Ch 11 vital signs - objectives and key terms
hyperthermia
When the body temperature is abnormally high, the condition is called hyperthermia
identify the rationale for each step of the vital signs procedures
okay, this is getting a little stupid
blood pressure
The blood pressure is the pressure exerted by the circulating volume of blood on the arterial walls, the veins, and the chambers of the heart. Blood pressure is measured in millimeters of mercury (mm Hg). Two pressures are actually elements of what we call blood pressure.
temperature
The body strives to maintain a temperature (a relative measure of sensible heat or cold) of 98.6° F (37° C that is considered normal. Variations from 97° to 99.6° F (36.1° to 37.5° C) are considered to be within normal range. Many factors have the potential to cause body temperature variances, including the environment, the time of day, the patient's state of health and activity levels, and the stage of the patient's monthly menstrual cycle. Regulation of body temperature is the job of the hypothalamus, which is located in the brain and forms the floor and part of the lateral wall of the third ventricle
diastolic
The lower number of the blood pressure reading, the second pressure, is the diastolic pressure.
cheyne-strokes respirations
Apnea is a lack of spontaneous respirations. Cheyne-Stokes respirations are an abnormal pattern of respiration characterized by alternating periods of apnea and deep rapid breathing. The periods of apnea increase as time goes on. Cheyne-Stokes respirations are noted in the critically or terminally ill patient
auscultate
Auscultate (listen for sounds within the body to evaluate the condition of heart, lungs, pleura, intestines, or other organs or to detect fetal heart tones) bowel, lung, and heart sounds with the diaphragm
hypertension
Hypertension occurs when the elevated pressure is sustained above 140/90 mm Hg. The diagnosis of hypertension in adults is not made with only one random elevated reading. For this diagnosis, an average of 90 mm Hg or higher of two or more diastolic readings on at least two subsequent visits is necessary, or an average higher than 140 mm Hg of two or more systolic readings on at least two visits.
state the normal limits of each vital sign
Neonate - HR per minute: 120-160, respiratory rate per minute: 36-60, BP: systolic 20-60 Infant - HR per minute: 125-135, respiratory rate per minute: 40-46, BP: systolic 70-80 Toddler - HR per minute: 90-120, respiratory rate per minute: 20-30, BP: systolic 80-100 School-age (6-10) - HR per minute: 65-105, respiratory rate per minute: 22-24, BP: systolic 90-100, diastolic 60-64 Adolescent (10-18) - HR per minute: 65-100, respiratory rate per minute: 16-22, BP: systolic 100-120, diastolic 70-80 Adult - HR per minute: 60-100, respiratory rate per minute: 12-20, BP: systolic 100-120, diastolic 70-80 Older adult - HR: 60-100, respiratory: 12-18, BP: systolic 130-140, diastolic 90-95
describe the benefits of and the precautions to follow for self-measurement of blood pressure
Self measurement is very convenient and allows the pt to play a bigger part in their health. Although the electronic devices are often easier to manipulate, there are some disadvantages. They easily become inaccurate and require recalibration more than once a year. Because of their sensitivity, improper cuff placement or movement of the arm frequently causes electronic devices to give incorrect readings. A useful blood pressure device that overcomes these difficulties fits around the wrist, does not require a stethoscope, is easy to use, and is well adapted for home use.
dyspnea
Shallow respirations make ventilation difficult to observe, and only a small amount of air is exchanged in the lungs. Dyspnea is breathing with difficulty.
List the factors that affect vital signs readings
factors that affect pulse rate: age, exercise, fever, heat, acute pain, anxiety, chronic pain, medications, hemorrhage, postural changes, metabolism, pulmonary conditions. factors that affect respiration rate: disease or illness, stress, fever, age, gender, body position, medications, exercise, acute pain, smoking, brainstem injury, hemoglobin function. factors that affect BP: age, anxiety, fear, emotional stress, pain, medications, hormones, face, obesity, gender, diurnal
tachycardia
if the pulse is faster than 100 beats per minute, the adult patient has tachycardia
bradycardia
if the pulse is slower than 60 beats per minute, the patient has bradycardia.
discuss the methods by which the nurse can ensure accurate measurement of vital signs
uhm... take them correctly?
hypotension
A blood pressure below normal is hypotension. A low blood pressure is considered healthy, provided there are no ill effects, such as vertigo (dizziness) or syncope (fainting).
pulse
A pulse is a rhythmic beating or vibrating movement. In the body, it signifies the regular, recurrent expansion and contraction of an artery produced by the waves of pressure that are caused by the ejection of blood from the left ventricle of the heart as it contracts. Each pulse beat corresponds to a contraction of the heart. The adult pulse rate is normally between 60 and 100 beats per minute, with the approximate average being 80.
tachypnea
A rapid respiratory rate is called tachypnea. Exercise and fever increase respiratory rate
bradypnea
A slow respiratory rate, below 10 per minute, is called bradypnea.
stethoscope
A stethoscope (an instrument that is placed against the patient's chest or back to hear heart and lung sounds) (Figure 11-4) is used to measure the apical rate of the heart (see definitions of apical and radial in the following section on the pulse). The major parts of the stethoscope are the earpieces, the binaurals, the tubing, and the chest piece.
accurately record and report vital signs measurements
Accuracy in documentation is important. Most facilities have graphic flow sheets for charting vital signs; Figure 11-1 shows an example. In some facilities, a rectal temperature is indicated with a small circled R, and axillary temperature with a small circled Ax (see Figure 11-1) next to the reading. The blood pressure is always written with the systolic first and the diastolic beneath: 120/80 mm Hg. A final /0 may be added (120/80/0) if the beat is clearly heard until the end. All abnormal findings must be immediately reported to the nurse manager or health care provider. In addition to actual vital signs values, any accompanying or precipitating signs and symptoms such as chest pain, vertigo, shortness of breath, flushing, and diaphoresis should be noted in the nurse's notes. Any interventions initiated as a result of vital signs measurement, such as tepid sponging (for temperature elevation), should also be documented.
pulse deficit
At times, a difference is found between the radial and the apical rates. This is called a pulse deficit. A pulse deficit is confirmed by one nurse listening to the apical rate, and a second nurse palpating the radial pulse at the same time, using the same watch for 1 full minute. A deficit exists when the radial rate is less than the apical rate. For example, an apical rate of 92 beats per minute and a radial rate of 88 beats per minute means there is a pulse deficit of 4. A pulse deficit signifies that the pumping action of the heart is faulty or there is a peripheral vascular issue.
apical pulse
Auscultation of the apical rate is essential on all cardiac patients, and when the radial pulse is irregular or is difficult to palpate or when certain medications such as digoxin (Lanoxin) make this necessary (Skill 11-3). Apical refers to apex (the tip, the end, or the top of a structure) of the heart. The apical pulse represents the actual beating of the heart. The apical pulse site is the best site to use when taking the pulse rate of an infant. When auscultating the apical rate, the "lub-dub" that is heard represents one cardiac cycle, or heartbeat
discuss the importance of accurate assessment of vital signs
Because vital signs are an indication of basic body functioning, it is appropriate to begin the physical assessment by obtaining these data. Vital signs and other physiologic measurements often provide the basis for problem solving. Careful technique ensures accurate findings. Many facilities have begun using a fifth vital sign: pain level or comfort level. Assessment of vital signs enables the identification of nursing diagnoses, implementation of planned interventions, and evaluation of success when vital signs have returned to acceptable values
sphygmomanometer
Blood pressure readings are taken with a sphygmomanometer and a stethoscope. A sphygmomanometer (a device for measuring the arterial blood pressure) consists of an inflatable cuff and a gauge. The gauge is aneroid (use of mercury-calibrated manometers is no longer advised) (see Box 11-8 and Figures 11-9 and 11-10). Inflate the cuff around the patient's arm to compress the artery, which occludes blood flow; then, slowly deflate it, which allows blood flow to resume. While doing this, listen at the brachial artery with the stethoscope to hear pulsating sounds
accurately assess the blood pressure
Blood pressure readings are taken with a sphygmomanometer and a stethoscope. A sphygmomanometer (a device for measuring the arterial blood pressure) consists of an inflatable cuff and a gauge. The gauge is aneroid (use of mercury-calibrated manometers is no longer advised). Inflate the cuff around the patient's arm to compress the artery, which occludes blood flow; then, slowly deflate it, which allows blood flow to resume (see the Evidence-Based Practice box). While doing this, listen at the brachial artery with the stethoscope to hear pulsating sounds. These are called Korotkoff sounds. The sounds go through five phases (Figure 11-11). At the first audible sound, make a mental note of the point on the sphygmomanometer gauge at which it occurs, and note again the point at which the sound disappears. That first point is the systolic pressure, and the second is the diastolic pressure. As the pressure is lowered, the Korotkoff sounds sometimes seem to disappear temporarily. In this case, listen for a subtle difference in the quality of what you hear as the manometer approaches the diastolic reading. In patients with hypertension, the sounds usually heard over the brachial artery disappear as pressure is reduced and then reappear at a lower level. This temporary disappearance of sound is the auscultatory gap. It typically occurs between the first and the second Korotkoff sounds. The gap in sound sometimes covers a range of 40 mm Hg and thus has the potential to cause an underestimation of systolic pressure or overestimation of diastolic pressure. Be certain to inflate the cuff enough to hear the true systolic pressure before the auscultatory gap.
accurately assess the height and weight measurements
For patients who are able to stand, ascertain height by using the metal rod attached to the back of the standing scale, which swings out and over the top of the head. A measuring stick or tape attached vertically to the wall is also possible to use. Ask patients to remove their shoes, step onto the platform or against the wall, and stand erect, exercising good posture. After obtaining the measurement, help the patient to carefully step off the scales and return to chair or bed as needed. Cleanse the scale with appropriate disinfectant Patients are weighed to give the health care provider information for prescribing medication dosages and to determine nutritional status and water balance. Because 1 L of fluid equals 1 kg (2.2 lb), a weight change of 1 kg (2.2 lb) often reflects a loss or gain of 1 L of body fluids. A significant loss of weight frequently points to an underlying disease. Patients should be weighed at the same time of day, on the same scale, and in the same type or amount of clothing to allow an objective comparison of subsequent weighings. An ideal time to weigh patients is in the morning after voiding and before breakfast.
dysrhythmia
If the amount of time between beats varies, there is an irregular pulse or dysrhythmia (any disturbance or abnormality in a normal rhythmic pattern, specifically, irregularity in the normal rhythm of the heart). In the normal pulse, the amount of time between beats is even.
describe the procedure for determining the respiratory rate
In assessing respirations, note the rate, the depth, the quality, and the rhythm. Assessment of the depth of respirations is completed by observing the movement by the diaphragm and the intercostal muscles. The best time to assess respirations is immediately after counting a radial or an apical pulse. The patient is unaware you are doing so and is less likely to consciously alter respirations.
accurately assess oral, rectal, axillary, and tympanic temperatures
Normal Body Temperatures According to Measurement Sites. oral 98.6° F, rectal 99.5° F, axillary 97.6° F, tympanic/temportal 98.6° F. Centigrade (C) 37.0° C 37.5° C 36.4° C 37.0° C When it is necessary to convert temperature readings, formulas are available to use. To convert Fahrenheit to centigrade, subtract 32° from the Fahrenheit reading and multiply the results by 5/9: (98.6 − 32) × 5/9 = 37. To convert centigrade to Fahrenheit, multiply the centigrade reading by 9/5 and add 32° to the reading: 37 × 9/5 + 32 = 98.6. 99.6° F (36.1° to 37.5° C) are considered to be within normal range. Many factors have the potential to cause body temperature variances, including the environment, the time of day, the patient's state of health and activity levels, and the stage of the patient's monthly menstrual cycle (Box 11-4). Regulation of body temperature is the job of the hypothalamus, which is located in the brain and forms the floor and part of the lateral wall of the third ventricle. The hypothalamus helps maintain a balance between heat lost and heat produced by the body.
orthostatic hypotension
Orthostatic hypotension (a drop of 25 mm Hg in systolic pressure and a drop of 10 mm Hg in diastolic pressure when a person moves from a lying to a sitting or from a sitting to a standing position) occurs when a person rises too quickly, usually from a supine position. The patient frequently feels lightheaded and unstable.
respiration
Respiration (the taking in of oxygen, its utilization in the tissues, and the giving off of carbon dioxide; the act of breathing [i.e., inhaling and exhaling]) is both internal and external. Internal respiration refers to the exchange of gas at the tissue level caused by the process of cellular oxidation (any process in which the oxygen content of a compound is increased), and the gas exchange that occurs in the alveoli of the lungs. The breathing movements of the patient that are observed are called external respirations
tympanic
Specially designated electronic thermometers are used to obtain the tympanic (membranous "eardrum") temperature (Figure 11-3, C). Tympanic thermometers have been available for many years and are now widely accepted. They are very likely more accurate than traditional thermometers, when placed correctly, because measurement is
pulse pressure
The difference between the two readings is called the pulse pressure. A reading of 120/80 mm Hg reveals a pulse pressure of 40, which is a normal pulse pressure. Pulse pressure is an indication of cardiac function.
accurately assess an apical pulse, a radial pulse, and a pulse deficit
The radial pulse rate is obtained at the radial artery, which is located on the thumb side of the inner wrist. On initial assessment, all major pulses should be palpated and the apical rate should be auscultated. Auscultation of the apical rate is essential on all cardiac patients, and when the radial pulse is irregular or is difficult to palpate or when certain medications such as digoxin (Lanoxin) make this necessary. Apical refers to apex (the tip, the end, or the top of a structure) of the heart. The apical pulse represents the actual beating of the heart. The apical pulse site is the best site to use when taking the pulse rate of an infant. When auscultating the apical rate, the "lub-dub" that is heard represents one cardiac cycle, or heartbeat (Figures 11-6 and 11-7). At times, a difference is found between the radial and the apical rates. This is called a pulse deficit. A pulse deficit is confirmed by one nurse listening to the apical rate, and a second nurse palpating the radial pulse at the same time, using the same watch for 1 full minute. A deficit exists when the radial rate is less than the apical rate. For example, an apical rate of 92 beats per minute and a radial rate of 88 beats per minute means there is a pulse deficit of 4. A pulse deficit signifies that the pumping action of the heart is faulty or there is a peripheral vascular issue. This is often seen in atrial fibrillation.
korotkoff sounds
The sounds you hear while taking the blood pressure are called Korotkoff sounds. The sounds go through five phases. At the first audible sound, make a mental note of the point on the sphygmomanometer gauge at which it occurs, and note again the point at which the sound disappears. That first point is the systolic pressure, and the second is the diastolic pressure.
systolic
The systolic pressure is the higher number and represents the ventricles contracting, forcing blood into the aorta and the pulmonary arteries. The occurrence of systole is indicated by the first sound heard on auscultation.
febrile
The terms pyrexia, febrile, and hyperthermia are used to describe the condition of having above-normal body temperature. Fever is actually a body defense. Elevated body temperature destroys invading bacteria. Temperatures exceeding 105° F (40.5° C) also have the potential to damage normal body cells, and therefore, intervention is often necessary
identify the guidelines for vital signs measurement
Vital signs are a part of the database obtained during assessment. The procedure for assessing vital signs is not routine. Part of the nurse's task is to individualize the procedure to each patient's needs and condition. Nurses must ensure their skills include all of the following: •Measuring vital signs correctly •Understanding and interpret the values •Communicating findings appropriately •Beginning interventions as needed Whether and how frequently vital signs are measured depend on the nurse's judgment of the need, the patient's condition, and the orders of the health care provider. If a possibility of contact with body secretions exists, gloves should be worn while obtaining vital signs.
vital signs
Vital signs include temperature, pulse, respirations, and blood pressure. The ability to obtain accurate measurements of vital signs is critical. Because vital signs are an indication of basic body functioning, it is appropriate to begin the physical assessment by obtaining these data. These data are called vital signs because of their importance.
hypothermia
When the body temperature is abnormally low, the condition is called hypothermia
list the various sites for pulse measurement
temporal, carotid, apical, brachial, radial, femoral, popliteal, posterior tibia, dorsalis pedis
discuss optimal frequency of vital signs measurements
• During admission and discharge to a health care facility • On a routine schedule as determined by health care provider's order or agency policy • Before and after surgical procedures • Before and after invasive diagnostic procedures • Before and after administering certain medications, especially those that affect cardiovascular, respiratory, and temperature control function • When the patient's general condition changes (loss of consciousness, hemorrhage, cardiac dysrhythmias, or the onset of intense pain) • Before and after certain nursing interventions (when a patient ambulates for the first time or after tracheal suctioning) • When the patient reports nonspecific symptoms of physical distress (reports of "feeling funny" or "different") • Routinely as part of a procedure (e.g., blood transfusion, liver biopsy, paracentesis, thoracentesis) • When assessing patient during home health visit • Pain is considered the fifth vital sign. Pain must be evaluated and documented each time other vital signs are taken.
