Yoost Chapter 19

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Vital signs allows the nurse to ...
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Vital signs allows the nurse to ...
detect changes in the health status of the patient, identify early warning signs of life threatening health conditions, and evaluate the effectiveness of interventions
Name the 5 vital signs
temperature, pulse, respirations, blood pressure and pain
The frequency of vital signs are accessed...
individually for each patient and is dependent on patient status.
How to track pain assessment
SOCRATES (site, onset, character, radiation, associations, time course, exacerbating/relieving factors, severity)
Vital signs are interpreted on the basis of...
current health status and previously established normal values for the patient
Medical Factors that affect vital signs include...
infection and renal, respiratory, and cardiovascular disease, medications
Nonmedical factors that affect vital signs include...
physical environment, emotional state of the patient, food and fluid intake, and activity level and tolerance
Vital sign documentation
Both normal and abnormal vital sign results are appropriately documented and communicated to all members of the health care team.
Temperature
measure of heat in the body
Pulse
palpable, bounding contractions created by the left ventricle of the heart

measured as number of heartbeats per minute (bpm)

pulse strength and pattern often specified as well
Respirationassessed for frequency, or breaths per minute (BPM) abnormal quality and pattern of breathing also should be notedBlood pressuremeasurable pressure of blood within the systemic arteriesPulse oximetryamount of oxygen available in the tissuesNewborn normal... (1)temperature (2) pulse (3) respiration (4) systolic blood pressure (5) diastolic blood pressure(1) 35.5°-37.5° C (96°-99.5° F) (2) 80-160 (3) 30-80 (4) 60-90 (5) 20-60One year old normal... (1)temperature (2) pulse (3) respiration (4) systolic blood pressure (5) diastolic blood pressure(1) 37.4°-37.6° C (99.4°-99.7° F) (2) 80-140 (3) 24-40 (4) 74-100 (5) 50-70Six year old normal... (1)temperature (2) pulse (3) respiration (4) systolic blood pressure (5) diastolic blood pressure(1) 36.6°-37° C (98°-98.6° F) (2) 75-110 (3) 15-25 (4) 84-120 (5) 54-80Fifteen year old normal... (1)temperature (2) pulse (3) respiration (4) systolic blood pressure (5) diastolic blood pressure(1) 36.1°-37.2° C (97°-99° F) (2) 50-90 (3) 15-20 (4) 94-120 (5) 62-80Adult normal... (1)temperature (2) pulse (3) respiration (4) systolic blood pressure (5) diastolic blood pressure(1) 35.5°-37.5° C (95.9°-99.5° F) (2) 60-100 (3) 12-20 (4) 90-120 (5) 60-80_____ temperatures may be approximately 1° less than _____, which in turn are approximately 1° less than ______Axillary; oral readings; rectal temperaturesNormal oral temperature in an adult36.0°-37.6° C (96.8°-99.68° F)Normal axillary temperature in an adult35.5°-37.0° C (95.9°-98.6° F)Normal rectal temperature in an adult34.4°-37.8° C (93.92°-100.04° F)Normal tympanic temperature in an adult35.6°-37.4° C (96.08°-99.32° F)Normal temporal temperature in an adult36.1°-37.3° C (96.98°-99.14° F)What part of the hypothalamus controls heat loss through the mechanisms of diaphoresis (sweating) and vasodilation of blood vessels?anterior hypothalamusWhat part of the hypothalamus conserves heat through mechanisms such as vasoconstriction to reduce heat loss and shivering?posterior hypothalamusWhat factors can affect temperature?age (very young and very old), recent exercise, hormone fluctuations, circadian rhythms, stress, smoking, and environmentHow does smoking affect temperature?it causes vasoconstriction, which can cause a drop in temperatureHow does stress affect temperature?levels of epinephrine and nonepinephrine increaseSymptoms of a fever include...loss of appetite (anorexia), headache, malaise, hot and dry skin, flushing, thirst, shivering, and a general feeling of not being wellSigns of a fever include...dehydration, decreased urinary output, and rapid heart rateCauses of a feverinfection, tissue injury, cancer, trauma, or surgeryName the five sites commonly used to assess temperaturemouth, ear, rectum, forehead (where the temporal artery is close to the skin), and axillaTemperature site selection if affected by...patient age, state of consciousness, amount of pain the patient is suffering, and treatment the patient is undergoing, such as oxygen supplementationTypes of thermometerselectric, temporal, tympanicMost common site of temperature measurementOralAdvantages of oral temperaturereadily accessible and comfortable for the patientDisadvantages of oral temperatureEating, drinking, smoking, and the use of oxygen by cannula or mask can affect measurementsOral temperature is not preferred for...infants and young children, unconscious patients, post-oral surgery patients, or people with seizure disordersRectal temperature should not be used for...newborns, patients who are neutropenic (manifested as a low white blood cell count), and in patients with spinal cord injury.Core temperature sites...tympanic, temporal, and rectalUse of tympanic temperature is appropriate for patients who are...confused or unconsciousUse of tympanic temperature is not appropriate for patients who..have ear drainage or ear scarringTemporal temperature is well tolerated by patients who are...infants and young childrenWhat can affect the accuracy of a temporal temperature reading?covering on the headWhen should axillary temperature be used?when oral or rectal sites are contraindicated or inaccessible; frequently used for healthy newbornsElectronic thermometersDisposable probe cover Same probe can be used for oral and axillary locations Separate probe (red) for rectal measurementsDisposable paper thermometersSingle-use or reusable Nurse reads highest reading among the dots that have changed color. Excellent choice for maintaining asepsis Can be used for oral or axillary sitesTemperature sensitive stripsgives body surface temperature perspiration can affect readings placed on forehead or abdomen must verify results by another method if younger than 2 and readings are abnormalTreatment for increased temperaturesNSAIDS Cool sponge baths, cooling blankets, and packs Antibiotics as prescribed if bacterial infection Oxygen Monitoring vital signs Monitoring intake and output Increasing fluid intake Maintaining oral hygieneNursing activities to restore normal body temperature include:Identify the underlying cause of the fever Assess the patient frequently for changes. Monitor body temperature and other vital signs Provide oral and/or intravenous fluids to replace fluid loss Provide prescribed interventions such as antibiotics to treat the underlying cause of the fever. Implement nonpharmacologic measures to reduce the fever without causing shivering Keep clothing and bedding dry to reduce shivering. Encourage physical rest to reduce metabolic demands and oxygen use. Provide nutritional support to meet increased metabolic demands.Patient specific factors that can affect pulseage, gender, exercise, presence of fever, medications, fluid volume status, stress, electrolyte imbalance, and underlying diseaseHow does hypovolemia (loss of blood) affect pulse?increases pulse rateHow does hypoxia (loss of oxygen) affect pulse?increases pulse rate due to increased cardiac outputNormal Pulse rate for (1) newborns (2) 1 year olds (3) 6 year olds (4) 15 year olds (5) adult(1) 80-160 (2) 80-140 (3) 75-110 (4) 50-90 (5) 60-100Pulse is an indicator of...circulatory status. Electrical impulses originating in the sinoatrial (SA) node of the heart stimulate cardiac muscle contraction, which sends a pulse wave.What factors regulate the strength of ventricular contraction and the subsequent cardiac output?mechanical, neural, and chemical factorsApical pulsecentral pulse that can be auscultated over the apex of the heart at the point of maximal impulse (PMI).Peripheral pulse sitestemporal artery; the carotid artery; the brachial and radial arteries; and the femoral, popliteal, dorsalis pedis, and posterior tibial arteries .Most common site used to access quality, rate, and rhythm of the pulseradialIn an emergency or during cardiopulmonary resuscitation...carotid or femoral pulse may be used to assess the pulse rate and adequacy of cardiac compressionsWhat pulse is accessed in children during emergencies?brachialWhat pulse sites are used to access the peripheral vascular system but not to assess heart rate or rhythm?dorsalis pedis and posterior tibial arteryPulse assessment measures...Rate Rhythm Volume And comparing findings on both sides of the bodyHow are pulse accessed?Palpation Auscultation (listening with a stethoscope) Electronic monitoringWhat is the bell of the stethoscope used for?to hear low pitched noisesWhat is the diaphragm of the stethoscope used for?to hear high pitched soundWhen is a Doppler ultrasound used to obtain pulse?to assess peripheral circulation when a pulse cannot be palpatedReasons why pulses may be difficult to palpate?poor circulation, edema, obesity, and other obstructive issuesTachycardiapulse rate >100Factors that can lead to tachycardiadrop in blood pressure; an elevated temperature; anemia; exercise; prolonged application of heat; pain; strong emotions; and some medications, including bronchodilators.Bradycardiapulse rate <60Bracycardia can occur in...athletes, persons with hypothermia, in association with medications such as beta blockers, during tracheal suctioning, in association with increased intracranial pressure, and in myocardial infarction.Pulse deficitwhen apical pulse excels radial pulse (apical pulse minus radial pulse)Rhythmregularity of the heart beatPulse volumealso called amplitude; is the strength of the pulseHow is pulse volume described?normal (full and easily palpable), weak (thready and rapid), or strong (boundingPulse volume scale0=absent pulse 1+=weak and thready pulse, difficult to palpate 2+=normal pulse 3+=bounding pulse,Causes of a bounding pulseoverhydration and vasodilationCauses of a weak or thready pulsevasoconstriction, stiff vessel walls from disease, and shockWhat chemoreceptors in the body are especially sensitive to low oxygen levels in the blood?Chemoreceptors located in the aortic arch and carotid arteriesWhat chemoreceptors in the body are especially sensitive to high levels of carbon dioxide in the blood (hypercapnia) and PH?Receptors in the medullaWhat factors affect respirationage, exercise, illness process, acid base balance, medications, pain, emotionsAssessment of respirations always includes measurement of the ...breathing rate, depth, rhythm, and often oxygen saturationeupneanormal breathing rate and depthtachypneabreathing rate>24 bpmcauses of tachypneaAny 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)bradypneabreathing rate <10 bpmcauses of bradypneamedications, especially opioids, metabolic disorders, or brain injuryWhen measuring depth of respirations, you are looking for...hypoventilation and hyperventilationhypoventilationshallow respirations (associated with obesity, copd, cervical spine injury, drug overdose)hyperventilationdeep, rapid ventilations (associated with stress or anxiety)apneaabsence of breathingdyspneadifficult breathingCheyne-Stokes respirationsRhythmic respirations, going from very deep to very shallow or apneic periodsAssociated factors of cheyne-stokes respirationsHeart failure, renal failure, drug overdose, increased intracranial pressure, impending deathKussmaul's breathingRespirations abnormally deep, regular, and increased in rate (caused by diabetic ketoacidosis)Biot's breathingRespirations abnormally shallow for two or three breaths, followed by irregular period of apnea (caused by meningitis and brain injury)Arterial blood gas levels include...ph and carbon dioxide levelsWhat is considered a significant change in blood pressure?increase or decrease of 20 to 30 mm HGsystolic pressurepeak of the pressure wave on the arterial walls as heart contractsdiastolic pressureThe lowest pressure on arterial walls, which occurs when the heart restspulse pressurethe difference between the diastolic and systolic pressuresCauses of hypotensionDecreased blood volume (hemorrhage) Decreased cardiac output (heart attack or heart failure) Decreased peripheral vascular resistance (shock).Orthostatic hypotensionoccurs when patient moves from lying down to sitting up; occurs from peripheral vasodilation with no rise in cardiac output for compensation.Risk factors for orthostatic hypotensionelderly, medications, prolonged immobility, dehydration, and blood lossPrehypertension120-139 / 80-89Primary hypertensionoccurs when there is no known cause for the high blood pressure.Secondary hypertensioncaused by a known illness process, such as renal failure.Risk factors for hypertensionsmoking, stress, obesity, sedentary lifestyle, family history, alcohol, high salt and fat dietStage 1 hypertensionsystolic: 140-159 diastolic: 90-99Stage 2 hypertensionsystolic: >160 diastolic:>100Factors affecting blood pressureage, gender, race, circadian rhythms, medications, weight, head injuries, pain, emotions, food intake, weight, blood volumeKorotkoff sounds.The sounds for which the nurse listens when assessing blood pressure