Module 4: Vitals Flashcards
Vital Signs
Temperature Pulse Respiration Blood Pressure O2 Saturation (Pain is often included but not necessarily)
Vital Signs reflect…
the health of a person
When should vitals be taken?
- to get a baseline with pre/post medications or pre/post vitals
- upon admission
- based on institutional policy/procedure
- before and after activity that increases risk, surgery, or medication administration affecting cardio/resp.
- when physician orders it
- WHENEVER YOU FEEL YOU NEED TO DO THEM
Can you take just one vital sign?
Absolutely Not
Who can take vitals?
People who are delegated healthcare personnel, but it is the nurses responsibility to assure its correct
We need to have a what for vital comparison?
Baseline vitals
“Close the Loop”
Responsibility of the nurse to follow up on delegation of vitals - the nurse has the responsibility if someone else is told to do it
Thermoregulatory center is in …
the hypothalamus
Primary source of body heat production?
metabolism
What things increase metabolism and heat production?
- hormones (EP and NEP), muscle movements, and exercise
- NEP and EP are released and alter metabolism which leads to energy production decreases and heat production increases
Sources of Heat Loss
- Skin (primary source)
- evaporation of sweat
- warming and humidifying inspired air
- eliminating urine and feces
Physical Processes Transferring Body Heart to External Environment?
- Radiation
- Convection
- Evaporation
- Conduction
Radiation
the diffusion or dissemination of heat by electromagnetic waves (ex: not having a hat)
Convection
transference of heat by motion between areas of unequal density
Evaporation
conversion of a liquid to a vapor (lose heat)
Conduction
transference of heat to another object during direct contact (ex: ice pack)
Factors Affecting Body Temperature
- Circadian Rhythm
- Age and Gender
- Environmental Temperatures
How does core temperature fluctuate during the day?
- core temperature is lowest in the morning
2. body temperature highest in the alte afternoon (4-8 pm)
How does Age and Gender influence core body temperature?
- Older and Younger people have less adaptable ability (from things like less sweat glands or less muscle mass)
- Men and Woman have hormone changes differing body temperature (Female Progesterone leads to more fluctuation)
Types of Fever
- Intermittent - Temp returns to normal once every 24 hours
- Remittent - fluctuating a few degrees
- Sustained/Continuous - stays stable at the same temperature
- Relapsing - returning to normal for 1+ days with fever for several days reoccurring
FUO
Fever of unknown origin - a fever greater than 38 Celsius lasting more than 3 weeks with no identifiable cause
Methods of Taking Temperature
Blue Oral Blue Axillary Red Rectal Tympanic Membrane Temporal Arterial Temperature Sensitive (invasive) Single Use Thermometer Mercury Glass Thermometer Infrared Thermometer
Sites for Temperature Assessment
Forehead Orallly Axillary Rectal Temporal Artery
Contraindications for Oral Temperature
Vomiting Cognition issues Eating or Drinking Oxygen Use Smoking Age Seizure Status Open Sores Age (<4 is too young to cooperatre) Recent Oral Surgery
Contraindications for Rectal Temperature
Cardiac Issues (Vagus nerve stimulation lowers HR) Rectal Surgery Thrombocytopenia Neutropenia Age Cognitive Issues
Contraindications of Tympanic Temperature
Pain Infection Scar Tissue Cerumen Excess Age (Under 3 can perforate the E tubes)
What might alter Temporal Artery Temperature?
Hair, Scarring, Cranial Surgery
Oral Normal Temperature
37 C / 98.6 F
Rectal Normal Temperature
37.5 C / 99.5 F
Axillary Normal Tempearture
36.5 C / 97.7 F
Tympanic Normal Temperature
37 C / 98.6 F
Forehead Normal Temperature
34.4 C / 94 F
Temporal Arterial Normal Temperature
37.5 C / 99.5 F
What temperatures are about a degree above and below Oral?
Above: Rectal, Temporal Arterial
Below: Axillary
Core Temperatures
Rectal, (possibly tympanic)
Routine newborn temperature is taken…
Axillary
Important thing to do when taking Tympanic Temperature?
in an adult, pull back on the ear
In a child above age 3/4 y/o you pull down and back
When taking a rectal temperature you must use what 2 things?
Gloves and Water Soluble Lubricants
Pulse is regulated by the ____ through _____
ANS through pacemaker (cardiac sinoatrial node)
What is the heart’s pacemaker?
Cardiac Sinoatrial Node
Parasympathetic stimulation does what to heart rate
decreases it (Sympathetic increases it)
What is Pulse Rate?
number of contractions over a peripheral artery for one minute
Physical Effects of Fever?
Anorexia Headache Diaphoresis Thirst Dehydration Muscle Aches Elevated Respiration Elevated pulse Rate Due to Fluid Deficiency Possibly Seizures
Hypothermia
Temperatures below 95/93.2 F or 34C
Febrile
100.4 F or 38.3 C
Peripheral Pulse
throbbing sensation that can be palpated over peripheral arteries (due to a pump of blood being put into circulation by the contraction of the left ventricle)
When taking pulse you are on the look out for what 3 things?
Rate, Amplitude/Quality, Rhythm
Tachycardia
Increased heart rate 100-180 bpm in adults
Bradycardia
Decreased heart rate (below 60 bpm) in adults
How to record pulse amplitude/quality?
0,+1,+2,+3 scale with 0 being absent, 1 being weak, 2 being normal, and 3 being bounding
Normal Adult Heart Rate?
60 to 100 bpm
Ways to Measure Pulse?
- Palpate peripheral arteries
- Auscultate apical pulse with stethoscope
- Assessing apical-radial pulse
Methods of Assessing Pulse?
- Inspection
- Palpation (2-3 middle fingers lightly over the pulse)
- Doppler Ultrasound
- Stethoscope and Apical Pulse
When palpating pulse, never use your…
thumb
The apical pulse is located…
on the left side, mid-clavicular, 5th intercostal space
Areas of Peripheral Pulses
Temporal Carotid Brachial Radial Ulnar Femoral Popliteal Dorsalis Pedis Posterior Tibial
Which peripheral pulse is checked only during an emergency for RATE?
Carotid
Never do what with carotid pulse?
take both sides at the same time
Pulse/Apical Deficit
Difference between the apical and radial pulses
Do not want this to occur, and the radial pulse will never be higher than the apical
Requires two people to learn
Stroke Volume
the volume of blood ejected from the left ventricle with each heartbeat(contraction)
Cardiac Output
the amount of blood ejected per minute
Cardiac Output Equation
Stroke Volume * Heart Rate
Dysrhythmia
irregular heart rate
Decent Cardiac Output Range?
3.5 to 8 Liters of blood per minute
Typical Child Pulse Rate
80-100 bpm
Typical Infant Pulse Rate
100-160 bpm
Typical Older Adult Pulse Rate
low 70s - 60 bpm
Pulmonary Ventilation
movement of air in (inhalation) and out (exhalation) of the lungs
Respiration involves what three things?
Ventilation, Diffusion, and Perfusion
While heart rate is controlled by ANS, what controls respiration?
ANS and External Control
External Respiration (Diffusion)
the exchange of oxygen and carbon dioxide between the alveoli and circulating blood
Internal Respiration (Perfusion)
the exchange of oxygen and carbon dioxide between the circulating blood and tissue cells
Respiratory Centers controlling Rate and Depth of Breathing are located in..
the Medulla and Pons
What stimulation causes activation of breathing?
stimulation of peripheral chemo receptors detecting oxygen OR pH
The most powerful respiratory stimulant is…
an increase in CO2
Factors Affecting Respiration
Exercise Respiratory and Cardiovascular Disease Alterations in Fluid, Electrolyte, and Acid Balances Medications Trauma Infection Pain Anxiety
Diabetic Ketoacidosis increasing resp to get rid of ketones (and cause a sweet smell)
Low Carb/High protein diet increasing resp to get rid of ketones (and cause a sweet smell)
Medications like opioids suspend/decrease drive for respiration
Medications like EP and Caffeine increase drive for respiration
Ways to Assess Respiration?
Pulse Oximeter
Auscultate with Stethoscope
Inspection
Monitoring Arterial Blood Gas Results
Things to look for when Inspecting Respirations?
Rate
Depth
Rhythm
Ease of Breathing
Use of accessory muscles of the neck
color of skin
blanching of nail bed within 3 seconds is good circulation, longer is concerning
Tachypnea
increased respirations
Bradypnea
decreased respirations
Minimal time to count respiration/pulse is…
30 seconds (multiply by 2) (sometimes can do 15 seconds for pulse and multiply by 4)
But, first time should always be done for 60 seconds
Apnea
periods with no breathing (greater than 4-6 minutes leads to brain death)
Dyspnea
means rapid breathing or shallow breathing
Blood Pressure
the force of blood against the arterial walls
Blood pressure rises when and falls when?
Rises when the ventricle contracts (Systolic) and falls when the heart relaxes (Diastolic)
Pulse Pressure
Differences between systolic and diastolic pressure (S-D = PP)
Equipment for BP
Stethoscope
Sphygmomanometer (with right cuff size)
Doppler Ultrasound
Electronic or automated devices
Too small a BP cuff can lead to…
false high reading
Too small a BP cuff can lead to…
false low reading
Average adult breathing rate?
12-20 BPM
Contraindications for Blood Pressure
IV placement on arm
AV Fistula
Birth control implant in arm
Any healthcare device in arm indicates to use the other
Mastectomy leading to lymphoedema potential
BP cuff being made of latex could cause allergies
hypo/hypervolemia
wounds in upper extremities
Korotkoff sounds?
First noise is the systolic pressure, fifth/final is diastolic
Aucultatory gap between the first and second sounds
Basic BP Pressure Reading Procedure
- pick correct cuff and wash hands
- Assume sitting position with arm horizontal to heart and find brachial artery pulse
- Expose arm and place cuff
- palpate radial pulse and inflate until extinction, note number and add 30 mmHg
- pump to that number after putting stethoscope diaphragm over brachial pulse a minute later
- allow deflation of 2-3 mmHg per second and note first and final sounds
- remove, clean equipment and hands, mark recordings
Systolic
highest amount of pressure (working phase of heart)
Diastolic
lowest amount of pressure (resting phase of heart)
How is BP written?
Systolic/Diastolic
How is Pulse Pressure written?
Systolic - Diastolic
Factors that Influence BP?
Age, Gender, Race Circadian Rhythm Food Intake Exercise Weight Emotional State Body Position Drugs/Medications Peripheral Resistance Blood Volume Viscosity of Blood
Standard “Normal” BP in Adults
below 120/80
Hypertension
- Diagnosis after 3 readings above normal limit (140/90)
- Prehypertension, stage 1, and stage 2 stages
Prehypertension Average
120-139/80-89
Stage 1 Average
140-159/90-99
Stage 2 Average
Greater or Equal to 160/100
Hypotension
below the lower limit of normal for blood pressure
Orthostatic Hypotension
temporary fall in BP related to postural changes (standing up) that can lead to falls
What can lead to False BP Highs
Uncalibrated Sphygmomanometer
Assessing BP after exercise
A narrow Cuff
Releasing the valve too slowly
Reinflating the bladder during auscultation
What can lead to False BP Lows
hearing deficit in nurse
noise in environment
viewing the meniscus from above eye level
applying too wide a cuff
crack stethoscope
misplacing the bell instead of the diaphragm
failing to pump cuff 30 mmHg above the disappearance of the pulse
Abnormalities in Vitals as titled by Nursing Diagnosis
Risk for Altered Body Temperature
Hypothermia
Hyperthermia
Ineffective Thermoregulation
Impaired Gas Exchange
Ineffective Airway Clearance
Ineffective Breathing Pattern
Inability to Sustain Spontaneous Ventilation
Rectal thermometers are what color?
Red (and only rectal thermometers ared red, while oral is blue)
