Ch 19 vital signs

fever

(pyrexia) is a rise in body temperature above normal, caused by trauma or illness. *can be associated with and infection, tissue injury, cancer, trauma, surgery *causes loss of appetite, headache, malaise, hot and dry skin, flushing, thirst, shivering, not feeling well *signs: dehydration, decreased urinary output, rapid heart beat *treatment: nonsteroidal drugs with antipyretic effect, cool sponge baths, cooling blankets, cool packs ***aspirin should not be given to children younger than 2, or children and teens with viral infections- Reye's syndrome can occur

Vital sign assessment situation

*on admission to establish base line *as part of physical assessment *during an impatient stay, as routine monitoring *change in health status, especially chest pain, shortness of breath, feeling hot, faint or dizzy *before and after surgery *before and after meds that impact cardiac, respiratory, or thermal regulation systems *before and after interventions such as ambulation *in ongoing care to detect improvement in patient condition *before discharge or transfer from a unit

pulse

The palpable, bounding blood flow created by the contraction of the left ventricle of the heart. Electrical impulses originating in the sinoatrial SA node of the heart stimulate cardiac muscle contraction, which sends a pulse wave. the number of pulsing sensations in one minute is the pulse rate.

arterial blood gases

measure is a way of assessing the respiratory component of acid-base balance and the adequacy of oxygenation

pulse rhythm

the regularity of the heartbeat *dysrhythmia or an arrhythmia- an irregular rhythm in the pulse, caused by an early, late, or missed heartbeat. *when an irregular rhythm is detected the apical pulse is assessed.

heat loss

the skin regulates temperature through insulation of the body with subcutaneous tissue and fat, and in conjunction with the circulatory system, is the primary source of heat loss

korotkoff sounds

the sounds for which we listen for when assessing blood pressure

SOCRATES

*site- where is the pain located *onset- when did the pain start, was it gradual or sudden *character- what's the quality of the pain, is it stabbing, burning, aching in nurture *radiation- does the pain radiate anywhere *associations- what signs and symptoms are associated with the pain *time course- is there any pattern to the pain *exacerbating/relieving factors- does anything make the pain worse or help it *severity- on a scale of 0 to 10, what is the intensity

pulse sites

*the most common site for assessing the quality, rate, and rhythm of the pulse is the radial artery. **in infants and children younger than 2, the pulse rate is obtained by auscultating the apical pulse. * posterior tibial is used to assess blood flow to feet.

respirations

-the act of breathing -breathing is the movement of air into and out of the lungs: inspiration- inhalation, the act of breathing in expiration- exhalation, the act of breathing out *normal rate is 12 to 20 BPM for an adult.

afebrile

A person who maintains normal body temperature

Vital signs

Are a basic but very important component of physiological assessment of the patient *typically done every 4 to 8 hours on stable patients , *every 15 to 60 minutes for postprocedure or post surgical patients *every 5 minutes or continuously for critical or unstable patients.

Hypertension

High blood pressure Leading cause of cardiovascular disorders and the most important risk factor for stroke

Baseline values

Initial vital signs are used to identify changes in patient status; a series of vital sign measurements establishes patient trends

Temperature

Measurable heat of the human body

Pulse oximetry

Measures the amount of oxygen available to tissues -reading is the saturation of peripheral oxygen (SpO2)

Respiration

The act of breathing, so respiration are assessed for frequency, or breaths per minute

Pulse

The detectable rhythmic expansion of an artery that occurs with the pumping action of the beating hearts

Pain

The fifth vital sign

Blood pressure

The measurable pressure of blood within the systemic arteries

heat production

a by-product of metabolism food is the primary source of for metabolism exercise, increased release of epinephrine and norepinephrine, and increased production of thyroid hormones all can increase heat production

febrile

a person with a fever

oxygen saturation

amount of oxygen in the arterial blood reflects how much oxygen enters the bloodstream

pulse volume

amplitude- is the strength of the pulse with each beat *normal- full and easily palpable *weak- thready and rapid (readily obliterated- causes include vasoconstriction, stiff vessel walls from disease, and shock) *strong- bounding (A forceful volume that is obliterated only with difficulty- caused by vasodilation or overhydration

quality of repirations

apnea- absence of breathing, brain damage occurs 4 to 6 minutes of apnea. dyspnea- difficult, labored breathing, usually rapid, shallow pattern, that may be painful. orthopnea- difficulty breathing experienced in positions other than sitting or standing

palpation

assessment by feeling with the hand or fingers

cyanosis

bluish discoloration of the skin and mucous membranes, results from decreased oxygen levels in arterial blood

peripheral pulses

can be palpated over arteries located away from the heart *are assessed where arteries lie over bony prominences ***if peripheral pulse is irregular, count the apical pulse for one minute to ensure accurate rate

apical pulse

central pulse that can be auscultated over the apex of the heart at the point of maximum impulse PMI.

hypotension

decreased blood pressure

hypertension

elevated blood pressure -leading cause of cardiovascular disorders and most important risk factor for stroke. -occurs when there is a dysfunction of the neurohormonal system. When angiotensin and aldesterone are overstimulated, blood pressure increases, and the result may be permanent thickening of the blood vessels, leading to increased peripheral resistance. *systolic pressure of 120 to 139 mm Hg or diastolic pressure of 80 to 89 mm Hg is classified as prehypertension *pressures above this is considered stage 1 or stage 2 hypertension *primary hypertension- no known cause *secondary hypertension- known illness

respiratory rate

eupnea- normal respiration with a normal rate and depth for the patient's age tachypnea- an increase in respiratory rate to more than 24 BPM in the adult- caused by increased carbon dioxide levels and increased need for oxygen or increased metabolic rate. bradypnea- decrease in respiratory rate to less than 10 BPM in the adult. - caused by medications, opioids, meatbolic disorders or brain injury

tachycardia

excessively fast heart rate >100 bmp in the adult -decreases cardiac filling time leading to decreased caridac output. -factors include: drop in blood pressure, elevated temperature, anemia, poor oxygenation, exercise, prolonged heat, pain, strong emotions, medications, bronchodilators

hyperthermia

high body temperature

hypercapnia

high levels of carbon dioxide

pain

is a subjective experience, and the intensity and quality of pain are whatever the patient says they are. *acute- it resolves when the underlying injury heals *chronic- it lasts longer than the healing period.

auscolatory gap

is the absence of korotkoff sounds noted in some patients after the initial systolic pressure ; the gap may cover a range of 40 mm Hg. May occur in the latter part of phase I and during phase II.

blood pressure

is the force of the blood against arterial walls. the left ventricle pushes blood through the aortic valve and into the aorta. The pressure rises as the ventricle contracts, and it falls as the heart relaxes, creating a pressure wave through the arterial system. *systolic pressure- the peak of the pressure wave *diastolic pressure- the lowest pressure on the arterial walls, which occurs when the heart rests. *pulse pressure- the difference between the diastolic and systolic pressures.

hypotension

is the systolic blood pressure of less than 90 mm Hg (or 20 to 30 mm Hg below the patient's normal blood pressure) or diastolic blood pressure of 60 mm Hg or less. *caused by the disruption in cardiovascular dynamics, such as decreased blood volume (hemorrhage), decreased cardiac output (heart attack or heart failure), decreased peripheral vascular resistance (shock). *an initial compensatory response to decreased blood pressure in an increased pulse.

auscultation

listening with a stethoscope

hypothermia

low body temperature signs- *decreased body temperature and respirations *pale and cool skin *hypotension *decreased muscle coordination and urinary and output *disorientation *and drowsiness progressing to coma

hypoxia

low oxygen levels in the blood

five sites for body temp

mouth, ear, rectum, forehead, axilla *oral- most common, not recommended for infants or young children, or unconscious patients, post-operative patients, seizure disorders *tympanic- core temperature, for adult- grasping the pinna and gently pulling up and back for adult, or down and back for child younger than 3, and angling toward jaw line. *rectal- very accurate, not recommended for infants, neutropenic patients, patients with spinal cord injuries *temporal- well tolerated by children and infants, measures ambient air temperature and corrects the temperature reading for heat loss. *axillary- when oral or rectal sites are contraindicated, used frequently on healthy newborns

frosbite

occurs from exposure to subnormal temperatures. *ice crystals inside cells and may cause permanent circulatory and tissue damage. *common sites- earlobes, tip of the nose, fingers, and toes *interventions- gradual warming, pain management, protection of the injured area

heatstroke

occurs when prolonged exposure to the sun or high environmental temperatures overwhelms the body's heat loss mechanisms *risk factor: very young or very old age, cardiovascular disease, diabetes, and alcoholism, predisposing conditions like exercise or work outdoors *signs and symptoms: confusion, delirium, excessive thirst, nausea, muscle cramps, and high temperature and heart rate, hot dry skin, absence of sweat

radial pulse

palpated by placing the first two or three fingers over the radial artery at the groove along the radial, or thumb side of patient's hand

body reflection

reflects the difference between the amount of heat produced by body processes and the amount of heat loss to the external environment. Heat is generated by metabolic processes in core tissues of the body and is transferred by circulating blood to the skin, where it is dissipated into the environment.

pulse deficit

results when the apical pulse rate exceeds the radial pulse rate. -when a cardiac ejection of a volume of blood is too small to initiate a peripheral pulse wave.

bradycardia

slow heart rate <60 bpm in the adult -occurs in athletes, during sleep, state of hypothermia, medications such as beta blockers, tracheal suctioning, increased intracranial pressure, myocardial infarction. **bradycardia with difficulty breathing, and decreased blood pressure can be an indication of imminent cardiopulmonary collapse

orthostatic hypotension

sudden drop of 20 mm Hg is systolic pressure and 10 mm Hg in diastolic pressure when the patient moves from a lying position to sitting or standing position. -the low pressure occurs from peripheral vasodilation with no rise in cardiac output for compensation.

core temperature

temperature of deep tissues or environmental tissues *because skin is exposed to the environment, there is constant heat loss through radiation conduction, convection, and evaporation -radiation: is the transfer of heat as waves or particles of energy. ex: no contact, peripheral vasodilation increases blood flow to the skin, therefore increasing radiant heat loss. Vasoconstriction minimizes heat loss from the skin. If the environmental temperature is higher than the skin temperature, the body will also absorb heat by radiation -conduction: is the transfer of and reaction to heat through direct contact. ex: heat of the body is lost when something cool touches the body -convection: is the transfer of heat by movement of circulation of warmth matter such as air or water -evaporation: a liquid is changed to a vapor through heat. Diaphoresis increases during exercises, the process of evaporation lowers body temp.

depth of respirations

vary from shallow to deep hypoventilation- characterized by shallow respirations - associated with drug overdose and obesity, COPD and cervical spine injury hyperventilation- exhibited by deep, rapid respirations- caused by stress or anxiety

heat exhaustion

when extreme or prolonged environmental heat exposure leads to profuse sweating with consequent excessive water and electrolyte loss.