nur203 - vital signs

oral temperature

averages 97.7°F/36.5°C

most convenient, not for patients with breathing difficulties

wait 15min after eating/drinking something hot/cold

rectal core temperature

averages +0.4-0.6°C from oral temperature (98.4-98.8°F/36.9-37.1°C)

most accurate, also most intrusive. not for immunocompromised or any rectal issues (hemorrhoids, scars, surgery)

axillary temperature

averages -1°C from oral temperature (95.9°F/35.5°C)

least accurate but can be good when time is a factor but temperature isn’t a concern

tympanic temperature

averages +0.2°C from oral temperature (97.3°F/36.3°C)

noninvasive and accurate, earwax may impact reading

temporal temperature

questionable accuracy, quick, noninvasive

hyperthermia

higher than 100°F/38°C

pyrogens from bacteria make body heat up, can be cause by infection, tissue breakdown (surgery/trauma), or neurological issues (stroke, tumor, trauma)

symptoms include flush, sweating, high heart rate and pulse, and low bloop pressure

hypothermia

95°F/35°C

from prolonged exposure to cold, can be accidental or induced therapeutically.

can cause heart issues, keep an eye on pulse!

symptoms include pale, shivering, cold, and low heart rate

other effects on temperature

dinural cycle: bodys daily rhythm, changes -1°F in the early AM and +1°F in mid PM

menstrual cycle: +1°F during ovulation, -1°F during menstruation

exercise: + during physical activity

age

pulse definition

pressure wave from heart pumping blood into aorta

average pulse rate, how to take it

60-100 beats per minute; count for 30sec and multiply result by 2, if heartbeat is irregular, count for whole 60sec

pulse force scale

3+ full, bounding

2+ normal

1+ weak

0+ nonexistent

bradycardia

low pulse rate (<60) which is a medical emergency when combined with hypertension. found typically in athletes or with medication

symptoms include fatigue and dizziness

tachycardia

high pulse rate (>100) which is okay if unsustained, found in pain, sepsis, or hemorrhage

symptoms include dizziness, high pulse, low blood pressure, and shortness of breath

average respiratory rate and procedure

12-20 breaths per minute, DONT tell patient your counting respirations as they will change the way they breathe; take at the same time as pulse

tachypenia

>20 breaths per minute

bradypenia

<10 breaths per minute

apenia

no breaths

pulse oximetry

arterial oxygen saturation, sound be >95, anything <90 is a medical emergency!

hypertension

blood pressure over 120/80

caused by smoking, diabetes, age, gender, and anxity

interventions aim to reduce sodium intake, encourage weight loss, and increasing physical activity

stage 1 hypertension

blood pressure of 130/80

stage 2 hypertension

blood pressure of 140/90

hypotension

blood pressure lower than 90/60

can be caused by shock, hemorrhage, or vasodilation

can make patient dizzy or faint

pulse pressure

systolic BP - diastolic BP = pulse pressure

pulse pressure >50 is widened

blood pressure definition and procedure

the force of blood pushing against the vessel walls

feel the pulse on the arm as you puff up the cuff- when you feel it stop, use that number +30 to puff the cuff up to. listen for systolic pressure, or when the beats start, they then stop (auscultatory gap) and restart again, when they stop its diastolic pressure