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2014-01-08 21:29:41
Unit Vital Signs

Unit 1 Vital Sign
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  1. Name the 5 Vital signs
    • Temp
    • Pulse
    • Respiration
    • Blood Pressure
    • Pain
  2. What do vital sign provide
    A good baseline of a patients overall condition and clues to changes in conditions
  3. What should be known as part of the assessment process
    Age variable normal values and physiologic regulators
  4. When should vital signs be assessed
    • Admission
    • Change in Symptoms, AMS, and LOC
    • Surgery, Procedures, Therapy and Treatment
    • Certain Medications
  5. Why are vital signs assessed
    To establish a baseline
  6. This is a by product of normal body metabolism
  7. What happens if a body is invaded by pathogens
    The body raises the temperature to elevate the basal metabolic rate in a effort to destroy pathogens
  8. When is body temperature the lowest/highest
    • Lowest in the morning bc the body has been at rest
    • Highest in afternoon/evening bc activity increases temperature
  9. What hormone affects body heat production
  10. Cause of increased thyroid hormone
    Causes a increase in metabolic rate and increased temp.
  11. Causes of decreased levels of thyroid hormone
    Decrease in metabolic rate and decreases body temp
  12. Name other hormones that affect body heat production
    • Epinephrine
    • Norepinephrine
    • Testosterone
  13. Name ways to increase heat production
    • Shivering
    • Huddled body position
    • Piloerection (goosebumps)
    • Placing something on head holds heat in
  14. What percentage of body heat is lost through the head
  15. What does the hypothalamus do
    Acts as a thermostat to control body temp
  16. What happens when you have a decrease in body temp
    Peripheral vasoconstriction and shivering
  17. What happens in an increase in body temp
    Vasodilatation and diaphoresis (sweating)
  18. Name the way heat loss occurs with exposure to the enviroment
    • Radiation
    • Conduction
    • Convection
    • Evaporation
  19. Temp is above the normal range, called a fever or pyrexia
  20. Lowering of the temp of the entire body
  21. Name the problems of temp regulation
    • Hyperthermia
    • Hypothermia
  22. 97.5 to 99.5
    Normal body temp
  23. Temp measurements vary depending on
    Site used
  24. Differences in rectal and axillary temp than oral
    • Rectal 1 degree higher
    • Axillary 1 degree lower
  25. This measurement approximates core body temps
  26. Steps for taking oral temps
    • Nothing to eat or drink 20 mins prior
    • Place cover over tip (remove cover before reading a glass thermometer
    • Place tip of thermometer in sublingual pocket (under tongue)
    • Tongue down, mouth and lips closed
  27. Steps for rectal temp
    • Provide privacy
    • Use gloves
    • Cover thermometer
    • Lubricate tip
    • Insert 1 to 2 inches, do not force
    • Hold in place 3-5 min
    • Wipe thermometer from stem to bulb
    • Wipe off buttocks
    • Correctly dispose of hazard materials
  28. Contraindications of use of rectal temp
    • Combative patients
    • Hemorrhage
    • Diseases or surgery of rectum or colon
    • (Cancer, diarrhea, cardiac disease)
  29. Steps for axillary temp
    • Place thermometer w/sleeve in center of armpit
    • Patient holds arm tightly against chest
    • Hold for 3-8 mins or until signals complete
    • Remove and dispose of sleeve, wipe clean
  30. Name the types of thermometers
    • Glass
    • Electronic
    • Disposable
  31. Rarely used anymore, and cannot be used in inconscious, confused, or agitated patients
    Glass Themometer
  32. Name the types of electronic thermometers
    • Tympanic- ear
    • Temporal- non invasive, good for kids and combative patients
  33. What substance is used in glass thermometers now
  34. How to read a glass thermometer
    • Hold horizontally
    • Rotate towards you until you can see alloy
    • End of the alloy on lined scale is the temp
  35. Long lines on glass thermometer represent and short lines represent
    • Each degree
    • Two tenths of a degree
  36. These register body temp in 5 seconds to 1 min
    Electronic thermometer
  37. What makes a tympanic thermometer less accurate
    • User error
    • Because it must be placed correctly in the ear canal to get a accurate reading
  38. How to use a tympanic thermometer in a child under 3
    In an child older than 3/adult
    When do you not use a tympanic
    • Under 3- pull ear up and back
    • 3 and up- pull ear down and back
    • Ear infection, drainage, wax buildup
  39. Provide the least accurate readings of temps
    Disposable Thermometer
  40. Factors that affect temp measurements
    • Time of day (circadian rhythm)
    • Environmental temp
    • Age of patient- temp decreases with age
    • Physical exercise
    • Menstrual cycle/pregnancy
    • Emotional stress
    • Disease conditions
    • Drugs
    • Eating, drinking, breathing
    • Mental status
  41. Fever is also called
  42. Pyrexia occurs
    when normal regulation mechanisms cannot keep up with heat produced by the body

    Temp is higher than 100.2
  43. Diaphoresis
    Excessive sweating produced to cool the body
  44. Name the alterations in temps
    • Afebrile-Normal
    • Sustained-Stays above 100.2
    • Remittent-Fluctuates above normal
    • Intermittent-Fluctuates btween normal/above
    • Relapsing-times w/out temp, then returns
  45. Alterations in body temp
    • Heat Exhaustion
    • Heat Stroke
  46. Describe Heat Exhaustion
    Signs and Symptoms
    Excessive heat exposure & dehydration

    • pale, dizzy, weak, low grade temp (<102)
    • dehydration, fainting, some sweating
  47. Signs and Symptoms of Heat Stroke
    • Medical ER- call 911
    • Flushed warm skin, no sweat, high temp of 106, seizures, signs of stroke (weakness in one side)
  48. Clinical signs of fever
    • Prodromal
    • Onset
    • Stationary
    • Resolution
  49. The phase of fever that has aches and lethargy
  50. The phase of fever that has shivers, pale, vital sign changes
  51. The phase of fever that feels hot, flushed skin, glassy eyed, thirst, loss of appetite
  52. The phase of fever where sweating occurs and risk of dehydration
  53. Signs of dehydration
    sticky, dry mucous membranes, no sweating, decrease urine output, tenting of skin

    Check the elderly for dehydration on the sterum
  54. Nursing interventions to reduce fever
    • increase fluid intake
    • lower room temps
    • increase air circulation
    • remove extra clothes or covers
    • decrease activity
    • antipyretics (acetaminophen)
  55. Body temps lower than 94 F
  56. At risk for hypothermia
    • infants
    • patients in OR
    • Elderly exposed to cold for long periods
    • People exposed to extreme cold (hikers)
    • Exposure to cold water immersion
    • Confused Patient
  57. Causes of hypothermia
    • Excessive heat loss
    • Inadequate heat production
    • Impaired control mechanism
  58. Signs of hypothermia
    • Slow vitals
    • Irregular heart rate
    • Pale, cool, puffy skin
    • Decreased muscle strength, sensation
    • Decreased urine output
    • Frostbite
    • Confusion
  59. Nursing interventions for hypothermia
    • Warm environment
    • Dry, layered clothing
    • Cover head
    • Limbs close to body
    • Warming pads/blankets
    • Warm fluids/IV if needed
    • Monitor vitals for increase in temp
    • Monitor skin for changes
  60. How is a pulse produced
    Cardiac contractions causing a pressure wave against the walls of arteries

    Each contraction propels 60-70 mL of blood into aorta (stroke volume)

    5 liters/min cardiac output average adult
  61. What initiates cardiac contractions
    Sinoatrial Node
  62. How are pulses normally found
    by Palpation or Auscultation
  63. What determines the strength of a pulse
    Force of cardiac contraction and circulating volume
  64. What affects the rate of a pulse
    • fever
    • pain
    • hypoxia
    • anxiety
    • exercise
    • cardiac disease
  65. Average pulse rate in an adult
    72 bpm
  66. Pulse greater than 100 bpm
  67. Pulse less than 60 bpm
  68. How do you determine the difference between the apical and radial pulse
    apical - radial = deficit
  69. How do you note pulse characteristics
    Rate, Rhythm and Volume
  70. Dysrhythmia
    A period of normal rhythms broken by periods of irregular or skipped beats
  71. Strengths of a Pulse
    • Weak and Reg (even beats/poor force)
    • Strong and Reg (even beats/moderate force)
    • Full and Bounding (even beats/strong force)
    • Feeble (barely palpable)
    • Irregular (strong/weak beats within 1 min)
    • Thready (weak/irregular)
    • Absent (no palpable or heard)
  72. Pulse point
    • Temporal-front of ear
    • Carotid-side of neck
    • Brachial-bend of arm
    • Femoral-groin
    • Apical-apex of heart
    • Popliteal-behind knee
    • Pedal-back/inside of ankle
    • Dorsalis Pedis-top of foot
  73. Factors that affect pulse rate
    • Age
    • Body build and Size
    • Blood Pressure
    • Drugs
    • Emotions
    • Blood Loss
    • Exercise
    • Increased body temp
    • Pain
    • Hypoxia
  74. Factors affecting a pulse
    • Condition of Heart and Vessels
    • Age
    • Gender
    • Exercise/Activity
  75. Plaque buildup in arteries
  76. Hardening of arteries
  77. Too much volume
  78. Too little volume
  79. Symptoms of Shock
    • Rapid/weak pulse
    • Rapid respirations
    • Falling blood pressure
    • Shortness of breath
  80. What medications will affect pulse
    • Antiarrythmics (Digoxin, Lanoxin)
    • If pulse < 60 do not give medication
    • Thyroid & Respiratory meds
    • Caffeine, Nicotine
    • Street drugs
  81. Assessing Circulation if unable to find a pulse
    • Go to distal pulse site
    • Capillary refill
    • Skin temp
    • Color of skin
    • Doppler Ultrasound
  82. Pulse located a 5th intercostal space, left mid-clavicular line
    Makes Lub-Dub sound
    Most reliable indicator of heart rate
    Always use for children under 3
    Apical Pulse
  83. Pulse deficit
    Difference in Apical and Radial rates
  84. Controlled by the pons and medulla in the brainstem
    Involuntary autonomic function
  85. How are respirations triggered
    By increased/decreased levels of CO2 or by serum hydrogen ion concentration
  86. Organs of respiration
    • Nose
    • Pharynx
    • Larynx
    • Trachea
    • Bronchi
    • Lungs
  87. How are oxygen, carbon dioxide, and hydrogen levels maintained
    Oxygen and Carbon dioxide are diffused across capillaries in the lungs
  88. Movement of air in and out of lungs
  89. Inspiration
    Lungs fill with air

    Pushes air out of lungs
  90. Normal resp. rates in adult
    In infants
    • 14-20/min
    • Sleeping may drop to 10/min

  91. Cause of increased respiratory rate
    increased levels of carbon dioxide/lower levels of oxygen in blood
  92. Respiratory Patterns
    • Eupnea-normal
    • Dyspnea-difficult and labored
    • Tachypnea-rapid breathing
    • Bradypnea-slow breathing
  93. Breathing/Respiratory Patterns
    • Hypoventilation-shallow/diminished, ineffective
    • Apnea-Absence or periods of absence
    • Orthopnea-difficult breathing lying down (CHF)
    • Hyperventilation-increase in rate and depth
    • Cheyne-Stokes-difficult/labored followed by apnea
    • Kussmaul's-Increase rate/depth with panting/grunting exhales
    • Biot's-Shallow for 2-3 breaths variable apnea
  94. Signs/Symptoms of Ineffective Respirations
    • Movement chest
    • Flaring of nostrils
    • Retractions (chest)
    • Position
    • Pain
    • Cyanosis
  95. Factors affecting respirations
    • Exercise
    • Stress
    • Environment/Temp
    • Body Position
    • Meds
    • Pathology/Disease/Injury
  96. Breath Sounds
    • Normal-breezy
    • Rubs-sand paper sound
    • Cough-productive/nonproductive
  97. Respiratory Patterns (Noisy)
    • Crackles-abnormal nonmusical sound during inspiration
    • Rhonchi-dry, rattling caused by partial obstruction
    • Stertor-Snoring when unable to cough up secretions from trachea or bronchi
    • Stridor-Crowing sound caused by obstruction of upper air passages (croup, laryngitis)
    • Wheeze- sound of air forced past a partial obstruction
  98. How to assess respirations
    Observe chest, abdomen, shoulders
  99. How to document respirations
    • Rate per minute(30 x 2)
    • Rhythm-(Reg/Irregular)
    • Depth/location-(Labored/Shallow, Abdominal/Chest)
    • Character- (unlabored/difficulty)
    • Associated S/S- (AMS, pain)
    • Normal/Abnormal sounds
  100. Where to measure oxygen saturation in blood
    • Toe,
    • Earlobe
    • Fingers
    • Bridge of nose
  101. Machine that measures oxygen in blood
    Pulse Oximeter
  102. Normal Pulse Oxygen Saturation Levels
  103. Factors that affect Oxygen Sat levels
    • Hemoglobin
    • Impaired Circulation
    • Activity/Movement- (shivering)
    • Edema
    • Broken Skin
    • Artificial Nail/Nail Polish
  104. In this poisoning, a pulse Ox cannot differentiate btween hemoglobin saturated with oxygen or carbon monoxide

    Reading will be high and inaccurate
    Carbon Monoxide Poisoning
  105. The pressure exerted on arterial walls by pumping action of the heart
    Blood Pressure
  106. Affected by condition of vascular bed, circulating blood volume, and cardiac output
    Blood Pressure
  107. In blood pressure, this pressure is exerted on the arterial wall during cardiac contraction
    Systolic Pressure
  108. In blood pressure, this pressure is exerted on the arterial wall between contractions. (Resting)
    Diastolic Pressure
  109. Blood Pressure is affected by
    cardiac output
  110. Blood pressure rises with increases and decreases in
    circulating blood volume
  111. What happens to blood pressure is blood volume decreases beyond the vascular beds ability to compensate

    It will decrease

    • Dehydration
    • Hemorrhage
  112. What alters blood pressure to compensate for changes in circulating volume
    Vasoconstriction & Vasodilatation
  113. Average adult blood pressure
    100/70 to 130/85
  114. Pulse Pressure
    Difference between Systolic & Diastolic
  115. Non-Modifiable factors affecting blood pressure
    • Age
    • Race
    • Gender
    • Heredity
  116. Modifiable factors affecting blood pressure
    • Good lifestyle changes
    • Circadian Rhythms (night shift workers)
    • Exercise
  117. Other factors affecting blood pressure
    • Pathology/Disease/Pain
    • Cardiac Output/Stroke Volume
    • Heart/Vessel Condition
    • Stress
    • Smoking
    • Meds
    • Alcohol/Street drugs
    • Caffeine
  118. Volume of blood that fills the heart
  119. Peripheral resistance, force against which heart pushes in vessels
  120. Thickness
  121. Increases BP
  122. Decreases BP
  123. Elevated cholesterol
  124. Blood pressure consistently above normal range
    • Hypertension
    • Systolic above 140
    • Diastolic above 90
  125. Prolonged hypertension can cause damage to
    brain, kidneys, heart, and retinas
  126. Stage 1 Hypertension range
    Stage 2 Hypertension range
    Prehypertension range
    • greater than 140/90
    • greater than 160/100
    • greater than 120/80 consistent
  127. Low blood pressure


    Safety Issue

    Less than 90/60

    Synscope (passing out)
  128. Ways to Assess Blood Pressure
    BP Cuff- Syhygmomanometer

    • Aneroid-gauge with needle on dial (used with stethoscope)
    • Electronic
    • Invasive/Direct
  129. Sites for blood pressure
    • Arms - most common over Brachial pulse
    • Leg/Thigh (systolic usually higher)
  130. When should you not take a blood pressure in arm
    • Flowing IV
    • Fractures/Cast
    • Dialysis Shunt
    • Burns
    • Mastectomy
  131. Recognized by the Joint Commission as the 5th vital sign
  132. Assessment of pain includes
    • Location
    • Intensity
    • Character
    • Frequency
    • Duration
  133. Vital Sign changes that occur in elderly
    • Temp- heat loss leads to hypothermia
    • Lower metabolic rate- hypothermia
    • Respiratory rates- could vary
    • BP- rises with hardening of arteries
  134. Recording Temperature Measurements
    Record in even numbers (2)
  135. ACE Inhibitors
    Angiotension Converting Enzyme Inhibitor
  136. Common ACE Inhibitor drugs

    Main Side Effect...
    • Capoten (captopril)
    • Lotensin (benazepril)
    • Vasotec (enalapril)
    • Zestril (lisinopril)
    • Monopril (fosinopril)
    • Accupril (quinapril)

    Chronic dry cough
  137. ACE drug interactions
    Antacids, NSAIDS interfere with effectiveness of drug, Digoxin increase of dix toxicity, OTC cold remedies/antihistamines
  138. ACE food interactions
    Avoid large amounts of caffeine and salt
  139. Nursing Considerations for ACE Inhibitors
    Report cough, shortness of breath, swelling of face & mouth, chest pain, need hydration with water
  140. Anti Arrhythmics
    Control cardiac irregularities, CHF, angina, MI, cardiomyopathy
  141. Hold anti arrhythmics when
    • pulse less than 60 or greater than 100-120
    • Certain abnormal rhythms- Vent Fibrilation
    • Heart Block
    • Sick Sinus Syndrome
  142. Side effects of Anti-arrhythmics
    • Hypotension
    • Headache
    • Weakness
    • Syncope
    • Confusion
  143. Drug and Food Interaction of Anti-arrhythmics
    • Herbs and supplements
    • Thyroid meds
    • alcohol
    • ephedrin
    • Licorice with Digoxin
    • Grapefruit Juice with Verapamil
  144. Nursing Considerations with Anti-arrhythmics
    • Check Apical pulse before administering
    • Must be on cardiac monitor for IV  use
    • Hold for pulse less than 60/greater than120
    • Do not double up if dose is missed
    • Lab monitoring for toxicity
    • Wear Medic ID