Kozier Ch 29 Vital Signs

The flashcards below were created by user cswett on FreezingBlue Flashcards.

  1. When to access vital signs
    Admission to your agency or your unit.

    Any change in health status.

    Before and after invasive procedures.

    • Before particular medications i.e.
    • respiratory and cardiac meds.

    Before and after nursing interventions such as ambulating a pt.
  2. Body Temperature
    Heat Balance
    Two Types of Temperature
    • Refers to a balance between the heat produced
    • by the body and that lost by the body.

    • Heat balance-
    • refers to amount of heat being produced by
    • the organism and the amount heat being lost being equal

    Core Temperature - deep tissue of body - abdominal and pervic cavity

    Surface Temperaure - temp at skin, sub Q, and fat
  3. Heat Production (5)
    Heat Loss (3)
    1. Basal metabolic rate (BMR) - rate of energy use required to maintain essential activities (breathing)

    2. Muscular activity example: shivering -increases BMR

    • 3. Thyroxine output - increases rate of cellular metabolism
    • Chemical Thermogenesis - heat production in body through increased cellular metabolism

    4. EPI & NOR - increase rate of cellular metabolism - directly effect liver and muscle cells

    5. Fever - increases cellualr metabolic rate

    • Heat Loss:
    • 1. Radiation - transfer of heat from one object to another without touching

    2. Conduction-convection - heat transfer from one molecule to a molecule of lower temperature (convetion is heat transfer in air)

    • 3. evaporation - loss of heat through moisture in respiratory tract and mucous membranes
    • - insensible heat loss & insensible water loss
  4. Factors that affect body temp
    • 1. Age - infants - puberty very affected by temperature changes
    • Older people >75 less sub Q fat and much more affected by the environment

    2. Circadian rhythms - temp.can vary as much as one degree during the day with the highest being between 4-6pm. And lowest between 4-6 am.

    3. Exercise

    4. Hormones - progesterone on ovulation

    5. Stress - release of EPI & NOR

    6. Environment
  5. Pyrexia
    Fever - body temp above usual range
  6. Hyperyrexia
    very high fever (41oC or 105.8oF)
  7. Febrile
    client who has a fever is referred to as febrile
  8. afebrile
    client who does not have a fever
  9. Intermittent fever
    body temp alternated between periods of fever and periods of normal or subnormal temperatures
  10. Fever spike
    • temp rises to fever level rapidly and them returns to normal within a few hours
    • - often caused by bacterial blood infections
  11. Hypothermia
    lowe than 36.5oC or 96oF

    • core temp is below lower limit of normal
    • Caused by:
    • 1. Excessive heat loss
    • 2. Inadequate heat production to counteract heat loss
    • 3. impaired hypothalamic thermoregulation
  12. Normal body temp range
    (F and C)
    96.4-99.1 Fahrenheit average 98.6 F.

    35.8-37.3 Celsius average 37 C.

    Generally considered an axillary temp. is one degree lower and rectal temp. is one degree higher.
  13. Ways to Measure Temp
    • 1. Oral - wait 10 mins after eating/ drinking
    • Traditional style stays in for 5 minutes

    • 2. Rectal
    • -Pt. is placed in Sims position with leg flexed.
    • -Sheath is placed over the thermometer, water soluble lubricant is used.
    • -Inserted 1-1.5 inches into the rectum and held in place.

    • 3. Tympanic membrane -
    • Pull pinna upward and backward for an adult
  14. Pulse
    • Pulse– represents the contraction of the left
    • ventricle of the heart.

    Peripheral pulse- a pulse located away from the heart.

    Apical pulse-is a central pulse located at the apex of the heart. It is also called the point of maximal impulse (PMI).
  15. Peripheral Pulse Sites
    • Temporal
    • Carotid
    • Apical
    • Brachial
    • Radial
    • Femoral
    • Popliteal
    • Posterior/tibial
    • Dorsalis/pedis
  16. Normal Pulse by age
    • Newborn 120-160
    • Toddler 90-140
    • School Age 75-100
    • Adolescent 60-90
    • Adult 60-100
  17. Tachycardia
    • -heart rate over 100 in an adult.
    • apical pulse should be assessed
  18. Bradycardia
    • -heart rate less than 60 in an adult
    • apical pulse should be assessed
  19. Pulse rhythm
    • -pattern of beats and intervals between them
    • normal = equal time between beats

    • dysrhythmia or arrhythmia - pulse with irregular rhythem
    • irregular = radon, irrugular beats
    • regularly irregular - predictable pattern of irregular beats
  20. Pulse volume
    -also called strength or amplitude

    • normal - felt with moderate pressure and can be obilterated with greater pressure
    • full or bounding - only obliterated with difficulty
    • weak, feeble, thready - easily obliterated
  21. Things that affect the pulse
    • Age-pulse decreases with age.
    • Gender-after puberty male pulses slightly less.
    • Exercise-normally increases with exercise however athlete’s tend to have a lower pulse due increased development of heart.
    • Fever-hrt. Rate will increase due to peripheral vasodilation which occurs with increased body temp. which lowers bld. Pressure.
    • Medications-some decrease, some increase.
    • Hypovolemia-loss of bld. Increases hrt. Rate in response to decreased bld. Volume.
    • Stress-increases rate and force of heartbeat.
    • Position changes-
    • Pathology-certain diseases particularly cardiac can increase or decrease hrt. Rate.
  22. Respiration
    Two Types of Breathing
    • - the act of breathing.
    • Also called ventilation.

    • Inhalation or inspiration is the movement
    • into the lungs of air.

    • Exhalation or expiration is the movement out
    • of the lungs of air.

    • Costal or thoracic breathing-using chest muscles.
    • Women tend to be thoracic breathers.

    • Diaphragmatic (abdominal) breathing- notice
    • in the abdominal muscles due to the movement of the diaphragm. - men usually
  23. Respiratory Rates
    • Newborn 30-60
    • Toddler 24-40
    • School-Age 18-30
    • Adolescent 12-16
    • Adult 12-20
  24. Bradypnea
    • -abnormally slow respirations.
    • <12 in an adult.
  25. Tachypnea
    -abnormally fast respirations.

    >20 in an adult.
  26. Apnea
    -absence of breathing
  27. Hyperventilation
    -very deep, rapid respirations
  28. Hypoventilation
    -very shallow respirations
  29. Assessing Respirations
    • Matter of counting the number of times per
    • minute a client has a complete respiratory cycle.

    Respiratory rhythm-refers to regularity of inspiration and expiration.

    Respiratory quality-refers to depth and quality.
  30. Blood Pressure
    Arterial blood pressure is the measure of he pressure exerted by the blood as it is flowing through the arteries.

    • Systolic pressure represents the pressure exerted on the arteries with the contraction of the ventricles. It is
    • expressed as the top number in a blood pressure.

    Diastolic pressure represents the pressure exerted when the ventricles are at rest. It is the bottom number.

    • Blood pressure is measured in mmHg.
    • Blood pressure is expressed as a fraction.
  31. Pulse Pressure
    • difference between the systolic and diastolic pressures
    • Normal pulse pressure
    • is 40mmHg. May be as high as 100.

    Consistently high pulse pressures occur in arteriosclerosis.

    Low pulse pressure occurs in heart failure.
  32. Hypertension
    -blood pressure is always above normal
  33. Hypotension
    blood pressure that is constantly below normal
  34. Orthostatic hypotension
    blood pressure that falls when the client sits or stands

    a drop of 20 mmHg or more may indicate orthostatic hypotension

    Symptoms: dizziness, lightheadedness, falling
  35. Normal blood pressure ranges
    • Newborn
    • Systolic 60-90 diastolic 20-60
    • Toddler 80-112 50-80
    • School age 84-120 54-80
    • Adolescent 94-140 62-88
    • Adult 110-140 60-90
  36. Classification of Blood pressure
    Systolic Diastolic

    • Normal < 120 and < 80
    • Prehypertension 120-139 80-89
    • Stage One (hyper) 140-159 or 90-99
    • Stage Two (hyper) > 160 or > 100
  37. Factors that affect blood pressure
    • Age- pressure rises with age, peak is at onset of puberty then goes down some.
    • Exercise-increases c.o. so increases BP
    • •Stress-due to stimulation of the sympathetic nervous system. (EPI & NOR)
    • Race-african american males tend to have higher pressures.
    • •Gender-after puberty women are lower but then after menopause tend to be tend to be higher.
    • •Medications
    • Obesity
    • Diurnal variations-pressure tends to be lower in am - peaks in late afternoon or early evening
    • Disease process-any disease which affects c.o. affects bp.
  38. Assessing Blood Pressure
    • Measured with a sphygmomanometer and a stethoscope.
    • 1. Make sure cuff is proper size.
    • 2. Take blood pressure without clothing on the limb to be used.
    • 3. Have client sitting or supine with arm slightly flexed at the level of the heart.
    • 4. Legs should not be crossed.
    • 5. Palpate brachial pulse at the antecubital
    • level.
  39. Reasons to not do a Brachial Blood Presure
    • Burns or trauma.
    • Injury or disease.
    • Cast or bandage.
    • Surgical removal of axilla
    • IV infusing in the limb.
    • Arteriovenous fistula for renal dialysis.
  40. Procedure for assessing Blood Pressure
    • 1. Place cuff 1 inch above the level of the brachial pulsation. Fit snuggly but not too tightly.
    • 2. Sphygmomanometer should be eye level.
    • 3. Inflate cuff while palpating the brachial pulse.
    • 4.Release pressure all the way and wait 1-2 minutes.
    • 5. Position stethoscope over the artery, pump up cuff to 30 mmHg over palpated number.
    • 6. Release cuff 2-3 mmHg per sec. and note first sound and last sound.
  41. Pain
    Now considered to be the “fifth vital sign”.

    • Generally measured on a numerical scale from
    • 1-10.

    Assessed prn and with vital signs
  42. Oxygen Saturation
    • Measured with pulse oximeter.
    • Noninvasive method of measuring arterial blood oxygen saturation.
    • Can detect hypoxemia before clinical signs are evident.
    • Normal oxygen saturation (SaO2) is 95%-100%.
    • SaO2 < 70% is life threatening
  43. Factors that effect Pulse Oximetry
    Hemoglobin-if hemoglobin is completely saturated reading will appear normal.

    Circulation-if client has impaired circulation monitor will be unable to read.

    Activity-such as shivering or movement.

    Carbon monoxide poisoning-monitor is unable to tell the difference between carbon monoxide and oxygen saturation
Card Set:
Kozier Ch 29 Vital Signs
2011-09-23 02:18:49
Kozier Vital signs

PP notes from Kozier Ch 29 & Weber Ch 7
Show Answers: