Lesson 9 - Vital Signs

documenting pulse

Pulse is recorded to include the date, rate in beats per minute and a description of pulse quality.

* A patient experiencing tachycardia has a pulse ______

above 100 bpm

* A sphygmomanometer is used to measure

blood pressure

* the pressure of blood felt against the wall of an artery is best defined as _______

blood pressure

* A factor that may increase blood pressure is ________

exercise

* T/F An oral temperature is the most accurate method for determining core body temperature.

false

* T/F Blood pressure is recorded as a fraction with the systolic pressure over the pulse pressure.

false

* T/F You may use any size sphygmomanometer cuff to accurately measure a patient's blood pressure, regardless of the patient's height, weight and arm circumference.

false

* T/F normal body temperature increases with age.

false

arrhythmias

the absence of rhythm are considered irregular, inconsistent pauses and may be caused by disease, medications or electrolyte imbalances. Depending on the pulse pattern, the rhythm may be characterized as regularly irregular, or irregularly irregular. If you hear an arrhythmia, you need to further assess your patient. Patients may have irregular pulses based on their health status, but further evaluation is necessary to confirm whether a pulse rhythm has changed from the patient's baseline.

hypertension

• Hypertension is abnormally high blood pressure on at least two occasions. • High blood pressure is defined as a blood pressure higher than 140/90. • Essential Hypertension: High blood pressure of unknown cause or origin. • Secondary Hypertension: High blood pressure associated with other disease processes.

hypotension

• Hypotension is abnormally low blood pressure. • Low blood pressure is defined as a blood pressure lower than 90/60. • There is no absolute low numerical value for hypotension as long as the patient's organs are perfused.

diastolic phase

After contracting, the ventricles relax and allow time for the ventricles to refill with blood. The constant pressure exerted on the arteries during this relaxation period is called the diastolic phase of blood pressure. The pressures are expressed numerically as a fraction with Systolic/Diastolic in units of millimeters of mercury (mmHg).

* The correct notation of a blood pressure reading is _______

BP: 126/76

documenting blood pressure

Blood pressure is recorded as a fraction with systolic pressure over diastolic pressure. For example, a patient's blood pressure reading of systolic pressure of 118 and diastolic pressure of 76 would be documented as follows: 8-1-2006, 1420, BP: 118/76

* If a patient drinks cold water, how long do you wait before taking an oral temperature?

15 minutes

* If a blood pressure measures 110/86, the pulse pressure is ______

24

* The minimum amount of time required to accurately measure respiratory rate is ______

30 seconds

* You count 44 beats in 30 seconds, so the patient's pulse rate is _____-

88 bpm

* The normal range for an adult systolic blood pressure is ______

90 to 140 mmHg

* A patient must sit quietly for at least _______ before a blood pressure is taken.

5 minutes

* Which of the following pulse readings indicates bradycardia?

50

how to convert celsius to fahrenheit equation:

(C X 9) / 5 + 32 37 X9 /5 + 32 = 98.6 F

how to convert fahrenheit to celsius equation:

(F-32) X5 / 9 (102-32) X5 / 9 = 38.9 C

measuring blood pressure steps:

1. Identify the patient and explain the procedure. 2. Palpate the brachial pulse in both arms to determine the strongest rhythm. Use the side with the strongest rhythm. 3. Determine cuff size. Keep in mind that this can affect the reading. 4. Roll sleeve to 5 inches above elbow or remove sleeve from arm. 5. Place bladder of cuff 1 inch above crease of elbow. Support patient's arm at heart level and instruct the patient to relax the arm. 6. Place stethoscope in ears, with earpiece facing forward and stethoscope bell on brachial artery. 7. Close valve and inflate to 30 mmHg above the patient's baseline systolic pressure or ~180 mmHg at a rapid, smooth rate. 8. Open valve slightly and deflate at a rate of 2 mm per second while listening carefully for the heart beat. This first sound may be a dull "lub dub." This is the systolic pressure. When the sound stops or becomes faint, check the measurement again. This is the diastolic pulse. 9. Record these numbers. 10. The ausculatory gap is a loss of sound as the bladder deflates and the sound reappears later. If uncertain, let all of the air out of the bladder, wait 5 minutes and repeat. 11. Document the procedure.

* ________ best demonstrates the correct way to record respirations.

10-31-2006, 1820, R: 22, regular, symmetrical

* A patient experiencing pyrexia will have a temperature reading of _________.

101 degrees F.

* A factor that does not increase blood pressure is ______

rest

rhythm of respiration

A normal respiratory rhythm is regular and even. Each inspiration is approximately one-half the length of each expiration. Respiratory rhythm is normally irregular in children, but is not excessively labored or involves the use of abdominal accessory muscles, a sign of respiratory distress.

doppler

An ultrasonic Doppler machine is sometimes used to measure pulses in patients with diminished peripheral circulation, or when pulses are non-palpable. A transmitter is placed over conduction gel on the pulse site and high frequency waves are directed at the artery. When the waves meet the artery that has positive blood flow, signals are conducted back through the transmitter and converted into sound waves that are heard through the Doppler speakers. Doppler measurements are helpful with patients diagnosed with diabetes, peripheral neuropathy or who have edema resulting in diminished circulation.

heat loss

The body also continuously loses heat. Heat is lost through four processes: • Radiation • Conduction • Convection • Evaporation

thermoregulation

The body continuously produces heat as a byproduct of chemical reactions that occur in body cells, or metabolism. The automatic process of thermoregulation maintains a fairly constant core temperature regardless of where the heat is being produced. The rate of heat production is determined by the person's metabolic rate.

pulse rate

The number of beats per minute determines pulse rate. In the average adult, the SA node fires 60-100 bpm (beats per minute), and the impulses travel throughout the heart's muscle fibers, causing muscle contraction and ultimately blood to be ejected from the left ventricle and into the arterial system.

* Which of the following is not an example of respiratory quality? a. regular b. shallow c. labored d. abnormal

abnormal

hypothalamus

can be thought of as a "thermostat" for the body. As the body overheats, skin receptors send signals to the nervous system. The hypothalamus then sends signals to release perspiration in the skin and to dilate superficial blood vessels to release heat and lower the body's temperature.

* The pulse rate and characteristics give clues regarding how well the ______ system is performing.

cardiovascular

factors affecting blood pressure:

cardiac function and peripheral vascular resistance : As the heart's pumping action decreases due to cardiac disease, blood pressure decreases. As blood vessels become less elastic, blood pressure increases. As blood volume increases, so does blood pressure. As blood viscosity increases due to diseases such as diabetes, so does blood pressure. Drugs and other healthcare treatments can alter these situations to change the blood pressure. age: Blood pressure increases with age. Children experience rising blood pressure linked to their age, weight and height. Rising blood pressure in adults is due to arterial narrowing, decreased arterial compliance and disease processes such as atherosclerosis. ethnicity: Certain ethnic groups, like African Americans, experience higher blood pressure compared with other racial groups. gender: After puberty, females generally have lower blood pressure than males. diurnal variation: Blood pressure changes minute-by-minute, but overall pressure is lower in the morning and peaks in late evening. white coat hypertension: These patients experience an elevated blood pressure reading due to the anxiety caused by seeing a physician. Some studies found that if a nurse or MA performs the blood pressure reading, rather than a physician, the blood pressure reading is significantly lower, and often closer to the patient's baseline. Additionally, patients who take their own blood pressure outside of the clinic or hospital setting receive lower results than when measured in the medical office. If you think white coat hypertension may be the culprit in an abnormal reading, retake the patient's blood pressure near the end of his visit to compare with the initial reading. Caffeine and Tobacco: Research studies are unclear as to how caffeine affects blood pressure. Some statistics lean towards a predisposition for higher blood pressure caused by high amounts of caffeine intake, while others suggest that caffeine causes blood vessels to constrict by blocking the dilating hormone adenosine. Drinking two to three cups of coffee may raise systolic blood pressure between 3 to 14 mmHg. Smoking tobacco indirectly raises blood pressure by injuring blood vessel walls and speeding up the hardening of arteries, which increases the risk of heart disease and limits the heart's ability to manage pressure changes. Wait at least 30 minutes before checking blood pressure if a patient has recently ingested caffeine or cigarettes to allow the substances to dissipate in the body. Medications: Medications can raise or lower blood pressure depending on the drug. Specific drugs target blood pressure by causing blood vessel dilation or altered cardiac function. Diuretics can influence blood pressure by changing the circulating volume in the vascular system. Narcotics reduce sympathetic nervous system stimulation and decrease blood pressure. physical activity: Exercise raises blood pressure, while rest lowers blood pressure. blood pressure assessment technique: Appropriate technique is critical to measure an accurate blood pressure. The following tips will minimize reading errors. clothing: Tight clothing must be avoided when taking a blood pressure reading because it can falsely increase blood pressure by increasing occlusion of the arteries. Have patients remove sweaters or roll up their shirt sleeves above the blood pressure cuff. arm position: Raise the patient's arm to the level of the heart and make sure it is in a relaxed position. If the arm is lower than the heart level, the blood pressure reading will be falsely elevated. If the arm is higher than the heart level, the blood pressure reading will be falsely lowered. If the patient flexes or supports the arm, the reading will also be falsely increased. correct cuff size and placement: Using a sphygmomanometer cuff that is too large or too small for the patient provides an inaccurate reading. Cuffs that are too small for obese or muscular adults will often cause a reading to be 10 to 50 mmHg too high. Use a large-sized cuff for these patients. The correct width of the cuff bladder should cover 2/3 of the upper arm and the cuff length should reach 80 percent around the arm. Locate the center of the cuff bladder one inch above the antecubital fossa.

evaporation

causes heat loss as water is transformed to a gas. Examples of evaporation include diaphoresis (sweating) during strenuous exercise or when someone has a fever.

* The medical assistant requires a _______ to count respirations.

clock or watch with a second hand

* When checking a patient's respiratory rate, _______

count the respirations after taking the patient's pulse, without moving your hand away from his or her wrist. The patient remains unaware that her respirations are being timed.

bradycardia

describes a slow adult pulse rate less than 60 bpm. Some well-conditioned athletes have lower overall pulse rates that may be considered normal for them, while the same range is bradycardic for no-conditioned adults. Parasympathetic nervous system stimulation, also known as the "rest-and-digest" response, heart disease and certain medications may cause the pulse rate to decrease.

temperature measurement procedures

documenting temperature - Temperature should be documented to note the date and time, temperature value in Fahrenheit or Celsius and the site where the reading was taken.

* A Doppler should be used to assess pulses in patients with ______

edema

some of the terms used to describe fever are:

febrile : having a fever afebrile: without a fever hyperthermia: excess body heat, or fever associated with heat stroke, alcohol intake and problems with hypothalamus heat regulation signals. hypothermia: low body temperature associated with environmental cold exposure, paralysis, starvation and hypothyroidism. Therapeutic hypothermia may be used with surgical patients, such as with organ transplant to slow the metabolic process and prevent organ rejection. To avoid shock, hypothermic patients need to be warmed gradually.

* Which of the following factors does not lead to increased body temperature?

starvation or fasting

* The measurement of the balance between heat produced and heat lost is _______.

temperature

4 vital signs :

temperature pulse respirations blood pressure indicate how well the patient's body is functioning.

basal metabolic rate (BMR)

the amount of energy the body uses during absolute rest while awake. Physical exercise, increased production of thyroid hormones, and stimulation of the sympathetic nervous system can increase heat production.

core temperature

the body's temperature in the central circulation and organs. Three sites measure core temperature—the head, chest and abdomen. Core temperature varies by only one degree Fahrenheit during the day.

tachycardia

used to describe rapid adult pulse rates above 100 bpm. Factors such as sympathetic nervous stimulation, the "fight-or-flight" response, heart conduction abnormalities or certain medications may cause this pulse rate increase.

humans are "warm blooded" creatures:

which means that we can maintain an internal body temperature independent of the outside environment. your core internal temperature remains relatively constant, unless you develop an illness. Your organs require this constant internal temperature to function well.

normal adult temperatures

• Oral: 97.6 to 99.6 °F, 36.5 to 37.5 °C • Rectal: one degree Fahrenheit higher than oral • Axillary: one degree Fahrenheit lower than oral

* If you count eight respirations in 30 seconds, the patient's respiratory rate for one minute is ______

16

pulse is described in terms of :

rate, rhythm and quality The heart dictates the rate by activating conduction cells causing heart contraction. The heart's right atrium begins this electrical impulse conduction in the sinoatrial (SA) node. The SA node firing also influences the heart rhythm. Pulse quality is evaluated in terms of amplitude and is primarily evaluated when an irregularity is suspected.

there are 3 factors that conduct a patient's respiratory function:

rate, rhythm, and depth.

* Proper technique for taking pulses involves compressing the artery with _____

three fingers

pulse sites

The pulse is taken anywhere on the body where there is a superficial artery that lies over a bone. The pulse site is palpated, that is, gentle pressure is applied with the fingers to detect the pulse. radial - The radial pulse is located at the wrist on the thumb side. This is the most commonly assessed pulse site. carotid - The carotid pulse is located in the groove of the neck between the trachea and sternomastoid muscles. brachial - The brachial pulse is located on the medial arm at the fold of the elbow. femoral - The femoral pulse is located in the groin region, on the anterior, medial aspect of the thigh. temporal - The temporal pulse is located over the temporal bone, in front of the upper ear. popliteal - The popliteal pulse is located at the back of the knee. dorsalis pedis - The dorsalis pedis pulse is located on the superior surface of the foot. apical - The apical pulse is taken with the stethoscope just below the left nipple. Considered the most accurate assessment of pulse rate, the apical pulse is often performed on infants and cardiac patients.

measuring respiration

The purpose of assessing a patient's respiratory rate is to evaluate rate, rhythm and depth of respirations and the impacts of factors that can alter respiratory patterns such as medications, physical condition, age, gender and stress. Before counting respirations, review with the patient any potential respiratory risk factors such as smoking, asthma, medications or chest trauma. If the patient shows signs of reduced consciousness, shortness of breath, pain when inspiring or coughing, these may be signs of reduced respiratory function. Remember to assess respirations so that the patient is not aware, because the patient may easily alter her respirations if she knows she is being watched. This situation will provide inaccurate results.

* An accurate count of one respiration is ______

one rise and fall of the chest

isolated vital signs

one-time vital signs are not as valuable as vital signs taken over a period of time demonstrating trends and establishing a baseline to compare and evaluate treatments.

fevers have 3 stages:

the cold stage - Many pathogens find the temperature 98.6 °F to be quite conducive to growth, so raising the body's temperature is one way to combat the pathogen. When a bacteria or virus initiates an inflammatory process in the body, the body activates the immune system, signaling the brain to respond by raising the body's temperature. In other words, the body's thermostat is reset. The body may signal the blood vessels to constrict, conserving heat in order to raise the set point. A similar process allows the body to cool when a fever heats the body temperature. The cold stage occurs when the body shivers in order to produce necessary heat to reach the new higher set point. By putting on a sweater or covering themselves in a blanket, patients can assist in this heat production process. the hot stage - The fever reaches a plateau during the hot stage and the body radiates heat. If a fever is above 100.5 °F, the cause needs to be treated with medications, tepid sponge baths or cooling blankets. defervescence - The third stage of a fever, defervescense begins as the temperature subsides when heat loss is established by sweating or with medications.

respiration

involves the exchange of the respiratory gases oxygen and carbon dioxide. One respiratory cycle consists of one inspiration, breathing air in, and one expiration, or breathing air out. Respiration is both internal and external. External respiration involves the exchange of gases between the lung alveoli and capillaries. Internal respiration involves the exchange of gases between the capillaries and body cells. Breathing is largely an automatic act, controlled in the brain by the medulla oblongata and carried out by the respiratory muscles. The brain controls breathing by sensing chemical contents of the blood, especially carbon dioxide. While the act of breathing is often automatic, there are actions that we can take to control our breathing pattern. Due to this conscious control, you measure respirations without the patient's knowledge so that an accurate baseline is established. If a patient is aware that you are measuring her respiratory signs, she may alter her breathing pattern consciously or unconsciously.

radiation

is the emission of energy from any source, in this case from the body in the form of heat. Exposure to a cold environment increases your body's radiant heat loss. As you've probably noticed in the wintertime, covering your body with closely woven, dark fabric can reduce radiant heat loss.

convection

is the loss of heat through air currents such as from a breeze or a fan.

conduction

is the transfer of heat from one object to another. The body loses a considerable amount of heat to the air through conduction. It can also lose heat to water while swimming or during tepid baths.

* Body temperature is lowest at which period of the day?

morning

* The normal respiratory rate for adults is _____

12-20 per minute

* The normal resting pulse range for adults is ______

60 to 100 bpm

take a pulse steps

If obtaining a patient's pulse for the first time, measure a baseline pulse rate for one minute. Review the patient's medical history and risk factors with him prior to assessment to determine factors impacting the pulse rate and previous baseline measurements. Assess whether the patient demonstrates any physical symptoms that could alter pulse rate such as edema, dyspnea or palpitations. Identify the most appropriate physical site to assess pulse. Taking an Apical Pulse - 1. Wash hands. 2. Identify the patient and explain the procedure. 3. Assist patient to a sitting or supine position and help remove upper body clothing. 4. Offer patient a gown. 5. Place stethoscope over the 5th intercostal space, left of the sternum, midclavicle to locate the apex of the heart. 6. Count heartbeats for one minute, noting any irregularities. 7. Help the patient get dressed, if needed. 8. Document the procedure. Taking a Radial Pulse - 1. Wash hands. 2. Identify the patient and explain the procedure. 3. Position patient with arm relaxed, palm facing down. 4. Locate pulse point on the thumb side of wrist, 1 inch above base of thumb. Use pads of first three fingers, not thumb and apply slight pressure. 5. Count beats for one minute and note any irregularities or variations. 6. Document the procedure. Taking a Carotid Pulse - 1. Wash hands. 2. Identify the patient and explain the procedure. 3. Assist patient to supine position. 4. Locate pulse point on either side of larynx. 5. Place first three fingers over artery with slight pressure. 6. Count for one minute, note rhythm and any irregularities. 7. Document the procedure. Taking a Femoral Pulse - 1. Wash hands. 2. Identify the patient and explain the procedure. 3. Have patient remove outer clothing on the lower half of his body. Assist patient to supine position. 4. Locate the femoral pulse by pressing deeply with your first three fingers below the inguinal ligament. 5. Count beats for one minute and note rhythm and any irregularities. 6. Document the procedure. Taking a Popliteal Pulse - 1. Wash hands. 2. Identify the patient and explain the procedure. 3. Place patient in supine position with knee flexed and skin exposed. 4. Place stethoscope on back of knee to hear pulse as palpation at this site is difficult. 5. Count pulse for one minute. 6. Document the procedure.

orthostatic hypotension

aka postural hypotention, orthostatic hypotension occurs as a sudden, temporary drop in blood pressure when a patient moves from a horizontal to a vertical position.28 There are several causes of orthostatic hypotension including hypovolemia, anemia, atherosclerosis, neurological disorders, diabetes or medications. Patients experience lightheadedness, dizziness, headache, blurred vision and syncope.

* ______ pulse is usually taken on infants and children because they have a very rapid pulse rate.

apical

* A fast pulse is expected with ______

high blood pressure

* What is another name for hyperthermia?

high body temperature

* The part of the brain that activates heat loss and heat production mechanisms in order to maintain a normal core body temperature is the ________.

hypothalamus

pulse measurement

The most common and most efficient method of measuring pulse involves palpation of one or more body pulse sites. Using the pads of the first three fingers on one hand, light pressure is applied to determine the pulsation of the artery as it is compressed against firm muscle or bone. Pulses are first determined based on rate, rhythm and quality. If the pulse is regular, measurement is timed for 30 seconds, and the rate multiplied by 2 to determine the patient's bpm. The first pulsation is counted as zero. If the patient's pulse is being assessed for the first time, then a baseline pulse is measured for one full minute. If the patient's pulse is irregular, then apical pulses are measured.

Did you ever wonder why you get goose bumps when you're cold?

Did you ever wonder why you get goose bumps when you're cold? Well, when the body senses coolness, surface blood vessels constrict to keep the blood away from the surface of the skin and prevent the loss of heat. Chemical impulses to the sweat glands are stopped when the temperature falls below normal. The small papillary muscles around your hair follicles contract, causing "goose bumps."

rate of respiration

The respiratory rate is the number of breaths, consisting of one inspiration and one expiration, contained in one minute. The normal adult respiratory rate is 12-20 per minute.

* A carotid pulse should be assessed by ______

compressing one carotid artery only

breathing patterns

eupnea - normal breathing dyspnea - difficult, labored breathing apnea - temporary cessation of breathing orthopnea - difficulty breathing in position other than upright hypernea - increased depth of breathing tachypnea - increased rate of breathing cheyne stokes - alternating periods of apnea and tachypnea rales - crackling, gurgling sounds due to excretions in the bronchioles rhonchi - rattling in the throat as in snoring

types of thermometers

glass mercury thermometers - glass thermometers are being phased out due to the risks associated with mercury exposure if the glass thermometer breaks. The slender glass tube contains a sealed end and an end containing a bulb of mercury, presenting a safety risk if exposed to the hazardous substance. Instead, tympanic, digital or disposable paper thermometers are recommended. According to the Centers for Disease Control and Prevention (CDC), if elemental mercury is spilled or if a thermometer breaks, the exposed substance can evaporate and become an invisible, odorless toxic vapor.12 A patient runs the risk of breaking a thermometer in her mouth, and swallowing the mercury, but a greater risk exists if the thermometer is broken outside of the body and exposed to air. electronic thermometers - digital devices that use a stylus, covered with a disposable plastic sheath to assess temperature. The sheath is discarded after each use. The stylus can be placed orally or under the arm in the axilla. Once placed, the temperature is displayed digitally. Correct placement is necessary to yield an accurate reading. aural (tympanic) thermometers - are widely used in current healthcare practice. The thermometer measures blood flow temperature when placed in the ear by picking up infrared energy from the tympanic membrane. The temperature is immediately displayed on the digital screen. Disposable plastic covers are placed over the membrane sensor and discarded after use.

normal values for pulse pressure for ages : systolic/diastolic

newborn: 50/30 6 years: 95/62 10 years: 100/65 16 years: 118/75 adult: 120/80 elderly: 138/86

* The correct distance for inserting a rectal thermometer into a four-year-old child's rectum is ________.

no more than 1 inch.

* Which of the following ear positions do you use when inserting a probe for a tympanic temperature for a four-year-old child?

pull the ear pinna up and back

temperature

reflects the balance between heat loss and heat production. The body loses heat through perspiration, breathing and the elimination of body wastes. Illness upsets the metabolic process, disturbing the amount of heat that is produced. Most diseases increase metabolism. However, some disorders, such as syncope, dehydration and central nervous system injury decrease body temperature. Periods of growth also increase metabolism and therefore body temperature. There is an inverse relationship between body size and metabolic rate. The larger your body, generally the lower your metabolic rate. Children typically have a slightly higher body temperature, not only because of growth, but also because they have less body surface area where heat is lost. Another part of the temperature puzzle includes the skin receptors and the hypothalamus.

sphygmomanometry

the instrument used to manually measure blood pressure is the sphygmomanometer, a cuff with a pump and a calibrated mercury column or aneroid numerical scale. Cuff sizes are available in small, medium and large and are selected based on the measurement site, patient's age, weight and size. The cuff is applied to the site and inflated to 30 mmHg above the patient's baseline systolic pressure. At this inflation point, blood flow is compressed in the affected artery. Blood circulation in the distal artery ceases. The heart, however, continues to pump blood causing the proximal artery to increase in size. At this point no sound is heard because the cuff's pressure is greater than the artery. When the pressure valve is slowly opened, the cuff is gradually deflated, and blood begins to turbulently circulate again past the cuff. Sounds, called Korotkoff sounds, are auscultated using a stethoscope. As the cuff deflates, the sound becomes fainter until it is no longer heard. The numerical systolic pressure is noted at the point where the first beat is heard upon auscultation. The diastolic pressure is noted at the point where the last beat is heard before disappearing.

blood pressure

the pressure exerted by the blood against the walls of blood vessels. Measuring blood pressure is common with most medical visits because patients may not display noticeable signs and symptoms of hypertension. It is important to monitor a patient's baseline blood pressure. A blood pressure rise or fall of 20-30 mmHg is considered significant and is investigated and treated.

pulse

the wave of alternating expansion and relaxation of arterial walls with each contraction of the left ventricle. pulse indicates how hard, smooth and fast blood is pumped from the heart's left ventricle and flows through the arteries. The pulse rate and its characteristics give clues regarding how well the cardiovascular system is performing. Normally the arterial pulse is the same as the heartbeat heard as the left ventricle contracts. The pulse is physically assessed when light, three-finger pressure is applied at positions where arteries are located close to the skin surface, called pulse points, compressing the artery against firm muscle or bone. When doing so, a "throb" or tap is felt.

sites for measuring

tympanic - Measuring temperature in the ear's tympanic membrane is a widely used assessment site in hospitals and healthcare settings. Safe, fast and easy measurement can be used with a wide range of ages and health conditions. Tympanic temperatures assess the blood flow to the hypothalamus and is considered close to core body temperature. Fewer pathogens live in the ear canal, so the risk of infection or cross contamination is lower than in oral or rectal cavities. Large amounts of ear canal cerumen, or earwax, may cause inaccurate readings. Correct placement of the probe and position of the ear is key to accurate measurement. Tympanic measurement must not be used on infants or newborns less than one year old due to risk of ear canal injury from the large probe. When placing the probe, the ear pinna is pulled down and back for one- to two-year-old children. When placing the probe, the ear pinna is pulled up and back for children three years or older. Ensure a tight seal when inserting the probe into the ear canal. If the patient has been lying on the ear, the temperature may be artificially elevated. The patient must be indoors for at least 10 minutes prior to assessment to prevent false readings. Tympanic temperatures are not assessed on patients with ear drainage or recent ear surgery. axillary - The axillary site is often used when assessing infants and children due to the unobtrusive nature of placing a thermometer or stylus under the arm. The digital thermometer will beep when the measurement is complete. An older, mercury thermometer must be left in place for a longer time period than in other sites, so it is often considered not as reliable. The assessment time with a mercury thermometer is 10 minutes for adults and five minutes for children. Various factors influence axillary temperature including external skin temperature, friction from clothing and probe placement. rectal - Due to the invasiveness of the measurement procedure, rectal temperatures are not assessed as commonly as axillary, oral or tympanic routes. However, studies support the reliability and accuracy of rectal temperatures over those methods. Several research studies recommend rectal temperature as the most accurate indicator of core body temperature.10 A specialized thermometer is inserted, but never forced into the rectum approximately 1.5 inches for adults and no more than 1 inch in children younger than six years old. The thermometer is lubricated with water-soluble lubricant and gloves are worn to prevent fecal contamination. A major advantage of the rectal site is that eating food, drinking liquids or the patient's ability to hold the thermometer does not affect temperature readings. Disadvantages include patient embarrassment, difficult placement and cross contamination risks. Proper probe placement can affect temperature accuracy. If the thermometer is placed in fecal material, the reading may be falsely higher. Rectal temperatures are not used in patients with recent rectal surgeries, hemorrhoids, diarrhea and cardiac disorders. Rectal temperatures are only assessed in infants and newborns if no other site can be used due to potential injury risks to the rectal mucosa. oral - The most common site for temperature measurement is orally, or through the mouth, due to quick and easy access and patient comfort. The patient closes her mouth completely around a thermometer or stylus for a sufficient period of time. If the patient drinks hot or cold liquids immediately before oral temperature assessment, 15 minutes must pass before placing the thermometer to allow the mouth temperature to return to baseline. Oral temperatures are not recommended for patients who are prone to seizures, are unconscious, have an oral disease, use supplemental oxygen or children younger than five years of age. To be accurate, an oral temperature is taken by placing the thermometer probe in the posterior sublingual pocket, under the tongue.11 Use of a glass thermometer in temperature assessment is especially unsafe for infants or children, unconscious or irrational patients or those with seizure disorders. temporal artery (TA) - The temporal artery site, located on the forehead, is quickly becoming a popular site to measure temperature. TA measurement is more accurate than tympanic measurement, and at least as accurate as rectal measurement. You'll take the patient's temperature simply by scanning a TA thermometer over the temporal artery. This site provides the most comfortable, non-invasive method of temperature-taking for patients, does not involve any mucous membrane and is easy to use.

respiration assessment steps

1. Wash hands and identify patient. 2. First determine the patient's pulse. 3. When finished with pulse, while your fingers are still located at the pulse point, begin to count the patient's respirations by watching the patient's chest rise and fall with inspiration and expiration. 4. Count one respiration as the total of one inspiration and one expiration. 5. If unable to see the chest rise and fall, place your free hand on the patient's chest to detect respiratory movement. Do not explain this hand placement to the patient. 6. Count respirations for the following intervals: Adults with regular respiratory rate: 30 seconds and multiply by 2 to determine respirations per minute. Children younger than 2 years or adults with irregular respiratory rate: one minute. 7. Document rate, rhythm and depth of respirations.

take the rectal temperature steps

1. Wash hands. 2. Identify patient and explain the procedure. 3. Remove rectal electronic thermometer from battery pack and remove temperature probe from unit. The red probe is only used for rectal temperature to prevent cross contamination of blue oral probe. 4. Securely attach a clean cover on stylus. 5. Close privacy screen or door. 6. Put on clean, non-sterile gloves. 7. Assist patient to Sim's position with upper leg flexed. Expose anal area, keeping other patient areas covered. 8. Apply water-soluble lubricant to thermometer probe tip. 9. Separate patient's buttocks with one hand. 10. Instruct patient to take a deep, slow breath, while slowly inserting the probe into the anus towards the umbilicus. If resistance is encountered, do not force probe. 11. Insert no more than .5 inch for infants, and 1 inches for adults. 12. Hold the probe in place until thermometer beeps. 13. Slowly remove the thermometer, drop the probe cover off of tip into trash. 14. Remove and discard gloves. 15. Wash hands. 16. Document the procedure and communicate appropriate results to patient.

take a tympanic temperature steps

1. Wash hands. 2. Identify patient and explain the procedure. 3. Remove tympanic thermometer from recharging base and attach disposable tympanic probe to sensor. 4. Insert probe into ear canal until probe fits snugly with tight seal. Do not force probe. Position the ear pinna appropriately for the patient's age. 1-2 year old child: When placing the probe, the ear pinna is pulled down and back. 3 years and older: When placing the probe, the ear pinna is pulled up and back. 5. Activate the probe by pushing the read button. 6. Keep the thermometer in position until the probe beeps and a digital reading appears on the display screen. 7. Remove the thermometer and eject the probe cover into the trash. 8. Replace the thermometer into the recharging base. 9. Document the procedure and communicate appropriate results to patient.

* The normal respiratory rate for a newborn is ________

30-80 per minute

korotkoff sounds

5 phases: phase 1 : First sound heard as faint tapping that increases in intensity. This first sound is the Systolic Blood Pressure reading. phase 2: Swishing sounds develop as the vessel distends with blood due to cuff compression. phase 3: Crisp sounds that increase in volume. phase 4: Sounds become muffled. Phase 4 is considered the Diastolic Blood Pressure in children. phase 5: Sounds disappear. This last sound is the adult Diastolic Blood Pressure reading.

measuring blood pressure

Blood pressure should be measured in both arms on the initial exam to assess the patient's baseline measurement. If there is greater than 10 mmHg variation between arms, the arm with the higher reading is used to measure all future blood pressures. Allow the patient to rest for at least five minutes prior to taking an additional blood pressure reading to allow adequate time for the pressure to return to baseline levels.

How does shivering happen?

How about shivering? When cold signals are received by the hypothalamus, messages are sent to skeletal muscles throughout the body, causing increased muscle tone that produces heat. When the muscle tone rises above a certain level, shivering results and heat production rises dramatically.

blood pressure assessment

Prior to measuring blood pressure, interview the patient regarding factors that may affect readings, such as medications, lifestyle habits and physical conditions. Review the patient record to determine a baseline measurement. Select the best site based on the patient's physical condition including pulses, surgeries, injuries or implanted medical devices.

quality

Pulse quality is affected by the force of blood being ejected from the ventricle with each heartbeat. This force is called stroke volume. As blood flows from the left ventricle, through the aorta and into systemic arterial circulation, how easily the blood flows through the system is another indication of pulse quality. If blood encounters resistance due to damaged arteries or hemorrhaging, pulse quality will change. The healthy arterial wall is smooth and soft. When assessing pulse quality it is important to determine whether pulses are the same on both sides of the body, or bilaterally symmetrical. Pulses are palpated at simultaneous pulse points, except for carotid pulses. When palpating, an important assessment to make is; are pulses equal on both sides? Uneven pulses indicate a problem with local blood flow. Postoperative patients are especially susceptible to pulse alterations if radiographic dye is injected arterially and the blood's clotting process occludes the artery, diminishing circulation. Do not palpate both carotid pulses simultaneously due to the risk of decreased cerebral blood flow. A normal pulse quality is considered full or strong. Descriptions of altered pulse quality often include terms such as bounding, weak or thready. Bounding pulses are indicative of damage caused by aging and lost arterial elasticity. In other words, the heart must work harder to pump blood through stiff, rigid arteries, causing the flow to be stronger and more turbulent or bounding. Exerting too much force on an artery during palpation may cause weak or thready pulses. Numerical scales are a standard practice for describing pulse quality:

rhythm

Pulse rhythm is the interval of time required between beats and the pause characteristics. The pulse rhythm is considered regular if the pulsations and pauses are evenly spaced at continuous intervals.

documenting respiration

Respirations are recorded over 30 seconds and documented as respirations per minute. For example, a patient's respirations are counted for 30 seconds and found to be 11 respirations. The results are multiplied by 2 for 22 respirations per minute. Characteristics are also noted with respirations:

depth

Respiratory depth measures the movement of air volume as the patient inhales and exhales. The normal finding for respiration depth is unlabored and symmetrical rising and falling of each lung in the chest cavity. Questions to consider when evaluating respiratory depth include: • Is the patient's breathing pattern symmetrical in each lung? • Is the patient using abdominal muscles to perform breathing? If so, this may be a sign that the patient is having labored breathing. If chest rise and fall is not easily visualized, a patient is described as having shallow respiratory depth.

taking oral and axillary temperature steps

Taking an Oral Temperature - 1. Wash hands. 2. Identify the patient and explain the procedure. 3. Place a clean thermometer cover over the tip of the thermometer stylus. Push the power button. Do not take a patient's temperature if within 15 minutes of eating, drinking or smoking, as this will alter the result. 4. Place thermometer under the patient's tongue, in posterior sublingual cavity. Instruct patient to hold lips closed and breathe through nose. 5. When the thermometer beeps, remove the thermometer and drop probe cover off of tip into trash. 6. Document the procedure and communicate appropriate results to patient. Taking an Axillary Temperature - 1. Wash hands. 2. Identify the patient and explain the procedure. 3. Place a clean thermometer cover over the tip of the thermometer stylus. Push the power button. 4. Put on clean, non-sterile gloves. Pat the patient's armpit dry with towel. 5. Place thermometer in center of armpit and instruct patient to hold arm snugly against body with other arm. 6. Remove after thermometer beeps. 7. Remove and discard gloves. 8. Wash hands. 9. Document the procedure and communicate appropriate results to patient.

pulse pressure

The difference between systolic and diastolic pressures is called the pulse pressure. For example; a systolic pressure of 110 mmHg and a diastolic pressure of 80 mmHg will give a pulse pressure of 30 mmHg. The average pulse pressure is 40 mmHg with a systolic: diastolic: pulse pressure ratio of 3:2:1. As patients age, the systolic pressure increases causing the pulse pressure to increase.

systolic phase

The force of pressure exerted against the arterial walls during contraction is called the cardiac systolic phase of blood pressure.

measuring temperature

There are many methods of determining body temperature, using different types of equipment. The reliability of a temperature value depends on choosing the correct equipment, selecting the most appropriate site and following the correct procedure for placement and timing.

* T/F Respirations are counted in a manner so that the patient is unaware of the procedure.

True

documenting vital signs

Unless you're measuring a single vital sign, all vital signs are documented in sequence in the patient's chart. The date and time (using military time) should be noted in all vital signs. The sequence is temperature, pulse, respirations and blood pressure. When recording vital signs, it is important to document them as they are taken to reduce the opportunity for errors. In some cases, patients may have vital signs recorded on a flow sheet over time and the values are graphed to show trends. These trends can be helpful for physicians in tracking changes in patient conditions. Any vital signs reading outside of the normal ranges for the patient's age should be noted and reported to the physician.

factors affecting body temperature

age - Our normal body temperature decreases with age. It is not uncommon for elderly patients to have body temperatures less than 36.4 °C or 97 °F. Newborns have unstable body temperatures because their thermoregulatory mechanisms haven't matured completely. Normal infant temperature ranges from 97.7-99.5 °F, 36.5-37.5 °C. environment - As environmental temperatures change, core body temperature is not affected, but exposure to extremely hot or cold temperatures can alter body temperature based on length of exposure, humidity, environmental temperature and wind-chill. A core body temperature of 25 °C or (77 °F) is considered life threatening. exercise and physical activity - Physical activity increases temperature due to heat production as the body breaks down carbohydrates and fats to provide energy. It is possible to raise body temperature temporarily to 40 °C (104 °F) when performing strenuous exercise such as running a marathon. time of day - Body temperature has diurnal variation, or normal fluctuations throughout the day. Temperature is usually lowest in the morning, around 3:00 a.m. and highest between 5:00 and 7:00 p.m. A person's body temperature can vary by as much as 2 °C (1.8 °F) from early morning to late afternoon. Physiologic processes such as digestion or muscle activity may cause this fluctuation. emotional state - Emotional or physical stress can elevate body temperature. Stress stimulates the sympathetic nervous system, circulating increased levels of the hormones epinephrine and norepinephrine. This causes metabolism to increase, and this increases heat production. Emotional depression decreases temperature. hormones - Women usually have greater temperature variations than men. This is because progesterone, a female hormone secreted during ovulation, increases body temperature 0.3-0.6 °C (0.5-1 °F) above baseline. By measuring their temperature daily women can determine when they ovulate. This is the basis for the rhythm method of birth control. After menopause, this temperature fluctuation stops. fever - Fever, also called pyrexia or hyperthermia, is defined as a temperature over 100 °F, and is often caused by infection, brain tumors and hyperthyroidism. Untreated high fevers of over 105 °F, 40.5 °C can cause brain damage or death.

factors affecting pulse rate :

age and gender - The pulse rate decreases throughout the lifespan, based on age and health status. The heart becomes less efficient as age increases causing reduced cardiac output. After puberty, male pulse rates are normally slower than females due to hormone level differences. disease and illness - The pulse rate may increase or decrease depending on body conditions. Pain, atherosclerosis, hyperthyroidism, infection and fever will increase the pulse rate. Hypothyroidism, depression, chronic pain and central nervous system disorders may decrease the pulse rate. physical activity - Exercise and posture influence pulse. While increased activity correlates with increased pulse, well-conditioned athletes often have lower resting pulse rates. emotional state - Agitation and anxiety increase pulse, while depression often decreases pulse rate. medications - Depending on their effects, medications may increase or decrease pulse rates. Medications such as digoxin decrease pulse rate for patients with cardiac disease. Diuretics may cause a reflex increase in pulse rate due to the lowered intravascular volume resulting from fluid loss. Atropine increases pulse rate by blocking parasympathetic nervous responses from reaching the heart.

factors that affect respiratory function:

age and gender: As children grow, their lung capacity increases for air and gas exchange. This larger volume requires fewer respirations to exchange oxygen and carbon dioxide. As an adult, the aging process causes the lungs to become less elastic, requiring more respirations for adequate gas exchange. Due to their larger lung capacity, men generally have a lower baseline respiratory rate than women. It is not possible to assess an accurate respiratory rate in crying children. Try to calm the child before counting respirations, or wait until the child is asleep. Infants and children with respiratory distress may breathe using accessory muscles, flaring nostrils or grunting sounds. If you observe any of these signs, take them seriously and see that the child receives immediate treatment. Due to their lower lung capacity, children can progress to respiratory failure much faster than adults. physical activity: The need for oxygen increases during exercise. The respiratory rate and depth increases during exercise to help deliver more oxygen to body tissues, while blowing off the additional carbon dioxide and body heat produced. altitude: At higher altitudes, the oxygen content of the air is less than at lower altitudes. To compensate for this lower oxygen concentration, the respiratory rate and depth increase to take in a larger respiration volume. emotional status: When the sympathetic nervous system is stimulated during heightened emotional states such as stress, the rate and depth of respirations increases. medications: Depending on their effect, medications can increase or decrease respiratory depth and rate. Respiratory medications such as albuterol and Atrovent cause lung bronchioles to dilate, allowing more air to move into and out of the lungs. These medications are often used for patients with respiratory diseases such as Chronic Obstructive Pulmonary Disease (COPD), bronchitis or emphysema. Narcotics such as morphine cause significant decreases in respiratory rate and depth. Patients taking narcotic opiates are closely monitored for respiratory status. body position: Respiratory rate and depth can even be altered due to body position. When a patient bends forward, stoops or slumps, respiratory volume can decrease and gas exchange is impaired. Fever: Heat is released through the lungs during a fever, increasing the respiratory rate. Smoking: Cigarette smoke damages lung tissue and airways. The airway swells and makes clearing mucous increasingly difficult. Lung tissue damage lowers respiratory depth and rate.

measurement sites of blood pressure:

arm - the brachial artery : The site most commonly assessed is the upper arm. The cuff is placed around the upper arm and brachial artery blood flow is auscultated in the antecubital fossa. Do not use an arm to measure blood pressure if the patient has had recent arm surgery, a mastectomy or an implanted atriovenous fistula or hemodialysis catheter, burns, trauma to the arm or a peripheral IV. Use the opposite arm or another site if any of these situations apply. forearm - the radial artery : Apply the cuff to the arm five inches below the elbow. Auscultate the radial artery for blood flow. Do not use this site in patients with hand or wrist injuries. ankle - the dorsalis pedis, posterior tibial arteries : The cuff is applied on the lower leg with the cuff border at the ankle. A standard arm cuff is often used at this site. It is important to select the correct cuff size based on the site location to ensure an accurate reading. The patient is positioned prone or supine. Do not measure blood pressure at this site if the patient has an ankle or foot injury. thigh - the popliteal artery : The cuff is applied over the thigh and blood flow is auscultated over the popliteal artery. The patient is in a prone or supine position. A larger cuff is usually required for an accurate reading. The systolic readings at this site are normally 20 to 30 mmHg higher than arm blood pressure. Do not measure blood pressure at this site if the patient has a leg, hip or thigh injury.

abnormal breathing patterns

bradypnea - rate below 12 bpm ; neurological or electrolyte disturbances, narcotic overdose, post-anesthesia tachypnea - rate above 20 bpm ; trauma, injury, stress, pain, respiratory, cardiac or liver disease cheyne-stokes - cyclic breathing pattern with periods of increased, deep respirations, alternating with periods of apnea ; congestive heart failure, drug overdose, increased cranial pressure kussmaul - increased rate above 20 bpm and depth of respirations ; metabolic acidosis, diabetic ketoacidosis, renal failure

* the _________ site is most accurate for taking a temperature.

rectal