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vital signs
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assessment of vital or critical physiological functions; temp, pulse, respirations, blood pressure, pain
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vital signs
assessment of vital or critical physiological functions; temp, pulse, respirations, blood pressure, pain
although stable vital signs indicate physiological well-being,
they do not guarantee it; may remain stable in the presence of moderately large blood loss
pulse oximetry
assessing oxygenation
common occasions for assessing VS
admission to hospital; vistit to doctor; before, during, after surgery or special procedures; monitor effects of certain meds or activities; changes in patient's condition
frequency of assessing VS
in hospital- once every 4-8 hrs; home health setting- each visit; clinic- each visit; skilled nursing facilities- weekly to monthly
if VS vary from normal assess and document
every 5-15 min
initial measurement of VS is to
establish baseline; reason- a change in VS caused by disease state, effect of therapies, or change in activity/environment; and there are normal variations in VS
if VS not in normal range will be documented on
nurses' notes, along with symptoms; document any intervention as well
body temperature
degree of heat maintained by the body; diff between heat produced by the body and heat lost to the environment
need to knows for assess/support body temp
normal temp range, how heat is produced by and lost from the body, factors that influence body temp
body temp fluctuates w/
age, exercise, environmental conditions
core temperature
adult's internal temp; ususally 1-2 degree higher than surface temp; rectal and tympanic measurements
average temp
normal range
surface temp
oral and axillary measurements
degree of temp elevation doesn't always indicate seriousness of the disease or condition
some acute, even fatal infections may cause mild temp elevation; continuously elevated temp even slight always cause for concern
process of temp regulation; body must balance heat production and heat loss; controlled by the hypothalamus- can recognize small changes
decreasing body temp
activates peripheral vasodilation, sweating, inhibition of heat production
increasing body temp
reacts with shivering and release of epinephrine which increases metabolism; blood vessels constrict
goose bumps; not an important heat-conserving mechanism
behavioral control of temp
put on clothes in the cold, remove or take cold shower in the heat
body produces heat by
metabolism, movement of skeletal muscles, and nonshivering thermogenesis
uses energy and generates heat; basal metabolic rate (BMR)- energy required to maintain the body at rest, influenced by body size, lean muscle mass, numerous hormones
increases BMR
less heat produced; feel cold
body heat production can rise to about 4X the normal rate injust a few minutes
nonshivering thermogenesis
metabolism of brown fat to produce heat; used by infants- they cannot produce heat through shivering; disappears in the first few months following birth
exchange of hear between the body and the environment
radiation, convection, evaporation and conduction
loss of heat through electromagnetic waves emitting from surfaces that are warmer than the surrounding air; room warms by radiation when filled with people; accounts for almost 50% of body heat loss
transfer of heat through currents of air or water; immerision in a warm bath may raise body tem; currents of cool fan reduce fever; accounts for 15-20% of all heat loss
water is converted to vapor and lost from the skin or mucous membranes
insensible loss
loss by evaporation
process whereby heat is transferred from a warm to a cool surface by direct contact
influenced on body temp
developmental level, environmental temp, hormones, exercise, emotions and stress, circadian rhythm
developmental level
infants and older adults are most susceptible to the effects of environmental temp extremes; infants lose approx 30% of heat through head; older adults diff maintaining temp because of slower metabolism, decreased vasomotor control, and loss of subcutaneious tissue
common for older adults to have temp of
95 in the morning
environmental temp
warm room, hot bath increase body temp; very high can cause heat stroke; cold lead to hypothermia
womans body temp varies 1F with menstrual cycle; temp lower when progesterone levels are low, increase when progesterone rise
hot flashes
fluctuations of body temp during menopause
101-104F temp
emotions and stress
emotional stress, excitement, anxiety adn nervousness stimulat the sympathetic nervous system, producing epinephrine and norepinephrine, these increase metabolic rate and body temp
circadian rhytm
cyclical repetition of certain physiological processes (change in body temp, blood pressure) every 24 hrs; temp lowest early morning, highest late afternoon; fluctuate daily 1-2 degree
F to C
(F-32)x 5/9
advantages of glass thermometers
flexibility of use: oral, rectal, axillary; inexpensive initial cost; accuracy; easily disinfected
disadvantages of glass thermometers
fragile, slow (3-6 min); difficult for some to read
advantage of electronic thermometers
flexibility of use: oral, rectal, axillary, ease of use, fast (15-45 sec)
disadvantage of electronic thermometers
expensive, requires frequent calibration, conflicting data about accuracy, need to keep charged
advantages of infrared tympanic membrane thermometer
ease of use, fast (2-5 sec), most cost-effective
disadvantages of infrared tympanic membrane thermometer
expensive, less accurate, require frequent calibration, batteries
disposable chemical thermometer
not used very much
to obtain comparative oral temp
axillary reading add .9; rectal reading subtract .9; tympanic membrane reading subtract 1.1-1.5
advantages of oral temp
simple, convenient, comfortable
disadvantages of oral temp
eating/drinking affect accuracy; mouth closed; exposure to body fluids; slow; contraindicated for some clients
advantages of rectal temp
most accurate of core (internal) body temp
disadvantages of rectal temp
injury to rectal mucosa; embarrassing; special positioning; does not reflect changes in core temp as rapid as oral; exposure to body fluids; presence of stool may cause inaccurate reading
contraindication of rectal temp
clients who may be injured by the method; clients with cardiac surgury; can slow the heart rate by stimulating the vagus nerve
advantages of axillary temp
can be used on newborns, children, uncooperative or unconscious clients
disadvantages of axillary temp
least accurate; slow; diaphoresis can affect reading
advantages of tympanic membrane temp
disadvantages of tympanic membrane temp
expensive initial purchase; hearing aids removed; cerumen may affect accuracy
pyrexia; abnormally high body temp >100.4; occurs in response to pyrogens; phagocytes ingest the invaders and secrete pyrogens, pyrogens induce secretion of prostaglandins that reset the hypothalamic thermostat at a higher temp
fever above 105.8
initial phase (febrile episode or onset) of fever
temp is rising but has not yet reached new set point; may be sudden or gradual; feeling of chilly, uncomfortable and shivers
second phase (course) of fever
temp reaches max (set point) and remains fairly constant at the new higher level
third phase (defervescence or crisis) of fever
temp returns to normal; feeling of warmth, appears flushed in response to vasodilation; diaphoresis occurs, fever breaks
4 types of fever
intermittent, remittent, constant, relapsing
intermittent fever
temp alternates regularly between fever and normal/below normal temp
remittent fever
wide fluctuations in temp >3.6, all above normal, during 24 hr period
constant (sustained) fever
temp may fluctuate slightly but is always above normal
relapsing fever
short periods of fever alternating with periods of normal temps, each lasting 1-2 days
high temps up to 102.2 benefit the body by
enhancing the immune response because they kill/inhibit growth of many MO; enhance phagocytosis; cause breakdown of lysosomes and self-destruction of virally infected cells; cause the release of interferon (protects cells from viral infections)
very high temps 106 or greater can
damage cells throughout the body especially the brain, causing agitation, confusion, stupor or coma
death results in body temp
higher than 109-112
above normal body temp, fatigue, warm, flushed, increased heart rate; >96.8
ineffective thermoregulation
temp fluctuates above/below the normal range
risk for imbalanced body temp
temp is normal but client at risk for failure to maintain body temp w/in normal range
fluid deficiency
severe hypothermia
body temp drops below 82.4; death usually results body temp <70-75F
lack of oxygen
rhythmic expansion of an artery produced when a bolus of blood is forced into it by contractions of the heart
normal pulse range
60-100 bpm; average 70-80
cardiac monitor to determine
rate, rhythm, and pattern of pulse
stroke volume
quantity of blood forced out by each contraction of the left ventricle; ave 70 mL; if decreases, body tries to maintain same cardiac output b increasing the pulse rate
cardiac output
total quantity of blood pumped per minute
cardiac output=
stroke volume x pulse (heart) rate
pulse rate is regulated by
autonomic nervous system; sympahtetic stimulation increases the heart rate (and thus the cardiac output); parasympathetic stimulation decreases it
pulse changes in response to
changes in teh volume of blood pumped through the heart, variations in heart rate, changes in the elasticity of the arterial walls, or any condition that interferes with the functioning of the heart
conditions that interfere with normal functioning of the nervous system
also affect the pulse
factors that may cause variations in pulse rate, rhythm, or quality include
age; sex; exercise; food; stress; fever; disease; blood loss; position changes; medications
newborn rapid pulse rate
females slightly faster
increase pulse rate but people who exercise regularly have lower heart rates
ingestion slight increase for several hours
fight/flight sympathetic nervous system response
increase 10 bpm fore each degree
heart disease, hyperthyroidism, respiratory diseases and infections increase pulse rate; hypothyroidism decreased pulse rate
blood loss
large loss stimulates the sympathetic nervous system; stable pulse and blood pressure do not by themselves guarantedd that there has been no blood loss
position changes
standing/sitting temporary increase in pulse rate and decrease in blood pressure as a result of blood pooling in the veins of the feet and legs, this decreases blood return to the heart, decreasing blood pressure and subsequently increasing heart rate
stimulant drugs increase pulse rate; cardiotonics and opioids or sedatives decrease pulse rate
bell of stethoscope
hear low-frequency sounds
diaphragm of stethoscope
hear high-frequency sounds
apical pulse
apex of heart; use when radial pulse is weak or irregular, less than 60 or higher than 100 bpm; patient taking cardiac meds, assessing infants and child up to 3 yrs
peripheral pulses
radial, brachial, dorsalis pedis, posterior tibial, carotid, femoral, popliteal, temporal arteries
radial artery
most common; for routine assessment of VS
brachial artery
when performing CPR of infants
carotid artery
CPR of adults and assessing circulation to the brain
femoral artery
infants and children to determine circulation to the legs, and in cases of cardiac arrest
dorsalis pedis (pedal pulse) and posterior tibial arteries
assessing peripheral circulation
popliteal artery
assessing circulation to the lower leg
finding apical pulse
anterior chest 3" or less to the left of the sternum, 4,5,6th intercostal space at the midclavicular line
pulse deficit
difference between apical and radial pulse; not all apex beats are being transmitted or felt at the radial artery
beats/min; if irregular count for full minute
rates below 60 bpm
rates above 100 bpm
pulse pattern between heartbeats
abnormal rhythm; too early, too late, or group of irregular beats
regularly-irregular rhythm
irregular rhythm that forms a pattern
irregularly-irregular rhythm
unpredictable rhythm
traces the electrical pattern of the heart
pulse volume and bilateral equality of pulses
pulse volume
amount of force produced by the blood pulsing through the arteries 0-3
0 pulse volume
absent; pulse cant be felt
1 pulse volume
weak, thready; pulse barely felt
2 pulse volume
normal quality; easily palpated, not weak or bounding
3 pulse volume
bounding or full; easily felt with little pressure; not easily obliterated
bilateral equality
used to determine whether the blood flow to a body part is adequate
paleness of skin compared to another part of the body
ineffective tissue perfusion (peripheral)
absent/weak pulse, cool, pale skin is present
exchange of O2 and CO2
pulmonary ventilation (breathing)
active movement of air into and out of the respiratory system
external respiration
exchange of O and CO2 between the alveoli and the pulmonary blood supply
gas transport
transport of these gases throughout the body
internal respiration
exchange of gases between capillaries and the body tissue cells
how does body regulate respiration
centers in the medulla oblongata and pons, nerve fibers of teh ANS, regulate breathing in response to minute changes in teh O and CO2 in the arterial blood
primary stimulus for breathing
leve of CO2 tension in the blood
central chemoreceptors
located int eh respiratory centers; sensitive to CO2 and pH concentrations
peripheral chemoreceptors
in carotid and aortic bodies stimuate respiration; Partial pressure of O in arterial blood falls below 100 Hg
diaphragm contracts, drawing air into the lungs; 1-1.5 sec
diaphragm relaxes; passive, 2-3 sec
influences on breathing
age, exercise, pain, stress, smoking, fever, pulse rate, hemoglobin, disease, meds, position
infant respiration
40-90 breaths per minute
adult respirations
12-20 breaths per minute
pain and breathing
acute pain increases respiration but a decreased depth
fever and breathing
for every 1F increase, breaths increase up to 4 per minute
respiratory rate: pulse rate
hemoglobin and breathing
respiratory rate and depth increase as a result of anemia, sickle cell anemia, high altitudes
meds and breathing
CNS depressants such as morphine or general anesthetics cause slower, deeper respirations; caffeine and atropine cause shallow fast breathing
position and breathing
respiratory depth is max by standing, hampered by lying flat
apnea for more than 4-6 min
brain damage and even death occurs
tachypnea (polypnea)
abnormally fast breathing
respirations that fall within normal parameters
tidal volume
amount of air taken in on inspiration; 300-500 mL normal
respiratory depth described as
deep, shallow, normal
normal/abnormal; period between each respiratory cycle is the same, regular breathing pattern
infant rhythm more irregular
than adult rhythms
Biot's respirations
periods of respirations of equal depth, alternating with periods of apnea
Cheyne-Stokes respirations
gradual increase in depth of respirations, followed by gradual decrease and then a period of apnea
respiratory effort
degree of work required to breath
labored breathing
inability to breathe when in a horizontal position
high-pitched, narrowing of the airways
low-pitched, caused by secretions in teh large airways; cleared by coughing
discontinuous sounds; high-pitched, popping sounds, or low-pitched, bubbling sounds
piercing, high pitched sound in infants who are experiencing respiratory distress
labored breathing that produces a snoring sound
intercostal retraction
visible sinking of tissues around and between the rigs that occurs when the person needs to make additional effort to breathe
substernal retraction
tissues are drawn in beneath the sternum
suprasternal retraction
tissues are drawn in above the clavicle
arterial blood gas
sampling directly measures the partial pressures of O and CO2 and blood pH
noninvasive monitoring respiratory status
pulse oximeter- measures oxygen saturation
rapid deep breathing, excess loss of CO2 (hypocapnia)
rate and depth of respirations are decreased and CO2 is retained or alveolar ventilation is compromised
blood pressure
important indicator of overal CV health
systolic pressure
peak pressure
diastolic pressure
trough pressure; at rest
pulse pressure
difference between systolic and diastolic pressures; ex 120/80, pulse pressure 40 mm Hg; indication of the volume output of the left ventricle, shouldnt be more than 1/3 of the systolic pressure
blood pressue influenced by
cardiac function, peripheral vascular resistance, and blood volume
change in either stroke volume or heart rate alters
cardiac output
conditions taht increase cardiac output by increasing stroke volume include
increased blood volume, more forceful contraction of teh ventricles
conditions that decrease cardiac output by decreasing stroke volume include
dehydration, active bleeding, damage to the heart, very rapid heart rate
peripheral resistance
arterial and capillary resistance to blood flow as a result of friction between blood and the vessel wall; friction depends on viscosity and arterial size and compliance (elasticity)
determined by percentage of red blood cells in plasma (hematocrit)
arterial size and compliance
constricted arteries prevent the free flow of blood, increase BP; dilated arteries allow unrestricted flow of blood, decrease BP; sympathetic nervous system controls vasoconstriction and vasodilation
common contributor to increased BP in middle-aged and older adults
normal volume of blood in the body
5000 mL
some factors that affect BP
age, sex, family history, lifestyle, exercise, body position, stress, pain, race, obesity, diurnal variations, meds, disease
sex and BP
men slightly higher, in women slight increase after menopause (due to increased estrogen)
lifestyle and BP
increased Na consumption, smoking, alcohol (3 or more/day); all increase BP; caffeine may raise BP for a short time
body position and BP
higher when standing; readings higher if taken with arm above heart or if arm is unsupported at the client's side; dangling feet higher
pain and BP
increase, severe pain can decrease BP
race and BP
AA higher rate of hypertension
obesity and BP
diurnal variations and BP
BP varies according to person's daily schedules and routines
aneroid manometers
dials that register BP by pointers attached to a spring
mercury manometers
use calibrated upright tube containing mercury; most accurate
electronic blood pressure monitors
less accurate; so auscultate a baseline BP prior to initating automatic monitoring
width of the bladder fits
2/3 the length fo the upper arm, entire arm of a child
systolic pressure may be
20-30 mm Hg higher in teh lower extremities than in the arms, but diastolic pressures are similar
Korotkoff sounds
1st- tapping sound corresponds to the pulse (systolic BP); 2nd- soft, swishing sound caused by blood turbulence; 3rd- begins midway through BP, sharp, rhythmic tapping sound; 4th- like 3rd but softer, fading; 5th- silence, diastole
inflate cuff rapidly to 70 mm Hg
then palpate radial pulse slowly increasing 10 mm Hg increments
auscultatory gap
loss of sound for as much as 30 mm Hg followed by the return of sound
systolic blood pressure is less than 100 mm Hg; problem if with dizziness, fatique, concentration problems, activity intolerance or shortness of breath or if of sudden onset
causes of hypotension
hemorrhage and heart failure
orthostatic or postural hypotension
BP drops suddenly on moving from a lying position to a sitting or standing position; decrease of 10 mm Hg w/ dizziness and/or fainting; postural hypotension results from peripheral vasodilation w/o a compensatory increase in cardiac output, more in older adults, pregnant women, prolonged bed rest, decreased blood volume
hypotension is a
medical diagnosis
primary or essential hypertension
no know cause for the BP elevation; accounts for at least 90% of all cases of hypertension
hypertension is realted to
thickening of the arterial walls and decreased elasticity of the arteries
secondarey hypertension
occurs when there is a clearly identified cause for the persistent rise in BP

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