V/S Taylor Fundamentals, Nursing 1010

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V/S Taylor Fundamentals, Nursing 1010
2013-09-16 13:00:43
Nursing 1010 Vital Signs Temperature Pulse Respiration Blood Pressure Taylor Fundamentals

Vital Signs, Taylor Fundamentals
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  1. Vital Signs
    Temperature, Pulse, Respiration, and Blood Pressure (abbreviated as T, P, R, BP). Pain, often as the fifth V/S. (Regulated by homeostasis and falling within a certain normal range, and a change in V/S might indicate a change in health.)
  2. Core body temperature vs. surface body temperature
    Core body temperature is high than surface body temperature, and is normally maintained within a range of 36 degrees Celsius (97 degrees Farenheit) to 37.5 degrees Celsius (99.5 degrees Farenheit). Core body temperature is lowest in morning and highest in the late afternoon. And it's regulated in the hypothalamus. Core temperature is measured by nurses at tympanic (ear) or rectal sites, but they may be measured in the esophagus, pulmonary artery, or bladder by invasive monitoring devices. Surface body temperatures are measured at oral (sublingual, under tongue), axillary, and skin surface sites.
  3. Name temperature rising mechanisms the hypothalamus initates
    Increased body metabolism (sympathetic neurotransmitters--epinephrine and norepinephrine--and hormones) is the primary one, shivering (muscle tremors), piloerection ("goosebumps", reduces the size of the surface of the surface to minimize heat loss), exercise (increase heat production through muscle movements), and vasoconstriction.
  4. Name temperature lowering mechanisms the hypothalamus initates
    Skin is primary source of heat loss. Circulating blood brings heat to surface of skin, where small connections called arteriovenous shunts may remain open to allow heat to dissipate to the skin and then to the external environment (or close to retain heat). The sympathetic NS controls the shunts. Other heat losses occur in the form of sweat, through warming and humidifying of inspired air, and through elimination of urine and feces. Heat is transferred to the external environment through the physical processes of radiation, convection, evaporation, and conduction.
  5. Hyperthermia
    Differs from fever in that the hypothalamic set point is not changed, but in situations of extreme heat exposure or excessive heat production (e.g., during strenuous exercise), the mechanisms that control body temperature are ineffective.
  6. Neurogenic fever
    The result of damage to the hypothalamus from pathologies such as intracranial trauma, intracranial bleeding, or increased intracranial pressure. This type of fever does not respond to antipyreticn (fever-reducing) medications.
  7. Fever (pyrexia)
    Is an increase above normal (considered to be 37 degrees Celsius or 98.6 degrees Farenheit) in body temperature. Person with a fever is said to be febrile.
  8. Fever of unknown origin (FUO)
    A fever of 38.3 degrees Celsius (101 degrees Farenheit) or higher that lasts 3 weeks or longer without an identified cause.
  9. Pyrogens
    Microorganisms or substances that cause fever.
  10. Hyperpyrexia
    High fever, usually above 41 degrees Celsius (105.8 degrees Farenheit).
  11. Intermittent (type of fever)
    The body temperature alternates regularly between a period of fever and period of normal or subnormal temperature.
  12. Remittent (type of fever)
    The body temperature fluctuates several degrees more than 2 degrees Celsius (3.6 degrees Farenheit) above normal but does not reach normal between fluctuations.
  13. Constant (type of fever)
    The body temperature remains consistently elevated and fluctuates less than 2 degrees Celsius (3.6 degrees Farenheit).
  14. Relapsing (type of fever)
    The body temperature returns to normal for at least a day, but then the fever recurs.
  15. Crisis (type of fever)
    The fever returns to normal suddenly.
  16. Lysis (type of fever)
    The fever turns to normal gradually.
  17. Radiation
    The diffusion/dissemination of heat by electromagnetic waves. (e.g. The body gives off waves of heat from uncovered surfaces.) (Heat radiating off of you)
  18. Convection
    The dissemination of heat by motion between areas of unequal density. (e.g. An oscillating fan blows currents of cool air across the surface of a warm body.) (Fan blows off body heat)
  19. Evaporation
    The conversion of a liquid to a vapor. (e.g. Body fluid  in the form of perspiration and insensible loss is vaporized from the skin.) (Body sweat)
  20. Conduction
    The transfer of heat to another object during direct contact. (e.g. The body transfers heat to an ice pack, causing the ice to melt.)
  21. Hypothermia
    Low body temperature. (may cause serious illness or death, especially below 34 degrees Celsius or 93.2 degrees Farenheit) (when one is exposed to extreme cold w/o adequate protective clothing)
  22. Hyperthermia
    High body temperature. (may cause serious illness or death) (if one is exposed to extremes of heat for long periods of time)
  23. S/S of fever
    Pts. with fever may experience: loss of appetite; H/A; hot, dry skin; flushed face; thirst; muscle aches; fatigue; respiration increases; and pulse rate increases. Young children with high fevers may experience seizures, and older adults may experience confusion and delirium. Fluid, electrolyte, and acid-base imbalances are potential complications.
  24. Afebrile
    Without fever. 98.6 degrees Farenheit (37 degrees Celsius)
  25. When is an tympanic membrane temp contraindicated?
    Should not be used for pts who have drainage from the ear/scars on the tympanic membrane.
  26. When is an oral temp contraindicated?
    Oral temp should not be taken in ppl with diseases of the oral cavity and in those who have had surgery of the nose/mouth. Also should not be assessed in pts receiving oxygen by mask, because the time it takes to assess a reading is likely to result in a serious drop in the pt's blood oxygen lvl.
  27. When is a rectal temp contraindicated?
    Should not be used in newborns, children with diarrhea, and in pts who have undergone rectal surgery or have a disease of the rectum. Because the insertion of the thermometer into the rectum can slow the HR by stimulating the vagus nerve, assessing a rectal temp for pts with heart disease or after cardiac surgery may not be allowed in some institutions. In addition, it's contraindicated in pts who are neuropenic (have low WBC counts, such as leukemia) and in pts who have certain neurologic disorders (e.g., spinal cord injuries).
  28. Examples of Nursing Diagnoses for Altered Body Temperature
    • - Hyperthermia (r/t streptococcal upper respiratory infection) (r/t exposure to environmental heat w/o adequate cooling) (r/t surgery w/general anesthesia)
    • - Hypothermia (r/t exposure to below freezing environmental temperature w/o adequate clothing)
    • - Risk for imbalanced body temperature (r/t age (92 years) and head injury causing loss of consciousness)
    • - Ineffective themoregulation (r/t premature infant delivered at 30 weeks gestation)
  29. Example of fever interventions and outcomes (NIC/NOC)
    • Interventions:
    • - monitor temp as freq as appropriate
    • - monitor BP, P, and R as appropriate
    • - monitor I/O
    • - monitor for seizure activity
    • - administer antipyretic med as appropriate
    • - administer IV fluids as appropriate
    • - apply ice bag covered w/a towel to groin and axilla

    • Outcomes:
    • - V/S
    • - Hydration
    • - Thermoregulation
    • - Risk control: Hyperthermia
  30. Pulse
    Wave produced in the wall of an artery with each beat of the heart. Is regulated by the autonomic NS through the sinoatrial (SA) node (the pacemaker) of the heart. Parasympathetic stimulation of the SA node via the vagus nerve decreases the heart rate, and sympathetic stimulation of the SA node increases the heart rate and force of contraction.
  31. Peripheral Pulse
    A throbbing sensation that can be palpated over a peripheral artery, such as the radial artery, or the carotid artery. May be felt wherever an artery passes over a solid structure, such as a bone or cartilage.
  32. Apical pulse
    May be auscultated over the apex of the heart as the heart beats. (Assess if peripheral pulse is difficult to assess accurately because it's irregular, weak, or very rapid.) (May also be assessed when giving meds that alter HR and rhythm.) The contractions of the heart can bed heard in the space between the 5th and 6th ribs about 8cm (3in) to the left of the median line and slightly below the nipple.) (Apical pulse of an infant can easily be palpated with the fingertips as well as being auscultated.)
  33. Stroke Volume (SV)
    The quantity of blood forced out of the left ventricle with each contraction.
  34. Cardiac Output (CO)
    The amount of blood pumped per minute, and averages from 3.5 L/min to 8 L/min in a healthy adult, and is determined by this formula: Cardiac Output = Stroke Volume x Heart Rate. (Thus, the cardiac output of an adult with a stroke volume of 70 mL and a heart rate of 70 beats/min is a 4.9 L/min.) CO increases during physical activity, and decreases during sleep. It also varies depending on body size and metabolic needs.
  35. Pulse rate
    Number of pulsations felt over a peripheral artery or heard over the apex of the heart in 1 minute. This rate normally corresponds to the same rate at which the heart is beating. Normal pulse rate for adolescents and adults range from 60 to 100 beats/min. The pulse rate increases/decreases in response to a variety of physiologic mechanisms. It also might be altered by activity, meds., emotions, pain, heat and cold, and disease processes.
  36. Difference between parasympathetic stimulation and sympathetic stimulation on heart rate
    The pulse is regulated by the autonomic NS through the sinoatrial (SA) node (the pacemaker) of the heart. Parasympathetic stimulation of the SA node via the vagus nerve decreases HR, and sympathetic stimulation of the SA node increases HR and force of contraction.
  37. Tachycardia
    A rapid rate. (As the heart rate increases, cardiac output increases. However, a rapid rate decreases cardiac filling time, which, in turn, decreases stroke volume and cardiac output.) An adult has tachycardia when the pulse is 100 to 180 beats/min.
  38. List some factors contributing to tachycardia
    • - A decrease in BP, like blood loss, when the heart's compensatory mechanisms attempt to meet the need for increased CO
    • - An elevated temp
    • - Any condition resulting in poor oxygenated blood (e.g. chronic pulmonary disease/anemia)
    • - Exercise
    • - Prolonged application of heat
    • - Pain
    • - Strong emotions, like fear, anger, anxiety, and surprise
    • - Some meds (e.g., epinephrine [Adrealin])
  39. Bradycardia
    Slow pulse rate, below 60 beats/min in an adult. Is normally slower during sleep, in men, and in people who are thin. Slows during hypothermia (metabolic processes decrease). With aging, pulse tends to become slower. Some meds. (The nurse should immediately report bradycardia associated w/ difficulty breathing, changes in lvl of conciousness, decreased BP, ECG changes and angina. Emergency treatment consists of administering atropine IV to block vagal simulation and to restore normal HR.)
  40. Sinus bradycardia
    Results when the sinoartial (SA) node (the pacemaker) generates a slower-than-normal impulse rate. This type of bradycardia occurs at times when metabolic needs are decreased (e.g., during sleep, in hypothermia, in trained athletics at rest); from certain meds., such as beta blockers; from vagal stimulation (e.g., from bearing down to have a bowel movement), during suctioning of respiratory secretions, with severe pain, and in increased intracranial pressure and myocardial infaction.
  41. Pulse amplitute
    Describes the quality of the pulse in terms of its fullness and reflects the strength of left ventricular contraction. It's assessed by the feel of the blood flow through the vessel. The amplitude of each pulse beat is normally strong at all areas where an artery can be palpated. It may be described and documented as full and bounding when it's forceful (4+), or weak (2+) and thready (1+) when it's feeble. Normal pulse is numbered as 3+, and an absent pulse is 0.
  42. Pulse rhythm
    The pattern of the pulsations and the pauses between them.
  43. Dysrhythmia
    An irregular pattern of heartbeats. (Must be reported immediately.)
  44. Acoustical Stethoscope
    Most common type used, has an amplifying mechanism connected to earpieces by tubing.
  45. Diaphragm
    For high frequency sounds, for respiratory sounds.
  46. Bell
    For low frequency sounds
  47. How can pulse be assessed?
    By palpating peripheral arteries or by auscultating the apical pulse with a stethoscope.
  48. Doppler ultrasound stethoscope
    Used to assess pulses that are difficult to palpate/auscultate. Device has an earpiece/headset connected to an audio unit with an ultrasound transducer.
  49. Name the common peripheral arterial sites you can palpate
    Temporal, Carotid (used during emergency assessments, and lightly palpate only one side), Brachial (used most often for infants), Radial (assessed most often in children and adults), Femoral, Popliteal, Posterior tibial, Dorsalis pedis. (Circulation to the legs and feet is assessed at the femoral, popliteal, posterior tibial, or dorsalis pedis sites).
  50. Apical-Radial Pulse Rate
    Counting the pulse at the apex of the heart and the radial pulse simultaneously.
  51. Pulse deficit
    A difference between the apical and radial pulse rates. Indicates that all of the heartbeats art not reaching the peripheral arteries or are too weak to be palpated.
  52. Example of Nursing Diagnoses for Alterations in Pulse
    • -Decreased Cardiac Output (r/t history of congestive heart failure and dysrhythmias) (r/t traumatic injury with extensive blood loss)
    • - Ineffective Peripheral Tissue Perfussion (r/t history of peripheral vascular disease with decreased popliteal pulses)
    • - Deficient Fluid Volume (r/t exposure to high environmental temperature, increased age, and tachycardia)
    • - Acute Pain (r/t first postoperative day following major surgery, crying, and tachycardia)
  53. Respiration
    (Involves ventilation, diffusion, and perfusion.) Gas exchange between the atmospheric air in the alveoli and blood in the capillaries.
  54. Ventilation (or breathing)
    Movement of gases in and out of the lungs
  55. Inspiration (or inhalation)
    Act of breathing in
  56. Expiration (or exhalation)
    Act of breathing out
  57. Diffusion
    The exchange of oxygen and carbon dioxide between the alveoli of the lungs and the circulating blood.
  58. Perfusion
    The exchange of oxygen and carbon dioxide between the circulating blood and tissue cells.
  59. Physiology of respirations
    Rate and depth of breathing can change in response to tissue demands. These changes are brought about by the inhibition/stimulation of the respiratory muscles by the respiratory centers in the medulla and pons. Activation of the respiratory centers occurs via impulses from chemoreceptors located in the aortic arch and carotid arteries, via stretch and irritant receptors in the lungs, and via recptors in the muscles and joints. An increase in carbon dioxide is the most powerful respiratory stimulant, causing an increase in respiratory depth and rate. The cerebral cortex of the brain allows voluntary control of breathing, such as when singing or playing a musical instrument. Rate and depth of inhalation and exhalation are normally smooth, effortless, and w/o conscious effort. However, factors ranging from environmental changes to pathophysiologic alterations in various body systems may result in increases/decrease in respiratory rate and depth.
  60. Different Factors Affecting Respiratory Rate, Depth, and Movements
    • - Age: Respiratory rate decreases as you get older, 30-60 breaths/min in a newborn to 12-20 breaths/min in an adult.
    • - Gender: In males, respiratory movements are mainly diaphragmatic. In women, there's greater intercostal muscle movement.
    • - Exercise: increase rate and depth
    • - Acid-base balance: Alterations in acid-base balance (especially acidosis) commonly result in increased rate and depth of respirations (hyperventilation).
    • - Brain lesions: Lesions of the brain (such as hemorrhage/tumors) or brainstem can cause a change in both the depth and rate of respirations, most commonly mainfested as Cheyne-Stokes respirations.
    • - Increased altitude: As an adaptation to high altitudes, healthy people may exhibit Cheyne-Stokes respirations, especially when asleep. High altitudes also increase respiratory rate and depth prior to adaptation by increasing hemoglobin levels.
    • - Respiratory diseases: Any alteration in the normal respiratory structures may result in changes in respiratory rate, depth, and patterns, most often manifested as difficult breathing, using accessory muscles of respiration (such as the intercostal muscles), and increased rate. The depth may be shallower. Smoking can alter the pulmonary airways, resulting in an increase in respiratory rate at rest.
    • - Anemia: Which is a decrease in oxygen carrying hemoglobin, may result in an increased rate of respirations.
    • - Anxiety: Can cause sighing type respirations (increased depth) and increased rate.
    • - Medications: Such as narcotics, sedatives, and general anesthetics slow respiratory rate and depth. Other drugs, including ampetamines and cocaine, may increase rate and depth.
    • - Acute pain: Increases respiratory rate but may decrease respiratory depth.
  61. Eupnea
    Normal respiration. (Under normal conditions, healthy adults breathe about 12 to 20 times each minute; infants and young children breathe more rapidly. The relationship of 1 respiration to 4 heartbeats is fairly consistent in healthy people.)
  62. Tachypnea
    Increased respiratory rate. >24 breaths/min, shallow. May occur in response to an increased metabolic rate when a person as a fever. Cells require more oxygen at this time and produce more carbon dioxide that must be removed. The rate increases as much as 4 breaths/min with every 1 degree Farenheit that the temp rises above normal. Any condition causing an increase in carbon dioxide and a decrease in oxygen in the blood, for example, respiratory disases such as acute pneumonia/chronic obstructive respiratory disease, also tends to increase rate and depth of respirations.
  63. Bradypnea
    Decrease in respiratory rate. <10 breaths/min, regular. Occurs in some pathological conditions. An increase in intracranial pressure depresses the respiratory center, resulting in irregular or shallow breathing, slow breathing, or both. Certain drugs, such as narcotics (e.g., morphine, meperidine [Demerol]), depresses the respiratory rate.
  64. Apnea
    Periods during which there is no breathing. If it lasts longer than 4 to 6 minutes, brain damage and death might occur.
  65. Dyspnea (and orthopnea)
    Difficult/labored breathing. A dyspneic pt. usually has rapid, shallow respirations and appears anxious. Dyspneic ppl can often breathe more easily in an upright position, a condition known as orthopnea. While sitting/standing, gravity lowers organs in the abdominal cavity away from the diaphragm. This gives the lungs more room for expansion within the ches, allowing the intake of more air with each breath.
  66. Cheyne-Stokes respirations
    Alternating periods of deep, rapid breathing followed by periods of apnea, regular
  67. Biot's respirations
    Varying depth and rate of breathing, followed by periods of apnea; irregular
  68. Pulse oximeter
    Device to determine oxygenation of blood.
  69. Hyperventilation
    Increased rate and depth
  70. Hypoventilation
    Decreased rate and depth; irregular
  71. Example of Nursing Diagnoses for Altered Respirations
    • - Ineffective Breathing Pattern (r/t anxiety about diagnostic procedure for possible malignancy) (r/t increased intracranial pressure following head injury) (r/t infant delivered by cesarean delivery at 28 weeks gestation)
    • - Impaired Gas Exchange (r/t presence of acute respiratory distress following smoke inhalation)
    • - Risk for Activity Intolerance (r/t history of smoking two packs of cigarettes a day for 20 years)
  72. Blood Pressure
    The force of the moving blood against arterial walls.