Chapter 26: Vital Signs Lecture Notes

This flashcard set covers the vital signs including temperature, pulse, respiration, and blood pressure, along with their normal ranges, methods of regulation, and clinical terminology based on early-level nursing lecture materials.

Vital Signs components

Temperature (T), Pulse (P), Respiration (R), Blood pressure (BP), Pain, and Pulse oximetry.

Normal Oral Temperature for adults

$35.8-37.5^{\circ}C$ or $96.4-99.5^{\circ}F$.

Normal Pulse Rate for adults

$60$ to $100$ beats/min, with an average of $80$.

Normal Respiration Rate for adults

$12$ to $20$ breaths/min.

Normal Blood Pressure for healthy adults

$<120/80\,mmHg$.

Primary Source of Heat Production

Metabolism.

Primary Source of Heat Loss

Skin.

Radiation

The diffusion or dissemination of heat by electromagnetic waves, such as heat lost through an uncovered head.

Convection

The dissemination of heat by motion between areas of unequal density.

Evaporation

The conversion of a liquid to a vapor, such as sweat on the skin.

Conduction

The transfer of heat to another object during direct contact.

Circadian rhythms

Biologic cycles that occur at 24-hour intervals and affect body temperature.

Afebrile

A state of being without fever.

Pyrexia

A state of having a fever; also known as being febrile.

Intermittent fever

Body temperature that returns to normal at least once every 24 hours.

Remittent fever

Body temperature that fluctuates a few degrees up and down but does not return to normal.

Sustained (Continuous) fever

Body temperature that remains above normal with minimal variations.

Relapsing (Recurrent) fever

Body temperature that returns to normal for one or more days with one or more episodes of fever, each lasting several days.

Cardiac sinoatrial node

The structure that regulates the pulse through the autonomic nervous system.

Parasympathetic stimulation

Nervous system activity that decreases heart rate.

Sympathetic stimulation

Nervous system activity that increases heart rate.

Pulse rate

The number of contractions over a peripheral artery in 1 minute.

Tachycardia

A rapid heart rate, characterized as one of the variations in pulse rate.

Bradycardia

A slow heart rate, characterized as one of the variations in pulse rate.

Stroke volume

The volume of blood ejected with each heartbeat.

Brachial pulse site

Pulse site located on the inside of the elbow.

Radial pulse site

Pulse site located on the wrist.

Femoral pulse site

Pulse site located in the groin.

Temporal pulse site

Pulse site located on the side of the head.

Pulse Grade 0

Absent pulse, unable to palpate.

Pulse Grade +1

Diminished pulse, weaker than expected.

Pulse Grade +2

Normal pulse; brisk and expected.

Pulse Grade 3+

Bounding pulse.

Ventilation

The movement of air in and out of the lungs, comprising inhalation and exhalation.

Diffusion (Respiration)

The exchange of oxygen and carbon dioxide between the alveoli of the lungs and circulating blood.

Perfusion (Respiration)

The exchange of oxygen and carbon dioxide between circulating blood and tissue cells.

Respiratory centers location

Located in the medulla and pons.

Primary Respiratory Stimulant

An increase in carbon dioxide.

Eupnea

Normal, unlabored respiration, typically maintaining a ratio of one respiration to four heartbeats.

Tachypnea

Increased respiratory rate, often in response to increased metabolic rate.

Bradypnea

Decreased respiratory rate, occurring in some pathologic conditions.

Apnea

Periods when no breathing occurs.

Dyspnea

Difficult or labored breathing.

Orthopnea

Changes in breathing that occur when sitting or standing.

Systolic pressure

Maximum pressure reached when the left ventricle contracts and pushes blood into the aorta.

Diastolic pressure

Lowest pressure reached when the heart rests between beats.

Pulse pressure

The difference between systolic and diastolic pressure.

Hypotension

Low blood pressure, characterized by a reading of $<90/60\,mmHg$.

Orthostatic hypotension

Postural hypotension resulting from an inadequate physiologic response to position changes when rising to an erect position.

Korotkoff sounds

The sounds listened for with a stethoscope when assessing blood pressure; the first sound represents systolic pressure.

When to asses vital

On admission

Facility policy and procedure

Change in condition

Before and after surgical or invasive procedure

Before medication that affect cardiovascular and respiratory

Core body temp

Higher than surface body temperature

Circadian rhythms

24 hours

Temperature higher

Evening ( 4pm to 8pm)

Temp lowest

Early in the am

fever and hyperthermia

Monitor temp, bp, intake and output, administrator antipyretic medication

Glass temp probe

Encourage patients to use alternative

glass probe

Not used in unconscious person, irrational person, i infants or children

Tympanic probe

Cover with probe and insert snug into ear canal to seal

Normal pulse

60-100 beats per mins

Tachycardia

Decrease cardiac filling m which decrease stroke volume and cardiac output

Tachycardia

100-180

Bradycardia

Below 60 pulse

Hypothermia

Cause bradycardia and increase inter cranial pressure

Sinus arrhythmia

Normal in children under 8

Pulse amplitude

Quality of pulse felt through vessels

Full and bounding

Pulse is forceful

Weak and thready

Pulse feeble

Dysthymia

Irregular heartbeat

Palpate pulse

Fingers

Diaphragm

High pitch sounds

Bell

Low pitch sounds; bruits and heart murmurs

Stethoscope

Listen to apical pulse

Emergency pulse

Cartoid

Stethoscope ear piece

Fit snug in ear canal,

Earpiece tips

Directed into ear canal can be turned anyway, block outside sound

Doppler

Assess pulse difficult to pulsate or auscultate

Periphery Pulses

Carotid

Radial

Brachial

Femoral

Popliteal

Posterior Tibial

Dorsalis Pedis

Asses Cartoid

One at a time prevent decrease of blood flow to brain; can cause fainting

Weak or thready peripheral pulse

Auscultate apical pulse

Infant pulse

Brachial

Apocalypse pulse

5th intercostal space on mid clavicle line

Infant apical

Use finger tips

Apical - radial pulse

Assess when other peripheral pulses are to palpate; blood isn’t reaching extremities

Apical radical pulse different

Two nurses; one count a radial and other listen to radial, measure should be the same

Pulse deficit

Difference in apical and radial pulse

Respiration

Normal 12-20 adults

Ventilation

Breathing- moving gases. In and out lungs

Inspiration

Inhalation- breathing in

Expiration

Exhale- breathing out

Diffusion

Exchange of carbon and oxygen between alveoli of lungs and circulating blood

Perfusion

exchange of blood and carbon between blood and tissues

Hyperventilating

Increase carbon and decrease blood increase rate and depth not respirations

Bradypnea

Decrease respirations; associate with increase inter-cranial pressure

Apnea

Periods of no breathe; 4-6 minutes equal death

Dyspraxia

Difficulty or labor breathing; sit in upright position

Orthopnea

Breathe easy sitting upright

Respiration

Rate, depth, rhythm

Assess respiration

Monitor arterial blood gas and use pulse oximeter

Systole( high pressure)

Contraction