Vital Signs

Temperature:

  • Meausres the balance between heat body loses and heat body produces

  • Heat can be lost through perspiration, respiration, excretion, and slow metabolism

  • Heat can be produced by metabolism and muscle and gland activity

Homeostasis:

  • Stable condition inside the body’s organs, tissues, and systems

  • abnormal temperature affects homeostasis, which affects health of patient

Methods of taking temp:

  • Tympanic(ear) Core temp

  • Oral (mouth) average is 98.6 and 37C

  • Rectal(butt) Most accurate average is 99.6 and 37C

  • Axillary or groin(armpit) exteranl=less accurate average is 97.6 and 36.4C

  • Temporal forehead

Factors that affect temp:

  • Increase: illness, infection, exercise, excitment, air temp

  • Decrease: temp, starvation, sleep, decreased, muscle activity, disease, air temp

  • other factors include mouth breathing, metabolism, and time of day

Abnormal temps:

  • hypothermia: rectal below 95F Death below 93F

  • Fever: rectal temp above 101 but less than 104F

  • Hyperthermia: rectal above 104F very dangerous over 106F

Types of thermometers:

  • Glass

  • electronic

  • tympanic

  • temporal

Temporal Artery Thermometer:

  • Temporal artery (TA) thermometers are alos known as temporal thermometers

  • temperature taken over the temporal aretery

  • quick, accurate and non invasive

Blood Pressure:

  • Force of blood against artery walls when the heart contracts and relaxes

  • systolic indicates when left ventricle controcts to push blood into arteries

  • Diastolic indicates pressure on artery walls when left ventricle relaxes

  • Measured in millimeters of mercury (mm HG)

Normal Blood Pressure:

  • average is systolic is less than 120

  • average diastolic les than 80

  • normal pulse pressure (systolic- diastolic) 40

Blood Pressure Guidlines:

  • Normals less than 120/80 mmHG

  • Elevated: Systolic between 120-129 mmHG and diastolic less than 80 mmHg

  • Stage 1 Hypertension: Sytsolic at least 140 mmHG or Diastolic at least 90mmHg

  • Stage 2 Hypertension: Systolica t least 140 mmHg and or diastolic as least 90 mmHg

  • Hypertensive Crisis: Systolic over 180mmHg and or a diastolic over 120mmHg

  • Hypertension: High blood pressure

Hypertension:

  • Risk Factors: Diet, exercise, heredity, stress, drug abuse and smoking

  • effects: can result in other disorders such as heart attack, storke, kidney disease or organ failure

  • Hypertensive Crisis: requires immediate medical attention

Hypotension:

  • Reading below 100/60

  • Causes: rest, sleep, shock, dperessants, blood loss, fasting

  • orthostatic hypotension results from a quick change in position.

Blood pressure factors:

  • Elasticity: The ability of the arteries to return to normal size after being stretched by each pulsation of blood.

  • volume of the blood in the arteries.

  • different patient positions: Laying down, sitting, etc

Sphygmomanometer:

  • used to measure blood pressure

  • older versions contained mercury

  • aneroid versions use air but still measure in millimeters of mercury

Digital Blood Pressure monitors:

  • Easier and less time consuming

  • does not require stethoscope

  • sometimes a manual cuff with an analog gauge may be preferable

Pulse:

  • Pressure of blood pushin against wall of artery as the heart contracts

  • several pulse sites on the body

  • abnormalities can signal disease

Assessing Pulse:

  • Rate: number of beats per min

  • Rhythm: Pattern of beats

  • Volume: Character, or strength of beats

Pulse sites:

  • detected where superficial artery has a bone behind it

  • sites often names according to nearby bones or structures

  • most common sites are radial and brachial

Palpation and Auscultation:

  • Palpation: Examination by applying slight pressure to a pulse point with fingertips

  • Auscultation:Examination by listenin usually with a stethoscope

Pulse rate:

  • Increase Pulse: Exercise, stimulants, excitement, fever, shock

  • Decrease Pulse: Sleep, depressants, heart disease, coma

  • abnormally high or low pulse can signal disease such as bradycardia and tachycardia

Pulse Rhythm:

  • Regular: Equal spacing of beats

  • Irregular: Unequal spacing of beats

  • Arrhythmia is abnormal rhythm

Radial Pulse:

  • Normally apical and radial pulse are the same

  • diffence between apical and radial pulse rates: subtract radial pulse from apical pulse

  • Occurs if heart is too weak to produce pulse or the heart is beating too fast to fill with blood

Pulse Volume:

  • Describes as strong, weak, thready, or bounding

  • often recorded using 0(absent) 1(thready) 2(strong) 3(bounding)

Apical Pulse:

  • Apical pulse is a patients heartbeat

  • stethoscpe is placed over apex of the heart

  • used for infants, small children and patients with certain illnesses

Respirations:

  • Rate of breathing

  • counted as one inhalation and one exhalation

  • assesed by rate, character, and rhythm

Repiration Rate:

  • Number of respirations per minute

  • Adults:14-18 Breaths per minute or 12-20

  • Children: 16-27

  • infants: 30-50

Respiration Character:

  • Described as normal, shallow, deep, or labored

  • Normal is effortless, quiet, and regular

  • also: difficult, moist, stertorous(similar to snoring)

Respiration Rhythm:

  • Described as regular or irregular

  • Regular has equal spacing of breaths

  • Irregular has unequal spacing of breaths

Abnormal Respiration:

  • Dyspnea: difficult or labored breathing

  • Apnea: Temporary absence of respirations

  • Tachypnea: Over 25 breaths per min

  • Bradypnea: Under 10 breaths per min

  • Orthopnea: respiration possibly only when sitting or standing erect

  • Cheyne- Stokes: Short, shallow breaths followed by deeper, frequent breaths, followed by apnea for 10-20 sec

  • Rales: Noisy

  • Wheezing: High-Pitched whistle during exhalation and difficulty breathing

  • Cyanosis: skin, nail beds, and lips turn blue

Assessing Respiration:

  • Measured right after pulse

  • patient should believe that pulse is still being taken

  • Patient may alter breathng patttern if aware respiration is being assessed

Pulmonary function tests:

  • Used to measure breathing and how well lungs are functioning

  • ex: spirometry and plethysmorgaphy