Flashcards in Quiz 2 Vital signs Deck (69):
Pain Assessment (5th vital Sign)
Oxygen saturation via Pulse Oximetry
reflects the balance between heat the body produces and loses
is the measurement of heart rate and rhythm. Pulse corresponds to the bounding of blood flowing through various points in the circulatory system
is the body’s mechanism for exchanging oxygen and carbon dioxide between the atmosphere and the cells of the body, which is accomplished through breathing and recorded as the number of breaths per minute.
Blood pressure (BP)
reflects the force the blood exerts against the walls of the arteries during contraction (systole) and relaxation (diastole) of the heart
Guidelines for Measuring Vital Signs
-Ensure that equipment is functional and is appropriate for the size and age of the patient.
-Appropriately perform or delegate measurement.
-Be able to understand and interpret values.
-Know the patient’s usual range of vital signs.
-Determine the patient’s medical history, therapies, and prescribed medications.
-Control or minimize environmental factors that affect vital signs
-Use an organized, systematic approach when taking vital signs.
-Accurately document findings.
-Analyze the results of vital sign measurement.
Instruct the patient or family caregiver in vital sign assessment and the significance of findings.
Interpretation of Vital signs
Evaluate the reading (parameters)
Correlate w/ client’s medical history, therapies, prescribed medications, & symptoms
Consider environmental factors that may affect vital signs
When should vital signs be taken
Based on the provider’s (MD, DO, NP, PA) order set
Established minimum frequency
Acceptable temperature range
96.8° F to 100.4° F or 36° C to 38° C
Oral, rectal, axillary, tympanic membrane, temporal artery, esophageal, pulmonary artery, and urinary bladder
controls the physiological and behavioral mechanisms that regulate heat loss and heat production.assists in maintaining homeostatsis
CONTROLS HEAT LOSS
Controls heat production
Heat Loss Mechanism
sweating and vasodilation-widening or relaxation of blood vessel walls and inhibition of heat production. Redistributes blood to surface vessels to promote heat loss
Heat Conservation Mechanism
vasoconstriction- narrowing or tightening of blood vessel walls to reduce blood flow to the skin and extremities. Compensatory heat production is stimulated through voluntary muscle contraction and muscle shivering
Factors Affecting Body Temperature
Age(lower in older adults), exercise(up), hormonal levels,
Circadian rhythm(low 0100-0400, high 1800), environment, Temperature alterations, emotional stress, infection
Excessive heat production
Excessive heat loss
Minimal heat production
Minimal heat loss
Combination of these alterations
fever- important defense mechanism
-Pyrogens-such as bacteria and viruses elevate body temperature.
-Febrile/afebrile-Febrile means having fever; afebrile means not having fever
-Fever of unknown origin (FUO)-a fever with an undetermined cause
-occurs because the body is unable to keep pace with a heat production mechanism. This can occur because the hypothalamus is unable to keep the “set point.”
-Mild temperature elevations as high as 39° C (102.2° F) enhance the immune system of the body. But also increases oxygen demand and can stress the cardiac and respiratory systems.
. During a febrile episode, white blood cell production is stimulated.
elevated body temperature resulting from the body’s inability to promote heat loss or reduce heat production.
a hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs.
body temperature of 40° C (104° F) or more] occurs from prolonged exposure to the sun or high environmental temperatures
Signs and symptoms of heatstroke
giddiness, confusion, delirium, excessive thirst, nausea, muscle cramps, visual disturbances, elevated body temperature, increased heart rate, and lower blood pressure.
occurs when profuse diaphoresis(perspiration) results in water and electrolyte loss
risks of fever in cardiac and respiratory patients
A prolonged fever weakens a patient by exhausting energy stores. Increased metabolism requires additional oxygen. If the body cannot meet the demand for additional oxygen, cellular hypoxia (inadequate oxygen) occurs. Myocardial hypoxia produces angina (chest pain). Cerebral hypoxia produces confusion. Interventions during a fever include oxygen therapy.
body temperature is constant and is continuously above 38° C (100.4° F) with little fluctuation
temperature returns to an acceptable value at least once in 24 hours
febrile episodes and periods of normothermia are often longer than 24 hours
occurs with exposure to cold. The core body temperature drops, and the body is unable to compensate
The patient suffers uncontrolled shivering, loss of memory, depression, poor judgment, becomes cyanotic
occurs when the body is exposed to subnormal temperatures. Ice crystals form inside the cell, and permanent circulatory and tissue damage occurs
What do you do to change the patient’s temperature?
-Change environment, Loosen or add clothes/blankets, warm slowly to allow body to regulate. In frostbite, interventions include gradual warming measures, analgesia, and protection of the injured tissue.
-Change activity level, bathe with certain temperature water, cool compresses, rehydrate.
Guidelines for taking Temperature
-No cold or hot liquids/foods for 15-30 minutes with oral route
-Mouth breathing/hyperventilating will affect oral
-Wear gloves in clients w/ mouth lesions and all rectal temps
-Check for ear wax or hearing aids in tympanic route
Removing wet clothes, replacing them with dry ones, and wrapping patients in blankets are key nursing interventions. In emergencies away from a health care setting, have the patient lie under blankets next to a warm person. A conscious patient benefits from drinking hot liquids such as soup and avoiding alcohol and caffeinated fluids. It is helpful to keep the head covered, to place the patient near a fire or in a warm room, or to place heating pads next to areas of the body (head and neck) that lose heat the quickest.
The volume of blood pumped by the heart during 1 minute
-the product of heart rate (HR) and stroke volume (SV) of the ventricle. A change in HR or SV does not always change the output of the heart or the amount of blood in the arteries.
-An abnormally slow, rapid, or irregular pulse alters cardiac output
60-100 beats per min
an abnormally elevated HR
slow rate—below 60 beats/min in adults
Factors that affect pulse
Fever or excess temperature
Acute pain and anxiety
Unrelieved chronic pain
Movement of gases into and out of the lung.
Movement of oxygen and carbon monoxide between alveoli and red blood cells.
Distribution of red blood cells to and from the pulmonary capillaries.
a low blood level of oxygen.
-helps to control ventilation in patients with chronic lung disease. Because low levels of arterial O2 provide the stimulus that allows a patient to breathe
Ventilation of normal rate and depth
During inspiration the diaphragm
during expiration the diaphragm
Respiratory control center
medulla oblongta; monitors the levels of oxygen & carbon dioxide in blood. CO2 especially, generates the patients respiratory drive to breathe
oxygen saturation of blood
The percentage of hemoglobin that is bound with oxygen in the arteries is the percent of saturation of hemoglobin, or SaO2. This value should be between 95% and 100%.
12-20 per min
Rate of breathing is regular but abnormally slow (less than 12 breaths/min).
Rate of breathing is regular but abnormally rapid (greater than 20 breaths/min)
Respirations are labored, increased in depth, and increased in rate (greater than 20 breaths/min) (occurs normally during exercise).
Respirations cease for several seconds. Persistent cessation results in respiratory arrest
Rate and depth of respirations increase
Respiratory rate is abnormally low, and depth of ventilation is depressed. Hypercarbia sometimes occurs.
Respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. Respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth. The pattern reverses; breathing slows and becomes shallow, climaxing in apnea before respiration resumes.
Respirations are abnormally deep, regular, and increased in rate
Respirations are abnormally shallow for two to three breaths followed by an irregular period of apnea
subjective sensation of difficult of uncomfortable breathing “I feel short of breath
low 02 saturation
Maintain their airway!
Use your resources—RT--!!!
Oxygenate them (MD order)!
Factors affecting BP
Diastolic readings greater than 90 mm Hg and systolic readings greater than 140 mm Hg define hypertension, asympotmatic
Systolic <90 mm Hg
causes pallor, skin mottling, clamminess, confusion, increased heart rate, and decreased urine output.
Orthostatic or postural hypotension
occurs when a normotensive person develops symptoms and low blood pressure when rising to an upright position. Patients who are dehydrated, anemic, or on prolonged bed rest and those who have had recent blood loss are at risk for orthostatic hypotension
Potential Errors in BP Assessment
Improper cuff size
Improper application of cuff
Deflating too quickly
Repeating reading too quickly