Routine part of complete physical assessment
- To understand the present problem
The balance between the heat produced and heat lost from the body is measured in Celsius or Fahrenheit.
Body Temperature
The body continually produces heat as a by-product of ___.
metabolism
There are two kinds of body temperature:
Core temperature
Surface temperature
- This is the temperature of the deep tissues of the body, such as the abdominal cavity and pelvic cavity. It remains relatively constant.
Core temperature
The normal core body temperature is a range of temperature ___.
37C
- This is the temperature of the skin, the subcutaneous tissue, and fat. It rises and falls in response to the environment.
Surface temperature
Factors affecting the body’s heat production
Basal Metabolic Rate (BMR)
Muscle Activity
Thyroxine Output
Strong Emotions
Presence of disease/illness
Change in atmospheric temperature
It is the rate of energy utilization in the body required to maintain body essentials (breathing, digestion).
Basal Metabolic Rate (BMR)
Increases metabolic rate up to 2000 times and heat production can increase up to 50 times than normal.
Muscle Activity
Increased ___ output increases the rate of cellular metabolism throughout the body.
This effect is called ___, the stimulation of heat production in the body through increased cellular metabolism.
thyroxine
thermogenesis
Fight/Flight and stress hormones will be stimulated -> Increasing the rate of cellular metabolism
Strong Emotions
Increased levels of carbon dioxide and other greenhouse gases in the atmosphere -> Increased temperature of the earth’s atmosphere
Change in atmospheric temperature
Factors affecting the body’s heat loss
- Through the skin
- Through lungs
- Through kidneys
- Through bowel
- is the transfer of heat from the surface of another without contact between two objects.
Radiation
- is the transfer of thermal energy through direct contact.
Conduction
- is the transfer of heat energy in a gas or liquid by movement of currents like the heat of the stove while cooking, or the breeze.
Convection
- is the process of losing heat through the conversion of water to gas (sweat).
Evaporation
Factors affecting body temperature
Age
Diurnal variations
Exercise or Activity
Stress
Hormones
Environment
The point of highest body temperature is usually between ___
The lowest point is usually between ___
8 pm and midnight.
4 am and 6 am.
Sites for measuring body temperature and thermometers used
- Oral
- Rectal
- Axillary
- Tympanic membrane
- Skin/Temporal artery
- Peripheral
Ensure that the patient has not taken any hot or cold food or fluids or smoked in ___ minutes prior to the procedure
15 – 30
. A temperature above the normal range.
Pyrexia
A very high temperature above 40°C.
Hyperthermia or fever.
. Temperature below 34°C.
Hypothermia
Hyperthermia or fever. A very high temperature above .
40°C
Hypothermia. Temperature below
34°C.
Common Types of Fever
- Intermittent fever
- Remittent fever
- Relapsing fever
- Continuous fever
- Fever Spikes
- Resolution of pyrexia by crisis
- Resolution of pyrexia by lysis
A fever where temperature is elevated for several hours followed by an interval when temperature drops back to normal. Occurs in malaria, PTB
- Intermittent fever
Sustained fever is a pattern in which there is little change (0.3°C or less) in the elevated temperature during a 24-hour period. In sepsis, RHF.
- Remittent fever
A variant of the intermittent pattern, fever spikes are separated by days or weeks of intervening normal temperature like in lymphoma.
- Relapsing fever
A type or pattern of fever in which temperature does not touch the baseline and remains above normal throughout the day like in viral pneumonia.
- Continuous fever
A sudden sharp increase in temperature usually up as high as 105°F like in borreliosis (Lyme disease, is transmitted to humans by the bite of infected ticks).
- Fever Spikes
a rapid drop of body temperature to normal, ina few hours. It can disrupt the functions of cardiovascular system and therefore isdangerous for the patient’s life.
- Resolution of pyrexia by crisis
the fall in the body temperature follows a pattern of slow and gradual decrement of the body temperature. This type of fall in body temperature is seen in the case of infectious diseases (e.g., measles, typhoid, Scarlett fever).
- Resolution of pyrexia by lysis
It is the wave of blood created by the contraction of the left ventricle of the heart.
Pulse
is a pulse located away from the heart, like in the foot, wrist neck, etc.
Peripheral pulse
Sites for peripheral pulses:
Temporal
Carotid
Apical
Brachial
Radial
Femoral
Popliteal
Posterior tibial
Dorsalis Pedis
this pulse is located at the apex of the heart.
Apical pulse
Factors affecting pulse
- Age
- Gender
- Exercise
- Fever
- Medications
- Hypovolemia
- Stress
- Position changes
- Pathology
The average adult male heart rate is between ___ beats per minute, while the average for adult women is between ___ beats.
70 and 72
78 and 82
___ decreases the heart rate, whereas ___ increases the PR.
Cardiotonics (digitalis)
epinephrine
Loss of blood from the vascular system normally increases pulse rate.
Hypovolemia
Description of a pulse
Volume
Rhythm
– is the force or strength of the pulse.
Volume
– is the pattern of long and short sounds in every beat.
Rhythm
is a steady beat like a ticking clock or of a heartbeat. It can be measured in time by counting the number of beats per minute (BPM).
Pulse
Palpation should be done using the fingertips and the intensity of the pulse graded on a scale of 0 to 4 +.
0 = no palpable pulse
1+ = faint, but detectable pulse;
2+ = slightly more diminished pulse than
normal
3+ = normal pulse
4+ = bounding pulse
is the medical term for a heart rate over 100 beats per minute.
Tachycardia
is slower than 60 bpm or a normal heart rate.
Bradycardia
–the difference between the apical and peripheral pulse rates.
Pulse deficit
is the difference between systolic and diastolic blood pressure.
Pulse pressure
The normal range of pulse pressure is between ___ mm Hg. Pulse pressure tends to increase after the age of 50.
40 and 60
