Jarvis Health Assessment chapter 10 vital signs PDF

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Chapter 10 vital signs summary...

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Chapter 10: Vital Signs -

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Objective measure of body’s basic functions. Includes temperature, pulse, respiratory rate, and blood pressure. Help monitor pt’s health & can indicate deterioration TEMPERATURE The normal oral temp in a resting person is 37o C (98.6O F) range from 96.4-99.1oF Normal temp is influenced by diurnal cycle, the menstruation cycle due to progesterone secretion, exercise—moderate to hard exercise increase body temp. Age- in older adults temp is usually lower than other age groups. Normal for older adults is 36.2oC (97.2oF) via oral route  Hyperthermia: aka fever is caused by pyrogens secreted by toxic bacteria during infections from tissue breakdown – this can reset the thermostat of the brain at a higher lvl resulting in heat production & conservation. A body temp of GREATER than 38o C (100.4o F) IS accepted as hypothermia. Oral temp is the most convenient & accurate site. The sublingual pocket has a rich blood supply from the carotid arteries that quickly responds to changes in inner core temp.  Hypothermia – cause by exposure to cold for too long. May be done on purpose to reduce body’s O2 requirements during heart or peripheral vascular surgery… a body temp below 36.0oC – 96.8 F is accepted hypothermia

The procedure for glass thermos.: Oral Temperature: Instruct person to keep his/her lips close—leave in mouth for 3-4 mins. Procedure for electronic thermos: Can be used for both oral & rectal. Blue-tipped probes are for oral. Red-tipped probes are for rectal. (RED-RECTAL)  Rectal temperature: The most accurate route bc result is as close to core temp. More invasive than other measures.  Rectal is preferred when pts are comatose, confused, patients in shock, or cannot close mouths.  Procedure for rectal temp: a) Place pt in left lateral decubitus… wear gloves. Place cover on thermometer & apply lubricant to probe. b) Insert lubricated probe 2-3cm into rectum. For infants younger than 6 months— insert ½ inch. c) Leave inside until electronic thermometer beeps. Tympanic membrane thermom: Senses infrared emissions of tympanic membrane (eardrum) shares same vascular supply that perfuses the hypothalamus, making it accurate. -place probe tip in person’s ear canal

The temporal artery thermometer (TAT) is used by sliding the probe across the forehead & behind the ear. Takes multiple readings & provides an average. – More accurate than tympanic.

Pulse Definition: W/ every beat the heart pumps an amount of blood called stoke volume – into aorta. This force flares into arterial walls & generates a pressure wave which is felt in the periphery as the pulse. We palpate the pulse. -

Palpate the radial pulse at the flexor aspect of wrist along radius bone—if beat is regular count the beats in 30 seconds & multiply by 2. Assess pulse including: 1. Rate: 60-100 bpm is regular. Rate is more rapid in children, more moderate during adult. After puberty, females have a slightly faster rate than males. Athletes push out larger stroke volumes w each beat, thus requiring fewer bpm to maintain a stable cardiac output 2. Rhythm: Normally has a regular, even tempo. Irregularity commonly found in children/young adults is sinus arrhythmia—hr varies w respiratory cycle 3. Force: Shows strength of heart’s stroke volume. A “full, bounding pulse” denotes an increased stroke volume (e.g. w anxiety, exercise…) 3+ - Full, bounding 2+ - Normal – Most healthy adults have this force of 2+ 1+ - Weak, thready – reflects a decreased stroke volume (occurs w hemorrhagic shock) 0 – Absent

In adults, a resting hr less than 50 bpm = bradycardia. A hr over 95-100 bpm = tachycardia – occur w anxiety or increased exercise

Respirations Should be relaces, regular, automatic, & silent More rapid in infants

Blood pressure Is the force of blood pushing against the side of its vessel wall. Systolic pressure: Maximum pressure felt on artery during ventricular contraction Diastolic pressure: (elastic recoil) The resting pressure that blood exerts constantly b/een each contraction *Mean Arterial Pressure (MAP): Pressure forcing blood into tissues averaged over the cardiac cycle

How bp varies: Factors Age: rise in bp from childhood to adult yrs Sex: After puberty, females have lower bp than males Race: African-American bp be higher than other races. Twice as high Diurnal rhythm: A daily cycle of peak & trough occurs. bp rises in late afternoon & declines to earlymorning low Weight: BP is higher in obese ppl Exercise Emotion- BP momentarily rises w fear Stress: BP is elevated w ppl who have stress

5 Factors that affect BP 1. Cardiac output – If the heart pumps more blood into the container (i.e. blood vessels) the pressure on the container walls increases 2. Vascular resistance – When vascular resistance increase – vasoconstriction When resistance decreases – vasodilation 3. Volume – decreased volume = hemorrhage; volume increased = increased sodium & water retention, intravenous fluid overload. How tightly the blood is packed into the arteries 4. Viscosity – increased viscosity = increased hematocrit in polycythemia. When contents are thicker, pressure increases 5. Elasticity of arterial walls – increased rigidity, hardening as in arteriosclerosis

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The width of the rubber bladder inside cloth cover = 40% of the circumference of person’s arm The length of bladder should be 80% of the arm circumference For each person, verify BP in both arms once… either on admission or for the first complete physical examination. There shouldn’t be a 10-15 mm difference b/een both arms Bare arm should be supported at heart level. Pt’s feet should NOT be crossed bc it could lead to a false-high measurement Perform a palpated pressure before auscultating blood pressure & go up to maximum inflation pressure (20-30mm) to avoid missing an auscultatory gap—when Korotkoff sounds disappear during auscultation Record person’s arm being used & even #s should be used for bp calculations

Orthostatic/Postural Vital Signs...