Vital Signs

vital signs

vital or critical physiological functions

\-state of health and/or functional ability

standard vitals

\-temperature

\-pulse

\-respirations

\-blood pressure

other vital signs

\-pain

\-oxygen saturation

\-smoking status

\-emotional distress

temperature

degree of heat maintained by the body; different between heat produced by the body and heat lost to the environment

thermoregulation

process of maintaining a state of internal body temperature

decreasing body temperature

\-heat sensors in hypothalamus are stimulated and send impulses to reduce body temp

\-activates sweating and vasodilation

vasodilation

increase in diameter of blood vessels to increase blood flow

increasing body temperature

\-cold sensors in hypothalamus are stimulated and send impulses to increase heat production and reduce heat loss

\-body responds to heat production by shivering and releasing epinephrine

\-stimulates vasoconstriction and piloerection

vasoconstriction

narrowing of blood vessels to help reduce heat loss

piloerection

hairs standing on end, “goosebumps”

radiation

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

convection

transfer of heat through currents of air or water

evaporation

water is converted to vapor and lost from the skin or mucous membranes

conduction

heat is transferred from a warm to a cool surface by direct contact

factors that influence body temperature

\-developmental level

\-environment

\-gender (females have more thermoregulation)

\-exercise

\-emotions or stress

\-circadian rhythm

pyrexia

fever; oral temp higher than 100 degrees Fahrenheit

febrile

person with a fever

afebrile

person without a fever

moderate fever

body’s natural defense against infection up to 103 degrees Fahrenheit, doesn’t pose a threat

hyperpyrexia

fever above 105.8 degrees Fahrenheit; dangerous & requires intervention to prevent damage to body cells

pyrogens

fever-producing substances; stimulates phagocytes

initial phase (febrile episode)

body temperature is rising but has not yet reached the new set point; person feels chilly, shivers, and uncomfortable

second phase (course)

body temperature reaches its maximum & remains fairly constant at the higher level; patient feels warm, flushed, and dry

third phase (crisis)

body temperature returns to normal; personal feels warm & flushed and diaphoresis occurs

diaphoresis

sweating

intermittent fever

temperature alternates regularly between periods of fever and periods of normal or below-normal temperature

remittent fever

fluctuations in temperature all above normal during a 24 hour period

constant fever

temperature may fluctuate slightly but is always above normal

relapsing fever

short periods of fever alternating with periods or normal temperatures, each lasting 1-2 days

core temperature

97\.8-100.8 degrees Fahrenheit

\-higher than surface temperature

assessing core temperature

pulmonary artery, esophagus, bladder, rectal, tympanic, and temporal

surface temperature

98\.6 degrees Fahrenheit/ traditional normal range

\-lower than core temperature

assessing surface temperature

mouth, axillae, tympanic, skin over temporal artery

hypothermia

abnormally low core temperature, usually less than 95 degrees Fahrenheit

causes of hypothermia

\-environmental exposure to extreme cold

\-surgery

\-medically induced

assessment of hypothermia

\-cool skin

\-shivering

\-fatigue

\-cyanosis of lips and hands

\-decreased heart rate & respirations

interventions of hypothermia

\-move to warm environment

\-remove cold & wet clothing

\-apply head coverings

\-put warm blanket on them

hyperthermia

body temperature above normal and higher than set point

causes of hyperthermia

excessive hot environment & rigorous physical activities, dehydration

assessment of hyperthermia

heavy sweating, weakness, tachycardia/tachypnea, red, hot, dry skin, nausea & vomiting

interventions

move to cool environment, drink plenty of fluids, provide cool-clothed ice packs

pulse

rhythmic expansion of an artery

systole

contraction of the heart

diastole

resting phase of the heart

normal pulse range

60-\`100 beats per minute

autonomic nervous system

regulates heart rate

sympathetic system

increases heart rate & cardiac output

parasympathetic system

decreases heart rate & cardiac output

factors that influence pulse rate

\-developmental level

\-gender

\-exercise

\-food intake

\-stress

\-fever

\-disease

\-blood loss

\-position change

\-medication

apical pulse

pulse at apex of the heart

peripheral pulse

artery pulses away from the heart

\-radial

\-brachial

\-carotid

\-temporal

\-dorsalis pedis

\-femoral

\-popliteal

\-posterior tibial

pulse deficit

difference between radial and apical pulse reading

bradycardia

slow heart rate, below 60 bpm

tachycardia

rapid heart rate, above 100 bpm

pulse rhythm

intervals between heartbeats,pattern

pulse quality

determined by pulse volume and bilateral equality of pulses (used for peripheral pulses only)

0=no pulse

1=weak pulse

2=normal pulse

3=full pulse

4=bounding pulse

bilateral equality

blood flow to a body part is adequate and equal

respiration

exchange and transport of O2 & CO2

external respiration

exchange of oxygen and carbon dioxide between alveoli and pulmonary blood supply

internal respiration

exchange of oxygen and carbon dioxide between capillaries and body tissue cells

primary stimulus

medulla oblongata drives breathing; level of CO2 tension in blood

central chemoreceptors

located in the respiratory centers; sensitive to CO2 and pH concentrations

peripheral chemoreceptors

located in the carotid and aortic bodies; stimulate respirations when partial pressure of oxygen in arterial blood falls between 80-100

inspiration

drawing air into the lungs, diaphragm flattens

expiration

expulsion of air from the lungs; diaphragm retracts/curves

factors that influence respirations

\-developmental level

\-exercise

\-pain

\-stress

\-smoking

\-fever

\-hemoglobin

\-disease

\-medication

\-positions

apnea

cessation of breathing

eupnea

normal respirations

normal range of respirations

12-20 breaths per minute

bradypnea

slow respirations; less than 12 breaths/minute

tachypnea

fast respirations; greater than 24 breaths/minute

deep respiration

large volume that fully expands chest or abdomen

shallow respiration

chest barely rises and is difficult to observe

normal respiration

between shallow and deep respirations

1; 4

every __degree that temperature rises, respirations rises ___ breaths /min__

1; 10

every *degree that temperature rises, pulse rises* _ beats/min

regular respirations

normal respiration with equal rate and depth

abnormal respirations

irregular respiration of variable depth

kussmaul respirations

respirations that are regular by abnormally deep and increased in rate

biot respirations

irregular respirations of variable depth, alternating with periods of apnea

cheyne-stokes respirations

gradual increases in depth of respirations, followed by gradual decrease and then a period of apnea

dyspnea

increased effort with breathing

orthopnea

inability to breathe in a horizontal position

wheeze

high-pitched, continuous musical sound usually heard on expiration; narrowing of the airway

\-ex: asthma

rhonchi

low-pitched, continuous gurgling sounds; fluids in lungs

crackles

discontinuous sounds heard on inspiration caused by fluid in alveoli

stridor

piercing, high-pitched sound during inspiration, narrowing of airway

intercostal retraction

visible sinking of tissues around and between ribs

substernal retraction

tissues are drawn in beneath the sternum

suprasternal retraction

tissues are drawn in above the clavicle

hypoxia

inadequate cellular oxygenation

signs of hypoxia

pallor or cyanosis, restlessness, fatigue, tachycardia, tachypnea, changes in blood pressure

signs of cyanosis

blue color in lips, nails, and skin

hyperventilation

rapid and deep breathing, results in excess loss of CO2 (hypocapnia)

\-ex: panic attack

hypoventilation

rate and depth of respirations are decreased & CO2 is retained

blood pressure

pressure of blood forced against arterial walls during cardiac contraction

systolic pressure

peak pressure exerted against arterial walls

diastolic pressure

minimum pressure exerted against arterial walls

pulse pressure

difference between systolic and diastolic pressures

cardiac function

5-6 liters/min of blood exerted out of heart