Chapter 17 - Vital Signs

Blood pressure (BP)

-A function of the flow of blood produced by contraction of the heart and the resistance to blood flow through the vessels. (P=FxR) The force that blood exerts against the walls of the blood vessels in millimeters (mm) of mercury (Hg). systolic pressure - cardiac systole - vetricular contraction diastolic pressure - cardiac diastole - ventricular relaxation due to elastic recoil of vessels.

Decreased respiratory rates

-May be result of the action of medications (morphine, opiods) a decrease of CO2 in the blood, stroke, coma. Men have lower respiratory than women.

Inspiration

-active process Inspiratory muscles contract; increased intrathoracic volume as lungs expand; pressure in airway becomes negative, air flows inward.

Tympanic (aural) temperature

-closely reflect core body temperature. -cerumen, crying, otitis media will not affect significantly

Cheyne-stokes

-cyclic breathing pattern characterized by periods of respirations of increased rate and depth alternating with periods of apnea Conditions: congestive heart failure, drug overdose, increased intracranial pressure, death

Biot's

-cyclic breathing pattern characterized by shallow breathing alternating with periods of apnea. Conditions: neurologic problems (meningitis, encephalitis), head trauma, brain, abscess, heatstroke.

Respiratory assessment

-establish set of normal baseline measurements of rate, thythm, depth, quality for pt for comparisons -consider influences such as disease conditions, medications, therapies which can affect

Kussmaul

-increased rate >20/min and depth of respirations Conditions: metabolic acidosis, diabetic ketoacidosis, renal failure

Factors affecting pulse rate

-infants 100-160/min varies markedly; increases during inspiration/decreasing with expiration; -adult 60-100/min ANS - parasympathetic stimulation (active during rest) decreases pulse; sympathetic stimuli pain, anxiety, exercise, fever, caffeine, intravascular volume increases Medications: digoxin (decreases); diuretics (decrease intravascular volume) causes reflex INCREASE in pulse rate; atropine inhibits parasympathetic imput (increases pulse rate); propranolol blocks sympathetic action (decreases pulse rate)

Brachial artery

-inner aspect of the elbow - antecubital space -most commonly used site to obtain blood pressure measurements -support arm to prevent muscle contract which could obscure pulse

thermoregulation

-keeps core temp constant regardless of where heat is produced

Axillary temperature

-least accurate measurement -sweat, air temp may affect

Increased respiratory rates

-older age decreases lung elasticity resulting in increased respiratory rates to allow for adequate air exchange. -medications causing increase sympathomimetic drugs (albuterol), corticosteroids decrease airway inflammation. -affected by increased excercise, pain, anxiety, infection, fever, asthma, heart attack, hemorrhage, high altitudes, allergic reactions, nervousness, obstruction of air passages, shock.

Expiration

-passive process At end of inspiration: lung recoils, airway pressure becomes positive, air flows out as muscles relax.

Continuous fever

A fever that remains above the baseline; it does not fluctuate, but remains fairly constant.

Remittent fever

A fluctuating fever that does not return to the baseline temperature; it fluctuates, but remains increased.

Intermittent fever

A fluctuating fever that returns to or below baseline, then increases again.

Temporal artery (TA) thermometer

A new, non-invasive thermometer that is more accurate than the tympanic and rectal thermometers. It is used on adults and children. -may be affected by perspiration or air blowing over face.

Celsius (°C)

A scale for measurement of temperature in which 0°C is the freezing point of water and 100°C is the boiling point of water at sea level. Celsius is also known as centigrade.

Fahrenheit (°F)

A scale for measurement of temperature in which the boiling point of water is 212°F. The freezing point of water is 32°F at sea level.

Hyperpyrexia

A temperature reading above 105.8°F (41°C). A body temperature above 106.0°F (41.1°C) is generally fatal.

Spirogram

A visual record of respiratory movement made by a spirometer and used in the assessment of pulmonary function and capacity.

Factors affecting BP

ANS, blood volume, peripheral resistance of the vessels, condition of the heart muscle, vessel elasticity, and blood viscosity, medications, normal fluctuations.

Rales

Abnormal or crackling breath sounds that occur during the inspirational portion of breathing.

Vital signs

Also known as cardinal signs. They indicate that life is present. They are also indicators of the body's ability to maintain homeostasis. The vital signs include temperature (T), pulse (P), respiration (R), and blood pressure (BP).

Emphysema

An abnormal pulmonary condition with loss of lung elasticity, resulting in difficulty in exhaling.

Spirometer

An instrument that measures and records the volume of inhaled and exhaled air.

Blood volume and blood viscosity

BP elevates as the blood volume increases. Polycytopenia increases BP. Hemorrhage causes volume and BP to drop.

Avoid Faulty BP assessment

Be sure to wait at least 30 minutes after smoking, exercising, eating; select proper cuff size, keep arm at heart level, avoid venious congestion, detecting an auscultatory gap

Carotid artery

Best represents pulsation of aortic pulse due to proximity. Located between the larynx and the sternocleidomastoid muscle in the neck running from below the ear to the clavicle and sternum. DO NO palpate in upper part of neck -- May stimulate carotid sinus, dropping pulse rate. This site is used in emergencies and during CPR.

Cyanosis

Bluish discoloration of the skin and mucous membranes due to oxygen deprivation.

Nonessential hypertension

Caused by disorders of other organs in the body, such as the kidney, as well as endocrine disorders.

Stertorous

Characterized by a deep snoring sound that occurs with each inspiration.

Body temperature

Controlled by the hypothalamus, located in the brain, and maintained through a balance of the heat produced in the body and the heat lost from the body. Most heat is produced in the body by muscle contractions and cell metabolism. Fever and strong emotional states increase heat production in the body.

Dyspnea

Difficult or painful and labored breathing.

Orthopnea

Difficulty in breathing when lying down.

Respiration

External Respiration: taking oxygen into and climinating carbon dioxide from the body. Internal Respiration: use of oxygen, production of carbon dioxide, and exchange of these gases between the cells and the blood.

Dorsalis pedis pulse (Pedal)

Felt on the top of the foot slightly to the side of midline. It is commonly used to monitor lower limb circulation. May be absent in some patients.

Pyrexia

Fever, which is defined as any body temperature above 100.4°F (38°C). Causes of fever include infection, heat stroke, neoplasms, drug hypersensitivity, and central nervous system damage. Fevers are classified in five levels.

Pulse

Force of blood entering the aorta from left ventricle causes stretching or distention of elastic aortic valve. The valve expands then contracts, sending a pulse wave traveling along blood vessels.

Radial artery

Found in the groove on the thumb side of the inner wrist.

Febrile

Having a body temperature above the normal range.

Afebrile

Having a body temperature within the normal range.

Korotkoff's sounds

Heard during the taking of blood pressure by means of a sphygmomanometer and stethoscope. As air is released from the cuff, pressure on the brachial artery is reduced, and the blood is heard pulsing through the artery.

Hypertension

High BP, defined as systolic pressure consistently above 140 mm Hg and diastolic pressure above 90 mm Hg. According to the American Heart Association, patients with systolic readings from 130 to 139 mm Hg and diastolic readings from 85 to 89 mm Hg are considered prehypertensive.

Wheezing

High-pitched musical sound heard usually on expiration, often the result of an obstruction or narrowing of respiratory passage.

Blood stasis

Lack of circulation due to a stoppage of blood flow.

Popliteal artery

Located at the back of the knee. The patient must be in a supine position with the knee flexed for it to be felt because the artery is deep within the knee. This artery is the one used for leg blood pressure measurements and to monitor circulation.

Converting Celsius to Fahrenheit

Multiply the Celsius temperature by 9, divide by 5, and add 32.

Normal Blood Pressure at Different Ages

Newborn: 50/25 mm Hg 6-9 years: 95/65 mm Hg 6-9 years: 95/65 mm Hg 10-15 years: 100/65 mm Hg Young adult: 118/76 mm Hg Adult: 120 to 129 over 80 to 84

OSHA Guidelines for Taking Measurement of Vital Signs: Situation: In the presence of a patient suspected of having an airborne infectious disease

OSHA Guideline: Wear a mask. The patient should be weighed, measured, and examined in a room away from staff and other patients. Wear protective clothing. Use biohazard bags for disposal of wastes.

Hypothermia

Occurs when the temperature falls below 97°F (36°C). In general, a body temperature below 93.2°F (34°C) is fatal.

Tachypnea

Persistent respiratory rate above 20/min. Conditions: trauma, injury, stress, pain; respiratory, cardiac, liver disease.

Antipyretic

Pertaining to a substance that reduces fever.

Hyperpnea

Rapid and deep breathing.

Temperature method variation

Rectal 1 degree higher than oral axillary 1 degree lower than oral temporal artery close to oral tympanic mid-way between oral and rectal

Rectal temperature

Rectal temperature is 1°F higher than oral (99.6°F). -avoid placing into fecal material (can raise temp read) -contraindicated w/ diarrhea, rectal surgery, rectal disease, cancer & neurtopenic. -careful re: vagal stimulation - can result in bradycardia and snycope (loss of consciousness)

Types of thermometers

Several types of thermometers are used in the ambulatory care setting. They include: digital, disposable, electronic, tympanic, temporal artery (chemical), and glass Galinstan (gallium or alcohol).

Stridor

Shrill, harsh respiratory sound heard w/o stethoscope during inhalation in the presence of a laryngeal obstruction or croup in children.

Fever Classifications

Slight: 99.6-101.0 °F; 37.5-38.3 °C Moderate 101.0-102.0 °F; 38.3-38.8 °C Severe: 102.0-104.0 °F; 38.8-40.0 °C Dangerous: 104.0-105.0 °F; 40.0-40.5 °C Fatal: Over 106.0 °F; Over 41.1 °C

Bradypnea

Slow respiration in an adult, fewer than 12 cycles per minute. Conditions: neurological disturbances, electrolyte disturbances, opioid/barbiturate overdose, post anethesia.

Converting Fahrenheit to Celsius

Subtract 32 from the Fahrenheit temperature, multiply the remainder by 5, and divide by 9.

Apnea

Temporary cessation of respirations that last more than 15 seconds.

Elasticity of vessels

The ability of blood vessels to expand and contract. It decreases with age.

Depth of respiration

The amount of air being inhaled and exhaled.

Oral temperature

The average normal value is 98.6°F (37°C). -wait 15-30 minutes if drinking hot or cold liquid -not safe for infants, young children, unconscious, delirious, seizure disorders

Characteristics of respiration

The best way to check respiration is by watching the movement at the patient's chest, back, abdomen, or shoulders. Three important characteristics must be noted: rate, rhythm, and depth.

Pulse pressure

The difference between the systolic and the diastolic pressure readings.

Internal respiration

The exchange of O2 and CO2 at the tissue level.

External respiration

The exchange of O2 and CO2 in the lungs.

Lysis

The gradual return of body temperature to normal after a period of fever.

Respiratory rate

The normal adult range is 12-20 cycles per minute.

Pulse rate

The number of times the heart beats in a minute. The normal pulse rate in adults is 60 to 100 beats per minute. -factors that affect pulse rate: age, sex, body size, physical exercise, health status, and medications. Infants and children have a faster pulse than adults. The pulse is usually faster in women than in men.

Normal body temperature range

The range is from 97°F to 99°F (36°C to 37.2°C). The average temperature is 98.6°F (37°C).

Peripheral resistance

The relationship of the lumen of the vessel and amount of blood flowing through it. Fatty cholesterol deposits narrow the lumen, resulting in high BP.

Heart muscle condition

The strength of the heart muscle affects the volume of blood flow.

Crisis

The sudden decrease of body temperature to normal levels. The patient may perspire profusely (diaphoresis).

Essential hypertension

The vast majority of patients with hypertension (90%) have essential hypertension. The actual cause of essential high BP is not known. It may be genetic.

Rhonchi

Whistling sounds made in the throat, also called gurgles. They are heard in patients with various respiratory disorders or conditions, such as asthma or chronic obstructive pulmonary disease.

Temporal artery

across temporal bone of skull; best in from of upper part of ear.

Factors affecting body temp

age, environment, time of day, stress, exercise, hormone levels, metabolic rate, extremes of external temp.

Femoral artery

anterior, medial aspect of thigh, just below inguinal ligament; deep palpation may be necessary to feel

Apical pulse

apex of the heart, located in the left fifth intercostal space on the midclavicular line. It must be heard with a stethoscope. This site is used commonly for infants and children..

Pulse Rate: Auscultation

apical pulse most accurate; sounds due to opening and closing of cardiac valves; S1 = closure of mitral and tricuspid valves that separate atria from ventricles; S2= closure of the pulmonic and aortic valves count for a full minute

Pulse deficit

difference between the apical pulse rate (higher) and the radial pulse rate (lower); indicates inadequate perfusion; MUST document and report to physican for follow up

Internal body temp - Core Temp

maintained at a consistent temperature independent of outside environment. cells,tissues, organs function optimally with narrow temp range except in pyrexia and extreme outdoor temperatures LOOK UP IN PP

Falsely low BP readings

noise, hearing deficit, earpiece fit poor, tubing too long, not pumped high enough, cuff too large, arm above heart level, valve released rapidly, reading at inspiration

Eupnea

normal respiratory rhythm

hypercarbia

normal stimulus to breathe as a result of increased carbon dioxide level sensed by chemoreceptors.

Pulse Rhythm

normally occur evenly spaced intervals -may be affected by heart disease, medications, electrolyte imbalance. -regularly irregular - irregular pulse still displays consistent pattern -irregularly irregular - no pattern; may be atrial fibrillation (impulse not coming from SA node) IMPORTANT: if abnormal obtain apical pulse rate for one full minute; determine if irregularity is new finding - requires immediate investigation

Falsely high BP readings

pt just ate, in pain, anxious, full bladder, cold hands/stethoscope, cuff too small; cuff uneven, deflating too slow, venous congestion, unsupported arm, back unsupported, legs dangling, legs crossed at knee, arm below heart level.

Tachycardia

pulse rate above 100 beats per minute; -may be due to sympathetic nervous system activation or cardiac contraction comes from abnormal site in heart.

Bradycardia

pulse rate below 60 beats per minute; -may be resting HR in conditioned athlete; -may be disease in SA node (poor impulse formation); -may be enhanced parasympathetic nervous system activity (carotid sinus stimulation)

Pulse characteristics

rate, rhythm, quality (only when abnormalities anticipated) -out of range of normal (rate or rhythm) = dysrhythmic

Pulse quality

strength of pulsation; reflects stroke volume, compliance or elasticity of arteries; adequacy of blood delivery; palpate bi-laterally (except carotids) rated on numeric scale 1-no pulse 1+-thready, weak pulse 2+-difficult to palpate 3+normal pulse 4+bounding, hyperactive (aging causes arteries to lose elasticity - becomes bounding)

Pulse sites

temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis arteries.

Vital Signs Purpose

to yield info about underlying health status -patient teaching re: vitals -- key aspect of health promotion

Pulse Rate: Palpation

use first, second fingers; count first pulse as "0"; do not count pulses at or after completion of time interval; count for 30-60 sec

Converting From Fahrenheit to Celsius

°C = (°F − 32) × 5/9

Converting From Celsius to Fahrenheit

°F = (°C × 9/5) + 32