Vital Signs Chapter 19

Front 1

Key concepts

Back 1

•Vital signs
• Thermoregulation
• Perfusion (pulse, blood pressure)
• Oxygenation (respirations)

All of the content in this chapter pertains to the concept vital signs. The key concepts of thermoregulation, perfusion, and oxygenation pertain to specific (temperature, pulse, respirations, and blood pressure). A grasp of the underlying concepts will help you understand and remember the rationale for what you do when measuring vital signs.

Front 2

Vital signs

Back 2

Suggest assessment of vital or critical physiological functions. Such as temperature, pulse, respirations, and blood pressure.
*The fifth vital sign is the measurement of pain*

Front 3

When should I measure patient's vital signs?

Back 3

• On admission to the hospital.
• For inpatients, at the beginning of the shift.
• At a visit to the health care provider's office or clinic.
• Before, during, and after surgery or certain procedures.
• To monitor the effects of certain medications or activities.
• Whenever the patient's condition changes.
Frequency
• In the hospital once every 4 to 8 hours.
• In the home health setting at each visit.
• In the clinic at each visit.
• In skilled nursing facilities, also known as convalescent hospitals weekly to monthly.

Front 4

How do I Document Vital signs

Back 4

Special Flow Sheets if abnormal also document in nursing notes, along with any associated symptoms. Document any interventions as well.

Front 5

Body temperature

Back 5

The degree of heat maintained by the body. Normal temp is based on the individual but standard is 98.6°F (37°C).

Front 6

Core temperature

Back 6

Ranges from about 97°F to 100.8°F (36.1°C to 38.2°C). Usually 1°F to 2°F (0.6°C to 1.2°C) higher than surface body temperature.

Front 7

Thermoregulation

Back 7

The process of maintaining a stable temperature. Process controlled by the hypothalamus the body's thermostats.

Front 8

Decreasing the body temperature

Back 8

Heat sensors in the hypothalamus are stimulated,and send out impulses heat production and activate sweating and peripheral vasodilation to cool the body.

Front 9

Vasodilation

Back 9

Diverts core- warned blood to the body surface, where heat can be transferred to the surrounding environment.

Front 10

Increasing body temperature

Back 10

Sensors in the hypothalamus are stimulated and detect cold, they send out impulses to increase heat production and reduce heat loss. The body responds by shivering releasing epinephrine, which increases metabolism.

Front 11

Vasoconstriction

Back 11

(narrowing of the blood vessels) conserves heat by shunting blood away from the periphery (where heat is lost) to the core of the body, where the blood is warmed. Piloerecton (hairs standing on end) also occurs, but it is not an important heat-conserving mechanism in humans.

Front 12

Metabolism

Back 12

the sum of all physical and chemical processes that take place in the body.

Front 13

Basal metabolic rate (BMR)

Back 13

The amount of energy required to maintain the body at rest. Body size, lean muscle mass, and Numerous hormones influence BMR.

Front 14

The movement of skeletal muscles

Back 14

Fuel is needed for the skeletal muscles to function. The catabolism of fats and Carbohydrates in muscle produces energy and heat. After running the body temperature would be high as 101°F to 104°F (38.3°C to 40°C). In contrast going outside in cold temperatures 35°F (1.6°C) you would began to feel cold and the hypothalamus would sense that temp drop and you would begin to shiver.

Front 15

Nonshivering thermogenesis

Back 15

The metabolism of brown fat to produce heat. Used by infants because they Cannot produce heat through shivering. Disappears in the first few months after birth.

Front 16

Radiation

Back 16

The loss of heat through electromagnetic waves emitting from surfaces that are warmer than the surrounding air-

Front 17

Convection

Back 17

The transfer of heat through currents of air or water. Immersion in a warm bath may raise the body temp for a hypothermic Pt. Cool fans can reduce Pt fever.

Front 18

Evaporation

Back 18

When water is converted to vapor and lost from the skin (as perspiration) or the mucous membranes (through the breath). Causes cooling.

Front 19

Insensible loss

Back 19

Water loss through evaporation. Evaporation is affected by the relative humidity (moisture in the environment).

Front 20

Conduction

Back 20

The process whereby heat is transferred from a warm to a cool surface by direct contact.

Front 21

Development level

Back 21

Intense and ordered all the most susceptible to the effects of environmental temperature extremes. Infants lose about 30% of their body heat through the head. Older adults having difficulty maintaining body heat because it was slow metabolism, decreased fetal motor control, and loss of subcutaneous tissue. The average normal temperature for an adult 65 years or older is about 95°F to 96.8°F (35°C to 36°C).pt one 80.7 yr temp ranged from 94°F(34.4°C)to 99.6°F(37.6°C).

Front 22

Environment

Back 22

Strongly influences body temperature for example, one room temperatures, high humidity, or hot bath increase body temperature. Very high temperatures can produce high internal temperature is causing heat stroke. In contrast, cold environments can lower the body's temperature in severe cases leads hypothermia.

Front 23

Gender

Back 23

A woman's body temperature varies as much as 1°F (0.6°C) with her menstrual cycle and pregnancy you too frustrating of progesterone levels. Hot Flashes can produce episodes of intense body heat and sweating

Front 24

Exercise

Back 24

Increases metabolism Can raise body Core temp to 101°F to 104°F (38.3°C to 40°C)

Front 25

Emotions and Stress

Back 25

The sympathetic nervous system is stimulated causing production of epinephrine and norepinephrine which trigger an increase in the metabolic rate.

Front 26

Circadian Rhythm

Back 26

A cyclical repetition of certain physiological processes that occurs every 24 hours. Temperature fluctuates 1°F to 2°F (0.6°C to 1.2°C) over the Course of 24 hours. It is usually lowest in the early morning hours and highest in the late afternoon or evening.

Front 27

Fever or Pyrexia

Back 27

A temp above the usual range of normal. Oral over 100°F (37.8°C) or rectally 101°F (38.3°C).
Febrile: w / fever
Afebrile: w/out fever.
Taking several readings at different times of the day for definite diagnosis. Fever usually does not pose a threat, it's the body's natural defense.

Front 28

Hyperpyrexia

Back 28

Fever above 105.8°F (41.0°C). This is dangerous and requires intervention,

Front 29

Pyrogens

Back 29

Fever occurs in response to these fever-producing substances. Phagocytes (specialized WBC), which ingest the invaders in secrete pyrogens are stimulated when bacteria or other foreign substances in the body. Pyrogens induce the secretion of prostaglandins which are substances that reset in the hypothalamic thermostat at a higher temp. The reset value is called the set point.

Front 30

Three Phases of Fever

Back 30

• Initial phase: febrile episode or onset (temp rising but has not reached set point)
• Second phase: course (Reaches set point or maximum body temp)
• Third phase: Defervescence or crisis (temp returns to normal)

Front 31

Four Fever Types

Back 31

• Intermittent fever: temp alternates regularly between periods of fever and periods are normal or below normal temp without pharmacological intervention. Temp returns to normal at least once every 24 hours.
• Remittent fever: fluctuations in temp all above normal during in 24 period.
• Constant (sustained) fever: temp may fluctuate but it's always above normal.
• Relapsing (or recurrent) fever: short periods of fever alternating with periods of normal temps lasting 1 to 2 days.

Front 32

Antipyretic

Back 32

Fever-reducing medications such as Tylenol (acetaminophen) or Advil, Motrin (ibuprofen).

Front 33

Why should you think carefully before administering antipyretic meds to a client?

Back 33

A Fever to a point, is beneficial. High temps ap to 102.2°F (39°C) enhance the immune response.
1) Kill or inhibit the growth of many microorganism
2) enhance phagocytosis
3) Cause breakdown of lysosomes and self-destruction of ii rally infected cells
4) Cause the release of interferon, a substance that protects cells from viral infections.

Front 34

Hyperpyrexia can cause:

Back 34

Damage to cells throughout the body especially in the brain, causing agitation, confusion, stupor, or coma. Vascular collapse may follow, producing cerebral edema, shock, and death. Death usually results with temps of 109°F to 112°F (43°C to 44°C)

Front 35

Hyperthermia

Back 35

A body temp above normal. The elevated body temp is higher than the set point. The body cannot promote heat loss fast enough to balance heat production or high environmental temps. Overexposure to high temps an inadequate fluid replacement, the body loses the ability to sweat and is unable to cool down.

Front 36

Heat Exhaustion

Back 36

Core temp of 98°F to 103°F (37°C to 3 9.4°C). Warning signs include: weakness, nausea, vomiting, syncope, tachycardia, tachypnea, muscle aches, headaches, diaphoresis (heavy sweating), and flushed skin.

Front 37

Heat stroke

Back 37

Occurs when the body temp regulation fails, usually when the hyperthermia progresses to a temperature above 103°F (39.4°C). Symptoms include: rapid, strong pulse; throbbing headache; delirium; confusion; impaired judgement; lethargy; red, hot, dry skin; dizziness ; seizures; and coma. Temperatures of 106°F (41.1°C) and higher have been reached death can occur if you emergency treatment is not given.

Front 38

Hypothermia

Back 38

Abnormally low core temperature, less than 95°F (35 °C). Prolonged exposure to the cold is no longer correctable by shivering and may prove fatal. Maybe associated with extended exposure to cold, such as during surgery, extreme weather conditions, immersion in cold water, or lack of shelter and clothing. It is sometimes deliberately induced under close monitoring to decrease the need for oxygen in body tissues.

Front 39

Early signs of hypothermia

Back 39

Shivering, cyanosis of the lips and fingers, poor coordination. The first sign of hypothermia is pain in the extremities. As the body temperature continues to fall the person experiences mental impairment, confusion, disorientation, slowing of the heart rate and respirations, and the ability to take precautions out of the cold.

Front 40

Severe hypothermia

Back 40

Occurs when the body temperature drops below 82.4°F (28° C) the person becomes unconscious and stop shivering. The pulse and respiration are irregular and difficult to detect. Survival is possible at a core temperature of 68°F (16). That usually results when body temp falls below 70°F to 75°F (21°C to 24°C).

Front 41

Fahrenheit to centigrade

Back 41

Subtract 32 from Fahrenheit and multiply by 5 / 9.
Example: (102 - 32) x 5 / 9 = (70 x 5) ÷ 9 = 39°C

Front 42

Centigrade to Fahrenheit

Back 42

Multiply the centigrade temp by 9 / 5, and add 32.
Example: (39 x 9 / 5) + 32 = (351 ÷ 5) + 32 = 102°F

Front 43

Perfusion

Back 43

The continuous supply of oxygenated blood to all body cells.

Front 44

Pulse

Back 44

The rhythmic expansion of an artery produced when a bolus of oxygenated blood is forced into it by contraction of the heart.

Front 45

Systole

Back 45

The phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries.

Front 46

Diastole

Back 46

The phase of the heartbeat when the heart muscle relaxes and allows the chambers to fill with blood.

Front 47

Stroke volume (SV)

Back 47

The amount of blood pumped out of the heart (left ventricle - to the body) during each contraction measured in mL/beat (millilitres per beat).

Front 48

Cardiac output

Back 48

The total quantity of blood pumped per minute, expressed in liters per minute

Cardiac output = stroke volume x pulse (heart) rate.

Front 49

What factors influence the Pulse Rate?

Back 49

* Developmental level. Newborns have a rapid pulse rate, gradually slows through old age

* Gender. In general, adult women have a slightly higher pulse rate than adult men

* Exercise. Muscle activity normally increases the pulse rate

* Food. Ingestion of a meal causes a slight increase in pulse rate for several hours

* Stress. Triggers the fight-of flight sympathetic nervous system response. This increases both pulse rate and stroke volume

* Fever. Pulse rate tends to increase 10 beats/min for each °F of temp elevation

* Disease. Heart disease, hyperthyroidism respiratory diseases, and infections. Hypothyroidism is associated with decreased pulse rates.

* Blood loss. A large loss of blood stimulates the SNS, bringing about an increase in pulse rate

* Position changes. Standing and sitting generally cause a temporary increase in pulse rate.

* Medications. Stimulant drugs (e.g., epinephrine) increase pulse rate. Cardiotonics (e.g., digitalis) and opioids (e.g., narcotic analgesics) or sedative drugs decrease pulse rate.

Front 50

palpation

Back 50

To examine or explore by touching (an organ or area of the body), usually as a diagnostic aid.

Front 51

auscultation

Back 51

The act of listening for sounds made by internal organs, as the heart and lungs, to aid in the diagnosis of certain disorders.

Front 52

Stethoscope

Back 52

Consists of a sound-transmitting device (bell for low-frequency and diaphragm for high-frequency) that is attached to earpieces by rubber tubing and hollow metal tubes

Front 53

Apical pulse

Back 53

The pulse over the apex of the heart, as heard through a stethoscope or palpated.

Front 54

peripheral pulse

Back 54

*Radial artery

*Brachial artery

*Carotid artery

*Temporal artery

*Dorsalis pedis (pedal pulse)

*Femoral artery

*Popliteal artery

Front 55

When should I take an Apical Pulse?

Back 55

* The radial pulse is weak or irregular.

* The rate is less than 60 beats/min or greater than 100 beats/min

* The patient is taking cardiac medications (e.g., digitalis).

* The patient is an infant or is a child up to age 3 (because peripheral pulses may be difficult to palpate).

Front 56

When should I take an Apical-Radial Pulse?

Back 56

To assess for heart function or the presence of hart irregularities. A difference between the two counts is the pulse deficit.

Front 57

What data should I collect with pulse rate?

Back 57

The patient's pulse rate, rhythm, and quality.

Front 58

Pulse rate

Back 58

The count of beats per minute while palpating or auscultating. Normal range for healthy young and middle-aged adults is 60 to 100 beats/min with an average of 70 to 80 beats/min.

Front 59

bradycardia

Back 59

rates below 60 beats/min (brady=slow, cardia=heart)

Front 60

tachycardia

Back 60

rates over 100 beats/min (tachy=rapid, cardia=heart)

Front 61

Pulse rhythm

Back 61

The intervals between heartbeats

Front 62

dysrhythmia

Back 62

abnormal cardiac rhythm

Front 63

electrocardiogram (ECG)

Back 63

A graphic tracing of the variations in electrical potential caused by the excitation of the heart muscle and detected at the body surface. The normal electrocardiogram is a scalar representation that shows deflections resulting from cardiac activity as changes in the magnitude of voltage and polarity over time and comprises the P wave, QRS complex, and T and U waves.

Front 64

pulse quality

Back 64

Is assessed by determining the pulse volume and bilateral equality of pulses

Front 65

pulse volume

Back 65

The amount of force produced by the blood pulsing through the arteries.

0—Absent: Pulse cannot be felt.
1—Weak (thready): Pulse is barely felt and can be easily
obliterated by pressing with the fingers.
2—Normal quality: Pulse is easily palpated, not weak or
bounding.
3—Bounding or full: Pulse is easily felt with little pressure;
not easily obliterated.

Front 66

bilateral equality

Back 66

Is useful in determining whether the blood flow to a body part is adequate.

Front 67

pallor

Back 67

Refers to the paleness of skin in one area when compared to another part of the body.

Front 68

cyanosis

Back 68

Is a bluish or grayish discoloration of the skin due to deficient oxygen in the blood..

Front 69

Ineffective Tissue Perfusion (Peripheral)

Back 69

Can be used when a pulse is absent or weak and cool, pale skin is present.

Front 70

Risk for Impaired Skin Integrity and Risk for Impaired Tissue Integrity

Back 70

May be used as secondary diagnoses when Ineffective Tissue Perfusion is present. If tissue is not adequately perfused, tissue ischemia and necrosis may occur.

Front 71

Deficient Fluid Volume

Back 71

May cause the pulse to be weak and thready

Front 72

Excess Fluid Volume

Back 72

May cause the pulse to be bounding and full.

Front 73

Decreased Cardiac Output

Back 73

May cause tachycardia, bradycardia, or changes in pulse volume.

Front 74

Types of thermometers

Back 74

• Glass thermometers: Mercury-filled tube marked in degrees Fahrenheit or Centigrade and read visually
• Electronic thermometers: A recharable unit consisting of an electronic probe attached to a thin wire
• Electronic infrared thermometers: A recharable unit that contains a sensor that detects heat in the form of infrared energy given off by the body
• Disposable chemical thermometers: A thin plastic strip, patch, or tape containing a matrix of chemicals that change color at a designated
body temp

Front 75

What site should be used?

Back 75

• Temporal Artery
• Rectally
• Orally
• Axillary
• Tympanic membrane
• Skin

Front 76

Interventions: Hyperthermia

Back 76

Provide Focus Assessments
• Help determine the cause of the fever.
• Monitor the temperature and other VS at least every 2 hours
• Observe for the clinical signs that accompany a fever.

Provide Collaborative Care to Treat the Underlying Cause of the Fever

Provide Oral or Intravenous Fluids
• Replace fluids lost through diaphoresis

Use Nonpharmecological Measures to Reduce Fever
* Be mindful that you Can Cause your patient to shiver raising their temp*
• Cooling blankets that circulate water
• Alcohol or tepid baths
• cost covered ice packs or cool washcloth to the groin, neck, or axillae. Avoid prolonged use.
• Circulating fan in the room
• Instruct the patient to use minimal bed covers

Provide Nutritional Support
• Food is essential to meet the increased energy needs created by the high metabolic rate accompanying a fever

Provide Special Mouth Care
• apply a water soluble lip lubricant

Keep Clothing and Bed Linens Dry
• Promotes comfort and prevents chilling do to diaphoresis during fervescence

Provide Emergency Treatment, if Necessary
• Heat stroke is a medical emergency because death can occur rapidly. Cooling blankets or cool water baths can be used successfully if the surface temperature is not lowered too quickly . Rapid lowering of the surface temperature causes vasoconstriction, which delays core cooling.

Provide Patient Teaching
• Teach emergency treatment for hyperthermia and hyperpyrexia at home
• Advise older adults to stay in air-conditioned buildings when the outside temperature is extremely high and to take cool baths and showers, limit physical activity, and drink plenty of non alcoholic and non caffeinated fluids
• advise family to check on elderly neighbors and family members at least twice a day, and make sure they have any electric fan

Front 77

Interventions: Hypothermia

Back 77

•Provide warm, dry clothing, warm blankets, and warm environment. For mild cases of hypothermia, this may be enough to restore normal temperatures
•Pt with temp below 86°F (30°C), also use warm IV fluids , heating pads or electric blankets, and/or warm baths
• Give warm, sweet drinks if a person is conscious
* rewarm a patient who is severely hypothermic gradually to prevent complications, such a shock or dysrhythmias and to ensure core, as well as surface warming
** Do not use electric blankets. Vasoconstricted skin burns easily.
** Do not apply pulse oximetry probes to a vasoconstricted finger.

• Focus assessments include the following:
Monitor the temperature in other VS frequently. Hypothermia causes vasoconstriction, coagulation in the microcirculation, and tissue ischaemia in the heart it can lead to dysrhythmias.

Observe for the following symptoms of hypothermia:
• Body temperature less than 95°F (35°C)
• Decreased or irregular pulse, respirations, and blood pressure
• A subjective feeling of being cold
• Severe shivering (only initially)
• Pale cool shiny skin
• Decreased urine output
• Disorientation and/or drowsiness