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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.
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
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
- increases cellualr metabolic rate
- Heat Loss:
- 1. Radiation - transfer of heat from one object to another without touching
- 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
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.
- progesterone on ovulation
- release of EPI & NOR
Fever - body temp above usual range
very high fever (41oC or 105.8oF)
client who has a fever is referred to as febrile
client who does not have a fever
body temp alternated between periods of fever and periods of normal or subnormal temperatures
- temp rises to fever level rapidly and them returns to normal within a few hours
- - often caused by bacterial blood infections
lowe than 36.5o
C or 96o
- 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
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.
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
- 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).
Peripheral Pulse Sites
Normal Pulse by age
- Newborn 120-160
- Toddler 90-140
- School Age 75-100
- Adolescent 60-90
- Adult 60-100
- -heart rate over 100 in an adult.
- apical pulse should be assessed
- -heart rate less than 60 in an adult
- apical pulse should be assessed
- -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
-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
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.
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
- Newborn 30-60
- Toddler 24-40
- School-Age 18-30
- Adolescent 12-16
- Adult 12-20
- -abnormally slow respirations.
- <12 in an adult.
-abnormally fast respirations.
>20 in an adult.
-absence of breathing
-very deep, rapid respirations
-very shallow respirations
- Matter of counting the number of times per
- minute a client has a complete respiratory cycle.
-refers to regularity of inspiration and expiration.
-refers to depth and quality.
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.
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.
- 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.
-blood pressure is always above normal
blood pressure that is constantly below normal
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
Normal blood pressure ranges
- 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
Classification of Blood pressure
- Normal < 120 and < 80
- Prehypertension 120-139 80-89
- Stage One (hyper) 140-159 or 90-99
- Stage Two (hyper) > 160 or > 100
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.
- •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.
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
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.
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.
Now considered to be the “fifth vital sign”.
- Generally measured on a numerical scale from
Assessed prn and with vital signs
- 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
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