Vital signs CH. 25 study guide PDF

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Vital signs What is the purpose of vital signs? 

To monitor the functions of the body



They are indicators of physiologic function and reflect the health status of a person.

What does vital signs include? 

Body temperature: 96.7-100.5



Pulse: 60-100 beats per min

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Respirations: 12-20

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Blood Pressure: 120/80

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Pulse oximetry: (noninvasive measurement of arterial oxyhemoglobin saturation) is often included with vitals in hospitalized patients.



Pain (5th vital sign)

Vital signs are to have a baseline and gets us lots of information on the patient. When to assess for vital sign? 

Admission & Discharge



Policy & Procedures



Change in the Patient’s Status or condition

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Before & After Surgical Procedures

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Before & After Invasive Procedures

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Administration of Medications: before giving medications make sure you check vital signs and then check

Temperature 

Temperature is the difference between the amount of heat produced by the body and the amount of heat lost to the environment measured in degrees



Body temperature varies during the day; low in the early morning and high in the late afternoon

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A person with a normal body temp. is referred to as afebrile (without fever)



A person with a fever is said to be febrile

*Common sites to assess body temp: -

Most common- Oral (sublingual)

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Tympanic

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Temporal artery

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Rectal

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Axillary

If using any other site than oral, you must document it!!!!

*Rectal gives you the most accurate temperature in a patient, but it’s not often used due to patients feeling embarassed



Types of fever: -

Intermittent: the body temperature returns to normal at least once every 24 hours

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Remittent: the body temperature does not return to normal and fluctuates a few degrees up or down

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Sustained or continuous: the body temperature remains above normal with minimal variations

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Relapsing or recurrent: the body temperature returns t normal for one or more days with one or more episodes of fever, each as long as several days

What factors affect body temperature? •

Age -

Body temperatures in older adults may be lower than the average adult temperature

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Older adults are at risk for harm from extremes of temperature due to impaired thermoregulatory responses. -

•

Women tend to experience more fluctuations in body temperature than do men

Diurnal Variations (Circadian Rhythms) pg. 646 -

Body temperature being 1.0-2.0 lower in the morning than in the late afternoon. 24hour interval.

•

Exercise

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Increased metabolism resulting from muscle activity = production of heat.

Hormones -

Increase in progesterone secretion at ovulation increases body temperature.

•

Stress

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Environment Ex. Exposed to extreme cold without proper wear, heat loss may increase. If you know fever is environmental and you still document, it the doctor is required to do something about (do not document it)

Pulse physiology •

Pulse: is a throbbing sensation that can be palpated (felt) over a peripheral artery, such as the radial artery or the carotid artery

•

How is the pulse regulated? -

The pulse is regulated by the autonomic nervous system through the sinoatrial (SA) node (pacemaker) of the heart. o Ex. PNS stimulation of SA node decreases heart rate o Ex. SNS stimulation of SA node increases heart rate

•

The normal pulse rate for adolescents and adult range from? -

60-100 beats/min

•

Bradycardia: pulse rate is less than 60 BPM

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Tachycardia: pulse rate greater than 100 BPM

Pulse characteristics: rate, rhythm, volume, bilateral equality •

Rate -

Tachycardia: it’s a rapid heart rate that affects, that decreases cardiac filling time, which in turn, decreases stroke volume and cardiac output.

-

Bradycardia: is a lower heart rate that is less than 60. o It’s usually slower during sleep in men and people who are thin. o Slows down during hypothermia as metabolic process decreases

o Aging and medications can slow down heart rate as well •

Rhythm -

Pattern of beats and intervals between beats

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Regular: Pattern of beats and intervals between beats

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Irregular: when beats & pauses between beats occur at unequal intervals o An irregular pattern of heartbeats is called a dysrhythmia.

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Volume -

Strength or amplitude: describes the quality of the pulse in terms of its fullness and reflects the strength of left ventricular contraction o 0 is absent in pulse; unable to palpate o +1 is diminished, weaker than expected o +2 is Brisk, expected (normal) o +3 is bounding

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Range from absent to bounding (forceful pulse)

Bilateral Equality -

Compare corresponding pulse

-

If distal pulse is palpable, more proximal pulses will be also…why do you want them to be equal? 

Because if the apical and radial are not equal that indicates that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated.

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When assessing pulse rate, you also asses pulse rhythm.

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The most common place is the radial (wrist)

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If you can hear it with your stethoscope, you can also palpate it.

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Any irregular rhythm use stethoscope to assess apical rate for 1 min

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Patient losing volume you should expect to feel a weak pulse.

What are some factors that can affect pulse?

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Age: Pulse decreases with age due to decrease metabolic rate

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Hypovolemia/ dehydration: If a patient is hypovolemia that patient is tachycardia. That’s mean they are losing blood volume.

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Sex: Women have a slightly higher pulse than men

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Stress: an increase in stress causes an increase in pulse rate

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Exercise: Pulse increases with exercise. o Athletes may have low pulse rate due to greater efficiency & strength of heart muscle

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Position

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Fever: Increases pulse rate due to increased metabolic demands & compensatory mechanisms to increase heat loss.

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Pathology

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Medications: can be intended effect or an unintended adverse effect that can lower or increase pulse rate

Pulse sites •

Temporal

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Carotid -

-

•

Radial -

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Femoral

assessments

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Popliteal

Used for patients who are in

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Dorsalis pedis

shock or have had a cardiac

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On top of foot

arrest

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Usually last resort

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Usually people with diabetes lack

Between the 5th intercostal space

pulse on lower extremities

and midclavicular line

because of peripheral vascular problem.

Brachial -

Most common

Used during emergency

Apical -

•

•

Assessed most often used in infants

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Posterior tibial -

*Common pulse sites: Carotid, Radial, and dorsalis pedis When do you measure the apical pulse?

Medial side of foot

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For patients with irregular or unavailable peripheral pulse, patients with cardiovascular, pulmonary, and renal disease.

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It is done prior to administering medications that affect heart rate

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Preferred method of pulse assessment for infants and children less than 2 years of age

Respirations •

Respirations involves ventilation, diffusion, and perfusion.

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Has both autonomic an voluntary control

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to assess you need to have a visual of patient chest and count the rise and fall of the chest

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Normal respirations ranges from 12-20 breaths a min (count to 30 sec and multiply by 2)

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Eupnea: Normal, unlabored respiration

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Tachypnea: increased resp. rate (Ex/ may occur in response to an increased metabolic rate, such as a person with a fever)

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Bradypnea: a decrease in resp. rate

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Apnea: periods during which there is no breathing. (If apnea lasts longer than 4-6 minutes, brain damage and death might occur)

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Dyspnea: difficult or labored breathing

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Orthopnea: when dyspneic people can often breathe more easily in an upright position

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Ventilation -

•

•

Inhalation (inspiration) & exhalation (expiration)

Types of Breathing -

Costal (thoracic) breathing

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Diaphragmatic (abdominal) breathing

Assessing Respirations -

Rate, quality, depth, effectiveness, & rhythm

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When assessing, use the diaphragm of the stethoscope with the patients shirt off.

Rate and depth of Respirations: -

Changes in responds to body demands

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Controlled by respiratory center in the medulla and pons.

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Activated by impulses from chemoreceptors

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Increase in carbon dioxide (stimulant)

Factors affecting respirations: (pg.658) •

Exercise, stress, high environmental temperature and low oxygen increase respiratory rate

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Increase respiratory rate: o Fever= increases metabolic rate, cells require more oxygen & produce more carbon dioxide that must be removed. o Any condition that increases CO2 and decreases O2 in blood increases rate & depth. o Tachypnea above 24 breaths/min

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Low environmental temperature, some medications, and increased intracranial pressure decrease respiratory rate: o Opioid- morphine, hydromorphone: can depress respiratory rate o Increased intracranial pressure: depresses respiratory rate causing shallow, irregular, and slow breathing. o Bradypnea below 10 breaths/min

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Be aware of patient’s normal breathing pattern

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Know patient’s health problems, medications, therapies

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Know relationship of patient’s respirations to Cardiovascular function – The relationship of one respiration to 4 heart beats is consistent in healthy people.

Oxygen Saturation (SaO2) •

Pulse Oximeter - Noninvasive

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Estimates arterial blood SaO2

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Records oxygen in peripheral arterial blood, so reported as SpO2

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Detects hypoxemia before clinical signs & symptoms

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Normal SpO2 95-100%; < 70% is life threatening

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If patient has low O2 SAT, signs start changing. They start to look purple/blue (in white people), ashy (in black people)

Blood pressure (BP) •

Arterial blood pressure- force of the moving blood against arterial walls

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Systolic

•

-

Contraction of the ventricles (pressure rises as they contract)

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Highest pressure

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Numerator

Diastolic -

Ventricles at rest (falls as the heart relaxes)

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Lower pressure present at all times

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Diastolic

The continuous contraction & relaxation of the left ventricle creates a pressure wave that is transmitted through the arterial system. •

Measured in millimeters of mercury (mmHg)

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Recorded as fraction (120/80)

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Pulse Pressure = difference between systolic and diastolic pressures. Pulse pressure is 120-80=40 mm Hg

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Blood pressure readings should be measured on at least two readings obtained on at least two occasions and averaged to estimate the person’s level of BP.

Factors affecting BP •

Age -

-

pressure is low

Older adults decrease elasticity of arteries causing

•

Stress

increase in peripheral

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Race

resistance & increasing blood

-

pressure. •

Systolic rises during strenuous activity

Increase in BP (hypertension) more sever in African

Exercise -

In athletes there blood

American men & women •

Sex

-

•

Women have lower BP than

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Obesity (high blood pressure)

men until menopause

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Daily variations

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Medical conditions

Medications -

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Narcotics, sedatives, general

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Smoking increase rate at rest

anesthetics slow rate & depth

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Pain: increase rate but

Amphetamines, Cocaine may increase rate & depth

decrease depth •

Body temperature

Hypotension and Hypertension •

Hypotension: below normal. Is diagnosed when BP is lower than 90/60 mm Hg •

Occurs primarily as a result of the body’s inability to maintain or return blood pressure back to normal or not able to do it fast enough.

•

Orthostatic hypotension: o Is a decrease in systolic blood pressure of less than 20 mm Hg or decrease in diastolic BP of less than 10 mm Hg within 3 minutes of standing when compared to BP from a sitting or supine position. 

Remember the difference take vitals laying down, sitting & standing!!!!

o May be acute or chronic & asymptomatic or symptomatic o Caused by dehydration or blood loss; problems of the neurologic, cardiovascular or endocrine systems; and/or use of medications. o Patient may experience dizziness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpations, & headache. (return patient back to bed to restore blood flow to brain) •

Hypertension: BP above normal for a sustained period. Is diagnosed when the systolic pressure is 130 mm Hg or •

Overactivation of angiotensin & aldosterone result in high BP, overtime it thicken blood & increases resistance peripheral resistance and backs up pressure to organs.

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Usually asymptomatic, contributes to heart attack

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Primary or secondary

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Disorders resulting from this is: o Thickening of myocardium o Heart failure o Myocardial infarction (MI) o Cerebrovascular accident (stroke) o Kidney damage

Measuring BP •

Sphygmomanometer -

Aneroid or digital

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Doppler ultrasound

-

•

Amplifies the sound

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Used when sounds are distinct or inaudible with a regular stethoscope.

Cuff and bladder sizes o Choose correct size depending on patient to ensure accurate reading o Too narrow- erroneously high, pressure not evenly transmitted to the artery. o Too wide- erroneously low, pressure is dispersed over a disproportional large surface area.

•

•

Sites -

Upper arm (brachial artery)

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Thigh (popliteal artery)

Direct (invasive monitoring) -

Measuring BP directly through the insertion of a thin catheter into an artery.

-

Tip of catheter senses pressure & transmits information to a machine which displays systolic. & diastolic. In wave form.

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Indirect

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Korotkoff’s sounds: series of sounds we listen to when assessing BP * review chart on pg 665 -

Phase 1= first faint, clear tapping or thumping sounds (systolic)

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Phase 2= Muffled, whooshing, or swishing sound

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Phase 3= Blood flow freely, crisper, more than intense sound. Thumping is softer than phase 1

•

-

Phase 4= muffled, soft, blowing sound

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Phase 5= pressure level when last sound is heard; period of silence (diastolic)

Auscultatory gap -

The disappearance of the sound during the latter part of phase 1 and during phase 2. May cover a range of as much as 40 mm Hg.

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Failure to recognize gap may cause errors in underestimating systolic or overestimating diastolic...