chapter 29 - vital signs

7/29/2019 Chapter 29 - Vital Signs

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Basal metabolic rate


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The heat produced by the body at absol

rest


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Blood pressure is reflected by the follow

Briefly explain each.

Blood volume


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The volume of blood circulating within

vascular system affects blood pressure

which normally remains constant


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Cardiac output


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Cardiac output increases as a result of an

increase in heart rate, greater heart musc

contractility, or an increase in blood volu


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Elasticity


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With reduced elasticity, there is greate

resistance to blood flow, and the system

pressure rises (systolic pressure)


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Peripheral resistance


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Peripheral resistance is the resistance to

blood flow determined by the tone of

vascular musculature and diameter of blo

vessels


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Viscosity


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Viscosity is the thickness that affects the

ease with which blood flows through bloo

vessels, determined by the hematocrit


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Briefly explain the following alterations

breathing patterns.

Apnea


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Respirations cease for several second


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breathing patterns.

Biot


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Biot respirations are abnormally shallow

two to three breaths followed by irregu

period of apnea


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breathing patterns.

Bradypnea


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Rate of breathing is regular but slow; 20 breaths/mi


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breathing patterns.

Hyperventilation


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Rate and depth of respirations increas


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breathing patterns.

Hypoventilation


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Respiratory rate is abnormally low, an

depth of ventilation is depressed


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breathing patterns.

Kussmaul


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Kussmaul respirations are abnormally d

regular and increased in rate


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breathing patterns.

SaO2


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Sa02 is the percentage of hemoglobin th

bound with oxygen in the arteries is the

percent of saturation of hemoglobin; nor

range is usually between 95% and 100%


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breathing patterns.

Tachypnea


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Rate of breathing is regular but rapid; >

breaths/min


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Category: Normal

Systolic: ?

Diastolic: ?


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Systolic:


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Category: Prehypertension

Systolic: ?

Diastolic: ?


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Systolic: 120-139

Diastolic: 80-89


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Category: Stage 1 hypertension

Systolic: ?

Diastolic: ?


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Systolic: 140-159

Diastolic: 90-99


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Category: Stage 2 hypertension

Systolic: ?

Diastolic: ?


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Systolic: >_160

Diastolic: >_100


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Conduction


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Transfer of heat from one object to anot

with direct contact


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Convection


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Transfer of heat away by air movemen


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Core temperature


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Temperature of the deep tissues


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Define auscultatory gap


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In some patients with hypertension, the

sounds usually heard over the brachialartery when the cuff pressure is high

disappear as pressure is reduced and the

reappear at a lower level. This temporarydisappearance of sound is the auscultato

gap,


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Define the following term.

Bradycardia


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Bradycardia is a slow rate (


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Dysrhythmia


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A dysrhythmia is an abnormal rhythm

including early, late or missed beats


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Pulse deficit


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Pulse deficit is an inefficient contraction

the heart that fails to transmit a pulse wa

to the peripheral site; it is the difference

between the apical and he radial pulse ra


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Tachycardia


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Tachycardia is an abnormal elevated he

rate (>100 beats/min in adults)


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Define the following terms related to

respirations.

Diffusion


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Diffusion is the movement of oxygen a

carbon dioxide between the alveoli and

red blood cells


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respirations.

Hypoxemia


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Hypoxemia is low levels of arterial 02


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respirations.

Perfusion


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Perfusion is the distribution of red bloo

cells to and from the pulmonary capillar


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respirations.

Ventilation


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Ventilation is the movement of gases in

out of the lungs


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Define the following terms.

Blood pressure


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Blood pressure is the force exerted on t

walls of an artery by the pulsing blood un

pressure from the heart


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Diastolic pressure


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Diastolic pressure occurs when the ventr

relax; the blood remaining in the arteri

exerts a minimum pressure


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Pulse pressure


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Pulse pressure is the difference betwee

systolic and diastolic pressure


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Systolic pressure


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Systolic pressure is the peak of maximu

pressure when ejection occurs


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Evaporation


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Transfer of heat energy when a liquid

changed to a gas


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Explain the differences related to febri

states in each of the following.

Children


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Children have immature temperature-control mechanisms, so their temperatur

can rise rapidly, and they are at risk for

fluid-volume deficit


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Explain the differences related to febri

states in each of the following.

Hypersensitive response to drugs


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Drug fevers are often accompanied by ot

allergy symptoms such as rash or prurit


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First aid treatment for heatstroke is:


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Move the patient to a cooler environmen

remove excess body clothing; place cool,

towels over the skin; and use fans


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Frostbite


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Occurs when the body is exposed to

subnormal temperatures


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Give an example of each type of fever

therapy.

Nonpharmacologic


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Nonpharmacologic therapy includes tepisponge baths, bathing with alcohol water

solutions, applying ice packs to the axilla

and groin sites, and cooling fans


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Give an example of each type of fever

therapy.

Pharmacologic


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Pharmacologic therapy includes non

steroidal drugs and corticosteroids


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Heat exhaustion


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Profuse diaphoreses with excess water a

electrolyte loss


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Heatstroke


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A dangerous heat emergency


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Hyperthermia


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The body's inability to promote heat los

reduce heat production


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Hypothalamus


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Controls body temperature


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Hypothermia


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Cold that overwhelms the body's ability

produce heat


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Identify at least one teaching consideratithat emphasizes health promotion for the

following vital signs.

Blood pressure

Instruct patients on normal blood pressure value

risk factors for hypertension usual lack of


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risk factors for hypertension, usual lack of

hypertension symptoms, ability of therapy to con

but not cure, and benefits of a consistently followhypertension treatment plan.

Demonstrate how to obtain blood pressure to the

patient's family caregiver using an appropriate-s

blood pressure cuff for home use at the same tim

each day, after patient has had a brief rest, and t

same position and arm each time pressure is tak


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Identify at least one teaching consideratthat emphasizes health promotion for t


Pulse

Instruct patients on risk factors for hypother

frostbite and heat stroke Demonstrate self-


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frostbite, and heat stroke. Demonstrate self

assessment of heart rate using the carotid pu

Patients taking certain prescribed cardiac

medications need to learn to assess their own

pulse rate to detect side effects of medication

Patients undergoing cardiac rehabilitation neto learn to assess their own pulse rate to

determine their response to exercise.


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Identify at least one teaching consideratithat emphasizes health promotion for the


Respirations


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Instruct patient on signs and symptoms hypoxemia.

Instruct patient on the effect of cigarette

smoking on oxygen saturation.


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Identify at least one teaching consideratthat emphasizes health promotion for t


Temperature


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Explain measures to prevent body

temperature alterations


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Identify at least two variations that ar

unique to older adults.

Blood pressure

a. Older adults often have decreased upper arm m

which requires special attention to selection of b


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q p

pressure cuff size.

b. Older adults sometimes have an increase in sypressure related to decreased vessel elasticity wh

the diastolic pressure remains the same, resultin

a wider pulse pressure.

c. Instruct older adults to change position slowly

wait after each change to avoid postural hypoten

and prevent injuries.


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Pulse

a. If it is difficult to palpate the pulse of an obese older ad

Doppler device provides a more accurate reading.

b The older adult has a decreased heart rate at rest


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b. The older adult has a decreased heart rate at rest.

c. It takes longer for the heart rate to rise in the older adu

meet sudden increased demands that result from stress, il

or excitement. Once elevated, the pulse rate of an older ad

takes longer to return to normal resting rate.

d. When assessing the apical rate of an older woman, the b

tissue is gently lifted, and the stethoscope placed at the fifintercostal space (ICS) or the lower edge of the breast.

e. Heart sounds are sometimes muffled or difficult to hear

older adults because of an increase in air space in the lung


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Respirations

a. Aging causes ossification of costal cartilage and downward slant of ri

resulting in a more rigid rib cage, which reduces chest wall expansion.

Kyphosis and scoliosis that occur in older adults also restrict chest expan


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Kyphosis and scoliosis that occur in older adults also restrict chest expan

and decrease tidal volume.

b. Older adults depend more on accessory abdominal muscles duringrespiration than on weaker thoracic muscles.

c. The respiratory system matures by the time a person reaches 20 years o

and begins to decline in healthy people after the age of 25. Despite this d

older adults are able to breathe effortlessly as long as they are healthy.

However, sudden events that require an increased demand for oxygen (e

exercise, stress, illness) create shortness of breath in the older adult.d. Identifying an acceptable pulse oximeter probe site is difficult with old

adults because of the likelihood of peripheral vascular disease, decreased

cardiac output, cold-induced vasoconstriction, and anemia.


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Temperature

a. The temperature of older adults is at the lower end of the normal temperatu

range, 36 to 36.8 C (96.8 to 98.3 F) orally and 36.6 to 37.2 C (98 to 99

rectally. Therefore temperatures considered within normal range sometimes r

fever in an older adult In an older adult fever is present when a single oral


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fever in an older adult. In an older adult fever is present when a single oral

temperature is over 37.8 C (100 F); repeated oral temperatures are over 37.

(99 F); rectal temperatures are over 37.5 C (99.5 F); or temperature has inmore than 1 C (2 F) over baseline

b. Older adults are very sensitive to slight changes in environmental temperat

because their thermoregulatory systems are not as efficient.

c. A decrease in sweat gland reactivity in the older adult results in a higher thr

for sweating at high temperatures, which leads to hyperthermia and heatstrok

d. Be especially attentive to subtle temperature changes and other manifestatifever in this population such as tachypnea, anorexia, falls, delirium, and overa

functional decline.

e. With aging loss of subcutaneous fat reduces the insulating capacity of the sk

men are especially high risk for hypothermia.


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Identify evaluative measures for tempera

alterations


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Body temperature will return to anacceptable range, other vital signs will

stabilize, and the patient will report a se

of comfort


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Identify factors that influence the charac

of respirations and the mechanism of ea

factor (8)

a. Exercise - exercise increases rate and depth to meet the body's need for additional oxygen and to rid thCO2b Acute Pain - pain alters rate and rhythm of respirations; breathing becomes shallow ; Patient inhibits


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b. Acute Pain - pain alters rate and rhythm of respirations; breathing becomes shallow ; Patient inhibitschest wall movement when pain is in area of chest or abdomenc. Anxiety - anxiety increases respiration rate and depth as a result of sympathetic stimulationd. Smoking - chronic smoking changes pulmonary airways, resulting in increased rate of respirations atnot smokinge. Body Position - A straight, erect posture promotes full chest expansion; A stooped or slumped positionventilatory movement; Lying flat prevents full chest expansionf. Medications - opioid analgesics, general anesthetics, and sedative hypnotics depress rate and depth;amphetamines and cocaine sometimes increase rate and depth; bronchodilators slow rate by causing aidilationg. Neurological Injury - injury to brainstem impairs respirator center and inhibits respiratory rate and r

h. Hemoglobin Function - decreased hemoglobin levels (anemia) reduce oxygen-carrying capacity of the which increases respiratory rate; increased altitude lowers amount of saturated hemoglobin, which incrrespiratory rate and depth; abnormal blood cell function (e.g., sickle cell disease) reduces ability of hemcary oxygen, which increases respiratory rate and depth.


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Identify four nursing diagnoses related

thermoregulation. (4)


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a. Risk for Imbalanced Body Temperatub. Hyperthermia

c. Hypothermia

d. Ineffective Thermoregulation


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Identify seven factors that may increase

decrease the pulse rate. (7)

a. Exercise

b T t


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b. Temperature

c. Emotionsd. Drugs

e. Hemorrhage

f. Postural changesg. Pulmonary conditions


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Identify some of the risk factors for

orthostatic hypotension


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Dehydrated, anemic, experienced prolon

bed rest, recent blood loss, medication


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Identify the acceptable range for respirarates for the following age groups.

Adolescents


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16 to 20


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Adults


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12 to 20


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Children


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20 to 30


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Infants


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30 to 50


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Newborns


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35 to 40


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Toddlers


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25 to 32


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Identify the factors that affect body

temperature. (7)

a. Age

b. Exercise


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c. Hormone leveld. Circadian rhythm

e. Stress

f. Environment

g. Temperature alterations (fever, hypertherm

heat stroke, heat exhaustion, hypothermia)


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Identify the following Korotkoff sound

Fifth


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The disappearance of sound (diastoli

pressure in adolescents and adults)


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First


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Clear rhythmic tapping corresponding topulse rate that gradually increases in

intensity (systolic pressure)


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Fourth


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Muffled and low-pitched as the cuff furtdeflated (diastolic pressure in infants a

children)


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Second


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Blowing or swishing sound as the cuf

deflates


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Third


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A crisper and more intense tapping


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Identify the guidelines that assist the nuwith incorporating vital sign measurem

into practice. (12)

a. The nurse may delegate the measurement of vital signs but is responsible fo

analyzing and interpreting their significance and select appropriate interventi

b. Equipment needs to be appropriate and functional

c. Equipment needs to be based on the patient's condition and characteristics


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q p p

d. Know the patient's usual range of vital signse. Know the patient's medical history

f. Control or minimize environmental factors

g. Use a systematic approach

h. Collaborate with health care providers to decide on the frequency

i. Use measurements to determine the indications for medication administrat

j. Analyze the resultsk. Verify and communicate significant changes with the patient's health care p

l. Develop a teaching plan


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Identify the measurement criteria for tfollowing pulse sites.

Apical


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Fourth to fifth intercostal space at lef

midclavicular line


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Brachial


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Groove between biceps and triceps mus

at antecubital fossa


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Carotid


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Along medial edge of sternocleidomastmuscle in neck


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Dorsalis pedis


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Along top of foot, between extensiontendons of great and first toe


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Femoral


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Below inguinal ligament, midway betwesymphysis pubis and anterior superior i

spine


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Popliteal


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Behind knee in popliteal fossa


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Posterior tibial


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Inner side of ankle, below medial malleo


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Radial


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Radial or thumb side of forearm at wri


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Temporal

l l b f h d b


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Overal temporal bone of head, above alateral to eye

d if h i i f


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Ulnar

Ul id f f i


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Ulnar side of forearm at wrist

Id if h i l bl d f


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Identify the optimal blood pressure for following ages.

1 month

8 / H


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85/54 mm Hg

Id tif th ti l bl d f


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1 year

/6 H


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95/65 mm Hg



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6 years

/6 H


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105/65 mm Hg



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10 to 13 years

110/65 H


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110/65 mm Hg

Identify the optimal blood pressure for


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14 to 17 years

119/75 mm Hg


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119/75 mm Hg



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Newborn

40 (mean) mm Hg


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40 (mean) mm Hg



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Older than 18 years


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Identify the patients who are at risk fohypothermia.

Those at risk include the very young and

very old; persons debilitated by trauma,

stroke, or diabetes; those who are

intoxicated by drugs or alcohol; patients


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intoxicated by drugs or alcohol; patientswith sepsis; and those who have inadequ

home heating and shelter. Fatigue, dark

color, malnutrition; and hypoxemia alsoincrease the risk

Identify the two common sites to assess


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Identify the two common sites to assess pulse rate, (2)

a Radial


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a. Radialb. Apical

Identify which phase of respirations is acd h h


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Identify which phase of respirations is acand which is passive.

Expirations

Passive


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Passive

Identify which phase of respirations is acd hi h i i


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Identify which phase of respirations is acand which is passive.

Inspiration

Active


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Active

List at least one advantage and one

disadvantage of each of the following


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disadvantage of each of the followingtemperature sites.

Axilla

A~

a. Safe and inexpensive

b. Used with newborns and unconscious patients

D~

a. Long measurement timeb Underestimates core temperature


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b. Underestimates core temperature

c. Requires continuous positioning by nurse

d. Measurement lags behind core temperature during rapid temperature c

e. Not recommended to detect fever in infants and young children

f. Requires exposure of thorax, which results in temperature loss, especia

newbornsg. Affected by exposure to environment, including time to place thermom




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Oral

A~a. Easily accessible - requires no position change

b. Comfortable for patient

c. Provides accurate surface temperature reading

d. Reflects rapid change in core temperature

e. Reliable route to measure temperature in patients who are intubated

D


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D~

a. Causes delay in measurement if patient recently ingested hot/cold fluid

foods, smoked, or is receiving oxygen by mask/cannula

b. Not for patients who had oral surgery, trauma, history of epilepsy, or s

chillsc. Not for infants, small children, or patients who are confused, unconsc

uncooperative

d. Risk of body fluid exposure




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Rectal

A~a. Sometimes considered to be more reliable when oral temper

cannot be obtained

D~

a. Lags behind core temperature during rapid temperature ch

b. Not for patients with diarrhea, rectal disorders, or bleedingtendencies or those ho had rectal s rger


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tendencies or those who had rectal surgery

c. Requires positioning and is often source of patient embarras

and anxiety

d. Risk of body fluid exposure

e. Requires lubricationf. Not for routine vital signs in newborns

g. Readings influenced by impacted stool




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d s d ge o e c o e o o gtemperature sites.

Skin

A~

a. Inexpensive

b. Provides continuous reading

c. Safe and noninvasive

d. Used for neonatesD


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D~

a. Measurement lags behind other sites during temperatu

changes, especially during hyperthermia

b. Adhesion impaired by diaphoresis or sweat

c. Reading affected by environmental temperature

d. Cannot ne used for patients with allergy to adhesive




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g gtemperature sites.

Temporal artery

A~a. Easy to access without position change

b. Very rapid measurement

c. No risk of injury to patient or nurse

d. Eliminates need to disrobe or be unbundled

e. Comfortable for patient


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f. Used in premature infants, newborns, and children

g. Reflects rapid change in core temperature

h. Sensor cover not required

D~a. Inaccurate with head covering or hair on forehead

b. Affected by skin moisture such as diaphoresis or sweati




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g gtemperature sites.

Tympanic

A~a. Easily accessible siteb. Minimal patient repositioning requiredc. Obtained without disturbing, waking, or repositioning patientsd. Used for patients with tachypnea without affecting breathinge. Provides accurate core reading because eardrum close to hypothalamus; sensitive to core temperaturef. Very rapid measurement (2 to 5 seconds)g. Unaffected by oral intake of food or fluids or smoking

h. Used in newborns to reduce infant handling and heat lossD~a. More variability of measurement than with other core temperature devices


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a. More variability of measurement than with other core temperature devicesb. Requires removal of hearing aids before measurementc. Requires disposable sensor cover with only one size availabled. Otitis media and cerumen impaction distorts readingse. Not used in patients who have had surgery of the ear or tympanic membranef. Does not accurately measure core temperature changed during and after exerciseg. Does not obtain continuous measurementh. Affected by ambient temperature devices such as incubators, radiant warmers, and facial fansi. When used in neonates, infants, and children under 3 years old, use care to position device correctly becanatomy of ear canal makes it difficult to positionj. Inaccuracies reported caused by incorrect positioning of handheld unit

List eight factors that influence blood(8)


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gpressure. (8)

a. Ageb. Stress

c. Ethnicity

d. Gender


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e. Daily variations

f. Medications

g. Activity and weighth. Smoking

List some of the risk factors that are linkto h pertension


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to hypertension

Family history, obesity, cigarette smokin

heavy alcohol consumption, high sodium


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sedentary lifestyle, exposure to continuou

stress, diabetics, older African American

List the acceptable pulse ranges for thfollowing.


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following.

Adolescents

60 to 90


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List the acceptable pulse ranges for thfollowing.


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following.

Adults

60 to 100


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List the acceptable pulse ranges for th

following.


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g

Infants

120 to 160


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following.


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g

Preschoolers

80 to 110


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following.


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g

School-age children

75 to 100


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following.


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Toddlers

90 to 140


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List the characteristics to identify whe

assessing the following.


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Apical pulse

When assessing the apical pulse, considrate and rhythm only


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y y

List the characteristics to identify whe

assessing the following.


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Radial pulse

When assessing the radial pulse, considrate, rhythm, strength, and equality


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, y , g , q y

Malignant hyperthermia


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Hereditary condition of uncontrolled hproduction


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p

Nonshivering thermogenesis


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Vascular brown tissue is metabolized fheat production in the neonate


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Provide examples of goals for temperatu

alterations related to the environmen

L


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Long term

Obtain appropriate clothing to wear in cweather


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Provide examples of goals for temperatu

alterations related to the environmen

Sh t t


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Short term

Regain normal range of body temperatu


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Pyrexia


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Fever


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Pyrogens


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Bacteria and viruses that elevate bodytemperature


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Radiation


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Transfer of heat from the surface of on

object to the surface of another with ou

direct contact


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direct contact

Shivering


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Involuntary body response to temperatudifferences in the body


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State the formulas for the following

conversions.

Celsius to Fahrenheit


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Celsius to Fahrenheit

Multiply the Celsius reading by 9/5 and 32 to the product


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State the formulas for the following

conversions.

Fahrenheit to Celsius


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Fahrenheit to Celsius

Subtract 32 from the Fahrenheit readinand multiple the result by 5/9


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Summarize the treatment for hypotherm


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Remove wet clothes; wrap the patient blankets


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The ability to control body temperaturdepends on: (4)


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a. The degree of temperature extreme

b. The person's ability to sense feeling

comfortablec. Thought processes or emotions

d P ' bili bili


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d. Person's mobility or ability to remove

add clothes

The nurse bathes the patient who has a f

with cool water. The nurse does this to

increase heat loss by means of:

1. Radiation2. Convection


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3. Conduction

4. Condensation

3. The transfer of heat from one object to

other without direct contact (solids, liquand gases)


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g )

The nurse is assessing a patient who she susphas the nursing diagnosis hypothermia relate

vigorous exercise in hot weather. In reviewin

data, the nurse knows that the most importan

sign of heatstroke is:1. Confusion


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2. Excess thirst

3. Hot, dry skin4. Muscle cramps

3. Victims of heat stroke do not swea


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The nurse is auscultating Mrs. McKinnon's blood pressurenurse inflates the cuff to 180mm Hg. At 156mm HG, the n

hears the onset of a tapping sound. At 130mm Hg, the sou

changes to a murmur or swishing. At 100mm Hg, the soun

momentarily becomes sharper, and at 92mm Hg, it becom

muffled. At 88mm Hg, the sound disappears. Mrs. McKinn

blood pressure is:

1 130/88mm Hg


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1. 130/88mm Hg

2. 156/88mm Hg

3. 180/92mm Hg4. 180/130mm Hg

2. 156 is the onset of the first Korotkoff

sound (systolic pressure), and 88 is the fsound that corresponds with the diastoli

pressure


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pressure

The skin plays a role in temperature

regulation by:

1. Insulating the body2. Constricting blood vessels

3 Sensing external temperature variatio


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3. Sensing external temperature variatio

4. All of the above

4. The skin regulates temperature throu

insulation of the body, vasoconstriction, temperature sensations.


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Thermoregulation


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Mechanisms that regulate the balanc

between heat lost and heat produced


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chapter 29 - vital signs

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