Vital Signs (temperature, pulse, respiration, blood pressure)

oral temp. site

"blue end" sublingual space, affected by food, fluids or smoking, not for infants or young adults, 3 minutes, electronic thermometers 20-50 seconds to display temp., mercury thermometers dangerous

rectal temp. site

"red end", about 1 degree higher than oral, requires lube, 2 minutes, do not use with diarrhea or bleeding problems (98.6-100.6 F or 37-38.1 C)

pyrogens

(bacteria, viruses) cause a rise in body temp by triggering an immune response. This causes hypothalamus to raise the set point temp of the body

axillary temp. site

1 degree lower than oral, not reliable, 5-10 minutes, noninvasive, (96.6-98.6 F or 36-37 C)

tympanic temp. site (ear)

accurate core temp., unaffected by fluids/food, can not be used with infants/toddlers, unreliable adult = back and up child= back and down

depth (respiration)

assessed by observing the degree of movement (excursion) in the chest wall. Generally described as deep, normal or shallow

popliteal pulse

behind knee in popliteal fossa, Used to assess status of circulation to lower leg

femoral pulse

below inguinal ligament, midway between sympysis pubis and anterior superior iliac spine. Used to assess character of pulse during physiological shock or cardiac arrest when other pulses are not palpable (used to assess status oc circulation in leg)

chills

body's attempt to increase body temp to attain new "set point" temp set by hypothalamus affected by pyrogens. Client feels cold even though body temp. is rising

Types of abnormal breathing patterns (7)

bradypnea (slow), tachypnes (fast), apnea (cease), cheyne-stokes (irregular), hyperventilation (rate and depth increase), hypoventilation (rate and depth low), kussmaul's respiration (deep and increased)

rhythm (respiration)

breathing patterns, either regular or irregular. Determine by observing the chest or abdomen,

How is ventilation assessed?

by assessing the respiratory rate, depth and rhythm

erythema

caused by increase visibility of oxyhemoglobin caused by dilatation or increased blood flow. causes include fever, direct trauma, blushing and alcohol intake observe for on the face, areas of trauma, sacrum, shoulders or other common sites for pressure ulcers.

jaundice

caused by increased deposit of bilirubin in tissues caused by liver disease, hepatitis, newborn have jaundice due to destruction of red blood cells, observe in sclera, mucous membranes and skin

cyanosis

causes are heart or lung disease, cold temperatures. observe for this in nail beds, lips, mouth, and generalized skin

Chronotropic

chrono = time / tropic = a turn/change

treatment of heatstroke

cool client to increase heat loss and replace fluids by IV route

symptoms of heatstroke

cramps, confusion, visual disturbances, and hot, dry skin

Prolonged exposure to cold

danger point is at 95 F when uncontrollable shivering occurs, vital signs fail at 94 F,

pallor

decrease in color cause by reduced amounts of oxyhemoglobin such as anemia or reduced visibility or oxyhemoglobin resulting from decreased blood flow such as shock observe for this in face, lips, conjunctivea, nail beds, palms or soles

negative affects of fever

dehydration, increased cardiovascular workload, increased oxygen needs due to increased metabolism, weakness from depleting energy stores

Pulse Pressure

difference between the systolic and diastolic BP. BP 120/80 = PP 40

negative chronotropic property

drug slows down the heart rate (beta blockers or digitalis such as atropine and dopamine)

positive chronotropic property

drug speeds up the heart rate (epinephrine, tobacco)

Antipyretics

drugs to reduce fever, including Tylenol and Motrin

heat exhaustion

due to environmental conditions, excessive perspiration leads to fluid and electrolyte imbalances, can lead to heatstroke if not treated, move client to cooler environment and replace fluids

Indications for assessing apical and apical-radial pulse

dysrhythmia, dehydration, compromised cardiac condition and certain meds related to cardiac and vascular conditions

Factors that influence pulse rate

exercise, temperature, emotions, drugs, hemorrhage, postural changes, pulmonary conditions

Febrile

fever

Afebrile

fever has broken

common problems of body temperature

fever, pyrogens, chills, diaphoresis

interval (respiration)

generally a regular interval between respirations. Infants and children tend to breathe less regularly: may breathe slowly for a few seconds and then suddenly breathe more rapidly.

Types of thermometers

glass (home), electronic (health care), tympanic, disposable, continuous measurement probe

rate

number of pulsations counted over 1 minute

pulse deficit

occurs when there is a difference between an apical and radial pulse. caused by inefficient contractions of the hear that fail to transmit a pulse wave to the peripheral site.

surface body temperature sites

oral, skin, axillae

temporal pulse

over temporal bone of head, about and lateral to eye. Assess pulse in children

what two mechanisms affect temperature

physiological and behavioral

factors influencing respiratory rate

position, medications, neurological injury (brain stem), decreased hemoglobin (carries O2), anxiety, exercise, smoking, pain

Two types of hypothermia

prolonged exposure to cold and frostbite

health promotion for temperature

promote balance between heat production and heat loss

radial pulse

radial or thumb side of forearm or wrist, easy to locate on adults difficult with children. (general way)

core body temperature sites

rectal, tympanic, pulmonary, urinary bladder, esophagus

rhythm

regular or irregular, specific pattern, can be regularly irregular or irregularly irregular.

Thermoregulation

regulation of body temperature, done by balancing heat lost and heat produced

Bradypnea

respirations that are regular in rhythm but slower than normal in rate, less than 12 breaths per minute

Diaphragmatic Breathing

results from the cotraction and relaxation of the diaphragm and is best observed by watching the abdomen and is seen in healthy men and children.

equality

should assess pulse on both sides of the body to compare characteristics of each. All pulses can be measured simultaneously except carotid pulses because excessive pressure may occlude blood supply to the brain.

apical pulse (aka "Point of Maximum Impulse PMI)

site is 4th to 5th intercostal space at mid clavicular line, most accurate, auscultate with diaphragm of stethoscope (30 seconds x 2 or if irregular 1minute)

treatment of prolonged exposure to cold

slowly increase the temp with blankets, warming devices, and warm fluids

promotes chest expansion during respiration

straight erect posture

strength, quality and amplitude (character of the pulse)

strength or amplitude of a pulse reflects the volume of blood ejected against the arterial wall with each heart contraction and the condition arterial wall. It is described as strong, weak, thready or bounding

Diaphoresis

sweating to release heat and decrease body temp when fever is resolving

heatstroke

temp of 105 F can cause brain and tissue damage (brain first organ affected), emergency situation caused by prolonged exposure to sun or heat, hypothalamus malfunctions due to extreme temps and does not cause sweating

vital signs

temperature, pulse, respiration, blood pressure + pain assessment

Hypothalamus

the body's "thermostat" - responsible for controlling the body's temperature. Sends messages to blood vessels to help conserve heat by vasoconstricition and shivering or to release heat by vasodilation and sweating.

Dyspnea

the clinical sign for hypoxia and manifests as breathlessness. It is the subjective sensation of difficult or abnormal breathing

Circadian Rhythm

varies over the 24 hour period with lowest temp 1am-4am, highest at 6pm. Takes 1 to 3 weeks to change with change of work and sleep patterns

The 3 processes involved in respiration

ventilation, diffusion and perfusion

This provides a baseline assessment data of health status

vital signs

posterior tibial pulse

inner side or ankle below medial malleolus. Used to assess circulation to foot

labored respirations

involve accessory muscles that are visible in the neck

dysrthmias

irregular heart beats

Dysrhythmia

irregular pulse cause by an early, late or missed beats, it is generally these types of beats that can produce a pulse deficit

Shivering

is an involuntary response to create heat

core temperature

is in the deep tissues and remains stable

surface temperature

is of the skin and varies greatly depending on blood flow (oral temp)

Heat Loss

lost from the skin surface by radiation, conduction (contact), evaporation, diaphoresis

inhibits chest expansion during respiration

lying flat

pulse oximetry

measurement of the oxygen saturation with a device named the pulse oximeter. Through light waves, the oximeter measures the SpO2 (pulse saturation) in hemoglobin. Place sensor on nail beds, earlobe, or bridge of nose.

respirations

mechanism that is used by the body to transport gases (gas exchange)

number of respirations for an adult

12-20 should be smooth and quiet

How long do you wait to take an oral temp. after someone ate, drink or smoked?

23-30 minutes

Average temp for elderly?

96.8 F

what temperature does the body function best at?

96.8-100.4 F (36-38 C)

body temperature

= heat produced - heat lost

Factors that influence body temperature

age, exercise, hormone level (women), stress, environment, temperature alterations (infections), circadian rhythm

qualitative data

all information used other than counted rate (objective date) when assessing pulse and respirations (discriptive information)

carotid pulse

along medial edge of sternocleidomastoid muscle in neck. best site for quickly finding pulse.

dorsalis pedis pulse

along top of foot between extension tendons or great and first toe. Used to assess status of circulation in foot

Tachycardia

an abnormally elevated heart rate, above 100 beats per minute in an adult

treatment of fever

antipyretics, oxygen, fluid, do on use ice packs or tepid sponge baths (will promote shivering), caution with hypothermia blankest (shivering, and risk of injury to skin)

10 sites for pulse measurement

apical pulse, carotid pulse, radial pulse, brachial pulse, ulnar pulse, femoral pulse, temporal pulse, popliteal pulse, posterior tibial pulse, dorsalis pedis pulse

brachial pulse

groove between biceps and triceps muscles at antecubital fossa. used most often in infants/young children. Used to auscultate blood pressure

Compromised cardiac condition

heart disease, MI, congenital abnormalies, CHF, cardiomyopathy,

Two types of hyperthermia

heat exhausion and heatstroke

Basal Metabolic Rate (BMI)

heat produced by the body at absolute rest, is affected by thyroid hormones that control metabolism. (men have a higher BMI than women)

Dehydration

hemorrhage, trauma, burns situations which produce a reduced fluid volume can cause peripheral pulses to be weak and thready

Fever

hyperpyrexia, febrile episode (important defense mechanism that works to enhance the immune system)

what may be induced to decrease the body's need for heat and oxygen

hypothermia

Frostbite

ice crystals from in the cells, areas with decreased blood flow are affected first (such as toes, fingers, earlobes, nose), if severe can lead to amputation of affected parts

Muscular Activity

increases heat production in the body

Systole

the contraction, or period of contraction, of the heart,especially of the ventricles, during which blood is forced into the aorta and the pulmonary artery. The maximum blood pressure is when the left ventricle of the heart pushes blood through the aortic valve into the aorta.

Blood Pressure

the force of the blood against the arterial walls. Measured in millimeters of mercury (mm Hg) and is recorded as a fraction such as 120/80

Diastolic Pressure

the minimum pressure against the arteries when the ventricles relax

Systolic Pressure

the peak of maximum pressure when ejection of blood occurs

Diastole

the phase of the cardiac cycle in which the heart relaxes between contraction,specifically the period when the two ventricles are dilated by the blood flowing into them (60-85)

Pulse

the result the wave of blood being pumped from the left ventricle ("throbbing" sensation palpated using the first 3 fingers with moderate pressure, peripheral arteries or auscultated, by apex of the heart, with a stethoscope or doppler ultrasound

what muscles do women tend to use to breathe?

thoracic muscles, movements are in upper chest

ulnar pulse

ulnar side or little finger (pinky) side of forearm or wrist. Used to assess status or circulation to hand. Used to perform Allen's Test