Chapter 18 - Vital Signs and Measurement

Fever classifications

-Slight: 99.6-101.0 °F -Moderate: 101.0-102.0 °F -Severe: 102.0-104.0 °F -Dangerous: 104.0-105.0 °F -Fatal: Over 106.0 °F

Diastolic blood pressure

A measurement of the pressure exerted on the walls of various arteries in between heart beats, when the heart is relaxed.

Temporal artery (TA) thermometer

A new, noninvasive thermometer that is more accurate than most other thermometers. It is used on adults and children. The TA thermometer is fast and convenient to use. It is gently stroked across the patient's forehead, and uses infrared heat waves to measure the temperature from the temporal artery.

Pulse sites

A pulse can be taken at many locations on the body, including the temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis arteries.

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.

Manometer

A scale that registers the actual BP reading. A manometer is also called a pressure indicator.

Hyperpyrexia

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

BP cuffs

A thigh cuff is available when an adult arm is too large for the large arm cuff. When using a thigh cuff, the popliteal artery is palpated for a pulse.

Spirogram

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

Nonessential hypertension

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

Mercury thermometer

An old type of thermometer that has been almost entirely replaced by digital thermometers of various types, because the risk for mercury poisoning is great if a mercury thermometer is broken and mercury escapes into the environment. The sale of mercury thermometers is now widely restricted.

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. Radiation, evaporation, conduction, and convection all cause loss of heat from the body. Body temperature is measured with a thermometer.

Dyspnea

Difficult or painful breathing.

Orthopnea

Difficulty in breathing when lying down.

Tachypnea

Fast breathing, more than 35 respirations per minute.

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

Factors affecting BP

Five physiological factors affect BP: blood volume, peripheral resistance of the vessels, condition of the heart muscle, vessel elasticity, and blood viscosity.

Febrile

Having a body temperature above the normal range.

Afebrile

Having a body temperature within the normal range. The average normal value is 98.6°F (37°C).

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 130-139 mm Hg and diastolic readings 85-89 mm Hg are considered prehypertensive. Several factors contribute to hypertension, including hyperthyroidism, heart and liver disease, rigidity of blood vessels, smoking, anxiety, stress, and race. There are two types of hypertension: primary (essential) and secondary (nonessential). Hypertension should be found on at least two occasions before the patient is placed on medications, unless the diastolic reading is over 120 mm Hg.

Wheezing

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

Hyperpnea

Rapid and deep breathing.

Rectal thermometer

Rectal temperature is 1°F higher than oral (99.6°F). A rectal thermometer is used if a patient is unconscious, has had oral surgery, is very young, or is uncooperative. It is the most accurate method since it measures the body's core temperature.

Anthropometric

Relating to body size and proportion.

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.

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 deficit

The difference between the apical pulse rate and the radial pulse rate.

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.

Respiration

The exchange of oxygen and carbon dioxide between living organisms or tissues and their surroundings; also, breathing (inhaling and exhaling, or inspiration and expiration). The control center for breathing is in the medulla oblongata (in the brain). There are two types of respiration: external and internal.

Lysis

The gradual return of body temperature to normal after a period of fever; also, the gradual decline of a disease symptom.

Blood volume and blood viscosity

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

Cyanosis

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

Malignant hypertension

The most fatal form of hypertension. It is characterized by rapidly and severely elevated BP that commonly damages the intima of small vessels, the brain, the retina, the heart, and the kidneys. It is more common among African Americans and may be caused by genetic predisposition, stress, obesity, smoking, the use of contraceptives, and aging.

Electronic (digital) thermometer

The most prevalent type of thermometer used today, there are many varieties allowing quick, accurate temperatures to be taken in a number of body locations.

Respiratory rate

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

Blood pressure (BP)

The pressure of the blood against the walls of the arteries. There are two BP readings: systolic pressure and diastolic pressure. Readings of BP give the systolic measure first, then the diastolic measure, in millimeters (mm) of mercury (Hg). BP readings should routinely be started at the age of five years.

Tympanic (aural) thermometer

Tympanic thermometers are used by inserting their shielded tip in the ear. Their benefits are speed and patient comfort. Accurate readings are obtained in approximately two seconds. Average temperature is 98.6°F. It is used with uncooperative patients of any age.

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.

Measuring BP

Wrap properly sized cuff around the upper arm, one inch above the elbow with center of the bladder above the brachial artery. Inflate the cuff to the maximum inflation level, then release the air, and listen with the stethoscope as you watch the manometer. The point at which the heartbeat is first heard is the systolic pressure; the point at which the sound disappears is the diastolic pressure.

Tachycardia

above 100 beats per minute.

Bradycardia

below 60 beats per minute

Stethoscope

diagnostic instrument that amplifies sound, used to detect sounds produced by BP as well as heart sounds. This instrument consists of a chest piece consisting of a diaphragm and/or bell, flexible tubing, binaurals, a spring mechanism, and ear pieces.

Weight should be recorded to the nearest

1/2 lb (adult) 1/2 oz (infant)

Height should be recorded to the nearest

1/8 inch (infant)

Normal BP - 10-15yr

100/65

Normal BP - young adult

118/76

Normal BP - Adult

120 to 129 / 80 to 84

Normal BP - newborn

50/25

Intermittent fever

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

Mensuration

A general term for the measurement of weight and height. Mensuration for infants also includes measuring the circumference of the head and chest.

Systolic blood pressure

A measurement of the amount of pressure that blood exerts on arteries and vessels while the heart is beating.

Normal BP - 6-9yr

95/65

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.

Sphygmomanometer

An instrument used to measure BP. The components are the manometer, an inflation bulb with a control valve, and a pressure cuff. There are two types of sphygmomanometers: aneroid and digital (electronic). Mercury sphygmomanometers have been phased out with other mercury-containing medical equipment.

Rales

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

Orthostatic hypotension

Abnormally and temporarily low BP. It occurs when a patient rapidly moves from a lying to a standing position and is also called postural hypotension. Orthostatic hypotension can cause patients to experience vertigo or syncope. Some medications may cause orthostatic hypotension. Orthostatic blood pressure is ideally measured while the patient is lying down, then sitting, and then standing. For very frail patients, standing is avoided for measurement, and only lying-down and sitting BP is taken.

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). Pain assessment is also considered a vital sign.

Hypotension

An abnormal condition in which the BP is not adequate for full oxygenation of the tissues. Several factors may cause hypotension. They include anemia, dehydration, shock, hemorrhage, cancer, starvation, infection, high fever, and certain medications. The common drugs that affect BP and cause hypotension are analgesics, narcotics, antihypertensives, and diuretics. Persistent readings of 90/60 mm Hg or below are usually considered hypotensive.

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 stasis

Lack of circulation due to a stoppage of blood flow.

Decreased respiratory rates

May occur as a result of the action of certain drugs (morphine), a decrease of CO2 in the blood, stroke, and coma. The respiratory rate also can be affected by factors such as age.

Converting Celsius to Fahrenheit

Multiply the Celsius temperature by nine, divide by five, and add 32 °F = (°C × 9/5) + 32

Increased respiratory rates

Occur because of asthma, heart attack, fever, hemorrhage, high altitudes, allergic reactions, nervousness, obstruction of air passages, shock, and pain.

Hypothermia

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

Antipyretic

Pertaining to a substance that reduces fever.

Types of thermometers

Several types of thermometers are used in the ambulatory care setting, with digital thermometers being most common. Types of thermometers include reusable, disposable, and glass Galinstan (containing gallium or alcohol—these are not electronic or digital). Specific thermometers are available for a variety of locations on the body in order to measure temperature.

Stridor

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

Bradypnea

Slow respiration in an adult, fewer than 10 cycles per minute.

Converting Fahrenheit to Celsius

Subtract 32 from the Fahrenheit temperature, multiply the remainder by five, and divide by nine °C = (°F − 32) × 5/9

Normal Vital Signs - 0-1yr

T: 96-99.5(oral) or 99-100(rectal) P: 80-160 R: 26-40 BP: 60/50-95/65

Normal Vital Signs - 6-11yr

T: 97.5-99.6(oral) or 98.5-99.6(rectal) P: 70-115 R: 18-24 BP: 80/50-100/80

Normal Vital Signs - Adult

T: 97.6-99.6(oral) or 98.6-100(rectal) P: 60-100 R: 12-20 BP: 90/60-120/80

Normal Vital Signs - 11-16yr

T: 97.6-99.6(oral) or 98.6-100.6(rectal) P: 55-110 R: 16-24 BP: 94/58-136/88

Normal Vital Signs - 1-6yr

T: 98.5-99.5(oral) or 99-100(rectal) P: 75-130 R: 20-30 BP: 80/50-100/70

Oral thermometer

Taking temperature orally is the most convenient method. An electronic (digital) thermometer should be placed in the mouth for at least 10 seconds.

Apnea

Temporary cessation of respirations that last more than 15 seconds.

Normal body temperature range

The range is from 97°F-99°F (36°C-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). This term also refers to the turning point of a disease, when an important change has occurred.

Axillary thermometer

The thermometer is placed in the middle of the axilla, with the shaft facing forward. The average normal value is 97.6°F. It is the least accurate measurement site for body temperature; 1° is added to the temperature.

Pulse

The throbbing of an artery caused by the flow of blood when the heart beats.

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.

Heart sounds

There are two basic heart sounds: The first, produced at systole, when the atrioventricular valves close is dull, firm, and prolonged (a "lubb" sound); the second, produced at diastole when the semilunar valves close, is shorter and sharper (a "dupp" sound). A "lubb dupp" is the sound of one heartbeat.