Vital Signs

What are the main vital signs?

temperature, pulse, respiration, blood pressure

What do vital signs reflect?

General health status

Body temperature

-Reflects the balance between heat production and loss

-Measured in degrees

-Regulated by neurological and cardiovascular me

-Core and surface temperatures

The primary source of heat in the body is

metabolism, with heat produced as a byproduct of metabolic activities that generate energy for cellular functions

Thyroid hormone increases...

metabolism and heat production

Heat production results from

increases in basal metabolic rate, muscle activity, thyroxine output, testosterone, and sympathetic stimulation

Heat loss occurs through

The skin mainly through:

-Conduction

-Convection

-Evaporation

-Radiation

Factors that affect body temperature

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

Who has more fluctuations in body temperatures? Men or women?

Women

Afebrile

Absence of fever

Pyrexia or febrile

fever

When a set temperature in the body is increased, what does the hypothalamus initiate?

Shivering and vasoconstriction

Hyperthermia

Abnormally high body temperature but not because of a change in set point (essentially a heat stroke)

Neurogenic fever

damage to hypothalamus; origin in CNS; high fever resistant to antipyretic treatment; no sweating

FUO

Fever of unknown origin. Fever lasting 3 weeks or longer with no identified cause

Physical effects of fever

-loss of appetite

-increased respirations and/or pulse

-seizures

-confusion and delirium

-fever blisters

-fluid, electrolyte, and acid-base imbalances

Methods to reduce fever

-antipyretics (aka fever-reducing drugs)

-cool sponge baths, cool packs, cooling blankets, increased oral fluid intake, rest, dry clothing and linens

Decreased body temperature

Aka hypothermia. Death can occur if temperature falls below 34 degrees Celsius or 93 degrees Fahrenheit. Chemical reactions are slowed, resulting in decreased metabolic demands for oxygen

Peripheral pulse

Felt over a peripheral artery

Apical pulse

-Pulse taken over the apex of the heart

-Left, mid-clavicular, 5th intercostal space for a full minute

-Stethoscope to skin

What regulates a pulse

autonomic nervous system through the SA node

How does the parasympathetic nervous system affect the pulse?

By decreasing heart rate

How does the sympathetic nervous system affect the pulse?

By increasing the heart rate and force of contraction

What affects the pulse

-Presence of hemorrhage

-Elevated temperature

-Anemia

-Chronic pulmonary disease

-Exercise

-Pain

-Prolonged exposure to heat

-Strong emotions

-Medications

-Sleep

-Gender and age

-Hypothermia

Normal range of pulse rate

60-100 bpm

Normal range for temperature

36-38 degrees c or 97-99 degrees f

T or F. Pulse rate is normally slower in men, thin people, and during sleep

True

Tachycardia

Increased pulse rate over 100 beats per minute

Bradycardia

Decreased pulse rate below 60 beats per minute

Pulse amplitude and quality

describes the quality in terms of its fullness and reflects the strength of ventricular contraction

Pulse rhythm

The pattern between pulsations and the pauses between them

Dysrhythmia

Abnormal heart rhythm

When should the pulse be taken for a full minute?

For pediatric or cardiac patients or if the pulse is irregular or over 90

How should infants have their pulse measured?

Nipple line with a stethoscope

How should adults have their pulse measured?

Radial or apical pulse

Apical pulse only for...

Giving meds

What is pulse deficit

difference between the apical and radial pulse rates

What may be needed if a patient's pulse is difficult to palpate?

A doppler device

Pulse volume 0

absent, unable to detect

Pulse volume 1

weak, thready. barely felt and can be easily obliterated by pressing with the fingers

Pulse volume 2

normal. easily palpated. not weak or bounding

Pulse volume 3

bounding or full, difficult to obliterate with fingertips

Bilateral equality

useful in determining whether the blood flow to a body part is adequate. Assess by comparing pulses on both sides of the body. Some pulses can be stronger on one side than the other

What could cause an absent or weak pulse

compromised circulation in an extremity

How long should a nurse wait after a patient smoked, ate, drank liquids, or chewed gum to take oral temperature?

20-30 minutes

Types of thermometers placement locations

tympanic, rectal, axillary, temporal, sublingual

Where should an axillary thermometer be placed?

Middle of the axilla, close to the axillary blood vessels

What position must the patient be in for taking rectal temperature?

Sims position (essentially the superman sleeping pose)

Rectal temperature

-Have for 3-5 minutes

-Red probe

-Insert 1 to 1.5 inches

-Do not force past resistance to prevent injuring the rectal muscles

Tympanic temperature taking for adults and children

-For adults: pull the pinna up and back

-For children: pull the pinna down and back

What inhibits or stimulates the respiratory muscles

Respiratory centers in the medulla and pons

What factors affect respirations?

Respiratory or cardiac diseases, alterations in fluid/electrolyte/acid-base balances, medications, trauma, pain, infection, emotions

Eupnea

normal, relaxed, non-labored breathing. 12 to 20 breaths per minute

Dyspnea

Difficult and labored breathing, shortness of breath. Patient can have rapid, shallow breaths

Tachypnea

increased or rapid breathing; greater than 24 breaths per minute

Bradypnea

slow and shallow breathing; less than 10 breaths per minute

Apnea

absence of breathing

Hyperventilation

An increase in the rate and depth of breathing that leads to excessive loss of carbon dioxide from the blood.

Cheyne-Stokes respiration

dyspnea followed by a short period of apnea

Kussmaul's respiration

Increased rate and depth with panting and long exhalation

Biot's respirations

shallow for two to three breaths with a period of variable apnea

Respiration assessment

-Rate; breaths per minute

-Depth; deep or shallow

-Rhythm; regular or shallow

-Inspection; observing or listening

Pulse oximeter

Measures oxygen saturation by determining the percent of hemoglobin that is bound to oxygen using infrared and red light

What factors affect blood pressure?

age, circardian rhythm, gender, food intake, exercise, weight, emotional state, stress, caffeine, smoking, body position, race, medications

Normal BP

Systolic

Prehypertension

Systolic: 120-139

Diastolic: 80-89

Stage 1 hypertension

Systolic: 140-159

Diastolic: 90-99

Stage 2 hypertension

Systolic: >160

Diastolic: >100

Hypotension

low blood pressure; systolic 90-115 mmHg

Hypotension causes

vasodilation of the arterioles, ineffective heart, loss of blood volume

Hypotension signs that must be reported immediately

hypotension, tachycardia, pallor, sweating, and confusion

Place the bottom edge of the blood pressure cuff approximately..

1 inch above the antecubital space

If blood pressure measurements must be retaken, how long should a nurse wait?

2 minutes

To recheck a systolic reading, wait ______ before taking another measurement

1 to 3 minutes

FLACC scale is used for

(2 months - 7 years)

Nonverbal pain scale

Facial expression, activity, guarding, respiratory

Proxy reports (parent, caregiver)

Vital signs

Visual inspection - injury, swelling, redness

FACES scale is used for

Non-English Speakers or Ages (3-8)

Numeric rating scale

patient chooses level of pain for each site 0-10; most adults