COMBO -- VITAL SIGNS (II)
*C=?*F
*C=(*F-32)x5/9
Signs of hypoxemia
- cool extremities - diaphoresis (profuse sweating) - decreased mental function/confusion - increased RR and depth of breathing - tachycardia - arrhythmia - difficulty breathing (using accessory muscles)
Factors Affecting Body Temperature
-Age -Exercise -Hormone Level -Circadian Rhythm -Stress -Environment -Temperature Alterations
FACTORS Affecting Body Temperature
-Age -Exercise (increases temp) -Hormonal Levels (progesterone) -Circadian rhythm (changes during 24 hour range) -Environment -Temperature alterations
Factors affecting Pulse
-Age & Gender-women have higher pulse rates than men, decreases as you age due to decreased metabolic rate -Physical activity-increases with exercise, conditioned athletes have a decreased heart rate -Fever & Stress-Increases pulse due to increased metabolic demands & heat loss - pain, fever, anxiety -Medications- certain meds can increase or decrease pulse rate -Disease- COPD, pneumonia, sepsis
FACTORS affecting Blood Pressure
-Age (less elastic arteriole) -Genetics -Ethnicity -Circadian rhythm (time of day) -Activities and weight (lifestyle) -Exercise -Stress/pain -Smoking (effects vessel walls) -Medications -Peripheral resistance -Elasticity -Blood volume -Viscosity
Reducing Fever
-Antipyretics -acetaminophen (tylenol products) -Ibuprofen (Motrin/Advil products) -ASA (aspirin) -Antibiotics -Cool the body
Brachial Artery Readings for BP should not occur
-Arteriovenous fistula or shunt is present -Arm, shoulder, or hand is diseased -Cast or bulky dressing is present -Intravenous fluids are being infused -The side of the body where axillary nodes were dissected or a mastectomy was performed -Risk of lymphedema (localized fluid retention and tissue swelling)
Treatment of fever
-Bacterial-antibiotic or anti infective -Viral-antivirals -Antipyretics- aspirin, ibuprofen, acetaminophen -Cool sponges, cool packs, hypothermia blankets -Fluids (oral or IV)-to prevent dehydration -Simple carbohydrates -prevent tissue breakdown -Reye's syndrome- do not take aspirin & combination products containing aspirin or salicylates by anyone younger than 19yrs of age during fever or flu like illness- affects the brain & liver
Korotkoff Phase 3
-Blood flows freely -crisper and more intense sound -thumping quality but softer than phase 1
ALTERATIONS in Breathing Patterns
-Bradypnea -Tachypnea -Hyperventilation -Cheyne-Stokes -Kussmaul -Sighing
Rate and Depth of Breathing
-Changes in response to tissue demands -Controlled by respiratory centers in the medulla and pons -Activated by impulses from chemoreceptors -Increase in carbon dioxide is the most powerful respiratory stimulant-causes an increase in respiratory rate & depth
Factors Affecting Body Temperature
-Circadian rhythms (body temperature is usually about 0.6C (1-2F) lower in the early morning than in the late afternoon and early evening. -Age and gender - Very old & very young are more sensitive to changes, women experience more fluctuations in body temperature than men, progesterone during ovulation increases body temperature. -Physical activity-physical exertion increases body temperature -State of health-disease conditions -Environmental temperature- body responds to changes in environmental temperatures (Hypothermia & Hyperthermia)
Pulse Pressure
-Difference between the systolic and diastolic -Normal Adult: 30-50 mmHg
Categories of Antihypertensive Medications
-Diuretics (to decrease fluid volume) -Beta-adrenergic blockers (to block sympathetic stimulation and decrease cardiac output) -Vasodilators and calcium channel blockers (to relax smooth muscles of arterioles and decrease peripheral vascular resistance) -ACE inhibitors (to prevent vasoconstriction by angiotensin II and decrease circulatory fluid volume by reducing aldosterone production)
Equipment for Assessing Temperature
-Electronic and digital thermometers -Tympanic membrane thermometers -Disposable single-use thermometers -Temporal artery thermometers -Automated monitoring devices
Hyperthermia
-Elevated body temp related to the inability of the body to promote heat loss or reduce heat production -Results from an overload of the thermoregulatory mechanisms of the body -Any disease or trauma to hypothalamus impairs heat-loss mechanisms Those at risk: elderly, young, joggers
Respiratory Rates
-Eupnea: normal, unlabored respiration; one respiration to four heartbeats -Tachypnea: increased respiratory rate; may occur in response to an increased metabolic rate, fever, respiratory diseases Hyperventilation: increase in rate & depth of respiration, ex pneumonia -Bradypnea: decreased respiratory rate; occurs in some pathologic conditions, increased intracranial pressure, drugs such as opiods -Apnea: periods when no breathing occurs, lasts more than 4-6 mins brain damage & death can occur -Dyspnea: difficult or labored breathing-rapid & shallow breathing -Orthopnea: changes in breathing when sitting or standing Patterns of respirations: Table 24-6
Factors Influencing Respiration
-Exercise -Acute Pain -Anxiety -Smoking -Body Position -Medications -Neurological Injury -Hemoglobin Function
Factors Influencing Pulse Rate
-Exercise -Temperature -Emotions -Drugs -Hemorrhage -Postural Changes -Pulmonary Conditions
FACTORS Influencing Respiration
-Exercise -pain -anxiety -smoking -body position -medications -neurological injury -hemoglobin
Temperature ALTERATIONS
-Fever (PYREXIA) >102.2 F -Patterns of a fever: -sustained: constant body temp continuously above 100 -intermittent: fever spikes intermitted with usual temp -remittent: fever spikes and falls w/out return to norm -relapsing: febrile episodes and periods with acceptable temperature
Types of Fever
-Fever (Pyrexia)-increase above normal body temperature -Person with a fever-febrile -Person without a fever-afebrile -Intermittent: temperature returns to normal at least once every 24 hours -Remittent: temperature does not return to normal and fluctuates a few degrees up and down -Sustained or continuous: temperature remains above normal with minimal variations -Relapsing or recurrent: temperature returns to normal for one or more days with one or more episodes of fever, each as long as several days
Blood Pressure
-Force of blood moving against the arterial walls -Pressure rises as the ventricles contract (Systole) -Pressure falls as the ventricles relaxes (Diastole) -120/80: 120 is the systolic BP & 80 is the diastolic BP -Pulse pressure-difference between the systolic & diastolic pressure -Compliance-arterial walls stretch & distend -With increased age the walls get less elastic - increased BP
Hypothermia
-Heat loss during prolonged exposure to cold overwhelms the ability of the body to produce heat -Frostbite -Low body temp -Classifications -Mild; 93.2-98.6 F -Moderate: 86.0-93.2 F -Severe less than 86 F Nursing care: -provide warm environment -provide dry clothing -apply warm blankets -keep limbs close to body -cover client scalp -supply warm oral or intravenous fluids -apply warming pads
Blood Pressure
-Increased BP-Hypertension- when the systolic BP is 140 mm Hg or diastolic BP is 90 mm Hg or higher -AHA-recommends that BP readings be measured on 2 or more subsequent occasions -Taken 5 mins after the pt rests & not consumed caffeine or smoked for 30 mins before -Decreased BP-Hypotension (90-115 mm Hg), normal in trained athletes -Hypotension, tachycardia, pallor, increased sweating, & confusion-report it immediately -Orthostatic hypotension - postural hypotension, decrease in SBP of 20 mm Hg or a decrease in DBP of 10 mm Hg within 3 mins of standing when compared with BP from the sitting or supine position- dizziness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpitations & headache, caused by dehydration, neurologic, CV or endocrine problems
EFFECTS of Fever
-Increased oxygen demand -Increased heart rate and cardiac output -May lead to: -dehydration -acid-base and electrolyte imbalance (b/c of loss of fluid in diarrhea and vomiting ((sodium/potassium levels)) -cardiac dysrhythmia (brady:low HR, tachy: high HR) -neurological damage (assess consciousness)
Vital Signs
-Indicators of bodily function that reflect health status of the patient -Regulated through homeostatic mechanisms -Includes Temperature, Pulse, Respirations, Blood Pressure, and Pain -Oxygen saturation is frequently included -Vital signs are used to: -monitor patients condition -identify problems -evaluate response to intervention
Thermoregulatory center
-Located in Hypothalamus (regulates temp) -receives messages from cold and warm thermal receptors in the body -initiates responses to produce or conserve body heat or increase heat loss -to maintain normal temp, heat gained must equal heat lost
PAIN (5th vital sign)
-Location -Describe -pain scale -constant/intermittent -radiates -does anything make it better or worse? -does the patient want something for it? -OLDCARTS -When pain is rated at 5 or higher INTERVENTION is required!!!!!!!
Physical effects of Fever
-Loss of appetite -Headache -Hot, dry skin -Flushed face -Muscle aches -Thirst -Fatigue -Young children-seizures (febrile seizures) -Older adults-delirium 7 confusion -Fever blisters-fever activates the -Type 1 herpes simplex virus -Complications-Fluid , electrolyte & acid-base balances
Korotkoff Phase 4
-Muffled with a soft, blowing sound
Korotkoff Phase 2
-Muffled, whooshing, or swishing sound
RANGES for Blood Pressure
-Newborn 40mmHg -1 month 85/54 mmHg -1 year 95/65 mmHg -6 years 105/65 mmHg -10-13 years 110/65 mmHg -14-17 years 120-65 mmHg -18+ years 120/80 mmHg
CLASSIFICATIONS of Blood Pressure
-Normal 120/80 -Prehypertensive 139/89 -Stage 1 Hypertension 159/99 -Stage 2 Hypertension 160/100 +
Pulse Rate
-Normal-60-100 beats/min (vary across the lifespan) Table 24-1 -Tachycardia - rapid heart rate (100-180 beats/min)- fever, pain, blood loss, decreased BP, fear, anxiety -Bradycardia-decrease pulse rate (below 60 beats/min)- slower during sleep in men, thin people, hypothermia, severe pain, increase intracranial pressure, MI, suctioning, vagal stimulation (bearing down), beta blockers -Bradycardia with difficulty breathing, changes in LOC, decreased BP, ECG changes & chest pain (angina)-report it immediately -Atropine IV is the drug of choice
Assessing Temperature
-Oral - person must be able to close his/her mouth, should not be taken in people with diseases of the oral cavity or had oral surgery -Tympanic membrane-should not be used in pts with drainage from the ear, ear pain, ear infection or scars on the tympanic membrane, same as oral -Temporal artery - do not take it over scar tissue, open lesions or abrasions, only on exposed areas, same as oral -Axillary - used when both oral & rectal sites are contraindicated -Rectal-core temperature, most accurate route, should not be used in newborns, children with diarrhea, those who had rectal surgery, rectal disease, spinal cord injuries, low white blood cell count & low platelet count -Also stimulates the vagus nerve, slows the heart rate-not allowed in pts with cardiac or heard dz, 1 degree higher than oral.
Normal Ranges for Vital Signs for Healthy Adults
-Oral temperature—37.0°C, 98.6°F -Pulse rate—60 to 100 (80 average)beats/min -Respirations—12 to 20 breaths/min -Blood pressure—120/80 mm Hg
Normal Temperatures for Healthy Adults
-Oral: 37.0°C, 98.6°F -Rectal: 37.5°C, 99.5°F -Axillary: 36.5°C, 97.7°F -Tympanic: 37.5ºC, 99.5°F -Forehead: 34.4°C, 94.0°F
Factors Influencing Pulse Ox Test
-Outside light sources -Carbon Monoxide -Patient motion -Jaundice -Nail Polish, Artificial Nails -Dark Skin Pigments
Factors Affecting Frequency of Vital Signs Assessment
-Patient's medical diagnosis -Co-morbidities -Types of treatments received -Patient's level of acuity
Pulse Physiology
-Peripheral pulse-throbbing sensation that can be palpated over the peripheral artery -Apical pulse-auscultated over the apex of the heart -Lub-dub (closure of the valves) -Lub-closure of the tricuspid & mitral valves, Dub-closure of the pulmonic & aortic valves (combination is one beat) -Regulated by the autonomic nervous system through cardiac sinoatrial node -Parasympathetic stimulation—decreases heart rate -Sympathetic stimulation—increases heart rate -Pulse rate = number of contractions over a peripheral artery in 1 minute
Korotkoff Phase 5
-Pressure level when the last sound is heard -Period of silence -this is the diastolic reading
Heat Production
-Primary source is metabolism. -Hormones, muscle movements, and exercise increase metabolism. -Epinephrine and norepinephrine are released when additional heat is required, and alter metabolism. -Thyroid hormone and shivering also increase heat production. -Energy production decreases and heat production increases.
Heatstroke
-Prolonged exposure to the sun or a high env. temperature overwhelms the heal-loss mechanisms of the body -104 F or higher (some at 113 F) -Signs and symptoms: giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, incontinence -Most important symptom: HOT, DRY SKIN -Those At risk: cardiovascular disease, hypothyroidism, diabetes or alcoholism
Characteristics of the Peripheral Pulse
-Rate: Normal, tachycardia, bradycardia -Amplitude and quality (strong or weak) -Rhythm - Regular or Irregular (Dysrhythmia) -Volume of blood ejected with each heartbeat (stroke volume)
ASSESSMENT of Ventilation
-Respiratory rate -Ventilatory depth -ventilatory rhythm
Treatment of Hypothermia
-Rewarming the pt -Heated blankets or pads -Radiant warmers -Warm fluids orally or IV
Appropriate Times to Measure Vital Signs
-Screenings at health fairs and clinics -In the home -Based on agency or institutional policy & procedures -Upon admission to any health care agency -Anytime there is a change in patient's condition -When medications are given that affect cardiac rate and rhythm -Before and after invasive diagnostic and surgical procedures -Before & after activity that may increase risk, such as ambulation after surgery -In emergency situations
Sources of Heat Loss
-Skin (primary source) -Evaporation of sweat -Warming and humidifying inspired air -Eliminating urine and feces
Equipment
-Stethoscope: bell-low frequency sounds like the heart, diaphragm-high frequency sounds-respiration -Doppler Ultrasound-difficult to palpate or auscultate -Apical Pulse-preferred method for infants & children less than 2 years -Heard over the 5th & 6th rib about 3 in to the left of the median line slightly below the nipple -Apical-Radial pulse- a difference in the apical-radial pulse is called pulse deficit, heartbeat is not reaching the peripheral arteries or are too weak to be palpated
Patterns of Fever
-Sustained -Intermittent -Remittent -Relapsing
Pulse Sites
-Temporal -Carotid -Apical -Brachial -Radial -Ulnar -Femoral -Popliteal -Posterior tibial -Dorsalis pedis
BLOOD PRESSURE
-The pressure exerted by circulating volume of blood on the arterial walls, veins, and chambers of the heart -Systolic: the higher number; represents the ventricles contracting -Diastolic: the second number; represents the pressure within the artery between beats -Normal BP: 120/80 mmHg
INTERVENTIONS for those with Fever
-blood cultures if ordered (dependent) -minimize heat production -maximize heat loss -promote comfort -monitor client -control env. temp
Determines one's ability to control temperature
-degree of temperature extreme -person's ability to sense feeling comfortable or uncomfortable -though processes or emotions -person's mobility or ability to remove or add clothes
Korotkoff Phase 1
-first faint, clear thumping sounds -this is systolic reading
Fever-SIGNS/SYMPTOMS
-hot, dry, flushed skin -headache -thirst -loss of appetite -malaise (mild sickness or depression) -dry lips (water based lip balm ONLY) Dangerous signs and symptoms: -Rapid heart rate -dehydration -decreased urinary output -seizures
PULSE
-indicator of circulatory status -palpable bounding of blood flow noted at various points on the body -palpable over peripheral artery -auscultated over apex of heart -REGULATED BY SINOATRIAL (SA) NODE -mechanical, neural, and chemical factors regulate ventricular contraction and stroke volume
ASSESSMENT of Diffusion and Perfusion (SaO2)
-measurement of arterial oxygen saturation (SaO2), the percent of hemobloin that is bound with oxygen in the arteries -95-99% -Areas include; digits, earlobe, disposable
RANGES for Respiratory Rate
-newborn 30-60bpm -Infant (6 mo) 30-50bpm -Toddler (2 yr) 25-32bpm -Child 20-30bpm -Adolescent 16-19bpm -Adult 12-20bpm
Guidelines for Measuring Vitals
-nurse must measure vital signs correctly -know your equipment (troubleshoot equip) -ID your patient -be organized, use systematic approach (head to toe) -delegate appropriately (LPN, PCT, CNA) -analyze and interpret trends (normal ranges) -begin interventions (notify primary provider if vitals are too high) -communicate and document (record vitals in room, document outside room!)
Orthostatic/postural hypotension*
-occurs when a normotensive person develops symptoms and low BP when rising to an upright position (changes from a lying/siting/standing position. -drop in BP and dizziness with position change -Due to peripheral vasodilation accompanied by no increase in cardiac output -Those at risk: -elderly with bedrest -postoperative with dehydration -blood loss with cardiac, bp, sedative or narcotic medications Prevented by: -dangling for a few minutes (raising head of bed, then assist in sitting up) -Keep hand on patient to establish stability
Heat Exhaustion
-occurs when profuse diaphoresis results in excess water and electrolyte loss -caused by env. heat exposure, -signs and symptoms: FLUID VOLUME DEFICIT
Where can a temperature be measured?
-oral -axillary -rectal (most accurate) -tympanic
5 Vital Signs
-pulse -BP -temperature -respiratory rate -pulse oximetry
Term- Bradycardia
-pulse is lower than 60 beats per minute -may result from unrelieved severe pain, drugs, resting, and heart block
ASSESSMENT of Pulse
-review sites -use stethoscope for apical pulse -Character of pulse: rate, rhythm, strength, equality, comparison of apical and radius -dorsalis pedis used to check circulation of lower extremity*
Hypotension
-systolic falls to 90 mmHg or less -dilation of arteries -loss of blood volume -failure of heart muscle to pump adequately (myocardial infraction) -decrease of blood flow to vital organs
RESPIRATION
-the mechanism the body uses to exchange gases between the atmosphere and the blood and the blood and the cells -
Term- Tachycardia
-the pulse is faster than 100 beats per minute -may result from shock, hemorrhage, exercise, fever, acute pain, and drugs
Hypertension
-thickening of walls -loss of elasticity -family history -most common alteration in blood pressure -can be asymptomatic (no symptoms present) -major cause of death from CVA -major contributor to MI -Risks include: -obesity -smoking -alcohol -sodium intake -stress
Diversity Considerations of Blood Pressure
-upset or restless child - Getting readings are difficult and may be inaccurate. -Elderly - fragile skin; medication can increase BP -Females- lower BP after puberty than males -African Americans older than 35 - higher BP than European Americans -Obesity linked to a higher incidence of hypertension
Describe pulse quality
0- absent 1- weak or thread y 2- normal equality 3- bounding or full
Factors that cause Hypotension (5)
1. Age 2. Dehydration 3. Hemorrhaging 4. Medications 5. Inadequate heart contractions
Factors that influence respiratory assessment (7)
1. Age 2. Exercise 3. Pain 4. Disease 5. Altitude 6. Anemia 7. Medications
Factors that cause tachypnea (6)
1. Anything causing an increase in CO2 and a decrease of O2 2. Respiratory Distress 3. Fever 4. Medications 5. Anxiety 6. Age
What are the indicators of a person's state of health and function of the body systems?
1. BP - 120/80 2. HR - 60-100 3. RR - 12-20 4. Temp - 98.6
Facts that decrease vascular resistance
1. Exercise 2. Hydration 3. vasodilators 4. balance diet
Factors contributing to bradycardia
1. Medications 2. Hypothermia 3. Age 4. Fitness Level 5. Heart disease
Factors that influence increased vascular resistance (4)
1. Plaque 2. Decreased Elasticity 3. Dehydration (thickening of the blood) 4. vasoconstrictors- caffeine nicotine
Factors contributing to Tachycardia (7)
1. Temperature 2. Poor oxygenation of the Blood 3. Exercise 4. Medications 5. Pain 6. Anxiety 7. Low BP
Factors that cause bradypnea (2)
1. Too many narcotics or opioids 2. Increased intracranial pressure
(9) Causes of tachycardia
1. exercise 2. fear 3. anxiety 4. fever (hyperthermia/febrile) 5. hypoxemia (decrease 02 in blood) 6. medication 7. high ambient temperature 8. hypotension (low BP) 9. anemia
(8) Causes of tachypnea
1. hypoxemia 2. fever 3. exercise 4. anxiety 5. increased CO2 6. metabolic acidosis 7. pain 8. atelectasis
(2) Causes of biots
1. increased intracranial pressure 2. disease of medulla
Types of Interventions (3)
1. independent 2. dependent 3. collaborative
(3) Causes of bradycardia
1. medication 2. diseased heart 3. hypothermic (to preserve function)
(3) Causes of hypotension
1. medication 2. hypovelemia (not enough circulating blood volume) 3. diseased heart
(4) Causes bradypnea
1. medication (narcotics) 2. overdose 3. hypothermia 4. head injury
(5) Pulse points
1. radial 2. brachial 3. apical 4. carotid 5. femoral
(3) Causes of hypothermia
1. severe head injury 2. exposure 3. near-drowning
Factors that cause Hypertension and interventions
1. thick arterial walls and loss of vascular elasticity 2. Increase in peripheral vascular resistance Interventions: vasodilators or change diet and lifestyle
Under what circumstances do we treat a fever? (3)
1. uncomfortable pain 2. Fever is too high 3. Seizers occur
Typical Assessment of Patient with Fever (9)
1.Diaphoretic (sweaty) 2. Lethargic 3. Flushed Skin 4. Muscle aches 5. headache 6. Loss of appetite 7. Seizures- young children 8. Delirium - older adults 9. Increased respirations and HR
normal respiratory rate
12 to 20 BPM for an adult
Respiration
12 to 20 breaths/min
Normal RR
12-20
Normal adult respirations
12-20
Normal respiratory rate
12-20 breaths/min
Normal BP
120/80
Normal adult blood pressure
120/80
Aged adult respirations Normal
16-24
Pulse pressure
30 to 50 mmHg
Normal pulse pressure
35-40 mmHg (if <30, may be difficult to detect peripheral pulse)
Aged adult temperature Normal
35.8-36.8C 96.4F
Normal adult temperature
35.8-37.5C 96.4-99.5F
Aged adult pulse Normal
40-100
Discuss the guidelines for measuring pt vital signs: A. assessment B. routine measurement C. delegation considerations
A. Assessment: typically done q4-8 hours for stable pts; q 15-60mins for post procedure or post surgical; q5mins or continuously for unstable pts Identify changes in pt status Established pt trends baseline values are obtained at first visit B. Routine Measurements: pts have vital signs checked every time they visit outpt clinic or once a week in some psych settings or long term health care facilities C. Delegation Considerations: nurses can only delegate vital signs to a uap IF pt is STABLE
Normal tidal volume
500 mL/ 0.5 L
Normal adult pulse
60-100
Normal pulse rate
60-100 beats/min
Pulse
60-100 beats/min
Oxygen level
80-100
Normal body temperature
97.0*F-99.5*F
Average axillary temperature
97.7 F
Average oral/tympanic Temperature
98.6 F
37*C
98.6*F
Average Rectal Temperature
99.5 F
Describe bradycardia
< 60 bmp
Describe tachycardia
> 100 bmp
Assessing Blood Pressure
>Listening for Korotkoff sounds with stethoscope -First sound is systolic pressure. -Change or cessation of sounds occurs—diastolic pressure. >The brachial artery and popliteal artery are commonly used.
Major Classifications of Hypertension
>Primary (essential) -Characterized by an increase above normal in both systolic and diastolic pressures -No known cause >Secondary -Caused by another disease conditions -Common causes include kidney disease, adrenal cortex disorders, and aorta disorders -Table 24-7- categories for BP in adults -Risk factors: family hx of HTN, Type 2 Diabetes, obesity, high cholesterol, sedentary lifestyle, high intake of salts, fats & calories, use of oral contraceptives, sleep apnea, smoking & alcohol consumption
Respirations
>Pulmonary ventilation or Respiration: movement of air in and out of lungs -Inhalation: breathing in -Exhalation: breathing out >Diffusion -Exchange of oxygen and carbon dioxide between the alveoli of lungs and circulating blood >Perfusion -Exchange of oxygen and carbon dioxide between circulating blood and tissue cells
Korotkoff IV
A distinct, abrupt muffling sound
Term- Apnea
A lack of spontaneous respirations
Febrile
A person with a fever
bradypnea
A respiratory rate less than 12 breaths/min
Bradycardia
A slow heart rate <60 bpm in the adult
bradycardia
A slow pulse; any pulse rate below 60 beats per minute
Describe assessment findings for an adult pt A. Normal vital signs: temp, pulse, respirations, blood pressure B. Abnormal vital signs: temp, pulse, respirations, blood pressure
A. Normal Vital Signs: Temp: 96.8-99.6 F Pulse: 60-100 bpm Respirations: 12-20 bpm (EUPNEA) BP: <140 systolic (<150 in adults 60 and over), <90 diastolic B. Abnormal Vital Signs: 1. Temp: hypothermia: low body temp ( <96.8) hyperthermia: elevated body temp (> 99.6) Fever: (febrile, pyrexia); rise in body temp above norm 2. Pulse: Tachycardia: increase in heart rate (>100 bppm) Bradycardia: slow heart rate (<60 bpm) *pulse rhythm: dysrhythmia/arrhythmia: early, late or missed heart beat 3. Respiratory Rate: Apnea: absence of breathing Tachypnea: >24 bpm Bradypnea: <10 bpm Orthopnea: difficulty breathing in positions other sitting or standing Dyspnea: difficult or labored breathing; rapid, shallow Hypoventilation: shallow respirations Hyperventilation: deep, rapid repsirations 4. Blood Pressure: A. Hypotension: systolic <90, diastolic <60 B. Hypertension: systolic >140, diastolic >90
Identify factors that influence pt vital signs: A. temperature B. Pulse C. Respiratory rate D. blood pressure
A. TEMPERATURE: Age, (very young/very old), recent exercise, hormone fluctuations, circadian rhythm, stress, environment B. PULSE: 1. age: ^ age, v pulse 2. fever: (pulse ^ w/ fever), 3. medications: can either ^ or v pulse 4. Hypoxia and Hypoxemia: When O2 levels drop, cardiac output ^ and pulse ^ 5. Stress: Sympathetic nervous system stimulation from stress (anxiety, fear, etc) and pulse ^ 6. Pathology: heart conditions or illnesses that impair oxygenation can alter pulse as cardiac attempts to compensate for low O2 levels 7. Electrolyte Imbalance: changes in K, Na and Ca affect pulse rate and rhythm C. RESPIRATORY RATE: age, exercise, illness processes, acid-base balance, medications, pain, emotions D. BLOOD PRESSURE: 1. age: ^ age, ^ BP 2. gender: lower in women than in men (until menopause) 3. race: HTN more prevalent in African American men and women 4. medications: oral contraceptive can ^ BP in some women 5. weight: BP ^ in obese pts 6. circadian rhythm: v BP in morning, slightly ^ in PM 7. head injury: ^ intracranial pressure from injury causes ^ BP 8. food intake: ^ BP after eating 9. emotions: anger, fear, excitement will ^ BP until emotion passes 10. pain: pain causes ^ BP
Describe the methods of accurately assessing vital signs: A. temperature B. pulse C. respirations D. 2 step blood pressure E. Oxygen Saturation F. Pain
A. Temp: mouth, ear, rectum, forehead, axilla B. Pulse: palpate at: temporal, carotid, apical, brachial, radial, femoral, popliteal, posterior tibial, pedal (dorsalis pedis) C. Respirations: measurement of breathing rate, depth, rhythm; routinely includes measurement of levels of O2 saturation by pulse oximetry; assessment by observing chest and abdominal movements for effort and symmetry; count breaths per min (1 ins/1 exp = 1 cycle) D. 2-Step BP: Find brachial pulse (or radial if needed), palpate and use sphygmomanometer until pulse is no longer felt, ^ 30 more mmHg, release knob slowly and note when you feel pulse again (palpable systolic), wait 30 secs, and inflate cuff back up to palpable systolic (+30mmHg), using stethoscope listen for first sound and note, this will be systolic number, and listen for last sound before silence, this will be diastolic E. Oxygen Saturation: measured using pulse oximeter F. Pain: measured by asking pt to rate their pain on a scale of 1-10
Discuss nursing interventions used during the assessment of: A. temperature
A. temperature: when treatment is indicated for an ^ temp, non steroidal drugs with antipyretic effect (aspirin or acetaminophen) may be ordered, cool sponge baths, cooling blankets, and cool packs are used to reduce fever. but they can ^ energy expenditure by stimulating shivering. No aspirin to children <2 years of age. Identify underlying cause assess pt frequently for changes monitor body temp and other vital signs q2h, provide oral or IV fluids to replace fluid loss from ^ respirations and sweating Provide prescribed interventions (such as antibiotics, etc.) Implement nonpharmacologic measures to reduce the fever without causing shivering Keep clothing and bedding dry enourage physical rest to reduce metabolic demands and O2 use provide nutritional support to meet increased metabolic demands
Dysrhythmia
Abnormal cardiac rhythm
orthopnea
Abnormal respiratory symptom in which a person must sit or stand to breathe deeply or comfortably
Term- Kussmaul Respiration
Abnormally deep, regular and increased in rate
hypertension
Abnormally high blood pressure
hypotension
Abnormally low blood pressure
hypothermia
Abnormally low body temperature
Apnea
Absence of breathing
apnea
Absence of breathing
Apnea
Absence of breathing for several seconds Brain damage occurs after 4 to 6 minutes of apnea. Factors - Respiratory distress, obstructive sleep apnea
afebrile
Absence of fever
0 pulse amplitude
Absent, unable to palpate
Inspiration (inhalation)
Act of breathing in
Expiration (exhalation)
Act of breathing out
Situations that require VS assessment
Admission to establish baseline Part of Physical Assessment Inpatient Stay as routine monitoring With any change in health status Before & After surgery or invasive procedure Before & After taking medication Before & After interventions To detect improvement in condition Before discharge or transfer from unit
Factors Affecting Body Temperature
Age, Exercise, Hormone fluctuations, Circadian rhythms - lowest at 3:00am, highest at 6:00pm, Stress, Environment, and Smoking
Factors Affecting Respiratory Rate and Depth
Age, Exercise, Illness, Acid-base balance, Medications, Pain, and emotions
Factors Affecting Pulse Rate
Age, Gender, Fever, Medications, hypovolemia (loss of blood), hypoxia (low oxygen), hypoxemia (low arterial oxygen), stress, pathology, electrolyte balance
Factors Affecting Blood Pressure
Age, Gender, Race, Medications, Weight, Circadian rhythm, Head injury, Increased blood volume, food Intake, Emotions, and pain
Factors affecting BP
Age, circadian rhythm, stress, pain, gender, race/ethnicity, health: weight, exercise, food intake: emotional state, drugs/medication
Factors effecting respiratory rate, depth, and movements
Age, exercise, acid-base balance, brain lesions, increased altitude, respiratory diseases, anemia, anxiety, medications, acute pain
Factors affecting respirations
Age, exercise, smoking, respiratory/cardiovascular disease, medications, trauma, infection, pain, anxiety, injury to brain stem
Cheyne Stokes
Alternating periods of deep rapid breathing and periods of apnea
Cheyne-Stokes Respirations
Alternating periods of deep, rapid breathing followed by periods of apnea but regular due to drug overdose, heart failure, increased cranial pressure
Identify sites for assessing pulse.
Although peripheral pulses are most commonly assessed, an apical pulse or an apical-radial pulse should be assessed in certain situations.
Identify sites for assessing blood pressure.
Although various sites may be used to assess the blood pressure, the brachial artery and the popliteal artery are most commonly used. There is also blood pressure at the radial artery.
2. Dependent Intervention
Always requires Dr. order (taking vitals every 4 hours, offer water, turn patient to promote circulation)
Who evaluates the vital signs?
Always the nurse
tachypnea
An abnormally rapid rate of respiration usually or more than 20 breaths per minute.
Tachycardia
An excessively fast heart rate >100 bpm in the adult decrease in cardiac filling time, resulting a decreased cardiac output.
pulse
An indirect measurement of the patient's cardiac output. measured as the number of times the heart beats in 1 minute.
Pulse deficit
An inefficient contraction of the heart the fails to transmit a pulse wave to the peripheral pulse site.
dysrhythmia or an arrhythmia.
An irregular rhythm in the pulse, caused by an early, late, or missed heartbeat
How are you going to treat the fever?
Antipyretic; Motrin or Tylenol (alternate with each)
Term- Dysrhythmia
Any disturbance or abnormality in a normal rhythmic patten, specifically irregularity in the normal rhythm of the heart
Assess vital signs
Any time there is a change in the patient's condition
Assess vital signs
Any time there is a loss of consciousness
Pulse rate =
# of contractions over a peripheral artery/heart apex in one minute, as left ventricle contracts
Fahrenheit
(9/5 x C)+32
Celsius
(F-32)x5/9
Fever
(Pyrexia) is a rise in body temperature above normal, caused by trauma or illness with an infection, tissue injury, cancer, trauma, or surgery. Patients have loss of appetite (anorexia), headache, malaise, hot and dry skin, flushing, thirst, shivering, and a general feeling of not being well.
Compare and contrast factors that increase or decrease pulse.
As heart rate increases, cardiac output also increases which can include tachycardia. Can become decreased with bradycardia, sleeping, hypothermia, and some medications.
BP Error: Falsely high reading is caused by
Assessing blood pressure too soon after patient smoking or exercise - Use of a cuff that is too narrow - Releasing the pressure valve too slowly - -Re-inflating the bladder before it has completely deflated
Korotkoff sound phase II
Auscultatory gap
Blood pressure
Average: <120/<80 mmHg
Average adult temperature at 5 sites
Axillary 97.7 or 36.5 Oral 98.6 or 37 Temporal 98.6 or 37 Rectal 99.5 or 37.5 Tympanic 99.5 or 37.5
Hypotension
BP < 90/60 mmHg
Hypertension
BP > 140/90 mmHg (idiopathic)
Assess vital signs
Based on agency or institutional policy and procedures
Initially, you should always measure VS to establish a patient's __________.
Baseline
Assess vital signs
Before administering medications that affect cardiovascular and respiratory function
Assess vital signs
Before or after activity that may increase risk, such as ambulatory after surgery
Assess vital signs
Before or after any surgical or invasive diagnostic procedure
Hypotension
Blood pressure below the lower limit of normal
Assess blood pressure accurately.
Blood pressure can be within a wide range and still be normal. A rise or fall of 20 to 30 mm Hg in a person's blood pressure is significant, even if it is within the generally accepted normal range. Optimal blood pressure for adults is defined as less than 120/80 mm Hg.
Hypertension
Blood pressure elevated above the upper limit of normal
Explain the physiologic processes involved in homeostatic regulation of blood pressure.
Blood pressure refers to the force of the moving blood against arterial walls. The pressure rises as the ventricle contracts (systole) and falls as the heart relaxes (diastole). The highest pressure, created during ventricular contraction, is the systolic pressure. When the heart rests between beats during ventricular diastole, the pressure drops. The lowest pressure present on arterial walls at this time is the diastolic pressure.
Cyanosis
Bluish discoloration of the skin and mucous membranes, results from decreased oxygen levels in arterial blood
Ex of conduction
Body heat melting an ice pack
Vital signs
Body temperature, pulse, respiratory rate, blood pressure, and pain (the 5th vital sign)
+3 pulse amplitude
Bounding
Factors Affecting Blood Pressure
Box 24-5 Age, gender, race Circadian rhythm Food intake Exercise Weight Emotional state Body position Drugs/medications
Arteries for BP
Brachial, Radial, Popliteal, Posterior tibial, or Dorsalis pedis
Decreased respiratory rate
Bradypnea- decrease rate increase inter cranial pressure hypoventilation-decreased rate and depth
+2 pulse amplitude
Brisk, expected (normal)
Heat
By-product of metabolism
Factors that influence body temperature (5)
CARDIAC RHYTHMS (Different temp at different time of day lowest at morning highest between 4-8 pm), AGE & GENDER, PHYSICAL ACTIVITY (exercise increases temp), STATE OF HEALTH (illness raises body temperature), ENVIRONMENTAL TEMPERATURES (Being exposed to extremely hot or cold conditions with out adequate clothing)
Secondary hypertension
Caused by another disease condition; kidney disease, disorders of the adrenal cortex, disorders of the aorta
Apical pulse
Central pulse that can be auscultated over the apex of the heart at the point of maximal impulse (PMI).
Hypoventilation
Characterized by shallow respirations; it is associated with drug overdose, obesity, COPD and cervical spine injury.
Severe
Classification of Hypothermia <86
Moderate
Classification of Hypothermia: 86.0 - 93.2
Mild
Classification of Hypothermia: 93.2 - 96.8
Hyperventilation
Condition causing increase carbon dioxide and decrease oxygen in the blood, increasing rate and depth of respirations
Febrile
Condition in which the body temperature is elevated
Afebrile
Condition in which the body temperature is not elevated
Signs and symptoms of Heatstroke
Confusion, delirium, excessive thirst, nausea, muscle cramps, and high temperature and heart rate, hot, dry skin and absence of sweating.
Korotkoff III
Crisp, loud sounds as the blood flows through an opening artery
Describe circadian rhythm
Cyclical repetition of certain physiological processes (changes in temp and blood pressure that occurs in a 24 hour period) - low in am high in pm
Tachycardia causes
Decrease in BP, elevated temp, decreased O2, exercise, to much heat, pain, strong emotion, some meds
Bradycardia causes
Decrease metabolic demands, thinner, age, hypothermia, some meds/diseases, vagal stimulation
Hypothermia
Decreased body temperature and respirations, pale and cool skin, hypotension (decreased blood pressure), decreased muscle coordination and urinary output, disorientation, and drowsiness progressing to coma
PNS stimulation of SA node
Decreased heart rate
Hypoventilation
Decreased rate and depth and irregular respiration due to overdose of narcotics or anesthetics
Alkalosis
Decreased respiratory rate as the body tries to retain carbon dioxide
Hyperventilation
Deep, rapid respirations; it is often caused by stress or anxiety.
BP Error: Inaccurate reading is caused by
Defective equipment - Equipment not calibrated - Improper use of equipment - Patient not positioned correctly
Signs of fever
Dehydration, decreased urinary output, and rapid heart rate. Older people may demonstrate only a slight rise in temperature with pneumonia.
Nurse's Responsibility
Determines if the patients is medically stable Interprets or evaluate of vital signs Make sure the UAP knows the proper techniques Make sure the UAP knows what need to be reported immediately for each patient. Make sure the vital sign data is accurate Reports abnormal values along with physical symptoms. Double-checks vital signs to verify abnormal values.
dysrhythmia
Deviation from the normal pattern of the heartbeat
Pulse pressure
Difference between systolic and diastolic pressure
Pulse pressure
Difference between systolic and diastolic pressures.
temperature
Difference between the amount of heat produced by the body and the amount of heat lost to the environment
Pulse deficit
Difference between the apical and radial pulse rates
Dyspnea
Difficult or labored breathing
dyspnea
Difficult or labored breathing
Dyspnea
Difficult, labored breathing, usually with a rapid, shallow pattern, that may be painful. Dyspnea patients find it easier to breath in an upright position
Orthopnea
Difficulty breathing experienced in positions other than sitting or standing
Term- Orthopnea
Difficulty breathing when lying flat
Term- Dyspnea
Difficulty breathing, SOB
+1 pulse amplitude
Diminished, weaker than expected
Term-Perfusion
Distribution of red blood cells to and from the pulmonary capillaries
Hypertension
Dysfunction of the neurohormonal system - angiotensin and aldosterone are overstimulated and the result may be permanent thickening of the blood vessels, leading to increased peripheral resistance. This resistance affects the brain, heart, and kidneys.
eupnea
Easy or normal breathing
Fever
Elevation above the upper limit of normal body temperature; synonym for pyrexia
Describe respiratory rate/rhythm
Eupnea: normal respirations; Tachypnea: fast resp > 24, usually shallow; Bradypnea: slow resp <10
How often VS assessment is done?
Every 4 or 8 hours for stable patients; Every 15 to 60 minutes for post-procedure or post-surgical patients; Every 5 minutes for critical or unstable patients
Diffusion
Exchange of oxygen and carbon dioxide between the alveoli and the red blood cells
Increase heat production
Exercise, Increased levels of epinephrine, nor-epinephrine, and thyroid hormones
Frostbite
Exposure to subnormal temperatures. Ice crystals form inside the cells, which may cause permanent circulatory and tissue damage. Common sites are earlobes, the tip of the nose, fingers, and toes. The skin is white and firm, with a loss of sensation. Interventions for frostbite are gradual warming, pain management, and protection of the injured area.
Heat exhaustion
Extreme or prolonged environmental heat exposure leads to profuse sweating with consequent excessive water and electrolyte loss. Clinical manifestations are those of fluid volume deficit
Ex of convection
Fan blows cool air across warm body
Normal pulse
Felt easily, and moderate pressure causes it to disappear
Thready pulse
Felt with difficulty or not easily felt, and slight pressure causes it to disappear
Hyperpyrexia
Fever greater than 41.C (106.F); medical emergency
Fever of unknown origin (FUO)
Fever of 38.3.C (101.F) or higher that lasts for 3 weeks or longer without an identified cause
FUO
Fever of unknown origin, doctor diagnosis only
Remittent
Fever spikes and falls without a return to normal temperature levels
Antipyretic
Fever-reducing drug
Perfusion
Flow of blood to and from the pulmonary capillaries
Blood pressure
Force of blood against arterial walls
Respiration
Gas exchange between the atmospheric air in the alveoli and blood in the capillaries
Objective Signs of Pain
Grimacing or refusing to move or take breaths. Increases in the vital signs of respiratory rate or depth, pulse rate, and blood pressure
Bradycardia
HR <60 beats per minute (unless well conditioned athlete)
Tachycardia
HR >100 beats per minute
Discuss nursing interventions used during the assessment of: Pulse
Hand hygiene select appropriate site and method irregular pulse of new onset should be reported to PCP for increased pulse rate include: identification and treatment of cause Fluid replacement is used for tachycardia caused by hypovolemia. Fluid removal would be appropriate by use of diuretic med for tachycardia from fluid overload
How to measure apical-radial pulse
Have one person count the radial pulse at the same time another person is counting the apical pulse.
BP Error: Falsely low reading is caused by
Hearing deficit in assessing person - Arm positioned above heart level - Extraneous noise in surrounding environment - Use of a cuff that is too wide - Ear tips of stethoscope placed incorrectly - Breaks or kinks in cuff tubing - Cuff deflated too rapidly - Stethoscope bell not placed directly over artery - Failure to follow all steps in BP procedure
Site of apical pulse
Heart apex, lowest part of heart
Ex of radiation
Heat given off uncovered surfaces
How heat is produced
Heat is byproduct of metabolic activities (by Hormones, Exercise, Sympathetic nerve stimulation- Epinephrine alters metabolic reactions increase heat production/ decreases energy production, Thyroid Hormone- long period of time) Shivering (initiated by hypothalamus and results in muscle tremors, Also, goose-bumps reduce surface area for heat to leave)
Hyperthermia
High body temperature
hypercapnia
High levels of carbon dioxide
Systolic pressure
Highest point of pressure on arterial walls when the ventricles contract
Stethoscope bell
Hollowed, upright, curved appearance used for hearing low-frequency sounds
Categories for Blood Pressure Levels in Adults
Hypo-tension < 90 or < 60 Normal < 120 and < 80 Pre-hypertension 120-139 or 80-89 Stage 1 hypertension 140-159 or 90-99 Stage 2 hypertension > 160 or >100
orthostatic hypotension
Hypotension that is most marked in the upright position; caused by venous pooling or inadequate blood volume
What part of your brain controls your temperature?
Hypothalamus
Febrile
Increase in temperature because of infection
Hyperthermia
Increase in temperature due to exercise/brain injury/problem in hypothalamus
Compare and contrast factors that increase or decrease blood pressure.
Increased blood pressure is called hypertension and can be prevalent because of race, age, obesity, and major risk factors. Hypotension means consistently low blood pressure which can be normal in adults like athletes. There is also orthostatic hypotension which is a decrease in blood pressure compared with sitting or supine positions resulting from inadequate changes in blood pressure.
Acidosis
Increased rate and depth of respiration to rid the body of excess carbon dioxide
Hyperventilation
Increased rate and depth of respirations due to extreme exercise, fear
Compare and contrast factors that increase or decrease body temperature.
Increased temperature is called fever or pyrexia which is caused by pyrogens. Can be caused by various reasons such as hyperthermia. Decreases body temperature can be hypothermia which can be caused by alcoholism, malnutrition, or hypothyroidism. Is also prevalent in the elderly and infants.
SNS stimulation of SA node
Increases heart rate
respiration
Inhalation and exhalation of air.
Korotkoff I
Initial presentation of faint but clearly audible tapping sounds, which gradually increase in intensity to a thud or loud tap; the first sound is recorded as the systolic pressure.
Chronic Pain
It lasts longer than the healing period
Acute Pain
It resolves when the underlying injury heals
Interpreting any VS requires
Knowledge, problem solving, and clinical judgment UAP can take VS however the Nurse must evaluate VS
Stethoscope diaphragm
Large, flat disk used for hearing high-frequency sounds
Diastolic pressure
Least amount of pressure exerted on arterial walls, which occurs when the heart is at rest between ventricular contractions
Regulator of pulse
Left ventricular contractions
Physical effect of fever
Loss of appetite: hot, dry, skin: headache: flushed face: thirst: muscle aches: fatigue: increased respirations: increased pulse rate: seizures (children): confusion/delirium (older): fluid, electrolyte, acid-based imbalances
Hypothermia
Low body temperature
Term-Hypoxemia
Low levels of arterial O2 (physiological control)
When person has fever what happens to metabolism, HR, RR, O2 needs, and fluid status
M: Increase HR, RR: Increase O2: Increase Fluid: Decrease
Afebrile
Maintaining normal body temperature between 36.5° to 37.5° C; (97.6° to 99.6° F). The average oral temperature is 37° C (98.6° F).
3. Collaborative Intervention
Making decisions with other specialists (contact nutritionist for diet advice)
Tripod position
Maximal lung expansion - the patient assume a sitting position, leaning forward over a raised bedside table with arms resting on the table
Perfusion
Measure perfusion with pulse oximetry
Diffusion
Measure with pulse oximetry
Control Center for Respiration
Medulla and Pons
Describe heat in the body.
Metabolism (energy = heat), Skeletal muscles (running = heat), Non-shivering thermogenesis (infant)
Ventilation
Movement of gases in and out of lungs
Term-Ventillation
Movement of gases into and out of the lung -Inhalation: breathing In -Exhalation: breathing out
Korotkoff II
Muffled, swishing sounds
Do premies/infants and the elderly always develop fever in response to an infection?
No because there thermoregulatory centers are not mature (infant) or overused (elderly)
Primary hypertension (essential hypertension)
No known cause; characterized by increase above normal in both systolic and diastolic pressures
afebrile
Normal body temperature "without fever"
CHARACTER of Pulse
Normal rate: 60-100 beats per minute -Tachycardia: more than 100 bpm -Bradycardia: less than 60 bpm -Pulse Deficit: diff. btwn apical and radial pulse rates
Eupnea
Normal respiration
Term-Eupnea
Normal respiration
Eupnea
Normal respiration with a normal rate and depth for the patient's age. The range is 12-20 BPM for an adult
Pulse rate or frequency
Number of pulsations per minute
1. Independent Intervention
Nurse can perform task w/out Dr. order
Temperature Ranges
ORAL 36.0°-37.6° C (96.8°-99.68° F) AXILLARY 35.5°-37.0° C (95.9°-98.6° F) RECTAL 34.4°-37.8° C (93.92°-100.04° F) TYMPANIC 35.6°-37.4° C (96.08°-99.32° F) TEMPORAL 36.1°-37.3° C (96.98°-99.14° F)
Auscultatory gap
Occur in the latter part of phase I and during phase II. The absence of Korotkoff sounds noted in some patients after the initial systolic pressure Cover a range as wide as 40 mm Hg Failure to recognize it may lead to major errors in measuring blood pressure
How is orthostatic hypotension diagnosed?
Occurs when a person's BP drops suddenly on moving from a lying position to a sitting or standing position - a decrease in 10 mm HG associated with dizziness/fainting (peripheral vasodilation without a compensatory increase in cardiac output (pregnant women, bed rest, those with decreased blood volume from dehydration or recent blood loss)
Assess vital signs
On admission to any health care agency or institution
Medical factors that influence Vital Signs
Pain, Infections, Renal, Respiratory and Cardiovascular Diseases
Sustained
Pattern of Fever: A constant body temperature continuously above 100.4 F that has little fluctuation
Intermittent
Pattern of Fever: Fever spikes interspersed with usual levels (Temperature returns to acceptable value at least once in 24 hours)
Relapsing
Periods of febrile episodes and periods with acceptable temperature values (Febrile episodes and periods of normotheria are often longer than 24 hours
Low pressure occurs from
Peripheral vasodilation with no rise in cardiac output for compensation. Aging Side effect of several medications. Prolonged immobility, dehydration, and blood loss.
What are the compensatory mechanisms for decreasing body temperature?
Peripheral vasodilation, sweating, and inhibition of heat production
How is hypertension diagnosed?
Persistently higher than normal BP 140/90 on 2 or more separate occasions (increases stress on heart leading to heart attack, heart failure, PVD, kidney damage, stroke) TREATMENT: for lifestyle modification
Ex of evaporation
Perspiration
Korotkoff's Sounds (blood pressure reading)
Phases 1-5
Factors that affect pulse rate and volume
Physical Activity, Age & Gender, Medications, Diseases, Stress, Pain
Other Factors that influence the Vital Signs
Physical environment, emotional state of the patient, medications, food and fluid intake, activity level and tolerance.
Physical effect of hypothermia
Poor coordination, slurred speech, poor judgement, amnesia, hallucinations, stupor, respiration increase, weak irregular pulse, decrease BP
Orthostatic hypotension
Postural hypotension, decrease of 20 systolic/10 diastolic within 3 minutes of standing
blood pressure
Pressure exerted by the blood upon the walls of the blood vessels, especially arteries
diastolic pressure
Pressure in the arterial system when the heart relaxes and fills with blood during Diastole.
Evaporation
Process by which a liquid is changed to a vapor through heat. Diaphoresis (sweating) increases during exercise, emotional or mental stress, and fever. The process of evaporation lowers body temperature.
Heatstroke
Prolonged exposure to the sun or high environmental temperatures overwhelms the body's heat loss mechanisms.
Dorsalis pedis
Pulse Site: Along the top of the foot, site used to assess status of circulation to foot
Radial
Pulse Site: Common site used to access character of pulse peripherally and assess status of circulation of hand
Ulnar
Pulse Site: Site used to access status of circulation of hand; also used to perform an Allen's Test
Femoral
Pulse Site: Site used to assess character to pulse during physiological shock or cardiac arrest when other pulses are not palpable; used to assess status of circulation to leg
Apical
Pulse Site: Site used to auscultate for apical pulse
Carotid
Pulse site: Easily accessible site used during physiological shock or cardiac arrest when other sites are not palpable
Temporal
Pulse site: Easily accessible site used to assess the pulse of children
Brachial
Pulse site: Site used to assess status of circulation to lower arm and auscultate blood pressure
Pulse amplitude
Quality of the pulse in terms of its fullness and reflects the strength of left ventricular contraction
Bradypnea
RR <10 with normal TV
Tachypnea
RR > 20 with relatively normal TV
Hyperventilation
RR and TV above normal (decreased PaCO2)
Hypoventilation
RR and TV below normal (increased PaCO2)
Transfer of Body Heat to External Environment
Radiation Convection Evaporation Conduction
Tachycardia
Rapid heart rate (>100 bpm)
Tachypnea
Rapid rate of breathing
Term- Tachypnea
Rapid respiratory rate
Temperature
Refers to the hotness or coldness of a substance
Pulse rhythm
Regularity with which pulsation occurs
Pulse physiology
Regulated by ANS through cardiac SA node
Peripheral Vascular Resistance
Resistance to blood flow that is influenced by tone of the artery muscular wall and diameter of vascular lumen 1. Dilation decreases resistance and BP 2. Constriction increases resistance and BP
Kussmaul's breathing
Respirations abnormally deep, regular, and increased in rate - Diabetic ketoacidosis
Biot's breathing
Respirations abnormally shallow for two or three breaths, followed by irregular period of apnea Factors: Meningitis, severe brain injury
Term- Biot's Respirations
Respirations are abnormally shallow for two to three breaths followed by irregular period of apnea
Biot's respiration
Respirations are abnormally shallow for two to three breaths followed by irregular period of apnea.
Kussmaul's respiration
Respirations that are abnormally deep, regular and increased in rate
Term- Cheyne-Stokes
Respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. Cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth
Cheyne-Stokes respirations
Rhythmic respirations, going from very deep to very shallow or apneic periods Factors: Heart failure, renal failure, drug overdose, increased intracranial pressure, impending death
Prehypertension
S: 120-139 D:80-89
Normal Blood pressure (#)
S<120 and D<80
Korotkoff sounds
Series of sounds that correspond to changes in blood flow through an artery as pressure is released
Posterior tibial
Site used to assess status of circulation to foot
Popliteal
Site used to assess status of circulation to lower leg
Bradycardia
Slow heart rate (<60 bpm)
Bradypnea
Slow rate of breathing
Term- Bradypnea
Slow respiratory rate, below 12 bpm
pulse oximeter
Small device that is clipped to a fingertip, a toe, the nose, or an earlobe. The most desirable site is the fingertip; alternate sites are used only when use of the fingertip is not appropriate. The device has an electronic display for oxygen saturation and pulse rate.
Korotkoff Sounds
Sounds that result from the vibrations of blood within the arterial wall or changes in blood flow
High Blood Pressure (Stage 1 & 2)
Stage 1: S- 140-159 D- 90-99 Stage 2: S- >160 D- >100
Equipment for Assessing Blood Pressure
Stethoscope and sphygmomanometer Doppler ultrasound Electronic or automated devices
Heat Production
Stimulated by coldness, impulse is increase heat production causes vasoconstriction of vessels and shivering
What is amplitude of pulse and why is it a relevant assessment?
Straight of pulse and it reflects the strength of L ventricle contractions
Pulse quality
Strength of the palpated pulsation
Bounding pulse
Strong and does not disappear with moderate pressure
Weak pulse
Stronger than a thready pulse, and light pressure causes it to disappear
Pyrogens
Substances that cause fever
Korotkoff sound phase I
Systolic pressure
Prehypertension
Systolic: 120-139 Diastolic: 80-89 Recheck in 1 years
Stage 1 Hypertension
Systolic: 140-159 Diastolic: 90-99 Confirm within 2 months
Stage 2 Hypertension
Systolic: >/= 160 Diastolic: >/= 100 Evaluate or refer to source of care within 1 month. If over 180/110 within 1 week
Demonstrate knowledge of the normal ranges for blood pressure across the lifespan.
Table 24-1.
Demonstrate knowledge of the normal ranges for pulse across the lifespan.
Table 24-1.
Demonstrate knowledge of the normal ranges for respirations across the lifespan.
Table 24-1.
Demonstrate knowledge of the normal ranges for temperature across the lifespan.
Table 24-1.
Provide information to patients about measuring pulse at home.
Table 24-1.
Provide information to patients about blood pressure at home.
Table 24-1. The pulse is often taken before taking certain medications, such as those to make the heartbeat slower or stronger. People who exercise and want to monitor the effect of the exercise on heart function may also take their pulse. It is necessary to be able to see a watch or a clock with a second hand when taking the pulse. Place one arm on a firm surface so that the palm is upward. Using the middle three fingers of the other hand, gently feel the outside of the arm just below the wrist with the fingertips. Do not press hard. When pulsations are felt, observe the second hand of the watch or clock and begin to count when the second hand reaches 12 (any number is fine, but it is often easier to remember to always begin counting when the second hand is on 12). Count each pulsation (beat) for 1 minute (when the second hand again reaches 12), and write the number down. The blood pressure is often taken to determine how well medications are working to control high blood pressure. The blood pressure is usually checked once a week, or as instructed. Readings may be taken in the morning and evening. A record of blood pressure readings over time is more important than one reading. Use a validated monitor with an automatic inflation cuff. Avoid food, caffeine, tobacco and alcohol for 30 minutes before taking a measurement. Take your blood pressure before (not after) you eat. Rest 3-5 minutes before taking your blood pressure. Sit comfortably with your back supported and both feet on the floor (don't cross your legs). Elevate your arm to heart level on a table or a desk. Use the proper sized cuff. It should fit smoothly and snugly around your bare upper arm. There should be enough room to slip a fingertip under the cuff. The bottom edge of the cuff should be 1 inch above the crease of the elbow. Ideally, take 3 measurements at one sitting and record the average. Follow instructions that come with the home device.
Compare and contrast factors that increase or decrease respirations.
Tachypnea may occur in response to increased metabolic rate, like when one has a fever. Respiratory diseases such as acute pneumonia may cause tachypnea or hyperventilation. Bradypnea occurs in some pathologic conditions and with some medications.
Increased respiratory rate
Tachypnea-rapid rate of breathing hyperventilation-increase rate and depth anything that increases CO2 and decreases O2
Adult Normal Vital Signs
Temp 35.5°-37.5° C (95.9°-99.5° F) Pulse 60 - 100 Respiration 12-20 SpO2 >95% Systolic 90-120 Diastolic 60-80
Older Adult Normal Vital Signs
Temp 35°-37.2° C (95°-99° F) Pulse 60 - 100 Respiration 15-20 SpO2 >95% Systolic 90-120 Diastolic 60-80
15 year old Normal Vital Signs
Temp 36.1°-37.2° C (97°-99° F) Pulse 50-90 Respiration 15-20 SpO2 >95% Systolic 94-120 Diastolic 62-80
6 Year Old Normal Vital Signs
Temp 36.6°-37° C (98°-98.6° F) Pulse 75-110 Respiration 15-25 SpO2 >95% Systolic 84-120 Diastolic 54-80
1 year old Vital signs
Temp 37.4° - 37.6°C ( 99.4° - 99.7°F) Pulse 80 - 140 Respiration 24 - 40 SpO2 >95% Systolic 74 - 100 Diastolic 50 - 70
Newborn Normal Vital Signs
Temp 96 - 99.5 (35.5 - 37.5) Pulse 80 - 160 Respiration 30-80 SpO2 >95% Systolic 60-90 Diastolic 20-60
Vital Sign
Temperature (T) Pulse (P) Respiration (R) Blood pressure (BP) Pain (often included as fifth sign)
Vital Signs Ranges
Temperature T 96.8-100.4 F Temp. Tympanic 98.6 F Temp. Oral 98.6 F Temp. Rectal 99.5 F Pulse 60-100 bpm Resp. Rate 12-20 bpm Blood Pressure 120/80 Hypotension 90/70 Hypertension 140/90 Pulse Pressure 30-50 mmHg SpO2 95-100%
Remittent fever
Temperature does not return to normal and fluctuates a few degrees up and down
Sustained or continuous fever
Temperature remains above normal with minimal variations
Intermittent fever
Temperature returns to normal at least once every 24 hours
Relapsing or recurrent fever
Temperature returns to normal for one or more days with one or more episodes of fever, each as long as several days
vital signs
Temperature, pulse, respiration rate, blood pressure and pain
Site to assess pulse
Temporal, Carotid, Brachial, Radial, Femoral, Popliteal, Dorsalis pedis, posterior tibial, apical
Where are the 9 sites for pulses?
Temporal, Carotid, Brachial, Radial, Ulnar, Apical, Femoral, Popliteal, Posterior tibial, Dorsalis pedis
Pulse Sites
Temporal, carotid, Apical, Brachial, Ulnar, Radial, Femoral, Popliteal, posterior tibial, Doralis pedis
Orthostatic hypotension
Temporary fall in blood pressure associate with assuming an upright position. synonym for postural hypotension
Who is responsible for the vital signs?
The Nurse
Evaporation
The conversion of a liquid to a vapor. dispersion of heat through water vapor
Radiation
The diffusion or dissemination of heat by electromagnetic waves; transfer of heat from one object to another without contact
Convection
The dissemination of heat by motion between areas of unequal density; dispersion of heat through body currents
Korotkoff V
The last sound heard before silence—this is the diastolic measurement
diastolic pressure
The lowest pressure on arterial walls, which occurs when the heart rests. (bottom number). The arteries are relaxed
SOCRATES
The nurse ask the patient several things to assess the pain: Site, Onset, Character, Radiation, Associations, Time, Exacerbating/relieving, Severity (0 to 10)
Assess respirations accurately.
The nurse assesses respiratory rate (breaths per minute), depth (deep or shallow), and rhythm (regular or irregular) by inspection (observing and listening) or by listening with the stethoscope.
systolic pressure
The peak of the blood pressure wave. (top number). The arteries are stretched
Explain the physiologic processes involved in homeostatic regulation of respirations.
The rate and depth of breathing can change in response to tissue demands. These changes are brought about by the inhibition or stimulation of the respiratory muscles by the respiratory centers in the brain. Activation of the respiratory centers occurs via impulses from chemoreceptors located in the aortic arch and carotid arteries, via stretch and irritant receptors in the lungs, and via receptors in muscles and joints. An increase in carbon dioxide is the most powerful respiratory stimulant, causing an increase in respiratory depth and rate. The cerebral cortex of the brain allows voluntary control of breathing, such as when singing or playing a musical instrument.
Identify sites for assessing temperature.
The sites most commonly used to assess body temperature are oral (sublingual), tympanic, temporal artery, rectal, and axillary.
Korotokoff sound
The sounds a nurse listens for when taking BP Korotokoff sound 1= initial sound of faint, but audible tapping sound (systolic) Korotokoff sound 2= muffled, swishing sounds Korotokoff sound 3= Crisp, loud sounds as the blood flows through an opening artery Korotokoff sound 4= distinct, abrupt muffling sound Korotokoff sound 5= last sound heard before silence (diastolic)
Korotkoff sounds of BP
The sounds that the nurse listens when assessing blood pressure
Temperature Regulation
The thermoregulatory center in the Hypothalamus receives input from cold and warm thermal receptors throughout the body which monitor balance of heat production and heat loss
Assess temperature accurately.
To accurately assess body temperature, the nurse must know what equipment to use, which site to choose, and what method is appropriate.
Purpose of Baseline or Initial VS
To identify changes in patient status; series of VS measurements establish any patient trends
Conduction
Transfer of and reaction to heat through direct contact. Heat from the body is lost when it comes in contact with a cooler object, such as an ice pack or cool cloth.
Convection
Transfer of heat by movement or circulation of warm matter such as air or water.
Conduction
Transfer of heat to another object during direct contact
Orthopnea
Type of dyspnea in which breathing is easier when the patient sits of stands
Conduction
Type of heat loss: Transfer of heat to another object during direct contact, Interventions: cold press, cool shower, cold fluids
Radiation
Type of heat loss: diffusion of heat by electromagnetic waves from hotter to colder, 85% of body does this, ex: body steaming in the winter, Interventions- make room colder, reduce clothing
Evaporation
Type of heat loss: liquid to a gas, 600-900 mL of fluid loss/ day, sweat, Interventions: check fluids and electrolytes
Convection
Type of heat loss: transfer heat with air movement, Interventions: Fan
Unlicensed Assistive Personnel Delegation
UAP may measure, record, and report vital signs for the stable patient.
Respiratory Distress
Use of accessory muscles of the chest and neck and/or an exaggerated effort to breathe. Children and infants may exhibit nasal flaring or sternal retractions if they are having trouble breathing.
Assess pulse accurately.
Use various equipment if pulse is weak, irregular, or very rapid such as with a stethoscope.
What are the compensatory mechanisms for increasing body temperature?
Vasoconstriction, release of epinephrine, and shivering
Diaphoresis
Visible perspiration on skin
Pulse
Wave produced in the wall of an artery with each beat of the heart
Afebrile
When the fever "breaks"
When do you call the doctor?
When the patient's condition changes or is worsened
Can the Vital Signs vary? Why or why not?
Yes, Variations in VS reflect a person's state of health and or body system function
What does it mean to be febrile, explain the phases:
You have a fever; Initial - shivering; Second - course of the fever; Third - fever breaks
afebrile
a condition in which the body temperature is not elevated
Bradypnea
a decrease in respiratory rate; shallow, irregular, or slow breathing
Causes of Hypotension
a disruption in cardiovascular dynamics, like decreased blood volume (hemorrhage), decreased cardiac output (heart attack or heart failure), or decreased peripheral vascular resistance (shock).
Factors that lead to tachycardia
a drop in blood pressure an elevated temperature anemia exercise prolonged application of heat pain strong emotions, such as fear or anxiety medications like bronchodilators.
postural hypotension
a drop in blood pressure due to a change in body position , when a pt moves to a more vertical position (sitting --> standing OR from lying --> sitting --> standing)
Fever of unknown origin (FOU)
a fever of 101 or higher that last for 3 weeks or longer without an identified cause
malignant hyperthermia
a hereditary condition of uncontrolled heat production that occurs when susceptible people receive anesthetic drugs
orthostatic hypertension
a normotensive person develops symptoms and low blood pressure when rising to an upright position
Febrile
a person with a fever
vital signs
a person's pulse, temperature, blood pressure, and respirations
peripheral pulse
a pulse recorded in the arteries in the distal portion of limbs (radial, pedal, etc..)
fever
a rise in body temp above normal range, caused by trauma or illness (pyrexia)
Febrile
a rise in the temperature of the body
Bradycardia
a slow heart rate, below 60 beats/min in adults
From the nurse's understanding, which statements regarding temperature and heat production in the body are accurate? (Select all that apply.) a. Heat generates energy for cellular functions. b. Hormones such as thyroid decrease metabolism and heat production. c. Exercise decreases heat production through muscular activity. d. Body temperature is 1° to 2° higher in the morning than in late afternoon. e. Expected temperature readings vary by the route selected for measurement. f. Women tend to have more fluctuations in temperature than do men.
a. Heat generates energy for cellular functions. e. Expected temperature readings vary by the route selected for measurement. f. Women tend to have more fluctuations in temperature than do men.
The nurse is admitting a stable patient for a minor outpatient procedure. What site would the nurse most commonly use to assess pulse rate? a. Radial site b. Apical site c. Brachial site d. Carotid site
a. Radial site
dysrhythmia
abnormal cardiac rhythm; irregular pattern of heart beats, tells something is wrong with heart conduction
hypothermia
abnormal lowering of body temperature below 95 F, usually caused by prolonged exposure to cold.
dysrhythmia
abnormal rhythm, threatens the ability of the heart to provide adequate cardiac output
tachycardia
abnormally elevated heart rate above 100 beats/min
Hypertension
above normal BP; systolic pressure above 140 or diastolic pressure above 90
auscultatory gap
absence of Korotokoff sounds noted in some pts after the initial systolic pressure
apnea
absence of breathing
Cause of pulses paradoxus
air trapping (asthma, cardiac tamponade; any fluid in pericardial sac)
Describe guidelines for nursing documentation of vital signs
all vital signs should be documented in pt's chart, and any abnormal assessment should be reported to health care provider
Cardiac Output and how its increased
amount of blood that the heart pumps per minute, stroke volume (70 mL) x pulse rate 1. Greater cardiac contractility 2. increased HR and Blood Volume
oxygen saturation
amount of oxygen in the arterial blood measured by the pulse oximetry
dysrhythmia
an abnormal cardiac rhythm
Dysrhythmia/Arrhythmia
an irregular rhythm in the pulse, cause by an early, late or missed heartbeat
Axillary temperature
approximately 1° less than oral temperatures
Oral temperatures
approximately 1° less than rectal temperatures
Which clinical patient scenario is associated with the most critical need for the nurse to obtain vital signs? a. Ambulating for the first time after surgery b. Complaining of pressure in the chest c. Completes ambulating 100 feet after a stroke d. Complaining of a hunger while NPO (nothing by mouth)
b. Complaining of pressure in the chest
The nurse understands that which statement is correct regarding respiratory rates? a. Infants have a lower respiratory rate than adults. b. Healthy adults breathe between 12 and 20 times a minute. c. A compensatory response to a fever is to breathe at a slower rate. d. An increase in intracranial pressure results in an increased rate.
b. Healthy adults breathe between 12 and 20 times a minute.
The nurse is caring for a patient who has a blood pressure of 184/110. An hour after administering an antihypertensive medication, the nurse returns to rechecks the blood pressure, only to find the patient in the chair pale, sweaty, and feeling faint. Which is the expected explanation for the nurse's observations? a. The blood pressure is 184/110; the medication has not had an effect. b. The blood pressure is 118/76; the sudden drop has caused the signs. c. The blood pressure is 174/96; the medication has made the patient sick. d. The blood pressure is 130/82; the symptoms are from another cause.
b. The blood pressure is 118/76; the sudden drop has caused the signs.
pyrogens
bacteria or viruses that cause illness or disease. -act as antigens to trigger the immune system responses that elevates the body temperature
Basal metabolic rate (BMR)
basal metabolism accounts for the heat produced by the body at absolute rest; depends on the body surface area
Hypotension
below normal BP
Cause of Cheyne Stokes
bilateral damage in cerebral hemispheres (strokes, tumors, hemorrhage)
hypotension
blood pressure below the lower limit of normal
hypertension
blood pressure elevated above the upper limit of normal
hypertension
blood presuure elevated above the upper limit for a sustained period
vital signs
body temperature, pulse and respiratory rates, and blood pressure; and pain
vital signs
body temperature, pulse and respiratory rates, and blood pressure; synonym for cardinal signs
Hypopnea
breathing greatly reduced in depth, but normal frequency and rate (sometimes seen in patients with sleep apnea)
Ventilation
breathing; movement of gas in and out of the lungs
The nurse places a patient with a high fever on a cooling blanket. How is heat loss achieved with this treatment? a. Radiation b. Convection c. Conduction d. Evaporation
c. Conduction
It is 6 a.m. and the UAP reports to the nurse that the patient has a temperature of 96.7° F tympanic. Which factor explains this reading? a. The patient's room is cold. b. The patient was drinking cold water. c. The patient is exhibiting a normal circadian rhythm. d. The patient just completed a warm shower.
c. The patient is exhibiting a normal circadian rhythm.
Idiopathic
cause unknown
secondary hypertension
caused by another disease
Interventions and causes of orthostatic hypotension
causes: dehydration, blood loss, medications Interventions: move slowly, hydrate, exercise, monitor BP when moving
Orthostatic hypotension
change in position causes drop in BP (lying->standing, sitting->standing)
Pulsus alterans
change in strength of pulse because of breathing (left ventricular failure)
Discuss nursing interventions used during the assessment of: blood pressure
check PCP orders gather supplies and equipment hand hygiene maintain standard precautions introduce yourself provide for pt privacy identify pt, using 2 identifiers explain procedure to pt
Signs of Shock
clammy skin, thready pulse, decreased urinary output, and confusion from decreased cerebral blood flow.
febrile
condition in which the body temperature is elevated
heat stroke
continued exposure to extreme heat that raises the core body temperature to 105 F or higher
systolic pressure
contraction of heart forces blood under high pressure into the aorta, peak of maximum pressure when ejection occurs
Explain the physiologic processes involved in homeostatic regulation of temperature.
controlled by the thermoregulatory center in the hypothalamus.
The nurse is measuring blood pressures as part of a community health fair. Which blood pressure reading would cause the nurse to refer the patient for follow-up regarding potential hypertension? a. 118/78 b. 126/84 c. 136/90 d. 144/94
d. 144/94
The unlicensed assistive personnel reports vital signs for a patient to the nurse: temperature 99.2° F oral, pulse 88 bpm and regular, respirations 18 BPM and regular, blood pressure 178/112, oxygen saturation 96%, and pain score of 3 of 10 for headache. Which vital sign should the nurse be most concerned about? a. Temperature b. Pulse c. Respirations d. Blood pressure
d. Blood pressure
The nurse is performing an initial assessment of a patient with a severe infection at hospital admission. Vital signs for the patient indicate hypotension and tachycardia. Which data pair would support this evaluation? a. Pulse 88, blood pressure 140/88 b. Pulse 96, blood pressure 120/76 c. Pulse 100, blood pressure 118/80 d. Pulse 114, blood pressure 98/60
d. Pulse 114, blood pressure 98/60
bradypnea
decrease in respiratory rate (<10 bpm)
Bradypnea
decrease in respiratory rate of <10 BPM in the adult. Caused by medications, especially opioids, metabolic disorders, or brain injury.
orthostatic hypotension
decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within 3 minutes of standing when compared with blood pressure from the sitting or supine position.
hypotension
decreased blood pressure (<90 systolic and <60 diastolic)
bradypnea
decreased respiratory rate <10 breaths/mins causes: Depression of respiratory center by medications or brain damage
What happens to bacterial growth in fever
decreases
Periodic sighs
deep inhalations that fill the lungs with more air than during normal inspiration
Kussmauls Respirations
deep labored breathing use when a diabetic is in ketoacidosis
hyperventilation
deep, rapid respirations (caused by stress, anxiety)
pulse deficit
difference between apical and radial pulse rates and indicates not all the heartbeats are reaching the peripheral arteries or are too weak to be palpated
pulse pressure
difference between systolic and diastolic pressure
pulse pressure
difference between systolic and diastolic pressure normally 30 to 40 mmHg
pulse pressure
difference between systolic and diastolic pressures
pulse deficit
difference between the apical and radial pulse rates
pulse deficit and importance
difference between the apical and radial pulse rates tells you that the heart is not pumping adequately
Dyspnea
difficult or labored breathing
dyspnea
difficult or labored breathing
dyspnea
difficult or labored breathing, so change position, check vitals, mininebulizer treatment
Dyspnea
difficulty breathing under "normal" conditions (you cannot see this on monitor- look at patient to determine)
auscultatory gap
disappearance of sound when obtaining a blood pressure, typically occurs between the first and second Korotkoff sounds
Pain caused by
disease processes, medical or surgical procedures, trauma, immobility, wounds, and routine nursing care such as repositioning, changing a dressing, or starting an intravenous line.
hypertension
disorder characterized by high blood pressure persistently exceeding 120/80
fever
elevated above the upper limit of normal body temperature, heat loss us unable to equal heat production leading to increased temperature Names: febrile, hyperpyrexia
hypertension
elevated blood pressure (>140 systolic and >90 diastolic)
hypercarbia
elevated carbon dioxide
fever
elevation above the upper limit of normal body temperature; synonym for pyrexia
sphygmomanometer
equipment used to measure blood pressure
Circadian Rhythm
events in humans that reoccur in 24 hour intervals
diffusion
exchange of oxygen and carbon dioxide between the alveoli and the circulating blood
perfusion
exchange of oxygen and carbon dioxide between the circulating blood and tissue cells
expiration
exhalation; act of breathing out
Biots
fast, deep breaths with irregular pauses
neurogenic fever
fever as a result of damage to the hypothalamus, does not respond to antipyretic medications
Fever of unknown origin
fever with undetermined cause
Arterial pressure
force exerted against the wall of the artery as blood moves through it
Diastolic pressure
force occurring when heart is at rest
blood pressure
force of blood against arterial walls
blood pressure
force of blood against arterial walls Cardiac output x peripheral vascular resistance
blood pressure
force of the blood against arterial walls. The Lt 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
respiration
gas exchange between the atmospheric air in the alveoli and blood in the capillaries
primary hypertension
has no known cause and there is an increase above expected range in both systolic and diastolic pressure
Apical Pulse
heart rate measured at the apex of the heart on the anterior chest wall
diastole
heart relaxes
BODY TEMPERATURE
heat produced-heat lost=body temp oral, rectal, axillary, tympanic, temporal artery, esophageal, pulmonary artery, urinary bladder
Malignant Hyperthermia
hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs
hyperthermia
high body temperature
Hyperthermia
high body temperature due to extreme heat exposure or excessive heat production, hypothalamic set point does not change and mechanisms that control T are ineffective
systolic pressure
highest point of pressure on arterial walls when the ventricles contract
systolic pressure:
highest point of pressure on arterial walls when the ventricles contract
systolic pressure
highest pressure created during ventricular contraction
How does fever act as defense mechanism?
hostal environment
Heat Loss
impulse to decrease temperature by vasodilation and sweating
Fever (pyrexia)
increase above the normal body temperature
Tachypnea
increase in respiratory rate of >24 BPM in the adult. Any condition that causes an increased need for oxygen or an increased metabolic rate (e.g., high altitude or fever) or an increase in carbon dioxide levels (e.g., chronic lung disease)
Tachypnea
increase in respiratory rate to more than 24 bpm
hyperventilation
increase in the rate and depth of respirations caused by an increase in Carbon dioxide and a decrease in oxygen in the blood
Hyperpnea
increased depth of breathing with or without increased rate
Tachypnea
increased respiratory rate
tachypnea
increased respiratory rate >24 breaths/mins causes: fever, anxiety, exercise
Fever: what happens to interferon in viral infection
increases
what happens to body's WBC in fever
increases
inspiration
inhalation; act of breathing in
I:E ratio
inspiratory to expiratory ratios (normal 1:2) I/I:E/I
sphygmomanometer
instrument for measuring BP, consists of inflatable rubber cuff that is applied to arm, and connected to a column of mercury next to a graduated scale. Enables determination of systolic/diastolic BP. by increasing and gradually releasing the pressure in cuff
thermoregulation
internal control of the body temperature
Intermittent breathing
irregular breathing with periods of apnea
dysrythmia
irregular pattern of heart beats
pulse pressure
is the difference between the systolic and diastolic pressure readings (read in mmHG)
diastolic pressure
least amount of pressure exerted on arterial walls, which occurs when the heart is at rest between ventricular contractions
diastolic pressure
least amount of pressure exerted on arterial walls. which occurs when the heart is at rest between ventricular contractions, worst when this number is high because the heart needs rest
Sensorium
level of consciousness
Hypoxemia
low O2 levels in the blood
Hypoxemia
low PaO2 in blood (<90% or 60 mmHg)
hypothermia
low body temperature
hypoxemia
low levels of arterial oxygen
diastolic pressure
lowest pressure on the arterial walls, which occurs when the heart rests (last sound that you hear)
Pulse pressure
mathematical difference between the systolic and diastolic pressures (s-d=p)
pulse oximetry
measure of oxyhemoglobin saturation of arterial blood
Electronic thermometer
measure oral, rectal and auxiliary T within 1-60 sec
Pulse Oximetry
measures the amount of oxygen available to tissues. The reading is saturation of peripheral oxygen (SpO2)
antipyretics
medications that reduce fever
mm Hg
millimeters of mercury
diffusion
movement of molecules from an area of high concentration to one of lower concentration. ex. the movement of oxygen and carbon dioxide between the alveoli and the red blood cells
Term- Diffusion
movement of oxygen and carbon monoxide between alveoli and red blood cells
interferon
natural virus-fighting substance of the body
afebrile
no fever
treatment for increased temperature
non-steroidal drugs with antipyretic effect, such as aspirin and acetaminophen, to lower the set-point of the hypothalamus. Cool sponge baths, cooling blankets, and cool packs are used to reduce fever, but they can increase energy expenditure by stimulating shivering.
Sighing respiration
normal rate and depth, with periodic deep and audible breaths
eupnea
normal respiration rate w/ normal rate and depth for pt's age
eupnea
normal respirations
Eupnea
normal respirations that are quiet, effortless and rhythmical
eupnea
normal unlabored respirations
Eupnea
normal, comfortable breathing (10-20 breaths per minute)
Factors that lead to Bradycardia
occur in athletes during sleep hypothermia medications such as beta blockers during tracheal suctioning increased intracranial pressure myocardial infarction
Pyrexia
occurs because heat-loss mechanisms are unable to keep pace with excessive heat production, causes abnormal rise in body temperature
nonshivering thermogenesis
occurs primarily in neonates. Because neonates can't shiver, a limited amount of vascular brown adipose tissue present at birth can be metabolized for heat production.
heat exhaustion
occurs when profuse diaphoresis results in excess water and electrolyte loss due to environmental heat exposure.
frostbite
occurs when the body is exposed to subnormal temperatures area becomes white, waxy, and firm to the touch
Pulse
palpable, bounding blood flow created by the contraction of the left ventricle of the heart. It can be assessed at various points on the body. The pulse is an indicator of circulatory status.
pulse rhythm
pattern of the beats and the pauses between them
Systolic pressure
peak force during contraction of left ventricle
systolic pressure
peak of pressure wave when ventricle contracts (first sound you hear)
Hematocrit
percentage of RBC in the blood determines blood viscosity
apnea
periods of absence breathing common in infants
Apnea
periods that there is no breathing
febrile
pertaining to or characterized by an elevated body temperature
Assessing Orthostatic hypotension
postural hypotension indicative of dehydration or anemia, or prolonged immobility Symptoms - dizziness, fainting, changes in mental status, and anxiety, nausea, rapid onset of pallor, and fast, shallow breathing Assessment not delegated to UAP
Orthostatic hypotension
postural hypotension; decrease in systolic pressure of 20 mm Hg or a decrease in diastolic pressure of 10 mm Hg within 3 min of standing
PATS
pre-admitting testing services
Hypotension
present when systolic BP falls to 90 or more
diastolic pressure
pressure exerted in the arteries by the blood that remains when the ventricles relax
pulse oximetry
procedure used to measure the oxygen level (oxygen saturation) in the blood. *how much is available to tissues*
thermoregulation
process that allows the body to maintain its core internal temp
Bradycardia
pulse rate below 60 BPM in an adult
pulse deficit
radial pulse is less than the ventricular rate as auscultated at the apex. Indicated a lack of peripheral perfusion.
tachycardia
rapid heart rate
tachycardia
rapid heart rate (> 100bpm)
tachycardia, how would age affect this
rapid heart rate; decreases cardiac fill time, greater than 100 at rest (adult) number would be highier for younger children
tachycardia
rapid heart rate; pulse rate is 100-180 BPM
tachypnea
rapid rate of breathing
Hyperventilation
rate and depth of respirations increase. Hypocardia sometimes occurs
tachypnea
rate of breathing is regular but abnormally rapid (greater than 20 breaths/min)
Bradypnea
rate of breathing is regular but abnormally slow (less than 12 breaths/min
Nonsteroidal antiflammatory drugs
reduce fever by increasing heat loss
corticosteriods
reduce heat production by interfering with the immune system and mas signs of infection.
oxygen saturation
refers to the concentration of oxygen in the blood
temperature
refers to the hotness or coldness of a substance
Explain the physiologic processes involved in homeostatic regulation of pulse.
regulated by the autonomic nervous system through the sinoatrial (SA) node of the heart a.k.a. the pacemaker.
perfusion
relates to the ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs; acts of pouring through an organ ex. distribution of RBC to and from the pulmonary capillaries
Discuss nursing interventions used during the assessment of: Respirations
repositioning a pt supplemental oxygen suctioning medications (such as bronchodilators)
hyperpnea
respirations are labored, increased in depth and increased in rate (greater than 20 breaths/min) occurs normally with exercise
apnea
respirations cease for several seconds. Persistent cessation results in respiratory arrest
ventilation
respiratory process by which gases are moved into and out of the lungs
Cheyne-Stokes Respiration
respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. Respiratory cycle begins with slow, shallow breath that gradually increase to abnormal rate and depth. The pattern reverses breathing slows and becomes hallow, climaxing in apnea before respiration resumes.
Hypoventilation
respiratory rate is abnormally low, and depth of ventilation is depressed. Hypercardia sometimes occurs
Cheyne Stokes
rhythmic waxing and waning of depth of respiration with regular periods of apnea
Korotkoff sounds
series of sounds that correspond to changes in blood flow through an artery as pressure is released
Korotkoff sounds
series of sounds that correspond to changes in blood flow through an artery as pressure is released Table 24-9
hypoventilation
shallow respirations (associated w/ drug overdose and obesity)
Bradycardia with difficulty breathing and decreased blood pressure
should be reported immediately, because this is an indication of imminent cardiopulmonary collapse.
shivering
skeletal movement that increases heat production, involuntary response to temperature differences in the body.
bradycardia
slow heart rate
Bradycardia
slow heart rate (< 60bpm)
bradycardia
slow heart rate, Less than 60 at rest (adult), number be higher for younger children
bradypnea
slow rate of breathing
Orthostatic hypotension
sudden drop of 20 mm Hg in systolic pressure and 10 mm Hg in diastolic pressure when the patient moves from a lying to sitting to standing position. Measured by taking the blood pressure reading and pulse while the patient is in the lying position, sitting position, and standing position
orthostatic hypotension
sudden drop of 20mmHg systolic and 10mmHG diastolic when pt moves from lying to sitting to standing position
diaphoresis
sweating; especially to an unusual degree as a symptom or medication side effect
Pulsus paradoxus
systolic BP falls >10 mmHg during inhalation at rest
Hypotension
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.
core temperature
temperature of deep tissue (tympanic and temporal)
Core Temperature
temperature of deep tissues Range of 36.5° to 37.5° C (97.6° to 99.6° F); tympanic membrane temperature
core temperature
temperature of the deep tissues, kept relatively constant by temperature-control mechanisms
surface temperature
temperature of the skin; rises and falls with the changing environment surroundings
hyperpyrexia
temperature over 106; medical emergency, cause death or brain damage
orthostatic hypotension
temporary fall in blood pressure associated with assuming an upright position; synonym for postural hypotension
Pulse deficit
the apical pulse rate exceeds the radial pulse rate. A deficit occurs when the cardiac ejection of a volume of blood is too small to initiate a peripheral pulse wave. To measure this deficit, two people count both pulses simultaneously.
hypothalamus
the body's thermostat. Changes in body temperature are transmitted by thermal receptors located throughout the body to the hypothalamus by way of the spinal cord. Anterior hypothalamus - heat loss through diaphoresis (sweating) and vasodilation (opening) of blood vessels. Posterior hypothalamus - conserves heat through vaso-constriction (closing) of the blood vessels and shivering.
Temperature
the difference between the amount of heat produced by the body and the amount of heat lost to the environment measured in degrees.
Pulse Pressure
the difference between the diastolic and systolic pressures. For a patient with a normal blood pressure of 120/80 mm Hg, 120 is the systolic pressure, 80 is the diastolic pressure, and the pulse pressure is 40 mm Hg.
Blood pressure
the force exerted on the walls of an artery by the pulsing blood under pressure from the heart
Ongoing nursing assessment for pain
the intensity, quality, duration, and location of any pain
Orthopnea
the need to prop yourself up with pillows to breathe easier (the more pillows, the worse the SOB)
Pulse Amplitude
the quality of the pulse in terms of its fullness and reflects the strength of the left ventricular contraction; palpated; usually measured from 0 (absent) to +3 (Bounding)
pulse volume or amplitude
the strength of the pulse with each beat 0 Absent pulse 1+ Weak and thready pulse, difficult to palpate 2+ Normal pulse, able to palpate with normal pressure 3+ Bounding pulse, may be able to see pulsation
Radiation
the transfer of heat as waves or particles of energy. No actual contact occurs between the object transmitting the heat and the object absorbing it.
Pulse
throbbing sensation that can be palpated over a peripheral artery
convection
transfer of heat away by air movement
evaporation
transfer of heat energy when liquid is changed to a gas.
conduction
transfer of heat from one object to another with direct contact
radiation
transfer of heat from the surface of object to the surface of another without direct contact between the two. Increased by peripheral dilation
orthopnea
type of dyspnea in which breathing is easier when the patient sits or stands
orthopnea
type of dyspnea in which breathing is easier when the patient sits or stands (upright position), difficulty breathing laying down
Term- Eupnea
unlabored breathing, normal rate and depth of relaxed breathing (mechanics of breathing)
Tympanic membrane thermometer
uses infrared sensors to detect heat given off by the tympanic membrane, 1-3 seconds
Biots respirations
varying depth and rate of breathing followed by periods of apnea; irregular due to meningitis and severe brain damage
respirations
ventilation (breathing)
systole
ventricle contracts
Risk Factors for Heatstroke
very young or very old age, cardiovascular disease, diabetes, and alcoholism, along with exercise or work out of doors in predisposing conditions.
diaphoresis
visible perspiration
cardiac output
volume of blood pumped by the heart during 1 minute
pulse
wave produced in the wall of an artery with each beat of the heart
febrile
with fever (elevated body temperature)
Apnea
without breathing
afebrile
without fever
Health-promoting lifestyle changes for Hypertension
• Maintain normal body weight. • Use Dietary Approaches to Stop Hypertension (DASH) eating plan, which includes reduced fat intake and increased intake of fruits and vegetables. • Reduce dietary sodium intake to 2.4 g daily. • Engage in regular aerobic physical activity at least 30 minutes a day, on most days of the week. • Limit alcohol consumption: for men, two drinks a day; for women, one drink a day.
