Chapter 19 Vital Signs - Notes from Fundamentals of Nursing Yoost/Crawford PDF

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Notes from Fundamentals of Nursing Yoost/Crawford...

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CHAPTER 19: VITAL SIGNS! ! Key Terms:! afebrile - Maintaining normal body temperature between 36.5° to 37.5° C (97.6° to 99.6° F).! apical pulse - A central pulse that can be auscultated over the apex of the heart at the point of maximal impulse. Found at the fifth intercostal space at the midclavicular line. ! apnea - An absence of breathing; brain damage occurs after 4 to 6 minutes of apnea.! arrhythmia - An irregular heartbeat that can prevent the heart from pumping adequate blood.! auscultation - Listening, with the assistance of a stethoscope, to sounds within the body.! auscultatory gap - During blood pressure measurement, absence of Korotkoff sounds noted in some patients after the initial systolic pressure.! blood pressure - The measurable pressure of blood within the systemic arteries.! bradycardia - A slow heart rate of less than 60 beats per minute in the adult.! bradypnea - A decrease in respiratory rate to less than 10 breaths per minute (BPM) in the adult.! core temperature - The temperature of deep tissues.! cyanosis - Bluish discoloration of the skin and mucous membranes, caused by decreased oxygen levels in arterial blood.! diastolic pressure - The lowest pressure on arterial walls, which occurs when the heart rests.! dyspnea - Difficult, labored breathing, usually with a rapid, shallow patten and sometimes painful. Fowler or Semi-Fowler position.! dysrhythmia - An irregular rhythm in the pulse, caused by an early, late, or missed heartbeat.! eupnea - Normal respiration with a normal rate and depth for the patient's age.! febrile - Elevated body temperature.! fever - A rise in body temperature above normal, caused by trauma or illness.! frostbite - Ice crystals form inside the cells due to exposure to subnormal temperatures that may cause permanent circulatory and tissue damage.! heat exhaustion - Profound sweating resulting in excessive water and electrolyte loss after environmental heat exposure.! heatstroke - Prolonged exposure to the sun or high environmental temperatures overwhelm the body's heat-loss mechanisms. This health emergency has a high mortality rate.! hypercapnia - High levels of carbon dioxide.! hypertension - Elevated blood pressure; it is the leading cause of cardiovascular disorders and the most important risk factor for stroke.! hyperthermia - High body temperature. Signs: Malaise, Shivering, and Tachycardia hyperventilation - Deep, rapid respirations often caused by stress or anxiety. hypotension - Low blood pressure. Decreased blood volume. hypothermia - Low body temperature. hypoventilation - Shallow, slow breathing. Associated with drug overdose, obesity, COPD, and cervical spine injury. hypoxemia - Low oxygen levels in the blood. Korotkoff sounds - The sounds for which the nurse listens when assessing blood pressure. orthopnea - Difficulty in breathing when in positions other than upright. orthostatic hypotension - A sudden drop of 20 mm Hg in systolic pressure and 10 mm Hg in diastolic pressure when the patient moves from a lying to sitting to standing position. oxygen saturation - Amount of oxygen in the arterial blood. palpation - Physical examination using touch to assess body organs and skin texture, temperature, moisture, turgor, tenderness, and thickness. peripheral pulse - Pulses that can be palpated over arteries located away from the heart. pulse - The palpable, bounding blood flow created by the contraction of the left ventricle of the heart. pulse deficit - The apical pulse rate exceeds the radial pulse rate. pulse oximetry - Measures the amount of oxygen available to tissues, is typically assessed with respirations. radial pulse - Palpated by placing the first two or three middle fingers of one hand over the radial artery at the groove along the radial, or thumb side, of the patient's inner wrist. respiration - The frequency of breaths per minute (BPM). One inhalation and one exhalation is one breath. systolic pressure - The peak of the pressure wave on the arterial wall. tachycardia - An excessively fast heart rate (>100 bpm in the adult). Caused by Fever, Hypoxia, and Stress tachypnea - An increase in respiratory rate to more than 24 BPM in the adult. temperature - The sensible heat of the human body. vital signs - A basic but very important component of the physiologic assessment of a patient; used to monitor the functioning of body systems. VS consist of body temperature (T), pulse (P), respirations (R), and blood pressure (BP). Vital signs are done every 4-8 hours for stable patients. Unstable is every 5 minutes ! ! Pulse measurement: ! • The brachial artery is used for children in emergency situations. ! • Peripheral circulation can be evaluated by checking the posterior tibial arteries.! • Auscultation is required for the apical site. ! • A pulse deficit is measured by two nurses at once. ! • Measurement the should wait for 10 minutes if the patient has just exercised.! !

! ! The accuracy of pulse oximetry can be affected by cold or injured extremities, peripheral edema, jaundice, movement where the sensor is attached, shivering, and some types of nail polish.! ! Pulse intervention: Fluid replacement/removal, decrease anxiety, monitor oxygenation, compare HR with baseline data or to NL range for age of patient! ! Steps for pulse oximetry:! 1. Explain the procedure ! 2. Place probe on site! 3. Turn on the oximeter! 4. Observe reading! 5. Remove probe! 6. Clean probe with alcohol! ! Pulse Intensity Scale:! 0 - absent ! 1 - diminished! 2 - normal! 3 - bounding! ! BP measurement:! • If the cuff is too small, there may be a false high reading.! • The cuff should be placed 1 inch above the heart level.! • Placing the cuff directly on the patient’s arm will improve the accuracy of the reading.! • The systolic measurement is documented as the first Korotkoff sound heard.! ! Two-step manual BP measurement:! 1. Palpate the brachial and radial pulses! 2. Position the cuff! 3. Close valve and inflate cuff! 4. Palpate brachial pulse and note reading! 5. Deflate cuff and wait 2 minutes! 6. Place stethoscope diaphragm over brachial pulse! 7. Inflate cliff, release valve, and auscultation BP! ! ! Fluids accumulate in the lungs of patients with renal failure, which results in deep to shallow rhythmic breaths. This pattern of respiration is called Cheyne-Stokes respiration. Biot respiration is an abnormal respiratory pattern in which the patient takes 2 to 3 shallow breaths followed by an absence of breathing for a few seconds. This pattern is seen in conditions such as meningitis and brain injury. Kussmaul respiration is a breathing pattern that is abnormally deep, regular, and increased in rate. Patients with diabetic ketoacidosis exhibit Kussmaul respiration.! ! For an adult, the correct procedure for taking a tympanic temperature includes pulling the pinna of the patient’s ear up and back. Children’s pinnae are pulled down and back. Washing hands and explaining the procedure are appropriate.! ! Self-care measures for hypertension include 30 minutes of aerobic exercise on most days of the week, maintaining a normal body weight, limiting alcohol to two drinks/day for men and one drink/day for women, reducing sodium intake to 2.4 g/day, and following the DASH diet.! ! Radiation: the transfer of heat as waves or particles of energy. No actual contact occurs between the object transmitting the heat and the object absorbing it. For example, peripheral vasodilation increases blood flow to the skin, thereby increasing radiant heat loss. Vasoconstriction minimizes heat loss from the skin. If the environmental temperature is higher than the skin temperature, the body also will absorb heat by radiation.! Conduction: the transfer of and reaction to heat through direct contact. Heat from the body is lost when it comes in contact with a cooler object, such as an ice pack or cool cloth.! Convection: the transfer of heat by movement or circulation of warm maer such as air or water.! Evaporation: the process by which a liquid is changed to a vapor through heat. Diaphoresis increases during exercise, emotional or mental stress, and fever. The process of evaporation lowers body temperature.! ! A pulse that is hard to obliterate (a bounding pulse) can be caused by fluid volume overload, or over-hydration. The nurse should assess for this situation. The other actions are not necessary.! ! Head injury, increasing age, recent food intake, pain, and increased (not decreased) fluid volume all can increase blood pressure.! ! !

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