Vital Signs Flashcards
Define Heat Production
BMR
muscle activity (shivering & exercise)
Normal body temperature
35.9-38C
96.7-100.5F
Heat Loss
Evaporation
conduction
convection
radiation
Most accurate measurements of body temperature are
intracranial
intrathoracic(esophagus/heart)
intra-abdominal(bladder)
What route of obtaining body temperature is most accurate compared to oral, axillary, tympanic, and temporal arteries?
Rectal temperature is considered a core body temperature most accurate in comparison.
Factors affecting body temperature
Circadian Rhythms
Age & Biological Sex
Physical Activity
State of Health
Environmental Temperature.
Fever (Pyrexia)
is an increased above normal body temperature. A patient with a fever is said to be febrile.
Benefits of fever
Unless extremely high >40C/104F
Benefits include destruction/susceptibility of disease-causing microorganisms, enhanced immune response
Fever is caused by
triggered by microorganisms, tissue injury (myocardia infraction), and surgery.
SIgns and symptoms of fever
loss of appetite (anorexia), headache, hot/dry skin, flushed face, thirst, muscle aches, fatigue, increase pulse and respiration.
Treatment of fever
appropriate antibiotic, antipyretic, use of cool sponge baths, cool packs, cooling blankets, fluids, and simple carbohydrates.
Hyperthermia
caused by extreme heat exposure.
Neurogenic Fever
caused by increased intracranial pressure/intracranial bleeding
Does not respond to anti-pyretic
Fever of Unknown Orgin (FUO)
a type of fever (>38.3 C/101F) that lasts for 3 weeks or longer without an identified cause.
Pulse
a wave of blood being pumped into the arterial circulation by the contraction of the left ventricle. It is regulated by the autonomic nervous system.
Normal pulse range
60-100 beats/min
Tachycardia
pulse rate above 100
Bradycardia
pulse rate below 60
Dysrhythm
an irregular rhythm
Factors affecting pulse rate
age & biological sex
physical activity
body temperature/stress
medication
disease
Reasons for lower temperature in older adults
decreased metabolic rate
reduced subcutaneous fat
diminished hypothalamic regulation
impaired thermoregulation
What is a pulse defecit
occurs when there is a difference between the heartbeats (measured at the apical pulse) and the peripheral pulses( eg radial pulse). Not all heartbeats are strong enough to create a palpable pule wave at a peripheral artery, indicating that the heart is contracting but not all contractions are producing effective blood flow.
How to assess Pulse Defecit
One nurse listens to the apical pulse while another simultaneously palpates the radial pulse.
Both counts are taken for one full minute
the difference between the two is the pulse defecit
Significance of pulse defecit in nursing practice
indicator of arrhythmias
evaluation of cardiac function
guiding treatment
monitoring patient condition
Respirations
the movement of gases in and out of the lungs. Also called ventilation or in layman’s terms, breathing.
It is regulated by the autonomic nervous system and voluntary control.
Normal Respiration range
12-2o breaths/min.
Tachypnea
above 24 respirations/min
Bradypnea
below 10 respirations/min
Cheyne-Stokes/Biot’s respiration
irregular respiration
Eupnea
normal unlabored respirations
Hyperventilation (Kissmaul’s breathing)
increased in rate and depth of respirations
Apnea
absence of breathing
Dyspnea
difficulty breathingo
orthopenia
difficulty breathing that occurs when supine position and is relieved upon changing to a high fowlers position.
Factors affecting respiratory rate
age, exercise, acid-base balance, brain lesions, increased altitude, respiratory diseases, anemia, anxiety, medication, acute pain
Pulse oximeter
measures the amount of oxygen in the blood. Normal range is 90-100%
Blood Pressure
force of moving blood against the arterial wall. The numerator is the systolic, denominator is the diastolic.
Pulse Pressure
the difference between the systolic pressure and the diastolic pressure. It reflects the force that the heart generates with each contraction.
Mean Arterial Pressure (MAP)
the average pressure in a person’s arteries during one cardiac cycle. It gives an indication of overall perfusion to the organs.
Calculate Mean Arterial Pressure
MAP=DBP +1/3 X (SBP-DBP)
Normal Pulse Pressure
30-40 mmHg
Widened Pulse PRessure
> 60 mmHg may indicate stiffening of the arteries or atherosclerosis, which is common in older adults and increases the risk of cardiovascular events like stroke and heart failure.
Narrowed Pulse Pressure
< 25 mmHg can indicate heart failure, shock, or aortic stenosis. It often reflects poor stroke volume and may require immediate clinical intervention.
Clinical significance of pulse pressure
high= early sign of hypertension or cardiac disease
low= sign of left ventricular dysfunction or a compensatory mechanism during shock.
Mean Arterial Pressure
normal 70-100 mmHg
<60 mmHg indicated inadequate organ perfusion
>100 mmHg suggests hypertention
Normal Blood Pressure
<120/<80 mmHg
Hypertension
> 130/>80
Hypotension
<90/60
Orthostatic hypotension is
decrease is systolic > or equal to 20mmHg or decrease in diastolic >or equal to 10 mmHg when one rises to an erect position. Common among elderly related to underlying disease process, dehydration, or use of medications.
Factors that affect blood pressure
age, circadian rhythm, biological sex, food intake, exercise, weight, emotional state, body position, race drugs/medications
Auscultatory gap
In hypertensive clients, there is a wide gap (silence) of as much as 40 mmHg between the 1st and 2nd Korotkoff sound.
