Vital Signs

Factors affecting temperature
Click the card to flip 👆
1 / 89
Terms in this set (89)
Age, exercise, hormone levels, circadian rhythm, stress, environment

Age - Newborns' temperature control mechanisms are immature. Until a child reaches puberty, temperature regulation is unstable. It is not unusual for older adults to reach temperatures no higher than 96.8° F

Exercise - will increase heat production and body temperature

Hormonal level - Women experience greater fluctuations in body temperature than men. Hormonal variations occur during menstrual cycle & menopause. Women may experience hot flashes caused by an inability to control vasodilation and vasoconstriction.

Circadian rhythm - changes the body temperature over the 24-hour period. The lowest body temperature occurs between 0100 and 0400 hours. The body reaches maximum temperature at 1800 hours

Temperature alterations - related to excessive heat production, excessive heat loss, minimal heat production, minimal heat loss, or any combination of these

important defense mechanism
Pyrogens - bacteria & viruses elevate body temperature
Fever is usually not harmful if it stays below 39° C (102.2° F) in adults or below 40° C (104° F) in children.
Mild temperature elevations as high as 39° C (102.2° F) enhance immune system of the body.
During a fever cellular metabolism increases, and oxygen consumption rises. Body metabolism increases 10% for every degree Celsius of temperature elevation
Heart and respiratory rates increase to meet the metabolic needs of the body for nutrients. The increased metabolism uses energy that produces additional heat.
Normal Rectal Temp. Average99.5 (37.5c)Normal Tympanic temp range96.8-100.4 (same as oral temp) or 36-38cTypes of thermometersGlass, electronic, disposableFactors influencing pulseAge, exercise, position change, medications, temperature, emotional stress, anxiety, fearTrachycardiaIncreased heart rate (regularly above 100 in adults)BraycardiaDecreased heart rate (regularly below 60 in adults)Pulse CharacteristicsRate, Rhythm, Strength, EqualityNormal Pulse Range60-100 BPMNormal Respiration Range12-24Assessing RespirationsRate, Rhythm, Depth (shallow, deep, normal), labor, Symmetry (chest should rise and fall at the same time)Blood Pressure definitionLateral force on the walls of an artery by the pulsing blood under pressure from the heartSystolic Blood Pressure definitionThe peak of maximum pressure when ejection occursDiastolic Blood Pressure definitionWhen the ventricles relax, the blood remaining in the arteries exerts a minimum pressureNormal Blood Pressure120/80Standard unit for measuring blood pressuremillimeters of mercury (mm Hg)Factors influencing blood pressureAge, stress, race (blacks generally have higher blood pressure throughout the day), Medications, Diumal variation (changes in blood pressure throughout the day), genderHypertensionHigh blood pressureHypotentionLow blood pressure below normal rangeOrthostatic hypotension/ Postural hypotensionBlood pressure drops based on position of the patient's bodyHow long should you record an irregular respiration/ pulse?60 secondsVital signsTemperature, pulse, respiratory rate, blood pressure, Oxygen Saturation Pain - Often called the fifth vital Measurement of vital signs provides data from which to determine a patient's usual state of health (baseline data). Vital signs are used to: Monitor patient's condition Identify problems Evaluate response to interventionBaselineKnow patient's usual range and medical HxNeural and vascular controlHypothalamus establishes a body "set point." Anterior hypothalamus controls heat loss, posterior hypothalamus controls heat production.Heat loss (4)radiation, conduction, evaporation, convectionRadiationFrom the surface of one object to the surface of another without direct contact between the twoConductionFrom one object to another through direct contactEvaporationAway by air movementConvectionAway by air movementBehavioral controldepends on a person's ability to control body temperature through: The degree of temperature extremes, ability to sense comfort or discomfort, Processes or emotions, and the person's mobility or ability to add or remove clothingHeat productionOccurs through the basal metabolic rate (BMR), and through shivering and nonshivering thermogenesis, which is reported in neonates.Skin temperature regulationSkin, subcutaneous tissue, and fat keep heat inside the body.Thermoregulationconstitutes the physiological and behavioral mechanisms that regulate the balance between heat loss and heat productionHypothalamic Temperature ControlProlonged fever weakens a patient by exhausting energy stores. Increased metabolism requires additional oxygen. If the body cannot meet demand for additional oxygen, cellular hypoxia (inadequate oxygen) occurs. Myocardial hypoxia produces angina (chest pain). Cerebral hypoxia produces confusion. Interventions during a fever include oxygen therapy When water loss through increased respiration & diaphoresis is excessive, the patient is at risk for fluid volume deficit. Dehydration is a serious problem for older adults & children with low body weight. Maintaining optimum fluid volume status is an important nursing action.heatstroke(104° F or higher) - Occurs from prolonged exposure to the sun or high environmental temperatures. S&S: giddiness, confusion, delirium, excessive thirst, nausea, muscle cramps, visual disturbances, elevated body temperature, increased heart rate, and lower blood pressure.Heat exhaustionWhen profuse diaphoresis results in water and electrolyte loss.frostbiteIce crystals form inside cell, & permanent circulatory and tissue damage occursNursing processAssessment Sites: advantages & disadvantages - Rectal temperatures are usually 0.5° C (0.9° F) higher than oral temperatures, & axillary temperatures are usually 0.5° C (0.9° F) lower than oral temperatures. Core & surface body temperature can be measured at several sites. ICU's use the core temperatures of the pulmonary artery, esophagus, & urinary bladder. Thermometers Electronic: oral, axillary, rectal, tympanic membrane, temporal artery Disposable: oral, axillary, rectal Fahrenheit or Celsius scale Diagnosis Risk for imbalanced body temperature Hyperthermia Hypothermia Ineffective thermoregulation Planning Write individualized patient goals/outcomes. Set priorities of care Teach patient & caregiver importance of thermoregulation & actions to take during excessive environmental heat. Education is particularly important for parents of an infant or child Implementation Health promotion Consider activity, environment, and clothing. Acute care: Heatstroke Treatment - Move patient to cooler environment, remove clothing, place cool wet towels over the skin, & use fans to increase convective heat loss, providing IV fluids, irrigating stomach & lower bowel with cool solutions, hypothermia blankets. Hypothermia Treatment- Priority goal is to prevent further decrease in body temperature. Remove wet clothes, replace with dry ones, & wrap pt. in blankets. Evaluation Get patient's perspective, compare actual with expected outcomes, & determine whether goals were met.pulsePalpable bounding of blood flow noted at various points on the body The indicator of circulatory status Blood flows through body in a circuit. Volume of blood pumped by the heart in 1 minute is cardiac output, which is the product of heart rate & stroke volume of the ventricle.Pulse rateNumber of pulsing sensations in 1 minute Acceptable pulse Rates: 60 - 100 BPM Electrical impulses originate from the sinoatrial (SA) node. Regulation of ventricular contraction and stroke volumeSites of pulsetemporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, posterior tibial, and dorsalis pedisCharacter of pulserate, rhythm, strength, & equality Nursing process and pulse determination Before measuring a pulse, review the patient's baseline rate for comparisonratePostural changes affect the pulse rate, HR temporarily increases when a person changes from a lying to a sitting or standing position.Apical rateID S1 and S2, "lub"+"dub" = 1 heartbeat, Lub-dubs per minute = RateBradycardiaslow rate—below 60 beats/min in adults.Tachycardiaabnormally elevated HR—above 100 beats/min in adultsPulse deficitDifference between radial and apical pulse rates RhythmDysrhythmiaregularly or irregularly irregular Threatens the ability of the heart to provide adequate cardiac outputpulse strengthStrength Amplitude of pulse = volume of blood ejected against the arterial wall with each heart contraction The pulse strength: Bounding (4+) Full or strong (3+) Normal & expected (2+) Diminished or barely palpable (1+) Absent (0). Include assessment of pulse strength in the assessment of the vascular system. No palpable pulse, but found with Doppler Equality - Pulse in one extremity is sometimes unequal in strength or absent in many disease statesPulse determinationactivity intolerance, anxiety, fear, decreased cardiac output, deficient/ excess fluid volume, impaired gas exchange, hyerptheria, hypothermia acute pain, ineffective peripheral tissue perfusionRespiration has three processesventilation, diffusion, & perfusion.VentilationMovement of gases into and out of the lung.DiffusionMovement of oxygen and carbon monoxide between alveoli and red blood cells.PerfusionDistribution of red blood cells to & from the pulmonary capillaries.Respiration: Physiological controlBreathing is a passive process. Brain stem regulates involuntary control. Body regulates ventilation through CO2 concentrations in arterial blood. If oxygen falls below acceptable parameters, respiratory rate & depth of ventilation will increase.hypoxemiaLow blood level of oxygen Helps to control ventilation in patients with chronic lung disease. Levels of arterial O2 provide stimulus that allows a Pt to breathe, administration of high oxygen levels is fatal for patients with chronic lung disease.Eupneaventilation of a normal rate and depthRespiratory ratebreaths/minute: Acceptable respiratory Rate: 12 - 20 breaths/Min Age specific, & can be influenced by activity, age, & illness, injury, or disease.Ventilatory depthdeep, normal, shallowVentilatory rhythmregular/irregular Infants tend to breathe less regularly. Respiration is regular or irregular in rhythm.Diffusion and perfusionevaluate respiratory processes of diffusion and perfusion by measuring the oxygen saturation of bloodArterial oxygen saturationThe percentage of hemoglobin that is bound with oxygen in the arteries is the percent of saturation of hemoglobin, or SaO2.Factors Influencing Character of Respirationsexercise, anxiety, body position, neurological injury, acute pain, smoking, medications, hemoglobin functionbradypneaRate of breathing is regular but abnormally slow (less than 12 breaths/min).tachypneaRate of breathing is regular but abnormally rapid (greater than 20 breaths/minHyperpneaRespirations are labored, increased in depth, and increased in rate (greater than 20 breaths/min) (occurs normally during exercise).ApneaRespirations cease for several seconds. Persistent cessation results in respiratory arrestHyperventilationRate and depth of respirations increaseHypoventilationRespiratory rate is abnormally low, and depth of ventilation is depressed.Cheyne-Stokes respirationRespiratory rate & depth are irregular, alternating periods of apnea & hyperventilation. Begins with slow, shallow breaths that gradually increase to abnormal rate and depth. The pattern reverses; breathing slows and becomes shallow, climaxing in apnea before respiration resumes.Kussmaul's respirationRespirations are abnormally deep, regular, and increased in rate.Biot's respirationRespirations are abnormally shallow for two to three breaths followed by an irregular period of apnea.BPForce exerted on the walls of an artery by pulsing blood under pressure from the heart Acceptable Blood pressure Range for adults: <120/<80 Blood moves from areas of high pressure to areas of low pressure. Systolic = Maximum peak pressure during ventricular contraction Diastolic = Minimal pressure during ventricular relaxation Pulse pressure = Difference between systolic and diastolic pressures For a BP of 120/80, the pulse pressure is 40Cardiac outputvolume of blood ejected by ventricles of the heart (stroke volume) multiplied by the heart ratePeripheral resistancedetermined by tone of the vasculature & diameter of the blood vesselsBlood volumeNormal circulating volume is 5000 mL. Rapid infusion of volume elevates blood pressure. Decreased volume causes blood pressure to fall.ViscosityHematocrit, or percentage of red blood cells, determines viscosity (thickness)ElasticityNormal arterial walls are elastic & easily distensible. As blood pressure increases, the diameter of the vessels increases to accommodate the pressure. Distensibility prevents fluctuations in blood pressure. Systolic pressure is elevated more than diastolic pressure as a result of reduced arterial elasticity.Factors influencing BPage, stress, gender, ethnicity... Age - BP rises throughout the lifespan Ethnicity - incidence of hypertension is higher in African Americans than in European Americans. Stress - causes sympathetic stimulation, which increases heart rate, cardiac output, and vascular resistance. Gender - No clinical differences between boys and girls have been noted. However, after puberty, males tend to have higher blood pressure. After menopause, women tend to have higher blood pressure than men of similar age. Daily variation - BP is highest between 1000 and 1800 hours. Blood pressure is lowest between hours of sleep and 0300. As the person wakes up, the blood pressure will rise. Activity, weight - A period of exercise can reduce blood pressure for several hours. Inadequate exercise contributes to weight gain and perhaps obesity, which can trigger hypertension Smoking - directly affects vessels, producing vasoconstriction, which causes BP to rise. Medications - Antihypertensives alter blood pressure directly. Indirectly, opioid analgesics lower blood pressure and volume, and vasoconstrictors raise blood pressure.Patient Conditions Not Appropriate for Electronic Blood Pressure MeasurementIrregular heart rate Peripheral vascular obstruction (e.g., clots, narrowed vessels) Shivering Seizures Excessive tremors Inability to cooperate Blood pressure less than 90 mm Hg systolic