Vital Signs Assessment Ch 26

Front 1

BASAL METABOLIC RATE (BMR)

Back 1

Amount of energy the body uses.

Front 2

Factors Affecting Body Temperature

Back 2

* Age - Newborns have unstable body temps, elderly have lower body temps
* Environment
* Time of Day - fluctuates throughout the day
* Exercise
* Stress- sympathetic NS can increase heat
* Hormones - Progesterone/Birth Control

Front 3

Factors Affecting Pulse Rate

Back 3

* Age: Infants 100-160 bpm, Adults 60-100 bpm
* Autonomic Nervous System- Sympathetic^, Parasympathetic v
* Medications - affect volume, pulse rate, Para and Symp effectiveness

Front 4

Factors Affecting Respirations

Back 4

* Age
* Medications
* Stress
* Exercise
* Altitude

Front 5

EUPNEA

Back 5

Normal respiratory rhythm & depth.
- expiration is normally twice as long as inspiration

Front 6

4 Vital Signs

Back 6

body temp
pulse
respirations
blood pressure

Front 7

Vital Signs

Back 7

-indicate the function of some of the body's homeostatic mechanisms
- when several sets of VS have been obtained, this information forms a baseline for comparison of subsequent measurements
- the frequency of readings will be client specific - 8 hr min
- VS trends that deviate from normal are more significant than isolated abnormal values

Front 8

Core Temperature

Back 8

the temperature inside the body remains relatively constant, unless the client develops a febrile illness

Front 9

Normal Body Temperature - measurements

Back 9

Oral: 35.5-36.5C or 97.6-99.6F
Rectal: 1 degree higher than Oral
Axillary: 1 degree lower than Oral
Tympanic: between Oral and Rectal

Front 10

Body Temp Names

Back 10

Afebrile - normal
Pyrexia - exceeds 37.5C

Front 11

Regulation of Body Temperature

Back 11

The hypothalamus, located in the pituitary gland in the brain, is the body's built-in thermostat. It can sense small changes in body temperature and stimulates the necessary responses in the nervous system, circulatory system, skin, and sweat glands to maintain homeostasis (state of dynamic equilibrium).

Front 12

Heat Production

Back 12

The body continually produces heat as a byproduct of chemical reactions that occur in body cells. This collective process is known as metabolism. The process of thermoregulation keeps core temperature fairly constant regardless of where the heat is being produced. The basal metabolic rate (BMR) is the amount of energy the body uses, and thus the amount of heat produced, during absolute rest in an a

Front 13

Heat is lost through four processes:

Back 13

radiation, conduction, convection, and evaporation.

Front 14

5 common sites to access Temperature

Back 14

mouth, ear, rectum, forehead, axilla

Front 15

Oral Temp

Back 15

wait 15-30 min after drinking hot/cold fluids or smoking
- not prudent/safe for young children, unconscious, irrational or seizure client

Front 16

Rectal Temp

Back 16

do not place into fecal matter, temp will not be correct
- may cause trauma to rectal mucosa of infants

Front 17

Ear Temp

Back 17

rapid temp readings (2 sec)
- poor measurement technique leads to errors
- can be uncomfortable to client when pulling pinna

Front 18

Forehead Temp

Back 18

fast and safe - newer technology
- more accurate than temporal and about same as oral

Front 19

Axillary Temp

Back 19

least accurate and least reliable
- recommended for infants and children

Front 20

Temperature measurement Equipment: Thermometers

Back 20

Electronic - less than 60 sec
Tympanic Membrane - 2 sec
Temporal Artery - moisture can affect reading
Disposable Paper (chemical) - 1-3 min
Temperature-Sensitive Strips
Glass Mercury

Front 21

Pulse Characteristics

Back 21

Rate or frequency, rhythm, and quality.
Rate or frequency refers to the number of pulsations per minute.
Rhythm refers to the regularity with which pulsation occurs.
Quality refers to the strength of the palpated pulsation.

Front 22

Sinoatrial Node

Back 22

An electrical impulse in the sinoatrial (SA) node of the right atrium initially stimulates contraction of the ventricles.
Irregularities of heart rhythm usually indicate a failure in the conduction system or the generation of an impulse from a site other than the SA node.

Front 23

Sites to Access the Pulse

Back 23

temporal, carotid,
apical, brachial, radial,
femoral, popliteal, pedal, and posterior tibial

Front 24

Carotid Pulse

Back 24

Always palpate the carotid artery in the lower half of the neck to avoid stimulating the carotid sinus. Never palpate bilateral carotid pulses simultaneously because this can seriously impair cerebral blood flow. Palpating the carotid artery in the upper part of the neck may result in stimulation of the carotid sinus, which causes a reflex drop in pulse rate. The carotid pulse best represents the quality of pulsation in the aorta because of its proximity to the central circulation.

Front 25

Apical Pulse

Back 25

can be palpated with the hand or auscultated with a stethoscope placed over the area of the left ventricle. Normally, this area is at the level of the fifth intercostal space at about the midclavicular line.

Front 26

Radial Pulse

Back 26

the site most commonly assessed in the clinical setting

Front 27

Doppler

Back 27

generally used to determine the adequacy of blood flow to an area for which occlusive vascular disease threatens the blood supply or for postoperative assessment where peripheral circulation can be occluded. The Doppler also may be useful when obesity or edema obscures the pulse, or in situations of cardiopulmonary collapse where peripheral vasoconstriction makes pulses difficult to palpate

Front 28

Pulse: Palpation

Back 28

Clients with irregular or abnormally slow or fast pulse rates are best assessed for 1 full minute.
- Regardless of the time interval selected, count the initial pulsation as zero. Do not count pulses at or after completion of the time interval.

Front 29

Pulse: Auscultation

Back 29

Auscultation of the apical pulse provides the most accurate assessment of the pulse rate and is the preferred site when the peripheral pulses are difficult to assess or the pulse rhythm is irregular.
- Assess the apical pulse by placing the diaphragm of the stethoscope over the apex of the heart, which is located at the fifth intercostal space at the midclavicular line

Front 30

Pulse: Auscultation: S1 & S2

Back 30

Each heartbeat consists of two sounds. The first, S1, is caused by closure of the mitral and tricuspid valves that separate the atria from the ventricles. The second sound, S2, is caused by the closure of the pulmonic and aortic valves. The sounds are often described as a muffled “lub-dub.” Together, they constitute one heartbeat. To determine the apical pulse, count the heartbeats for 1 full minute.

Front 31

Normal Pulse Rate

Back 31

In adults, the normal rate is 60 to 100 pulsations per minute
- Average pulse rate of an infant is 100-160 bpm

Front 32

Tachycardia

Back 32

Adult pulse rates above 100 beats per minute
- can be due to Sympathetic nervous system activation or when the impulse for cardiac contraction comes from an abnormal site in the heart that stimulates the heart to beat faster.

Front 33

Bradycardia

Back 33

In adults, a pulse rate below 60 beats per minute
- may be the normal resting heart rate in a trained athlete. Disease of the SA node may result in bradycardia because of poor impulse formation. In addition, enhanced parasympathetic nervous system activity (e.g., stimulation of the carotid sinus) may cause bradycardia.

Front 34

Dysrhythmic

Back 34

Any pulse out of the range of normal (rate or rhythm)

Front 35

Regularly Irregular

Back 35

An irregular pulse rhythm that still displays a consistent pattern

Front 36

Irregularly Irregular

Back 36

If the pulse has no pattern
- may be a component of many conditions, including atrial fibrillation

Front 37

Pulse Safety Alert

Back 37

Many people have chronically irregular pulse rhythms,
but a new finding of pulse irregularity requires immediate investigation to determine the causes and to assess the need for treatment.

Front 38

Thready Pulse

Back 38

Weak pulses are obliterated easily by the examiner's fingers

Front 39

Normal Pulse

Back 39

described as full or strong and can be palpated easily

Front 40

Bounding Pulse

Back 40

stronger than normal and difficult to obliterate
- With aging, the arteries lose elasticity, and the pulse becomes bounding

Front 41

Pulse Quality

Back 41

reflects the stroke volume, the compliance or elasticity of the arteries, and the adequacy of blood delivery. When stroke volume is decreased, as in severe hemorrhage, the pulse is often thready and may be difficult to palpate in the peripheral arteries. The pulse is usually palpated more easily in the central areas, such as the carotid or femoral arteries.
- Palpate peripheral pulses bilaterally (except for carotids) to compare quality. Equality of pulsation provides information about local blood flow

Front 42

Pounding Heart

Back 42

The combination of rapid pulse rate and increased stroke volume with exercise results in a pulse that the client can feel

Front 43

Pulse Deficit

Back 43

When some of the ventricular contractions do not perfuse,
a difference exists between the apical and peripheral pulses.
Radial pulse rate is always lower than the apical pulse rate.
Document and report to the physician any new finding of a pulse deficit so that evaluation and follow-up can occur.

Front 44

External Respirations

Back 44

Process of taking oxygen into and
eliminating carbon dioxide from the body

Front 45

Internal Respirations

Back 45

refers to the use of oxygen, the production of carbon dioxide, and the exchange of these gases between the cells and the blood

Front 46

Respiration Process

Back 46

Inspiration is Active. Expiration is Passive.
Normal breathing is automatic and involuntary.
At rest, the normal adult respiratory rate is
12 to 20 breaths per minute.

Front 47

Tidal Volume

Back 47

Amount of air moving in and out with each breath.
Normal is 500 mL or 6 to 8 L/min

Front 48

Hypercardia

Back 48

The normal stimulus to breathe is an increased carbon dioxide level. Chemoreceptors throughout the body sense changes in carbon dioxide levels and stimulate the respiratory center, which increases or decreases respiratory rate and depth accordingly.

Front 49

Tachypnea

Back 49

An abnormally fast respiratory rate
(usually above 20 breaths per minute in the adult).

Front 50

Bradypnea

Back 50

An abnormally slow respiratory rate
(usually less than 12 breaths per minute in the adult)

Front 51

Apnea

Back 51

The absence of respirations, is often described by the length of time in which no respirations occur (e.g., a 10-second period of apnea).
Continuous apnea is synonymous with respiratory arrest and is not compatible with life.

Front 52

Normal Respiration Rates

Back 52

At rest, the normal respiratory rate for an infant is 30 to 60 breaths per minute, decreasing to 12 to 20 breaths per minute for an adult.

Front 53

Dyspnea

Back 53

Respirations that require excessive effort.
Respirations can be painful and labored.
Clients may report being unable to catch their breath. Dyspnea can occur at rest or with activity; dyspnea that occurs with activity is called exertional dyspnea. Healthy people who are not in good physical condition may experience exertional dyspnea.

Front 54

Stridor

Back 54

a harsh inspiratory sound that may be compared to crowing

Front 55

Wheezing

Back 55

a high-pitched musical sound. It is usually heard on expiration but may be heard on inspiration. It is associated with partial obstruction of the
P.434

bronchi or bronchioles, as in asthma.

Front 56

Blood Pressure - Def

Back 56

The force that blood exerts against the walls of the blood vessels.
The pressure in the systemic arteries is most commonly measured in the clinical setting.
Blood pressure is stated in millimeters of mercury (mm Hg).

Front 57

Systolic Blood Pressure

Back 57

measured during ventricular contraction
(cardiac systole).

Front 58

Diastolic Blood Pressure

Back 58

during ventricular relaxation
(cardiac diastole),
blood pressure is due to elastic recoil of the vessels, and the measured pressure

Front 59

Pulse Pressure

Back 59

The mathematical difference between the measured
systolic and diastolic blood pressures
- For instance, a systolic pressure of 120 mm Hg and a diastolic pressure of 80 mm Hg result in a pulse pressure of 40 mm Hg.

Front 60

Stroke Volume

Back 60

The amount of blood each ventricle pumps with each heartbeat

Front 61

Blood Flow

Back 61

essentially equal to cardiac output.
Cardiac Output = Stroke Volume X Heart Rate.
A stroke volume of 70 mL and a heart rate of 72 beats per minute result in a cardiac output of 5040 mL/min, or about 5 L/min

Front 62

Blood Pressure - Resistance

Back 62

Constricted vessels offer greater resistance, thus increasing blood pressure;
dilated vessels offer less resistance, thus decreasing blood pressure.

Front 63

Factors that affect Blood Pressure

Back 63

*Age - correlate with height, weight & age
*Autonomic Nervous System
*Circulating Volume - decrease lowers bp, increase raised bp
*Medications
*Normal Fluctuations - circadian pattern
- At least 30 minutes should elapse between smoking, exercising, or eating and the blood pressure reading

Front 64

Assessing Blood Pressure

Back 64

Blood pressure may be measured directly with a catheter placed into an artery. Direct measurement provides a continuous reading of blood pressure and is used in critical care settings. However, blood pressure is usually measured by indirect methods, using an inflatable cuff to temporarily occlude arterial blood flow through one of the limbs

Front 65

Sites to Assess BP

Back 65

Upper Extremity - brachial or radial - avoid arms with venus access devices or if client has had a mastectomy
Lower Extremity - Popliteal, posterior tibialis or dorsalis pedis

Make sure to use the proper sized cuff

Front 66

BP Equipment

Back 66

Sphygmomanometer
Stethoscope
Doppler - useful for difficult to find BP
Electronic Devices - good when frequent readings are needed - estimated bp

Front 67

BP Methods

Back 67

*Proper cuff size
*Proper Positioning
*Correlation w/ the Respiratory Cycle
*Proper Inflation and Deflation
*Auscultation
*Palpation

Front 68

Korotkoff Sounds

Back 68

As you deflate the cuff and blood flow returns,
the Korotkoff sounds can be heard with a stethoscope placed over the artery.

Front 69

Auscultatory Gap

Back 69

the absence of Korotkoff sounds between phases I and II
- Find the auscultatory gap by palpating the brachial or radial pulse while inflating the cuff. Inflate the cuff about 30 mm Hg above the number where palpable pulsation disappears

Front 70

Systolic Blood Pressure

Back 70

the point at which pulsation returns when estimating bp by palpation

Front 71

Hypertension

Back 71

the condition in which blood pressure is chronically elevated. Although in industrialized societies there is a trend toward increased blood pressure with advancing age, hypertension is a dangerous disease associated with an increased risk of morbidity and mortality due to cardiovascular complications, such as stroke or heart failure. Therefore, chronically elevated blood pressure is treated aggressively in adults of any age
- Adults with blood pressure above 140/90 mm Hg should be evaluated for hypertension.

Front 72

Prehypertension

Back 72

For adults of any age, blood pressure between 120/80 and 139/89 mm Hg is considered prehypertension.

Front 73

Hypotension

Back 73

blood pressure below 100/60 mm Hg. Low blood pressure readings can be normal for some healthy, young adults and are no cause for concern.

Front 74

Orthostatic Hypotension

Back 74

In adults, moving from a flat, horizontal position to a vertical position results in pooling of blood in the lower extremities. People with healthy, intact autonomic nervous systems reflexively compensate for the volume shift by increasing the rate and force of myocardial contraction and vasoconstriction, thus maintaining adequate blood pressure. Even with normal compensation, however, a position change usually results in a drop in systolic blood pressure and an increase in heart rate.
Inadequate reflex compensation upon position change results in orthostatic hypotension. Symptoms of orthostatic hypotension are those related to decreased cerebral perfusion, such as dizziness, weakness, blurred vision, syncope, and marked changes in blood pressure and heart rate.

Front 75

BP in USA

Back 75

in the United States. An estimated 30% of adult Americans—many of whom go undiagnosed and untreated every year—have clinically significant high blood pressure