Vital Signs Flashcards
Clinical measurement of temperature, pulse, respiration and blood pressure and give some indication of the state of health of an individual. Ir represents interrelated physiologic systems of the body
Vital Signs
Purposes of Vital Signs
- universally communicate a patient’s condition and severity of disease
- helps in identifying nursing diagnosis, assess interventions and make decisions concerning the reponse of patients to treatment
Normal Range of Temperature
36-37.5 degrees Celsius
temperature of internal organs
core temperature
temperature of skin, outside surface
surface temperature
Purposes of taking temperature:
- establish data for subsequent evaluation
- check whether the core temperature is within normal range
- determine changes in response to specific therapies
surface-surface without contact
Radiation
molecule-molecule with contact
Conduction
dispersion of heat through air currents
Convection
continuous evaporation of moisture from the repiratory tract, oral mucoda and skin
Vaporation
patients having fever
febrile
Methods of taking Temperature:
- Oral
- Axillary
- Rectal
- Non-contact
it is the difference between heat produced and heat lost by the body and is measured through the use of a thermometer
Temperature
Contraindications for Oral Method
- infants
- unconscious and irrational patients
- patients who breath through their mouths
- those with disease of the oral cavity or surgery of the nose or mouth
- patients who have had taken cold or hot foods or fluids
Purposes of Rectal Method
- to obtain first temperature of newborn to check rectal patency
- to check core temperature of an adult
contraindications for Rectal Method
- patients with recent rectal surgery
- patients having diarrhea
- patients having disease of the rectum
- patients having cardiovascular alternation because the thermometer may stimulate the vagus nerve causing bradycardia or rhythm disorder
- Patients with leukemia which may traumatize the rectal mucosa causing bleeding
it is a rhythmical throbbing that results from a wave of blood passing through an artery as the heart contracts
Pulse
possible sites for taking pulse:
apical
radial artery
facial artery
temporal artery
dorsalis pedis
femoral artery
popliteal artery
carotid artery
bracial artery
posterior tibialis
what to note when taking pulse:
rate
rhythm or regularity
tension or compressibility
volume
normal pulse rate per minute (Average and Range): Newborn
130 (80-180)
normal pulse rate per minute (Average and Range): 1 year
120 (80-140)
normal pulse rate per minute (Average and Range): 5-8 years
100 (75-120)
normal pulse rate per minute (Average and Range): 10 years
70 (50-90)
normal pulse rate per minute (Average and Range): Teen
75 (50-90)
normal pulse rate per minute (Average and Range): Adult
80 (60-100)
normal pulse rate per minute (Average and Range): Older Adult
70 (60-100)
purpose of taking pulse rate:
to obtain an estimate of the wuality of the heart’s action per minute
if patient is a newborn or an infant, pulse will be assessed through the
brachial, apical and femoral artery
the apical pulse is found where? (adult and children)
5th left intercostal space, midclavicular line (adults)
4th left intercostal space, miclavicular line (children)
cardiac rate is best assessed on the?
apex part of the heart
the heartbeat is usuallyt loudest over where?
at the apex part of the heart
the two heart sounds are produced by?
closure of the heart valves
normal respiration rate per minute (Average and Range): Newborn
35 (30-60)
it is the exchange of oxygen and carbon dioxide between the atmnosphere and body cells and is initiated by the act of bretahing
Respiration
normal respiration rate per minute (Average and Range): 1 year
30 (20-40)
normal respiration rate per minute (Average and Range): 5-8 years
20 (15-25)
normal respiration rate per minute (Average and Range): 10 year
19 (15-25)
normal respiration rate per minute (Average and Range): Teen
18 (15-20)
normal respiration rate per minute (Average and Range): Adult
16 (12-20)
normal respiration rate per minute (Average and Range): Older Adult
16 (15-20)
Purpose of taking RR
to obtain the respiratory rate per minute and an estimate of the patient’s respiratory status
is the lateral force exerted by the blood on the arterial walls
Blood Pressure
Purposes of taking Blood Pressure
- to aid in diagnosis
- to observe changes in a patient’s condition
Contraindications for Brachial Artery Blood Pressure Measurement
- surgery including the breats, axilla, shoulder, arm or hands
- Venous Access Device such as AV shunt and IVF
- Injury or disease to the shoulder, arm or hands such as trauma, burn or application of cast or bandage
Sites for BP taking:
- either arm on the antecubital space
- either leg on the popliteal space
- dorsalis pedis
Normal BP
<120/<80
Prehypertension
120-139 over 80-89
Hypertension, Stage 1
140-159 over 90-99
Hypertension, Stage 2
> 180 over >100
