Vital Signs ( Tpr, Apical Pulse, Peripheral Pulses)

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Vital Signs include

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Temperature, pulse, Respirations, blood pressure

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Nurses and physicians use Vital Signs

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to monitor clients' responses to health challenges, injuries, procedures, or surgeries.The first set of vital signs, usually taken at admission,providesa baseline. Then, subsequent findings are compared to the baseline to detectchanges. The clients' health statusdetermine the frequency of vital sign taking. Some clients may have a TPR donedailyor every four hours.

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roleof the hypothalamus in thermoregulation

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( balance between heat lost, and heat produced)is that it controls body temperature. Itsenses minor changes in body temperature. The anterior hypothalamuscontrols heat loss, and the posterior hypothalamus controls heatproduction. Whenever cells in the anterior hypothalamus becomeheated above the set point, impulses are sent to reduce bodytemperature. The posterior hypothalamus senses that the body’stemperature is lower than the set point heat conservation mechanismsare instituted.

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4 situations which heat is produced

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1.rest- BMR- basal metabolic rate accounts for the heat produced by the body at absolute rest.

2.voluntary movements-Metabolic rate can increase up to 2000 times normal during exercise.

3. involuntary shivering- is an involuntary body response to temperature differences in the body. The skeletal muscle movement during shivering requires significant energy. This can deplete energy resources. Shivering can increase heat production four to five times greater than normal.

4. metabolism- as metabolism increases, additional heat is produced ( when digesting)

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Heat Loss ( 4 processes)

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1. Conduction- Transfer of heat from the body directly to another surface. ( When body is immersed in cold water)

2. Convection- Dispersion of heat by air currents ( Wind blowing across exposed skin)

3. Evaporation- Dispersion of heat through water vapor ( sweating and diaphoresis- visible perspiration)

4. Radiation- Transfer of heat from one object to another object without contact between them. ( Heat lost from the body to a cold room)

Front 6

2 sites core body temp is measured

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1.Rectum( 37.5)

2.Tympanic Membrane( 37)

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3 sites where surface body temp is measured

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1. Skin-

2. Mouth ( orally)- ( sublingual pocket)( 37)

3. Axillae ( axillary)(36.5)

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factors that influence body temp ( 7)

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1. Age- low temp in newborns/ older adults

2. Exercise- temp can be raised to 41 degrees

3. Hormone Level- women have more fluctuation, menstruating increases body temp

4. Circadian Rhythm- during the day body temp rises and lowers in the night

5. Stress- physical and emotional stress increase temp.

6. Environment

7. Temperature Alteration- fever, pyrogens raise a fever or lower throughout the day

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pyrexia

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fever, occurs because heat-loss mechanisms are unable to keep pace with excess heat production.

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afebrile

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without fever, feverless ( broken fever)

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Febrile

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Feverish, pertaining to a fever- upward shift at the set point- above 37.5

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hyperthermia

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Hyperthermia is an abnormally elevated body temperature result of the body's inability to promote heat loss or reduce heat production. Overload of body's thermoregulatory mechanisms.

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Hypothermia

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Heat loss during prolonged exposure to cold overwhelms the body's ability to produce heat. - Classified by core body temps

- Body temp drops below 36 degrees celsius

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Lowest to highest tempterature

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axillary- 36.5

Oral/tympanic- 37 degrees

Rectal -37.5 degrees

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Equipment used for Body Temperature

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Electronic Thermometers use a probe to measure oral, rectal, axillary temperatures. Disposable single use thermometers are for oral or axillary temperature measurements. They reduce the risk of cross infection.

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Pulse

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Pulse is the bounding of blood flow that is palpable at various points of the body. Pulse is an indicator of circulatory status.the measurement of heart rate and rhythm.

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Cardiac Output

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The volume of blood pumped the heart during 1 minute: the product of heart rate and ventricular stroke volume. Mechanical, neural, and chemical factors regulate the strength of heart contractions and its stroke volume. As heart rate increases the heart has less time to fill, without a change in stroke volume, blood pressure decreases.

Front 18

Physiology of pulse

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electricalimpulses originating from the SA node travel through heart muscle tostimulate cardiac contraction. 60-70ml of blood enters the aorta witheach ventricular contraction ( stroke volume) With each stroke volumethe walls of the aorta distend, creating a pulse wave that travelsrapidly toward the distal end of the arteries. When a pulse wavesreaches a peripheral artery, it can be felt by palpating the arterylightly against underlying bone or muscle.

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fouraspects of assessment for the radial pulse.

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1. Easily palpable

2. Assess circulation to the hand

3. Place tips of you first two or middle three fingers over grooves along radial or thumb sides of clients inner wrist.

4. If pulse is regular count for 30 seconds and X 2. If pulse is irregular count for 60 seconds

Front 20

5 factors that increase or decrease Heart rate

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1. Exercise

2. Emotions

3. Temperatures

4. Drugs

5. Hemorrhage

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Normal expected characteristics of radial pulse

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Rate= 60-100 beats/minute

Rhythm= regular interval

Strength= Normally pulse strength remains the same with each beat

Equality= Pulses on both sides of the peripheral vascular system should be the same

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Apical Pulse

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Assess rate and rhythm only

If you detect an abnormal rate while palpating peripheral pulses, assess apical rate. Auscultation of heart sounds, more accurate assessment of cardiac contraction.

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Ventilation

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movement of gases into and out of the lung

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Diffusion

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the movement of O2 and CO2 between the alveoli and the RBC.

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Perfusion

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distribution of RBC's to and from the pulmonary capillaries

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Respiration involves ( 3 things)

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Diffusion

Perfusion

Ventilation

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hypoxemia

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Low levels of arterial O2. If arterial O2 levels fall, these receptors signal the brain to increase the rate and depth of ventilation. ( helps control ventilation for clients with chronic lung disease)

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Eupnea

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Normal rate and depth of ventilation

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Bradypnea

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Rate of breathing is regular but abnormally slow ( <12 breaths per minute)

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Tachypnea

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Rate of breathing is regular but abnormally rapid ( > 20 bpm)

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Hyperpnea

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Respirations are laboured, increased in depth, and increased in rate. Normally during exercise

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Apnea

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Respirations cease for several seconds. Persistent cessation results in respiratory arrest.

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3 aspects that of respiration a nurse must assess

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Respiratory Rate- Observe both inspiration and expiration when you count ventilation rate

Ventilatory Depth- assessing the degree of excursion or movement in the clients chest wall ( deep, normal , shallow)

Ventilatory Rhythm- Observing the chest or abdomen.

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8 factors that influence respiration

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1. Exercise- increases respiratory rate and depth to meet body's need for additional O2 and to rid body of CO2

2. Acute Pain- Pain alter rate and rhythm of respiration; breathing becomes shallow. 3.Anxiety- Anxiety increases respiratory rate and depth as a result of sympathetic stimulation.

4. Smoking- chronic smoking changes pulmonary airways, resulting in increased rate of respirations

5. Body Position- straight posture- promotes full chest expansions, stooped or slumped position impairs ventilatory movement. Lying flat prevents full chest expansions 6.Medications-Narcotics, general anaesthetics, and sedatives depress respiratory rate and depth.

7. Neurological Injury- injury to the brain stem impairs the respiratoy centre and inhibits respiratory rate and rhythm.

8.Hemoglobin Function- examples anemia, increased altitude lowers the amount of saturated hemoglobin, abnormalities in blood cell function ( sickle cell disease) reduce ability of red blood cells to carry oxygen, which results in increases in respiratory rate and depth.

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Normal Respiratory rate for adult

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12-20 BPM

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Peripheral Pulses ( 7)

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radialartery, brachial artery, carotid artery, femoral artery, poplitealartery, dorsalis pedis and tibialis posterior arteries

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purposeof assessing peripheral pulses

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toensure blood flow to all limbs, or if they had a amputation to ensureregular blood flow to the surviving limbs. To count BPM in other extremities . TO assess status of circulation to lower and upper extremeties

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edema

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Effusion of serous fluid into the interstices of cells in tissue spaces or into body cavities. Swelling in the feet could be a dependant when caused by heart failure

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Pitting edema

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Edema that retains for a time the indentation produced by pressure

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Non-pitting edema

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usually affects the legs or arms. If the pressure applies to the skin does not result in a persistent indentation, this type of edema is refereed to as non pitting edema

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Risk factors for arterial and venous disease

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- Venous- prolonged standing, sitting or bed rest

- Hyper copaguable states and vein wall trauma

- dilated and varicose veins

-Arterial- A complete blockage

Partial blockage cause blood supply to be insufficient

ischemia deficiency in the supply of O2 to tissue

Edema

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Health challenges that may have a weak or absent peripheral pulse

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-obesity

- huge muscles

- trauma to a wall vessel

-infection

- prolonged insertion of IV

-heart disease

-Hypoxia

-local trauma or surgery

- edema

-constricting casts or bandages

- systematic disease

Front 43

Describevaricosities

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Varicoseveins (varicosities) are twisted, enlarged veins at the skin surface.The word comes from the Latin word varix, which means "twisted."

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When you inhale diaphragm moves?

When you exhale diaphragm moves?

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inhale- contracts moves down

exhale-relaxes moves up

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2 peripheral pulses in the foot

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dorsalis pedis

tibilias

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PMI

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point of maximal impulse- occurs at the apex of the heart bumps against the chest wall, with each heartbeat

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pulse deficit

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s determined by simultaneous palpation at the radial artery and auscultation at the heart apex. It may be present in case of premature beats or atrial fibrillation.

Front 48

how long does the nurse count an apical pulse rate

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60 seconds- 1 minute

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locate the popliteal pulse

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Ask the subject to bend the knee so that it is flexed to about 90 degrees. Sit on the right hand edge of the bed close to the subject right foot. As before gently clasp the sides of the knee (of either limb) and press the pulps of your fingers into the popliteal fossa.

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where is the posterior tibial pulse located?

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Posterior to medial malleolus

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important about tibialis posterior

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slightly deeper

feel behind medial malleolus, not behind calf as too much muscle in the way

use pads of index and middle fingers

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Normal Temperature Range

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36 degrees celsius -38 degrees celsius