-
When should you measure vital signs?
- On admission to hospital
- At begining of shift
- Visit to healthcare provider office
- B4, during & after surgery
- To monitor effects of meds and txs
- When pt condition changes
-
Older adults tend to have _________ body temperatures
Lower
-
Pregnant women tend to have_________ baseline body temperatures.
Higher
-
Adult core body temp ranges from
97 to 100.8 degrees
-
oral and axillary measurements reflect __________ temperatures
surface
-
Rectal and tympanic membrane measurements reflect ______________ temperatures
core.
-
Process of temp regulation is
thermoregulation
-
Factors influencing Body temp
- Developmental level - infant older adult
- Environment
- Sex - women hormones increase
- Exercise- can raise to 100 to 104 degrees
- Emotions & stress
- Circadian Rhythm- lowest early am
-
Pyrexia
- fever- temp above person's normal range.
- Need severa readings at different times
-
-
Hyperpyrexia
- fever above 105.8
- dangerous damages body cells causes delerium.
-
Fevers occur in response to
pyrogens
-
Pyrogens induce secretions of ___________ (substances that reset the hypothalamic thermostat at a higher temperature)
prostaglandins
-
4 types of fevers
- Intermittent - temp fluctuates between normal to high without intervention
- Remittent- Fluctuations of temp all above normal 24 hr period
- Constant- fluctuates but always above normal
- Relapsing - short periods of fever alternating with normal temps over 1 to 2 days
-
Death results if temp becomes higher than
109 to 112
-
Hyperthermia
body temp is higher than set point. Hypothalamic set point is not reset
-
Hyperthermia examples
Heat exhaustion and heat stroke
-
heat exhaustion occurs when core body temp reaches
- 98.6 to 103
- weakness, nausea, vomiting, syncope, tachycardia, muscle aches, headache, diaphoresis, flushed skin
-
Heat stroke occures if hyperthermia progresses to temp above
- 103
- rapid strong pulse, throbbing headache, delirium, confusion, impaired judgement, red, hot, dry skin, dizziness, seizures, & coma
-
Hypothermia
- abnormal low core temp less than 95 degrees
- mental impairment, confusion, disoriention, slowing of heart rate & respirations
-
severe hypothermia
- below 82.4 degrees
- pt unconscious, pulse and resp difficult to detect
-
Although survival has occurred at core temp of 60.8 death results when body temp falls below
70 to 75 degrees
-
Formula to change temp from Fahrenheit to Centigrade
(temp F- 32) x 5/9
-
Formula to change temp from Centigrade to Fahrenheit
(Temp C x 9/5) + 32
-
least accurate site for temp
axillary
-
most accurate site for temp
- Temporal artery
- requires special scanning thermometer
-
Rank temp sites from lowest to highest
axillary, oral, tympanic, rectal, temporal
-
factors that influence pulse rate
- development level
- sex - women more rapid
- exercise
- Food- ingestion raises
- Stress
- Fever- rate up 10 beats for each degree
- Disease
- Blood loss - temporary increase in pulse
- Position changes- standing sitting
- Medications - stimulants up, sedatives down
-
Arteries where you palpate pulse
- temporal
- carotid
- brachial
- ulnar
- radial
- femoral
- popliteal
- posterior tibial
- dorsalis pedis
-
when to auscultate apical pulse?
- radial pulse weak or irregular
- rate less than 60 or greater than 100
- pt on cardiac meds
- assessin children & infants 3 and below (their pulses may be difficult to palpate.
-
where is apex of heart located?
adult - anterior chest 3 inches or less from sternum at 4th, 5th, or 6th intercostal space at midclavicular line
-
pulse deficit
difference between radial and apical pulse. Not all apex beats being transmitted to radial artery
-
How to report pulse
- Rate- also brady , tachy
- Rhythm- regular/ irregular
- Quality - Absent, weak , normal, bounding
- Bilateral equality
-
-
Cyanosis
bluish or grayish discoloration of skin
-
Respiration
exchange of O2 and CO2 in the body
-
mechanical aspect of respiration
pulmonary respiration or breathing
-
central chemoreceptors located in the respiratory centers are sensitive to
CO2 and hydrogen ion (pH ) concentrations
-
Factors that influence respiration
- Developmental level- newborn higher
- Exercise
- Pain- acute pain up
- Stress
- Smoking- increases resting rate
- Fever- increases
- hemoglobin-(anemia down) rate & depth increase
- Disease
- Medications
- Position- standing maximize lying flat reduces
-
data to collect for respirations
- rate- number of times person breathes complete in and out
- Depth-Deep, normal, shallow
- Rhythm- regular, irregular
- Effort - labored or easy
-
wheezes
- high pitched continuous musical sound on expiration
- caused by narrowing of airways
-
rhonchi
- low pitched contiuous gurgling
- caused by secretions in airways clear with coughing
-
crackles
- caused by fluid in alveoli
- discontinuous usually heard in inspiration
- high pitched popping sounds
-
stridor
- piercing high pitched heard without stethoscope
- obstructed airway
- infants respiratory distress
-
stertor
labored breathing snoring sound
-
intercotal Retraction
visible sinking of tissues around and between ribs
-
substernal retraction
tissue drawn in beneath sternum
-
suprasternal
tissues are drawn in above clavicle
-
hypoxia
inadequate cell oxygenation
-
ABS arterial blood gas
measures partial pressures of O2 and CO2 and blood pH
-
Hypoxia
rapid and deep breathing, excess loss of CO2
-
Hypoventilation
rate and depth of respirations decreased and CO2 is retained
-
Normal systolic
Normal diastolic
-
conditions that increase cardiac output/ blood pressure
- Increased blood volume (pregnancy)
- forceful contraction of ventricle (exercise)
-
conditions that decrease cardiac output/ blood pressure
- dehydration
- active bleeding
- damage to heart
- very rapid heart rate
-
Blood resistance
refers to arterial capillary resistanceto blood flow as a result between blood and vessel walls
-
blood viscosity
ease in which blood flows through vessels. Determined by hemocrit (% red blood cells in plasma)
-
arterial size
smaller radius of a blood vessel the more resistance it offers to blood flow
-
-
-
stage 2 hypertension
- greater than 160
- greater than 100
-
arteriosclerosis
hardening of arteries common in older adults
-
normal volume of blood in the bodyis about _________ liters
5
-
factors influencing blood pressure
- Developmental stage- increases with age
- Sex- female increase after menopause men higher in general
- Family HX
- Lifestyle- sodium, smoking , ETOH more than 3
- Exercise- wait 30 min after exercise to take
- Body position- up standing, up unsupported, up feet dangling
- Stress
- Pain
- Race
- Obesity
- Medications
- diseases
- Diurnal variations- daily schedule
-
sphygmomanometer
b/p cuff
-
direct method B/P
catheter inserted into artery attached to tubing connected to tubing
-
what cuff size to use?
- width of bladder 2/3 length upper arm (child all)
- cuff width is 40% arm circumference
- length of bladder encircles 80 % of arm
-
cuff too narrow= ________ B/P
too high
-
cuff too wide= B/P _________
too low
-
Using B/P cuff or bladder of incorrect size can result in measurement error of ________.
30mm HG
-
Korotkoff sounds
sounds you listen for when you assess BP
-
loss and return of sound when taking B/P is called
auscultatory gap
-
Hypotension
- systolic under 100
- dizziness, fatigue, concentration problems, activity intolerance, SOB
-
Orthostatic hypotension
- when person's BP drops suddenly when moving from lying to sitting to standing
- decrease 10mm Hg when standing assciatted with dizziness and fainting
-
rectal thermometer how far to insert
- 1 to 1.5 inch adult
- .9 inch child
- .5 inch infant
- glass thermometer 3 to 5 min
-
adult tympanic temp have to ____________________ ear.
pull up & backward slightly away from head
-
measure pulse for ____________ minutes
- 15 or 30 sec if regular
- 60 sec if irregular or when measuring apical
-
where to auscultate apical pulse
5th intercostal space at midclavicular line
-
wait _______ minutes after pt smokes or ingests caffiene to take BP
30
|
|
