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Chapter 21 measuring vital signs

Terms in this set (129)

common pulse points
five vital signs are
temperature, pulse, respiration, blood pressure and pain
basal metabolic rate (BMR)
the rate at which heat is produced when the body is at rest
BMR is affected by
the thyroid hormone
increased thyroid hormone causes
an increase in metabolic rate and increased temperature.
decreased levels of thyroid hormone result in
decreased metabolic rate and a decreased body temperature
other hormones affecting metabolic rate are
epinephrine, norepinephrine, and testosterone
men have a higher BMR than women because of
testosterone
voluntary muscle movement causes
increased heat production
how can shivering increase heat production
up to 5 times normal
hypothalamus acts as the
thermostat to control body temp
decrease in body temp results in
peripheral vasoconstruction and shivering
increase in body temp results in
peripheral vasodilation and diaphoresis
what actions increase body heat?
vasoconstrictions, shivering, pathogens or infections
what actions decrease body heat?
sweating, circulation of cool air, cool drinks
heat loss occurs with skins exposure to the environment through
radiation, conduction, convection, and evaporation
radiation
absorption of heat in the body
conduction
distribution of heat
convection
circulation of heat
evaporation
heat being lost by evaporation results in 800mL loss of water each day
pyrexia
fever
temp that indicates pyrexia
above 100.2° F
pyrogens
substances that causes fever
hyperthermia
temp is above the normal range
hypothermia
lowering of the temp of the entire body
very high fevers such as those greater than 105.8°F
cause damage to body cells, particullarly those of the CNS
normal body temp is
97.5°-99.5°F
rectal temps
about 1° higher than normal
axillary temps
about 1° lower than normal
tympanic membrane measures
approximate core temp
rectal, axillary, or tympanic temps are preferred for
small children and for patients who are unconcious or uncooperative
the temp in a healthy young adult averages
98.6°F
taking an oral temp:
-place the tip of the thermometer or probe in the sublingual pocket
-patient should keep the tongue down, close the mouth, and keep the lips closed.
-a plastic sleeve or probe cover is used
-remove the plastic sleve before reading a glass thermometer.
taking a rectal temp
-provide privacy
-drape the patient to reveal only the anal area
-don gloves
-lubricate the tip of the thermometer or probe
-hold the thermometer in place for 3 to 5 minutes or until temp is indicated
-wipe the thermometer or probe from the stem towards the bulb/tip
-wipe the buttocks to remove lubricant or stool
-correctly dispose of gloves and tissues
-wash hands
taking an axillary temp:
-place the thermometer in the center of the patients dry axilla (armpit)
-ask the patient to hold the arm tightly against the chest
-leave the thermometer in place for 3 to 8 minutes or until the thermometer indicates the reading is complete
-remove and wipe the thermometer clean from the stem to the tip
tympanic thermometers
-may be set for infant and toddler or child and adult
-the auditory canal probe is placed in a plastic cover that is used one time then discarded
-temp is displayed digitally on a small screen on the hand held unit
-reading is in tenths of a degree and can be displayed in degrees farenheit or celcius
temporal artery skin thermometer
-placed on the skin of the forehead over the temporal artery
- an electronic thermometer that is fast and accurate
-less invasive than the tympanic thermometer and more reliable when used correctly
factors affecting temperature measurements
-time of day (circadian rhythm)
-environmental temperature
age of the patient
-physical exercise
-menstrual cycle and pregnancy
-emotional stress
-disease conditions
-drugs
-eating, drinking, mouth breathing
diaphoresis
excessive sweat produced to cool the body
nursing interventions to reduce fever:
-increase patients fluid intake
-lower room temperature
-increase the rate of circulating air
-remove excessive clothing or bed covers
-control or reduce the amount of body activity
-provide sponge bath or cooling blanket
-antipyretics (aspirin, tylenol)
for a known infection
check temp every 4 hours
for an unknown infection
check temp every 2-4hrs
people at risk for hypothermia
-infants
-surgical patients in the operating room
-elderly exposed to cold for prolonged periods
-people exposed to extreme cold weather
-people exposed to cold water immersion
pulse is produced by
cardiac contractions causing a pressure wave against the walls of arteries
each contraction propels
60-70mL of blood into the aorta (stroke volume)
stroke volume affects
the character of the pulse
stroke volume×heart rate=
cardiac output
approximate cardiac output for the average adult is
5L/min
pulse rate may be affected by:
age,sex, and general health status of a patient
infants and children have ________pulse rates than adults
higher
womens pulse rates are _____than those for men
higher
pulse rates are_________for patients who have infections
higher
pulse is normally found by
palpation or auscultation
pulse rate is affected by
fever, pain, hypoxia, anxiety, exercise, and cardiac disease
pulse rate does not normally change with age but
dysrhythmias are common in the elderly
normal pulse rates are taken when
patients are calm and relaxed
average pulse rate in adult is
72bpm
tachycardia
pulse greater than 100bpm
bradycardia
slow pulse fewer than 60bpm
what is the most often used site to palpate the pulse
radial artery in the wrist
pulse deficit
the difference between apical and radial pulse
pulse characteristics
rate, rhythm, and volume should be noted
dysrhythmia
a period of normal rhythm broken by periods of irregularity or skipped beats
weak and regular
even beats with poor force, or 1+
strong and regular
even beats with moderate force, or 2+
full and bounding
even beats with strong force, or 3+
feeble
barely palpable
irregular
both strong and weak beats occur within 1 minute
thready
indicates that it is weak and may be irregular
absent
no pulse palpable or heard on auscultation
pedal pulses are checked to determine
any blockage in the artery going to the foot following cardiac catenation
what does pain increase?
pulse rate
factors affecting pulse rate
age, body build and size, blood pressure, drugs, emotions, blood loss, excercise, increased body temp, pain, hypoxia
respirations
an involuntary autonomic funtion controlled by respiratory center in the pons and medulla in the brainstem, triggered by increased levels of CO2 or serum hydrogen ion concentration or by decreased levels of o2
organs of respiration
nose, pharynx, larynx, trachea, bronchi, lungs
respiratory center works with
feedback mechanisms
the respiratory center is located
in the pons and medulla
respirations should be counted
for 30 seconds then multiplied by 2
in the case of a very ill patient or one who has irregular respirations,
count for a full minute
eupnea
a normal, relaxed breathing pattern
dyspnea
difficult and labored breathing
tachypnea
increased or rapid breathing
bradypnea
slow and shallow breathing
hyperventilation
breathing in which there is an increase in the rate and the depth of breaths
cheyne-stokes respiration
dyspnea followed by a short period of apnea
kussmauls respirations
increased rate and depth with painting and long, grunting exhalation
biots respirations
shallow for 2 or 3 breaths with a period of variable apnea
crackles
abnormal, nonmusical sound heard on auscultation of thelungs during inspiration
rhonchi
continous dry, rattling sounds heard on auscultation of the lungs caused by partial obstruction
stertor
snoring sound produced when patient unable to cough up secretions from the trachea or bronchi
stridor
crowding sound on inspiration caused by obstruction of the upper air passages, as occurs in croup laryngitis
wheeze
whistling sound of air forced past a partial obstruction
pulse oximeter
machine that measures oxygen in the blood
pulse oximeter measure oxygen saturation by
determining the percentage of hemoglobin that is bound with oxygen
blood pressure
the pressure exerted on arterial walls by pumping action of the heart
blood pressure is affected by
condition of vascular bed, circulating blood volume, and cardiac output
normal blood pressure may be affected by
posture, exercise, eating, emotions, rest, weight, and environmental temp
blood pressure increases with
increases in circulating blood volume
a systolic pressure greater than 140mmHg and a diastolic pressure greater than 90mmHg are regarded as
being outside the normal range, marking hypertension
what is prehypertension
a systolic pressure between 120 and 139mmHg and a diastolic pressure between 80 and 89mmHg
if blood volume decreases beyond the vascular beds ability to compensate
blood pressure may decrease (causes: dehydration or hemorrhage)
vasoconstriction and vasodilation alter
blood pressure to compensate for changes in circulating volume
the average blood pressure in a healthy young adult is
120/70 mmHg (120 is the systolic, 70 is the diastolic)
take a persons blood pressure
in a quiet room with a relaxed environment
auscultatory gap
no sound
korotkoff sounds
may be heard related to the effect of the blood pressure cuff on the arterial wall
Phase 1 of Korotkoff sounds
tapping
Phase 2 of Korotkoff sounds
swishing
phase 3 of Korotkoff sounds
knocking
phase 4 of Korotkoff sounds
muffling
Phase 5 of Korotkoff sounds
silence
when taking B/P listen until
the cuff is completely deflated
if your patient has orthostatic hypotension and is elderly and dehydrated your main concern is
falls
an electronic sphygmomanonmeter does not need a
stethoscope
always document and report
any unusual finding when taking vital signs
hypertension
pressure consistently above the normal range
systolic pressure above 140mmHg and a diastolic pressure above 90mmHg
are outside the normal range
prolonged hypertension can cause
permanent damage to the brain, the kidneys, the heart, and the retinas
hypotension
low blood pressure less than 90/60mmHg
______is recognized by the joint commission as the 5th vital sign
pain
assessment for pain should include
location, intensity, character,frequency, duration
standardized pain scale is used for
assessment
pain is called
the fifth vital sign
pain levels are assessed and recorded with
other vital signs
how can pain be described
slight, dull, throbbing, gnawing, faint, burning, sharp, acute, chronic, excruciating, intense, stabbing, spasmodic, sudden, cramping, stinging, boring, shooting, darting, colicky, continuous, persistant, and transient
pain be described by location
right side, left side, posterior, and anterior body
temperature: heat loss may lead to ______in the elderly
hypothermia
lower metabolic rate of the elderly may lead to
hypothermia
with age respiratory rates may vary with
decreases in vital capacity
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