Chapter 12 Vital Signs Copyright 2013 Wolters

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Количество слайдов: 54

Answer True. Pain is considered the fifth vital sign. The other vital signs include body temperature, pulse, respiratory rate, and blood pressure. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Body Temperature • Shell temperature: the warmth at the skin surface • Core temperature: the warmth in deeper sites within the body like the brain and heart Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Factors Affecting Body Temperature • Food intake, age, gender • Climate, exercise and activity • Circadian rhythm • Emotions • Illness or injury • Medications Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Temperature Measurement • Fahrenheit scale: uses 32˚F as the temperature at which water freezes and 212˚F as the point at which it boils • Centigrade scale: uses 0˚C as the temperature at which water freezes and 100˚C as the point at which it boils Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Normal Body Temperature • In normal, healthy adults, shell temperature generally ranges from 96. 6˚F to 99. 3˚F or 35. 8˚C to 37. 4˚C • Chances of survival diminish if body temperatures exceed 110˚F (43. 3˚C) or fall below 84˚F (28. 8˚C) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Normal Body Temperature (cont’d) • Based on temperature, animals are either: – Poikilothermic: temperature fluctuates depending on environmental temperature – Homeothermic: structural and physiologic adaptations keep body temperature within a narrow stable range Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Assessment Sites • Accurate assessment site: Brain, heart, lower third of the esophagus, and urinary bladder • Practical and convenient assessment sites: – Ear, temporal artery (on forehead or behind ear lobe), mouth, rectum, and axilla – Ear, temporal artery provide the temperature closest to the core temperature Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Automated Monitoring Devices • Equipment that allows for the simultaneous collection of multiple data • Measure the temperature, blood pressure, pulse, heart rhythm, and pulse oximetry • Portable to save time and money Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Continuous Monitoring Devices • Used primarily in critical care areas • Measure body temperature using internal thermistor probes within the esophagus of anesthetized clients, inside the bladder, or attached to a pulmonary artery catheter Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Elevated Body Temperature • Fever is a condition in which the body temperature exceeds 99. 3˚F (37. 4˚C) • Pyrexia is a condition in which the temperature is warmer than the normal set point • Hyperthermia is a condition in which core temperature is excessively high and the temperature exceeds 105. 8˚F (40. 6˚C) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Symptoms of Fever • Pinkish, red (flushed) skin that is warm to the touch • Restlessness in some; excessive sleepiness in others • Irritability; poor appetite • Glassy eyes and sensitivity to light • Increased perspiration • Headache Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Symptoms of Fever (cont’d) • Above-normal pulse and respiratory rates • Disorientation and confusion (when the temperature is high) • Convulsions in infants and children (when the temperature is high) • Fever blisters about the nose or lips in clients who harbor the herpes simplex virus Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Hypothermia • Core body temperature less than 95˚F (35˚C) • Mildly hypothermic: 95˚F to 93. 2˚F (35˚C to 34˚C) • Moderately hypothermic: 93˚F to 86˚F (33. 8˚C to 30˚C) • Severely hypothermic: below 86˚F (30˚C) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Symptoms of Hypothermia • Shivering until body temperature is extremely low • Pale, cool, and puffy skin • Impaired muscle coordination • Listlessness and irregular heart rhythm • Slow pulse and respiratory rates • Incoherent thinking and diminished pain sensation Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pulse • Produced by the movement of blood during the heart’s contraction • In most adults, the heart contracts 60 to 100 times per minute at rest – Pulse rhythm – Pulse volume – Pulse rate Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pulse Assessment Techniques • Primary pulse assessment site: radial artery located at inner (thumb) side of the wrist • Alternate assessment techniques – Counting the apical heart rate – Obtaining an apical–radial rate – Using a Doppler ultrasound device over a peripheral artery Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Respiration • Exchange of oxygen and carbon dioxide • Respiratory rate is the number of ventilations per minute • Cheyne-Stokes respiration: a breathing pattern in which the depth of respirations gradually increases, followed by a gradual decrease, and then a period when breathing stops briefly before resuming again Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Respiratory Rate • Rapid respiratory rate – Tachypnea accompanies elevated temperature or diseases affecting cardiac and respiratory systems • Slow respiratory rate – Bradypnea can result from medications; observed in clients with neurologic disorders or hypothermia Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Abnormal Breathing Characteristics • Hyperventilation • Hypoventilation • Dyspnea • Orthopnea • Apnea • Stertorous breathing • Stridor Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Blood Pressure • Force that the blood exerts within the arteries • Lower-than-normal volumes of circulating blood cause a decrease in blood pressure • Excess volumes cause an increase in blood pressure • Regular aerobic exercise increases tone of heart muscle and increases efficiency • Cardiac output Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Blood Pressure (cont’d) • Cardiac output is approximately 5 to 6 L in adults at rest • Blood pressure measurements provide physiologic data about: – Ability of arteries to stretch – Volume of circulating blood – Amount of resistance heart must overcome when it pumps blood Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Factors Affecting Blood Pressure (cont’d) • Lower blood pressure – Lower when lying down than when sitting or standing • Higher blood pressure – When urinary bladder is full, when the legs are crossed, when the person is cold – When drugs that stimulate the heart are taken Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pressure Measurements • Systolic pressure • Diastolic pressure • Blood pressure is expressed in millimeters of mercury (mm Hg) as a fraction; systolic pressure/diastolic pressure • Pulse pressure: difference between systolic and diastolic blood pressure measurements Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Assessment Sites • Usually assessed over the brachial artery • Lower arm and radial artery • Measured over the popliteal artery behind the knee in case: – Client’s arms are missing – Both of a client’s breasts have been removed – Client has had vascular surgery Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Equipments for Measuring Blood Pressure • Sphygmomanometer • Aneroid manometer • Electronic oscillometric manometer • Inflatable cuff • Stethoscope Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Measuring Blood Pressure • Phase I: first faint but clear tapping sound that follows a period of silence as pressure is released from the cuff • Phase II: change from tapping sounds to swishing sounds • Phase III: change to loud and distinct sounds—crisp knocking sounds Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Measuring Blood Pressure (cont’d) • Phase IV: sounds muffled and has a blowing quality—first diastolic pressure measurement • Phase V: point at which the last sound is heard—second diastolic pressure measurement Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question • Is the following statement true or false? First diastolic pressure measurement is taken at phase III of Korotkoff sounds. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Alternate Techniques for Assessing Blood Pressure • Palpation • Using a Doppler stethoscope • Automatic blood pressure monitoring • Measuring thigh blood pressure Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Abnormal Blood Pressure Measurements • Blood pressures above or below normal ranges indicate significant health problems • Hypertension: high blood pressure • Hypotension: low blood pressure • Postural or orthostatic hypotension: sudden but temporary drop in blood pressure when rising from a reclining position Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Abnormal Blood Pressure Measurements (cont’d) • Hypertension or high blood pressure is associated with: – Anxiety – Obesity – Vascular diseases – Stroke, heart failure – Kidney diseases Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Documenting Vital Signs • Once vital sign measurements are obtained: – Document the data in medical record for analysis of patterns and trends – Enter the data, along with any other subjective or objective information in narrative nursing notes Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Implications • Vital sign assessment is the basis for identifying problems • Nurses identify from the nursing diagnoses: – Hyperthermia, hypothermia, ineffective thermoregulation, decreased cardiac output, risk for injury, or ineffective breathing pattern Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Gerontologic Considerations • Lower “normal” or baseline temperature • Changes in thermoregulation system • Delayed or diminished febrile response to illnesses • Change in cognitive function, restlessness, or anxiety may be initial sign of illness Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Gerontologic Considerations (cont’d) • Susceptible to hypothermia and heatrelated conditions; elevated blood pressure readings in clinical settings • Blood pressure assessment in bilateral arms; document subsequent trends • Older adults are more susceptible to arrhythmias and postural and postprandial hypotension Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Gerontologic Considerations (cont’d) • If older client is hypotensive, plan for limited activities during the hour following eating or frequent smaller food consumption throughout the day • More profound responses to cardiovascular medications than younger adults Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins