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Vital Signs. Assessment of Vital Signs. Temperature Pulse Respirations Blood Pressure The fifth vital sign Pain Oxygen Saturation. Temperature. Regulation hypothalamus Core body temperature Set point. Heat Production. Metabolism Shivering Exercise. Radiation

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assessment of vital signs
Assessment of Vital Signs
  • Temperature
  • Pulse
  • Respirations
  • Blood Pressure
  • The fifth vital sign
    • Pain
    • Oxygen Saturation
temperature
Temperature
  • Regulation
    • hypothalamus
  • Core body temperature
  • Set point
heat production
Heat Production
  • Metabolism
  • Shivering
  • Exercise
heat loss
Radiation

transfer from surface

Conduction

transfer through direct contact

Convection

transfer by air movement

Evaporation

transfer when liquid changed to a gas

Heat Loss
oral temperature
97 - 100 F (98.6)

36 - 39 C (37)

must be able to close mouth

eating or smoking, wait

Contraindications

unconscious

seizures

infants, young children

oral disease/surgery

mouth breathing

oxygen by mask

Oral Temperature
rectal temperature
Reliable

Higher than oral by 1o

Contraindications

rectal surgery

diarrhea

rectal disease

heart disease

Rectal Temperature
other methods
Other Methods
  • Axillary
    • used when oral or rectal contraindicated
    • lower than oral by 1o
  • Tympanic membrane
    • readily accessible
    • not affected by eating, smoking cerumen
elevated temperature
Elevated Temperature
  • Pyrexia
  • Hyperpyrexia
chill phase
Signs and Symptoms

shivering

blood vessels constrict

absence of sweating

Care

assessment

blankets

fluids

nourishment

Oxygen

Chill Phase
fever phase
Temp at new set point

Signs and Symptoms

flushed skin

warm skin

weak, muscle aches

drowsy, restless

Care

Comfort

Hydration

Prevent shivering

Limit physical activity

Oral hygiene

Environmental temperature control

Fever Phase
flush or crisis phase
Signs and Symptoms

profuse diaphoresis

less shivering

flushed, warm skin

Care

fluids

light clothing

hypothermia blanket

Medications

Oral hygiene

Environmental temperature control

Flush or Crisis Phase
subnormal temperature
Subnormal Temperature
  • Hypothermia
  • Chemical reactions slowed
  • Metabolic demands for oxygen decreased
assessing temperature
Assessing Temperature
  • Glass thermometers
    • oral = blue, thin bulb
    • rectal = red, blunt tip
  • Electronic
    • oral = blue
    • rectal = red
  • Temperature sensitive patches
pulse
Pulse
  • Rate
    • pulsations per minute
    • Infant normal = 80 - 180 per minute
    • Adult normal = 60 - 100 per minute
    • Slow < 60, bradycardia
    • Fast > 100, tachycardia
    • Slowest at rest, early morning
tachycardia
pain

stress

fear

anger

anxiety

exercise

decrease BP

temp

low oxygen

medications

Tachycardia
pulse rhythm
Pulse Rhythm
  • Pattern of pulsations
  • Regular
  • Irregular
    • dysrhythmia
    • arrhythmia
pulse quality or amplitude
Pulse Quality or Amplitude
  • Description of fullness of pulse
  • Ratings
    • 0 = Absent
    • +1 = thready, weak
    • +2 = normal
    • +3 = bounding
assessment sites
carotid

brachial

radial

femoral

popliteal

posterior tibial

dorsal pedis

apical

5th ICS left

use stethoscope

Assessment Sites
apical radial pulse
Apical - Radial Pulse
  • 2 nurses
  • count at same time
  • differences found with irregular pulses
respiration
Respiration
  • Movement of air in and out of lungs
  • Regulation
    • carbon dioxide levels
    • oxygen levels
  • Normal adult rate: 12 to 20 per minute
  • Infant rate 30 - 80 per minute
deviations from normal
rate:

illness, fever

acute pain

stress

exercise

altitude

body position

rate

narcotics

CNS depressants

Deviations From Normal
respiratory terms
Apnea

Dyspnea

Orthopnea

Tachypnea

Bradypnea

Cheyne - Stokes

Respiratory Terms
blood pressure
Blood Pressure
  • Force of blood against vessel walls
  • Systolic pressure
  • Diastolic pressure
  • Pulse pressure
factors to maintain bp
Factors to Maintain BP
  • Peripheral Resistance
  • Pumping action of the heart
  • Blood volume
  • Viscosity of the blood
  • Elasticity of vessel walls
factors affecting bp
Factors Affecting BP
  • Age
  • Time of day
  • Gender
  • Eating
  • Exercise
  • Emotions
  • Position
  • Activity
  • Smoking/drinking
terms
Terms
  • Hypertension
  • Hypotension
    • Orthostatic
    • Associated illness
proper measurement
Proper Measurement
  • Correct position
    • arm at heart level
      • Arm above heart level - low reading
      • Arm below heart level - high reading
  • Korotkoff Sounds
    • first sound = systolic
    • absence of sounds = diastolic
  • Auscultatory gap
proper measurement32
Proper Measurement
  • Cuff Size
    • too large - low reading
    • too small - high reading
    • Bladder width 40% of limb circumference
    • Bladder length 80% of limb circumference