Health Assessment II (Class 3)

Average Temperature

36 C to 38 C (96.8 F to 100.4 F)

Average Respirations

12-20 bpm

Average Pulse

60-100 bpm

Blood Pressure

Systolic= Less than 120

Diastolic= Less than 80

Pulse Ox (O2 sat.)

Greater than or equal to 95%.

Pain

The sixth vital sign and the only subjective vital sign.

Importance of Vital Signs

* Quick and efficient way of monitoring conditions
* Identifying problems
* Evaluating responses to intervention

Importance of a baseline

Alterations in vital signs signal a change in physiological function and the need for medical or nursing interventions (early warning signs.)

Stable Clients

When nurses can delegate vital signs to nursing assistive personnel…

When vital signs are measured

* Upon admission
* When assessing a client
* Change in condition
* Before, during or after any invasive procedures, medications administration, blood transfusions, and nursing interventions.

True

The gland that controls thermoregulation in the body is the hypothalamus.

Body temperature

Heat produced - heat loss

Heat

A by-product of metabolism.

False

True or false: higher metabolisms can decrease the additional heat produced, therefore, decreasing overall body temperature.

Core Temperature

The temperature in the deep tissues

Acceptable oral temperature ranges for healthy adults

36 C to 38 C (98.6 F to 100.4 F)

Acceptable oral temperature ranges in older adults

35 C to 36.1 C (85 F to 97 F)

Temperature sites

* Oral
* Rectal
* Axillary
* Tympanic Membrane
* Temporal Artery
* Esophageal
* Pulmonary Artery

Evaporation

Transfer of heat energy when a liquid is changed to a gas.

* Ex. Sweating while exercising.

True

True or False: 600-900 mL is lost from the skin and lungs each day.

Conduction

Transfer of heat from one object to another with direct contact.

* Ex. Ice pack

Radiation

Ex. Coming from outside into a warm room.

Convection

Transfer of heat away from the body by air movement.

* Turning on a fan.

Factors affecting body temperature

* Age
* Exercise
* Hormone level
* Circadian rhythm
* Stress
* Environment
* Temperature alterations

Highest temperatures

Occurs around 4:00 PM

Lowest temperatures

Occur around 1:00-4:00 AM.

Pyrexia

Fever

Febrile

* Temperature of 38 C (100.4) and above.
* Caused by pyrogens like bacteria or viruses.
* Can present as chills, shivers, and feeling cold.

Afebrile

When the fever breaks.

Fever purpose

The increased temperature activates the immune system, interferon, and increases the white blood cell count in the body.

Hyperthermia

An elevated body temperature resulting from the body’s inability to promote heat loss or reduce heat production. Results from an overload of the thermoregulatory mechanism.

Malignant Hyperthermia

Hereditary condition, that occurs when susceptible individuals receive certain general anesthesia medications.

Heatstroke

A body temperature of 40 C (104 F), depressed hypothalamic function, prolonged exposure to the sun. (This is a medical emergency.)

Heat Exhaustion

Caused by environmental heat exposure and presents with profuse diaphoresis resulting in fluid and electrolyte loss.

Hypothermia

Prolonged exposure to cold. Skin temperature can drop below 34 C (93.2 F)

Newborns

An age where taking an oral temperature is contraindicated.

Interventions for febrile patients

* Remove excessive clothing or linens
* Obtain cultures
* Administer fluids
* Keep them dry

F=

(9/5C) - 32

C=

(F - 32) 5/9

Pulse

Palpable bounding of blood flow noted at various point on the body. An indirect indicator of the circulatory status.

Pulse Rate

Number of pulsing sensation in 1 minute.

Most common sites used for adult pulse rate

Brachial and radial

Tachycardia

Elevated heart rate above 100 bpm.

Bradycardia

Slow heart rate below 60 bpm.

Check the apical pulse

What should you do is you detect an abnormal pulse anywhere?

Factors that influence heart rate

* Exercise
* Temperature
* Acute pain
* Emotions
* Medications
* Hemorrhage
* Postural changes
* Pulmonary conditions

A full minute

How long should you check the apical pulse?

Dysrhythmia

Abnormal or irregular heart rate (rhythm)

Devices that monitor the heart rate

ECGs, telemonitors, and halter monitors.

Strength Scale

0- Absent

1- Diminished or barely palpable

2- Normal or expected

3- Full or strong

4- Bounding

Carotid

Which artery do you never palpate at the same time?

False

True or False: A nurse can estimate the respirations.

Ventilation

The movement of gases into and out of the lungs.

Diffusion

The movement of oxygen and carbon dioxide between the alveoli and RBCs.

Perfusion

The movement of gases between RBCs and tissues.

Bradypnea

Rate of breathing is slow (

Tachypnea

Rate of breathing is rapid (>20 bpm)

Apnea

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

Hyperpnea

Respirations are labored, increased in depth, and increased in rate (greater than 20 breaths/min) (occurs normally during exercise)

Hypoventilation

Respiratory rate is abnormally low and the depth of ventilation is depressed. Hypercarbia sometimes occurs.

Hyperventilation

Rate and depth of respirations increase. Hypocarbia sometimes occurs.

Cheyne-Stokes Respiration

Respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation.

Kussmaul’s Respiration

Respirations are abnormally deep, regular, and increased in rate.

Biot’s Respiration

Respirations are abnormally shallow for two to three breaths. Followed by irregular periods of breathing.

Labored breathing

Usually involves the use of the accessory muscles of respiration.

Factors that affect the measurement of oxygen saturation

* Circulation
* Skin pigmentation (jaundice)
* Skin thickness
* Tobacco use
* Skin temp

Blood Pressure

Force exerted on the walls of an artery by pulsing blood under pressure from the heart.

Systolic Pressure

Maximum peak pressure during ventricular contraction.

Diastolic Pressure

Minimal pressure during ventricular relaxation.

Pulse Pressure

Differences between systolic and diastolic pressures.

True

True or False: Elevated cardiac output elevates BP.

Factors that affect BP

* Age
* Stress
* Ethnicity and genetics
* Gender
* Daily variation
* Medications
* Activity and weight
* Smoking

Hypertension

* More common than hypotension
* Often asymptomatic
* High blood pressure

Hypotension

* Systolic falls to 90 mmHg or below
* Dilation of arteries
* Hemorrhage
* Myocardial infarction
* Decrease of blood flow to vital organs

Orthostatic/Postural Hypotension

A form of hypotension that occurs when a patient moves from supine to standing. Can cause lightheadedness, nausea, and syncope. Common in elderly patients or those who have not been upright for some time.

Syncope

Fainting

Equipment used to measure BP

* Sphygmomanometer
* Occlusive cuff
* Release valve

Concerning BP changes when assessing orthostatic BP

* A difference of 20 for systolic pressure
* A difference of 10 for diastolic pressure

Common BP measurement errors

* Incorrectly sized cuff
* Crossed feet/knees
* Consumption of coffee or nicotine prior to assessment.