Kozier Ch 29 Vital Signs

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cswett
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98466
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Kozier Ch 29 Vital Signs
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2011-09-22 22:18:49
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Kozier Vital signs
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PP notes from Kozier Ch 29 & Weber Ch 7
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  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
    Hyperthermia
    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

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