Unit 3- Vital Signs (Temperature, Pulse, Respiration, Oxygen Saturation, + Blood Pressure)

What is the normal range of temperature for a healthy adult?

1. Oral= 35.8ºC to 37.5ºC

2. Axillary (armpit)= 1 Celsius lower than oral

3. Tympanic Membrane (ear)= 0.3°C to 0.6°C higher than oral

4. Rectal Temperature (anus)= 1 Celsius higher than oral

What are vital signs?

Indicate a person’s hemodynamic (e.g. flow of blood within the organs + tissues) status

What factors can affect the patient’s temperature?

1. Age (e.g. newborn till puberty are higher or elderly are lower)

2. Exercise (e.g. increased metabolism= increased heat)

3. Hormone level (e.g. progesterone levels are low= lower temp or ovulation= high)

4. Circadian rhythm (e.g. low to high)

5. Stress (e.g. increase)

6. Environment

7. Temp alterations (e.g. hypothalamic set point= normal)

What are the sites used to assess body temperature?

1. Oral (mouth or under tongue)

2. Axillary (armpit)

3. Rectum (anus)

4. Tympanic membrane (ear)

How does smoking, chewing gum, and ingesting hot/cold liquids or food affect a patient’s temperature? What are the nursing actions for assessing temperature in relation to these activities?

What do the following terms mean: core temperature.

The temperature deep within the body (e.g. internal organs= rectum, tympanic membrane, temporal/ blood vessel @ side of hear, esophagus, pulmonary artery, + urinary bladder)

What do the following terms mean: fever/pyrexia

There is too much heat production resulting in the heat loss process can't catch up

What do the following terms mean: afebrile

Last stage of the defence mechanism= no more fever

What does blood pressure represent?

Pulsation + force of blood from the heart that against the walls of the artery (high pressure to low pressure)

What is the normal range for the blood pressure of a healthy adult?

120/80 mmHg

What do the following terms mean: systolic

maximum pressure on the arteries during left ventricular contraction

What do the following terms mean: diastolic

Resting/minimal pressure on the arteries between each cardiac contraction.

What do the following terms mean: pulse pressure

Difference between systolic + diastolic (e.g. 40= mm of mercury) Systolic - diastolic

What do the following terms mean: hypotension

Dilation of arteries in vascular bed, loss of blood volume (e.g. low bp= systolic bp decreases to 90 mm Hg or lower)

What do the following terms mean: hypertension

Thickening + loss of elasticity in arterial walls (e.g. increase in bp)

What do the following terms mean: sphygmomanometer

BP Cuff

1. Pressure manometer (e.g. used to measure pressure)

2. Occlusive cloth/ vinyl cuff + inflatable rubber bladder

3. Pressure bulb + release valve

What do the following terms mean: Korotkoff sounds

Nikolai Korotkoff (Artery Distal to bp Cuff)

1. Clear tapping= pulse rate + increase in intensity

2. Blowing or swishing= deflate

3. Crisper + more intense tapping

4. Muffled + low pitched= more inflating

5. No sound

What are the 2 types of manometers?

1. Aneroid (e.g. safe, lightweight, portable, + compact= can lead to inaccurate results due to calibration)

2. Mercury manometers (e.g. less used= contain mercury)

What are common mistakes in blood pressure assessment?

1. Cuff too wide (e.g. false low), too narrow (e.g. false high), too loose (e.g. false high)

2. Deflating cuff too slow (e.g. false high) or deflating too quickly (e.g false low)

3. Arm below or above heart level

4. Stethoscope not firm

What does orthostatic/postural hypotension mean?

Normotensive person (person w/ normal bp)= low bp when standing in an upright position (e.g. peripheral blood vessels constrict in the legs)

How does the psychiatric nurse measure blood pressure to detect postural/orthostatic hypotension?

1. Pulse + blood pressure is taken by having patient sit upright + standing.

2. Obtained after 1-3 min patient moves into a diff position

3. Detected within a 1 min of standing up

What is the normal range of heart rate for a healthy adult?

60–100 beats per min

What factors can affect the patient’s heart rate?

1. Activity intolerance

2. Anxiety

3. Impaired gas exchange

4. Hyperthermia or hypothermia

4. Acute pain

What do the terms rate, rhythm (irregular/regular), and quality (strength) mean in relation to assessing the pulse?

1. Rate: measurement of heart +auscultation of heart sounds

2. Rhythm: regular interval between each pulse or heartbeat

3. Quality (strength): remains same w/ heartbeat. The volume of blood ejected against the arterial wall with each heartbeat (contraction)

What does the term tachycardia mean?

Heart rate over 100 beats per min (e.g. fever, caffeine, low bp or high bp)

What does the term bradycardia?

Slow heart rate (e.g aging)

What are the 2 common pulse sites used to assess the heart rate?

1. Radial pulse: inner lateral wrist

2. Apical pulse:

Heart Rate w/ stethoscope placed over the 4th–5th intercostal space of the midclavicular line on the left side on adults

What is the normal respiratory rate range of a healthy adult?

12–20

What factors affect the patient’s respiratory rate?

1. Exercise

2. Acute pain

3. Anxiety

4. Smoking (e.g. change in pulmonary airways)

5. Body position

6. Medication

7. Neurological injury

8. Hemoglobin function (e.g. anemia)

How does the psychiatric nurse assess the respiratory rate?

1. Watch second hand

2. Vital sign flow sheet or record form

3. Note any signs + symptoms

4. Pulse oximetry (SpO2): 95-10% (normal) or 85-89 (abnormal)

What is tachypnea?

What is bradypnea?

What is dyspnea?

What is apnea?

What is orthopnea?

What do the terms rate, rhythm, and depth mean in relation to respiration?

What characteristics does the psychiatric nurse assess when observing respirations

What can affect our pulse rate

1. Infection

COPD O2 rate.

88-92%

Comorbidity O2

Greater than 92%

How apical pulse

What factors affect oxygen saturation readings?

1. Dark nail polish (artificial nail)

2. Anemia (low oxygen in blood)

3. Exercise

4. Jaundice

5. Colour of someone's skin

How does the psychiatric nurse select an appropriate pulse oximeter site?

Make sure it's clean

1. Best would be right middle finger

2. Toe

3. Nose

4. Ear lobe

How does the pulse oximeter measure oxygen saturation?