Measuring Vital Signs Flashcards
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- Are a means of assessing vital or critical physiological functions
- Variations reflect a person’s state of health and/or functional ability of body systems
- Importance of accurate assessments, interpretation, and documentation cannot be overemphasized
Vital signs
Facility Standards for Monitoring
Hospital: every 4-8 hours
Home health setting: each visit
Clinic: each visit
SNFs: weekly to monthly
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- Is degree of heat maintained by the body
- Difference between heat produced by the body and heat lost to the environment
Temperature
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- Temperature deep within the body
- Not routinely used as requires an invasive procedure
Core Temperature
Rectal measurements are used to represent ___ temperatures, while oral and axillary reflect ___ temperatures
CORE, SURFACE
The “traditional” normal body temperature was ___ ?
98.6°F
Older lit has a lower level (mean normal oral temperature) of ___ ?
97.3°F
Recent lit has a mean body temperature of ___. with a range of ___ to ___
- 9°F
- 5°F - 98.8°F
Core Temperature cont’d
Typically, 1-2°F higher than skin temp
Temp varies based on age
Rectal sites measures ___ temp
core
Surface Temperature
___ (↑ or ↓) than core temp ?
Use oral and axillary method
Lower
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- Process of maintaining a stable temperature
- Constant body temperature = balance between heat production and heat loss
- Center of control is the ___
Thermoregulation
hypothalamus
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Is the amount of energy needed to maintain the body at rest
Basal metabolic rate (BMR)
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High thyroxine, more heat, patient feels warm even in cool environment
Hyperthyroidism
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Low thyroxine, less heat, patient feels cold
Hypothyroidism
Skeletal muscle movement
- Muscles need fuel
- Breakdown (___) of fats and carbs in muscles produce energy and heat
catabolism
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Is usually seen in infants and disappears in the first few months after birth
Non-shivering thermogenesis
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Is the transfer of heat through currents of air or water
Convection
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Is loss of heat through electromagnetic waves emitting from surfaces that are warmer than the surrounding air
Radiation
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Is the transfer of heat from a warm to a cool surface by direct contact
Conduction
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Water is converted to vapor and lost from the skin (as perspiration) or the mucous membranes (through the breath)
Evaporation
Factors That Influence Body Temperature
- Developmental level (infants and older adults more susceptible)
- Environment (warm, cold, high humidity, hot baths)
- Gender (lower when progesterone levels are low and increases when progesterone levels are high; hot flashes during menopause)
Factors That Influence Body Temperature cont’d
- Exercise (sweat evaporates and helps cool body)
- Emotions, stress
- Circadian rhythm
Variances in Temperature
Fever (aka ?)
- High body temp (greater than ___)
- Occurs in response to pyrogens (e.g. bacteria)
- Pyrogens induce secretions of substances (___) that reset the hypothalamic thermostat at a higher temp
pyrexia
100°F
prostaglandins
Variances in Temperature cont’d
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- Abnormally high body temp; fever greater than ___
Hyperpyrexia
105.8°F
Variances in Temperature cont’d
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- Core temp below normal (less than ___)
- Associated with extended exposure to cold (e.g. extreme weather, immersion in cold water, or lack of shelter and clothing)
Hypothermia
95°F
Course of Fever
3 phases
Initial: febrile episode or onset
Second: course
Third: defervescence or crisis
Describing a fever
- Intermittent
- Remittent fever
- Constant (sustained) fever
- Relapsing (or recurrent) fever
* Antipyretic medications (i.e. acetaminophen, ibuprofen)
Advantages & Disadvantages of Various Thermometers
- Glass thermometers
- Electronic thermometers
- Infrared electronic thermometers
- Disposable chemical thermometers
Advantages & Disadvantages of Various Sites for Measuring Temperature
- Temporal artery
- Rectal
- Oral
- Axillary
- Tympanic membrane
- Disposable (i.e. forehead)
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Is the rhythmic expansion of an artery produced when a bolus of oxygenated blood is forced into it by a contraction of the heart
Pulse
Pulse rate
- Measured in beats per minute (bpm)
- Normal range for healthy adults = __ to __ bpm
Average = __ to __ bpm
60 to 100 bpm
70 to 80 bpm
Pulse cont’d
The “wave” that begins when the ___ contracts and ends when the ___ relaxes
Each contraction forces blood into the already-filled aorta, causing increased pressure within the arterial system
left ventricle, ventricle
___ is the peak of the wave, or contraction of the heart
___ is the trough or resting phase of the heart
systole
diastole
___ is the quantity of blood pumped out by each contraction of the left ventricle
Cardiac output = ___ x ___
___ nervous system: regulates heart rate
Stroke volume
stroke volume x pulse (heart) rate
autonomic
Factors That Influence Pulse Rate
- Developmental level
- Gender
- Exercise
- Food intake
- Stress
Factors That Influence Pulse Rate cont’d
- Fever
- Disease
- Blood loss
- Position change
- Medication
Obtaining a Pulse Rate
___ is most accurate
Use a stethoscope to auscultate the number of heartbeats at the apex of the heart
A watch or clock with a second hand or digital display is required
A heartbeat is one series of the LUB and DUB sounds
Apical
When to Measure an Apical Pulse
- The radial pulse is weak or irregular
- The rate is < than 60 beats/min or > than 100 beats/min
- The patient is taking cardiac medications
- The patient is an infant or child up to age 3 (because peripheral pulses may be difficult to palpate)
Variances in Pulse Rates
- Pulse ___: hear a heartbeat but do not feel a beat at a pulse point
- Pulse rate:
___: rate less than 60 bpm
___: rate greater than 100 bpm
- Pulse rhythm: does the rate have a regular or irregular rhythm?
- Pulse quality:
> What is the quality of the pulse?
> Volume = force
Absent? Weak or Thready? Normal? Bounding?
> Are pulses bilaterally equal?
> If absent or weak, check for cyanosis or pallor
deficit
Bradycardia
Tachycardia
___ - a bluish or grayish discoloration of the skin due to excessive carbon dioxide and deficient oxygen in the blood
___ - paleness of skin when compared with another part of the body
Cyanosis
Pallor
Analysis/Nursing Diagnosis
- Peripheral Tissue Perfusion Alteration
- Risk for Impaired Skin Integrity
- Risk for Impaired Tissue Integrity
- Deficient Fluid Volume
- Decreased Cardiac Output
Outcomes and Interventions
Nursing Outcomes Classifications (NOC) Standardized Outcomes Vital Signs
- Nursing Interventions Classification (NIC)
Dysrhythmia management
Vital signs monitoring
Respiration
The exchange of oxygen and carbon dioxide in the body
2 separate processes
* Pulmonary ventilation
- Pulmonary ventilation; breathing
- Active movement of air in and out of the respiratory system
* Chemical
- External respiration - exchange of O2 and CO2
- Gas transport - transport of O2 and CO2
- Internal respiration - exchange of gases between capillaries and tissues
Respiration: Rate and Regulation
Rate varies with age, exertion, emotions, and other factors
Regulators
- Level of CO2 in the blood
- Central chemoreceptors (located in respiratory centers)
- Peripheral chemoreceptors (located in carotid and aortic bodies)
Mechanics of Respiration/Pulmonary Ventilation
Factors That Influence Respirations
- Developmental level / Fever
- Exercise / Hemoglobin
- Pain / Disease
- Stress / Medication
- Smoking / Positions
Counting the Respiratory Rate
- Nurse should count respiratory rate (RR) after taking the radial pulse
- Patient can alter the rate and pattern of respirations
- RR must be accurate, especially in older adults
Variations in Assessment Findings
Rate
___ - cessation of breathing
___ - abnormally slow
___ - abnormally fast
Depth
- Deep, shallow, normal
Apnea
Bradypnea
Tachypnea
Variations in Assessment Findings cont’d
Rhythm
- Assessment of the pattern of respirations
- Abnormal: Cheyne-Stokes, Biot’s
Effort
- Work of breathing
___: labored breathing
___: inability to breathe when horizontal
Dyspnea
Orthopnea
Variations in Breath Sounds
___ - high-pitched continuous musical sounds, usually heard on expiration
___ - a piercing, high-pitched sound heard primarily during inspiration
___ - labored breathing that produces a snoring sound
___ - low-pitched continuous sounds caused by secretions in the large airways
___ - discontinuous sounds usually heard on inspiration; may be high-pitched popping sounds or low-pitched bubbling sounds
Wheeze
Stridor
Stertor
Rhonchi
Crackles
Associated Assessment
Chest and abdominal movement
- ?
Exists when tissues are drawn in beneath the sternum (breastbone)
- ?
Exists when tissues are drawn in above the clavicle (shoulder girdle)
- ?
Refers to the visible sinking of tissues around and between the ribs that occurs when the person must use additional effort to breathe
- Substernal retraction
- Suprasternal retraction
- Intercostal retraction
Assessment: Associated Signs
Hypoxia
Cyanosis
Cough
When you assess respiration, it’s important to assess for clinical signs of oxygenation and perfusion
Hypoxia → pallor, cyanosis, fatigue, dizziness, restlessness, changes in BP
Cyanosis → tongue and oral mucosa are good indicators
Cough → constant, intermittent, productive, nonproductive, hacking, whooping
Tools to Measure Oxygenation
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Noninvasive method of monitoring respiratory status
Uses an external device that measures oxygen saturation
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Directly measures the partial pressures of O2, CO2, and blood pH
Pulse oximetry
Arterial blood gases (ABG’s)
Ventilation and Oxygenation
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Rate and depth of respirations are decreased and CO2 is retained
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Rapid and deep breathing resulting in excess loss of CO2 (hypocapnea)
Client may complain of feeling light-headed and tingly
Hypoventilation
Hyperventilation
Blood Pressure
An important indicator of overall cardiovascular health
Pressure of blood as it is forced against arterial walls during cardiac contraction
? Is minimum pressure exerted against arterial walls between cardiac contractions when the heart is at rest
? Is peak pressure exerted against arterial walls as the ventricles contract and eject blood
Diastolic pressure
Systolic pressure
Blood Pressure cont’d
Measured in millimeters of mercury (mmHg)
Recorded as systolic pressure over diastolic pressure (120/80 mmHg)
Pulse pressure: the difference between the systolic and diastolic pressures
Blood Pressure cont’d
Normal
Elevated
Stage I hypertension
Stage II hypertension
Hypertensive Crisis
What is “normal” range blood pressure?
<120 and <80
What is “elevated” blood pressure?
120-129 and ≤80
What is hypertension stage I blood pressure?
130-139 or 80-89
What is hypertension stage II blood pressure?
≥140 or ≥90
What is hypertensive crisis blood pressure?
>180 and/or >120
Blood Pressure Regulation
* Influenced by 3 factors
- Cardiac function (increased, decreased stroke volume)
- Peripheral vascular resistance
- Blood viscosity [thickness] (high, low hematocrit)
- Arterial size
- Arterial compliance [elasticity] - Blood volume (5L)
- Cardiac output is the volume of blood pumped by the heart per minute, and it reflects the functioning of the heart
- Peripheral vascular resistance refers to arterial and capillary resistance to blood flow as a result of friction between blood and the vessel walls
Factors That Influence Blood Pressure
- Developmental stage / Pain
- Gender / Race
- Family history / Obesity
- Lifestyle / Diurnal variations
- Exercise / Medications
- Body position / Diseases
- Stress / Genetic variations
Korotkoff’s Sounds
1st sound
- As you deflate the cuff, a sound that occurs during systole (systolic BP)
- Is a tapping sound that corresponds to a palpable pulse
2nd sound
- As you further deflate the cuff, a soft swishing sound caused by blood turbulence
Korotkoff’s Sounds cont’d
3rd sound
- Begins midway through the blood pressure and is a sharp, loud rhythmic sound
4th sound
- Similar to the 3rd sound, but softer, fading, and muffled
5th sound
- Silence, corresponding with diastole (diastolic blood pressure)
Hypotension and Hypertension
- Are medical diagnoses
- Are symptoms
- May be etiology of a nursing diagnosis
* Risk for Falls related to orthostatic (postural) hypotension, or Fear of Falling related to fainting 2° orthostatic (postural) hypotension
* Risk for Unstable Blood Pressure, when the patient is “susceptible to fluctuating forces of blood flowing through arterial vessels which may compromise health”
- Treated as collaborative problems
Hypertension cont’d
- Is a major cause of illness and death in the US
- Increases the stress on the heart and blood vessels
- If untreated, can lead to heart, renal, cerebral, or respiratory complications
- Severity is directly related to the degree of elevation
- Primary or essential hypertension
* Diagnosed when there is no known cause for the increase
* Accounts for at least 90% of all cases of hypertension
* Clients may not know they have hypertension
