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