many facilities have began using a fifth vital sign which is...
pain level or comfort level
your assessment of vital signs enables you to...
identify nursing diagnoses, to implement planned interventions, and to evaluate success when vital signs have returned to acceptable values
whether and how frequently vital signs are measured depends on...
your judgment of the need, the patient's condition and physician orders
what are vital signs charted on?
graphic flow sheets
the body strives to maintain a temerature of...
98.6 F (37 C)
regulates body temperature/ located in the brain, forming the floor and part of the lateral wall of the third ventricle/ helps maintain a balance between heat lost and heat produced by body
two categories of body temperature are...
core temperature & surface temperature
temperature of the deep tissues of the body
the temperature of the skin
above-normal body temperature
above-normal body temperature
above-normal body temperature
factors affecting body temperature
age/ excercise/ hormonal influences/ diurnal (daily) variations/ stress/ environment/ ingestion of hot & cold liquids/ smoking
signs & symptoms of elevated body temperature
thirst/ anorexia/ flushed, warm skin/ irritability/ glassy eyes or photophobia (sensitivity to light)/ headache/ elevated pulse & respiratory rates/ restlessness or excessive sleepiness/ increased perspiration/ disorientation, progessing to convulsions in infants & children
remains elevated consistently and fluctuate very little
rise and fall; for example, temp. is normal or subnormal in the morning and spikes in the afternoon
similar to intermittent fevers except the temp. does not return to normal at all until the pt becomes well
abnormally low body temp.
sites for temperature measurement
oral/ rectal/ axilla/ tympanic/ temporal artery
an instrument that is placed against the pt's chest or back to hear heart and lung sounds
to listen for sounds within the body to evaluate the condition of heart, lungs, pleura, intestines, or other organs or to detect fetal heart tones
a rhythmic beating or vibrating movement; in the body it signifies the regular, recurrent expansion and contraction of an artery produced by the waves of pressure that are caused by the ejection of blood from the left ventricle of the heart as it contracts
normal adult pulse rate
between 60 and 100 beats per minute; approximate average being 80
abnormally fast pulse rate; faster than 100 beats per minute
pulse rate slower than 60 beats per minute
potential causes of tachycardia
shock, hemorrhage leading to hypovolemia (an abnormally low circulating blood volume), exercise, fever, medication or substance abuse, and acute pain
unrelieved severe pain/ some drugs (beta blockers)/ resting in a supine position/ cardiac condition called heart block
any disturbance or abnormality in a normal rhythmic pattern, specifically, irregularity in the normal rhythm of the heart
refers to apex of the heart
represents the actual beating of the heart/ used when taking the pulse rate of an infant
a difference between the radial and apical pulse rates
the taking in of oxygen, its utilization in the tissues, and the giving off of carbon dioxide; the act of breathing, i.e. inhaling & exhaling
refers to the exchange of gas at the tissue level caused by the process of cellular oxidation, as well as the gas exchange that occurs in the alveoli of the lungs
breathing movements of the pt that you can observe
cycle of external respirations
1: inspiration-inhaling air with oxygen into the lungs; 2: expiration- exhaling air with carbon dioxide out of the lungs
rate of respiration is controlled by the...
medulla oblongata in the brain
rapid respiratory rate
a slow respiratory rate ( below 10 per minute)
factors influencing respiration
disease or illness/ stress/ fever/ age/ sex/ body position/ medications/ exercise/ acute pain/ smoking/ brainstem injury/ hemoglobin function
breathing with difficulty
abnormal pattern of respiation characterized by alternating periods of apnea and deep, rapid breathing
when the rate of ventilation exceeds normal metabolic requirements for exchange of respiratory gases, such as during emotional trauma/ volume and depth of respirations increase
occurs when the rate of ventilation entering the lungs is insufficient for metabolic needs/ respiratory rate is below normal and depth of ventilation is depressed/ ex: after open cholecystectomy is performed, when deep breathing results in discomfort
best time to assess respirations
when counting a radial or an apical pulse
the pressure exerted by the circulating volume of blood on the arterial walls, the veins, and the chambers of the heart
blood pressure is measured in...
millimeters of mercury (mm Hg)
systolic pressure is the higher number and represents the ventricles contracting, forcing blood into the aorta and the pulmonary arteries/ indicated by the first sound heard on auscultation
lower number of the bp reading, represents the pressure within the artery between beats, that when blood enters the relaxed chambers from the systemic circulation and the lungs
difference between systolic and diastolic readings (a reading of 120/80 mm Hg reveals a pulse pressure of 40)
occurs when the elevated pressure is sustained above 140/90 mm Hg
values of 120-139/80-89 mm Hg
risk factors for hypertension
family history of hypertension/ obesity/ smoking/ heavy alcohol consumption/ elevated blood cholestrol level/ continued exposure to stress
below normal blood pressure
a drop of 25 mm Hg in systolic pressure and a drop of 10 mm Hg in diastolic pressure when a person moves from a lying to a sitting or from a sitting to a standing position/ occurs when a person rises too quickly, usually from a supine position & frequently feels lightheaded and unstable
a device for measuring the arterial blood pressure
first sounds heard while taking BP using sphygmomanometer and stethoscope