Vital Signs Lab Week 2

Afebrile

without fever

-When a patient breaks their fever

Blood Pressure

the amount of force excreted on artery walls by pulsing blood under pressure from the heart

Diaphoresis

visible sweat that forms on the forehead and upper thorax along with other places on the body

diastolic blood pressure

Pressure in the arteries when the heart relaxes and ventricles fill with blood

systolic pressure

Blood pressure in the arteries during contraction of the ventricles.

Apnea

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

hypertension

high blood pressure that is in the 95th percentile or greater and adjusted for age and gender

Hyperthermia

Abnormally high body temperature without increasing hypothalamic set point

hypotension

low blood pressure with systolic BP being at 90mmHg or less

hypothermia

A core body temperature that is below 35 degrees C or (95 F)

Pyrexia

A fever due to heat loss mechanisms that cant keep pace with excessive heat production

shivering

response to cold; body shakes to turn energy from food into body heat

-involuntary due to temperature differences in the body

Hypoxia

Low oxygen saturation of the body, not enough oxygen in the blood

postural hypotension

Drop in blood pressure upon standing by 10 mmHg within 2-5 mins of standing

radiation

heat that transfers due to direct contact with two surfaces

sethoscope

instrument used to hear internal body sounds

Bell

a bowl shaped chest piece that transmits low-pitched sounds

Diaphragm on stethoscope

flat endpiece of the stethoscope used for hearing relatively high-pitched heart sounds

sphygmomanometer

instrument to measure blood pressure

pulse oximeter

used to provide indirect and noninvasive measurement of a patients oxygen saturation

orthostatic hypotension

Decrease in systolic blood pressure related to positional or postural changes from lying to sitting or standing positions

acute pain

any sudden or sharp pain or discomfort that can signal bodily harm or tissue damage

persistant/chronic pain

recurring pain that continues for more than three months

vital signs

Measurements of the body's most basic life-sustaining functions

weight

a measurement of body mass typically measured in kg or lbs

height

linear measurement of the body on length from head to toe

PQRST

Provokes- how did it start? What makes it better or worse?

Quality- What does symptom feel like?

Radiates-where is symptom located

Severity- 0-10

Time- does symptom last or linger?

temperature range for adults

36-38 C (96.8-100.4 F)

oral/tympanic temperature

37 C (98.6 F)

Rectal Temperature

37.5 C (99.5 F)

Axillary

36.5 (97.7 F)

what four things do you measure when checking pulse

rate, rhythm, strength, and quality

what is an acceptable range for pulse

60 to 100 bpm

what three things do you measure for respirations

respiratory rate, ventilatory depth, and ventilatory rhythm

what two things do you measure during blood pressure

systolic and diastolic

what is an acceptable systolic range

less than 120 mmHg

what is an acceptable diastolic range

less than 80 mmHg

what is being measured during oxygen saturation

hemoglobin saturation in peripheral blood

SpO2 acceptable range

95%-100%

occasions when a nurse should measure vital signs

1. On admission to health care facility

2. Assessing at home care visits

3. routine schedule according to provider orders

4. Before, during, after surgical procedure

5. Before, during, after transfusion of blood

6. Patient reports symptoms of physical distress

7. Patients general physical condition changes

Are there occasions that a Registered nurse could delegate vital signs

When patient is in stable condition and for routine vital sign measurement

Are there occasions that a Registered nurse could not delegate vital signs

patient is considered unstable and the nurse shouldn't delegate to less expereinced staff

what is the importance of trending a patients vital signs over several hours or days

Important so a nurse can note changes from their baseline and detect changes in their condition

What factors affect body temperature

Age, exercise, hormone level, circadian rhythm, stress, environment, and temperature alterations

nursing interventions for febrile patients

• Obtain cultures of body fluids such as urine, sputum, or blood (before beginning antibiotics) if ordered.

• Obtain blood culture specimens to coincide with temperature spikes when the antigen-producing organism is most prevalent (check agency policy).

• Minimize heat production: reduce frequency of activities that increase oxygen demand such as excessive turning and ambulation; allow rest periods; limit physical activity.

• Maximize heat loss: reduce external covering on patient's body without causing shivering; keep patient, clothing, and bed linen dry.

• Satisfy requirements for increased metabolic rate: provide supplemental oxygen therapy as ordered to improve oxygen delivery to body cells; provide measures to stimulate appetite and offer well-balanced meals; provide fluids (at least 8 to 10 [8-oz] glasses for patients with normal cardiac and renal function) to replace fluids lost through insensible water loss and sweating.

• Promote patient comfort: encourage oral hygiene because oral mucous membranes dry easily from dehydration; control temperature of the environment without inducing shivering; apply damp cloth to patient's forehead.

• Identify onset and duration of febrile episode phases: examine previous temperature measurements for trends.

• Initiate health teaching as indicated.

• Control environmental temperature to 21° to 27°C (70° to 80°F).

factors that affect heart rate

age, activity level, fitness level, emotions, body position, body size, medications, environmental temperature, illness, medical conditions

factors that affect pulse ox saturation

Conditions that decrease arterial blood flow like hypothermia, hypotension and peripheral edema. Interference with light transmission such as dark nail polish can even interfere

Importance of selecting correct blood pressure cuff size

ensured accurate measurements are taken

patient has just taken a drink of ice water or coffee. How long should nurse wait before taking oral temperature

The nurse should wait 15-30 mins to ensure any hot or cold beverage doesn't alter the temperature creating an inaccurate reading

How do cold fingers affect pulse oximeter readings

Can cause vasoconstriction which reduces blood flow and weakens light based pulse signals

When you obtain a vital sign reading that is way out of the norm what should you do first

have another nurse repeat the measurement to confirm your reading

Factors that affect vital signs of older adults

Temperature

Aging decreases subcutaneous fat and lowers the basal metabolic rate, impairing the body's thermoregulation. Consequently, older adults typically have lower baseline body temperatures (around 96.8°F-97.4°F), meaning a "normal" 98.6°F reading can actually signal a fever, while serious infections may manifest with confusion instead of a significant temperature spike.

Pulse Rate

Natural pacemaking cells in the Sinoatrial (SA) node decrease with age, reducing the heart's overall responsiveness to stress and exercise. Structural changes and high rates of cardiovascular medications like beta-blockers frequently lower resting heart rate (bradycardia) and cause irregular rhythms, making peripheral pulse checks less predictable without an apical assessment.

Respirations

A stiffening rib cage and loss of elastic recoil in lung tissue decrease lung compliance, forcing older adults to take shallower, slightly faster breaths to maintain oxygen levels. Additionally, blunted neural sensitivity to low oxygen or high carbon dioxide levels means older adults may fail to hyperventilate appropriately during respiratory distress.

Progressive arterial stiffening (loss of elastin) raises resistance to blood flow, driving up systolic blood pressure and leading to isolated systolic hypertension. At the same time, impaired vascular baroreceptors slow down quick blood pressure adjustments, causing sudden drops when standing (orthostatic hypotension) and increasing fall risk.

antipyretics

Drugs that reduce fever

ausculatory gap

loss of sound while taking a BP, sound will return

Bradycardia

slow heart rate (less than 60 bpm)

Capnograpghy

noninvasive; measures end tidal CO2 levels

Core Temperature

The temperature of the central part of the body (eg, the heart, lungs, and vital organs).

Eupnea

normal breathing

Dysrthymia

any heart rhythm other than normal

Febrile

fever

fever

elevated body temperature

100.4

fever of unknown origin

refers to a fever with an undetermined cause

frostbite

Occurs when the body is exposed to subnormal temperatures. Ice crystals form inside the cells and permanent circulatory and tissue damage occurs

heat exhaustion

a form of physical stress on the body caused by overheating

heatstroke

a dangerous condition in which the body loses its ability to cool itself through perspiration

nonshivering thermogenesis

Occurs primarily in neonates. Because neonates cannot shiver, a limited amount of vascular brown adipose tissue present at birth can be metabolized for heat production.

oxygen saturation

a clinical measurement of the percentage of hemoglobin that is bound with oxygen in the blood

pulse deficit

difference between the apical and radial pulse rates

pulse pressure

difference between systolic and diastolic pressure

Tachycardia

fast heart rate

Ventilation

movement of air in and out of the lungs