Funds 1 Vital Signs Ch. 20 pt. 1
Terms in this set (82)
Suggests assessments of the vital or critical physiological functions. Variations in temperature (T), respirations (P), or blood pressure (BP) are indicators of a person's state of health and function of the body systems.
What are "other" vital signs?
Pain & Oxygen Saturation
What is the mean adult temperature? Oral? Rectal?
What is the normal range and average pulse rate for an adult?
Normal Range- 60-100 beats/min
Average- 80 beats/min
What is the normal range of respirations for an adult?
BP- Normal range, Prehypertensive, Average for an adult?
Normal Range- 100-119 systolic 60-80 diastolic
Prehypertensive- 120-139 systolic 80-89 diastolic
The degree of heat maintained by the body. It is the difference between heat produced by the body and heat lost to the environment.
An adult's normal internal temperature. Ranges from 97
F to 100
F. Typically 1-2 degrees higher than surface temperature.
What measurements represent core measurements? Surface measurements?
Core- Rectal and tympanic membrane
Surface- Oral and axillary
The process of maintaining stable temperature. The body must balance heat production by heat loss.
Hypothalamus r/t Thermoregulation
The hypothalamus controls thermoregulation. It recognizes changes in the body temperature due to sensory receptors in the skin.
Hypothalamus r/t decreasing body temperature.
When heat sensors in the hypothalamus are stimulated, they send out impulses to reduce the body temperature; vasodilation, sweating, inhibiting heat production.
An increase ing the diameter of the blood vessles. It diverts core-warmed blood to the body surface, where heat can be transferred to the surrounding environment.
Hypothalamus r/t increasing body temperature.
When the hypothalamus detects cold, it sends out impulses to increase heat production, and reduce heat loss; shivering, release of epinephrine (increased metabolism) vasoconstriction, piloerection.
Narrowing of the blood vessles. Conserves heat by shunting blood away from the periphery to the core of the body, where blood is warmed.
Hairs standing on ends.
How is heat exchanged between the body and the environment? (4)
Radiation, convection, evaporation, conduction.
Radiation r/t exchange of heat.
Radiation is loss of heat through electromagnetic waves emitting from surfaces that are warmer than the surrounding air. If an uncovered skin is warmer than the air, the body loses heat through the skin.
Convection r/t exchange of heat.
The transfer of heat through currents of air or water. A warm bath may raise the temp of a hypothermic client. A cool air produced by a fan can help reduce a fever.
Evaporation r/t exchange of heat.
Evaporation occurs when water is converted to vapor and lost through the skin (as perspiration) or the mucous membranes (through the breath). Causes cooling.
Conduction r/t exchange of heat.
Heat is transferred from a warm to a cool surface by DIRECT contact. Putting an ice pack on a bruised leg, the leg will drop in degrees.
What factors influence body temperature? (6)
Age, environment, gender, exercise, emotions and stress, circadian rhythm.
Age r/t influencing temperature
Infants lose about 30% of their heat through their head. Older adults have issues maintaining body heat because they have slower metabolism, decreasing vasomotor control, and loss of subcutaneous tissue.
Environment r/t influencing temperature
High external temperatures can lead to heat stroke. Cold external environments can lead to hypothermia.
Gender r/t influencing temperature.
A woman's body temperature fluctuates as much as 1*F with her menstrual cycle and pregnancy. Hormones fluctuate during menopause through hot flashes.
Exercise r/t influencing temperature.
Because it increases metabolism strenuous exercise can increase the core temperature to 101
F - 104
F. The sweat that is produced, helps cool down the body.
Circadian rhythm r/t influencing temperature.
Temperature fluctuates 1-2*F over 24 hours. From 5am-6am body temp is at its lowest. 5pm-8pm body temp is at its highest.
Temperature above a person's usual range of normal. Oral- higher that 100
F . Rectal- higher that 101
Febrile & Afebrile
Febrile- a person with a fever
Afebrile- a person without a fever
Temperature up to 103*F. Maybe very uncomfortable and show signs of influenza or infection.
A fever above 105.8*F dangerous and requires intervention.
What are the phases of a fever?
1. The febrile episode or onset
3. Defervescence or crisis
The initial phase of fever (onset).
Body temperature is rising. The onset of fever may be gradual or sudden. The person feels chilly, generally uncomfortable, and may shiver.
The second phase (course).
Body temperature reaches its maximum (set point) and remains fairly constant. The person feels flushed, warm, and dry. May last a few days or weeks.
The third phase (defervescence or crisis).
The temperature returns to normal. The person feels warm and appears flushed in response to vasodilation. This is the breaking of the fever.
Fever reducing medication.
Body temperature above normal; temperature is higher in the setpoint. The body cannot promote heat loss fast enough to balance heat production or high external environment.
Core temperature of 98.6-103*F. Warning signs include weakness, nausea, vomiting, tachycardia, tachypena, muscle aches, headache, slushed skin, and diaphoresis.
Above 103*F. Happens when body temp regulation fails due to hyperthermia progression.
Abnormally low core temperature, less that 95*F.
Early signs of hypothermia
Shivering, cyanosis of lips and fingers, poor coordination, some pain in the extremities, mental impairment, confusion, disorientation, slowing of heart rate and respirations.
Body temperature drops below 82.4
F. The person becomes unconscious and stops shivering. The pulse and respirations are irregular and difficult to detect. Death usually occurs when body temp drops below 70-75
Advantages and disadvantages of glass thermometers.
Advantages- Can be used for many areas of temp, inexpensive, easily disinfected, good accuracy.
Disadvantages- Easily broken: keep replacing and risk of injury, takes 3-8 minutes to get reading.
Difference between oral and rectal thermometers.
Oral- End part is narrow and pointy; top is blue.
Rectal- End part is rounded; top is red.
Advantages and disadvantages of electronic thermometers.
Advantages- Can be used for many areas of temp, 2-60 sec to obtain reading.
Disadvantages- Need to keep charged, usually only one per unit, requires regular inspection.
Advantages and disadvantages of electronic with infrared sensor.
Advantage- Easy use, 2-5 sec to obtain reading, low rate of operator error.
Disadvantages- Less accurate when used for tympanic membrane temps, requires inspection, must keep charged.
Advantages and disadvantages of disposable chemical thermometer.
Advantages- Easy to use, less expensive, prevents spread of infection.
Disadvantages- Less reliable than glass or plastic, skin must be dry, only indicates surface temp- not core.
The continuous supply of oxygenated blood though the blood vessles to the vital organs.
The rhythmic expansion of an artery produced when a bolus of oxygenated blood is forced into it by contraction of the heart.
What is the normal pulse rate for a healthy adult?
The peak wave. The contraction of the heart.
The trough. The resting phase of the heart.
The quantity of blood forced out by each contraction of the left ventricle.
The total quantity of blood pumped per minute.
Cardiac Output = stroke volume x pulse rate.
Age r/t pulse rate.
Newborns have a rapid pulse. The rate stabilizes through childhood and gradually slows during old age.
Gender r/t pulse rate.
Women have a slightly higher pulse rate then men do.
Exercise r/t pulse rate.
Muscle activity normally increases the pulse rate. A well-conditioned heart returns to normal quicker than a non-conditioned heart. People who are well conditioned have lower heart rates.
Food r/t pulse rate.
Ingestion of food causes a slight increase in pulse rate for several hours. It is pulling blood from the brain to the stomach.
Stress r/t pulse rate.
Stress triggers the fight-or-flight response which increases both the pulse rate and the strength of heart contractions.
Fever r/t pulse rate.
The pulse rate tends to increase about 10 beats/min for each degree of F elevated. The metabolic rate increases and the body attempts to compensate for the decrease in blood pressure.
Disease r/t pulse rate
Hyperthyroidism, heart disease, respiratory disease, and infections typically raise the pulse rate.
Blood loss r/t pulse rate.
Large blood loss stimulates the sympathetic nervous system, bringing about an increase in pulse rate to compensate for the decreased blood volume.
Position changes r/t pulse rate.
Standing and sitting positions generally cause a temporary increase in pulse rate and decrease in blood pressure as a result of blood pooling in the veins of the feet and the legs.
Medications r/t pulse rate.
Stimulant drugs (epinephrine) increase pulse rate. Cardiotonics (digitalis) and opioids or sedative drugs decrease pulse rate.
Pulse at the apex of the heart.
A place where an artery can be presses by fingers against a bone.
When is the radial artery used?
For routine assessments of vital signs. Most commonly used site.
When is the brachial artery used?
During blood pressure and when preforming cardiopulmonary resuscitation on infants.
When is the carotid artery used?
When preforming CPR of an inpatient adults and for assessing circulation of the brain.
When is the temporal artery used?
When assessing circulation to the head or when other sites are not easily accessible.
When is the dorsalis pedis used?
Assessing peripheral circulation.
When is the femoral artery used?
To determine circulation to the legs, in cases for cardiac arrest, and for children.
When is the popliteal artery used?
For assessing circulation to the lower leg.
When should I take an apical pulse? (4)
1. The radial pulse is weak or irregular.
2. The rate is less than 60 beats/min or greater than 100 beats/min.
3. The patient is taking cardiac medications.
4. The patient is an infant or child.
Intervals between heartbeats establish a pulse pattern.
When the intervals between beats vary enough to be noticeable. The rhythm is abnormal.
Regularly Irregular & Irregularly Irregular.
Regularly Irregular- An irregular rhythm that forms a pattern.
Irregularly Irregular- An unpredictable rhythm.
The quality of the pulse is assessed by determining the pulse volume and bilateral equality of pulses.
The amount of force produced by the blood pushing through the arteries.
Pulse volume 0-3.
0- Absent: No pulse felt.
1+ -Weak: Pulse is barely felt and can be easily obliterated by pressing with fingers.
2+ -Normal: Pulse is easily palpated.
3+ -Bounding: Pulse is easily felt wit little pressure.
Comparing pulses on both sides of the body for equal volume.