Vital Signs - Summary Fundamentals of Nursing: the Art and Science of Nursing Care PDF

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Chapter 25- Vital Signs ...

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Vital Signs Temperature o Body temperature is the difference between the amount of heat produced by the body and the amount of heat that is loss o Normal body temperature ranges from 96.7- 100.5F o Core body temperature (intracranial, intrathoracic, and intra-abdominal) is higher than the surface body temperature  Individual variations of these temps can be influenced by:  Related to age  Biological sex  Physical activity  State of health  environmental temperatures Physiological Body Temperature  thermoregulatory center in the hypothalamus  center receives messages from the cold and warm thermal receptors located throughout the body, compare with the temperature set point, and initiates responses to either produce or conserve body heat or to increase heat loss. Heat Production o primary source of heat in body- metabolism, with heat produced as a byproduct of metabolic activities that generate energy for cellular function o when additional heat is required to maintain balance, o epinephrine and norepinephrine are released to rapidly alter metabolism so that energy production decreases and heat production increases. o Thyroid hormone – increase metabolism and heat production, but over a much longer time o Shivering – response that increases the production of heat – initiated by the hypothalamus and results in muscle tremors – causing the production of heat.  Pilomotor muscles of the skin, occurs with shivering, causes piloerection aka “goose bumps” and reduces the area for heat loss. Heat Loss

Circadian Rhythms o Circadian meaning nearly every 24 hrs o Predictable fluctuations in measurements of body temperatures and bp are examples of Circadian Rhythms o Peak elevations of a person temperature 4 and 8 pm Age and biological sex o Older adults loose thermoregulatory w/ age o Very old and very young are more sensitive to environmental change

o Older adults – risk for harm from extremes of temp due to impaired thermoregulatory responses o Body temp of infants and children changes more rapidly in response to both hot and cold o Women – experience more fluctuations in body temp than men – prob resulted from hormones.  Increase in progesterone secretion at ovulation increases body temp as much as 0.3-0.6C (0.5-1.0F) Physical Activity Increases body temperature State of Health Environmental Temperature o Hypothermia – low body temp o Hyperthermia – high body temp Normal Body Temperature Body temp varies among ppl A person w/ normal temperature is Afebrile (w/out fever) Increased Body Temperature o Fever or pyrexia is an increase in body temperature. o Fever occurs in response to upward displacement of the thermoregulatory set point of hypothalamus o Person that has a fever is febrile -

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Substances that can trigger increase in temperature include: bacteria, bacterial products, and whole microorganisms, such as viruses. o May also result from chemical produced in the body in response to tissue injury, like from MI (myocardial infarction), pulmonary emboli, cancer, trauma, and surgery. Purpose of fever not fully understood, but we do know that its signals increase immune function, inflammation, and important in health status. Most fever (unless extremely high), are not harmful. They are beneficial effects of a fever . o But when a fever is equal to or higher than 40C (106F) it is known hyperpyrexia and is a medical emergency. The body must be cooled, if not brain damage will occur. When the thermostatic set point of the hypothalamus is increased in response to a pyrogen, the hypothalamus initiates temperature-rising mechanisms: shivering, piloerection, vasoconstriction, and increased metabolism. Body temp rises to new temp- heat loss mechanisms begin (such as sweating, vasodilation, increased respirations) to keep the body rising from dangerous levels. Onset of a fever can be sudden or gradually. More rapid in children than adults. A mild elevated fever in infants younger than 3 months- can indicate serious infection (because their thermoregulatory system is not yet stable)

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It is important to always check your patient baseline to be able to identify a manifestation of a fever.

Types and Definitions of fevers: - Intermittent: The body temperature returns to normal at least once every 24 hours. - Remittent: The body temperature does not return to normal and fluctuates a few degrees up or down. - Sustained or Continuous: The body temperature remains above normal with minimal variations. - Relapsing or Recurrent: The body temperature returns to normal for one or more days with one or more episodes of fever, each as long as several days. Other types of increased body temperature are hyperthermia, neurogenic fever, and fever of unknown origin (FUO). - Hypothermia: hypothalamic set point is not changed, but in situations of extreme heat exposure or excessive heat production (ex: during strenuous exercise), the mechanisms to control temp are ineffective. - Neurogenic fever: result to damaging the hypothalamus from pathologies such as intracranial trauma, intracranial bleeding, or increased intracranial pressure. o This type of fever does not respond to antipyretic medications - Fever that last 3 weeks or longer and is higher than 38.3C (101F) w/out identifying cause is diagnosed as an FUO Physical effects of fever - experience loss of appetite; headache; hot, dry skin; flushed face; thirst; muscle aches; and fatigue. Respirations and pulse rate increase - young children w/ high fevers- may experience seizures - adults w/ high fevers- may experience delirium and confusion - Fever blisters may develop in some people as the fever activates the type I herpes simplex virus. - Fluid, electrolyte, and acid–base imbalances are potentially dangerous complications of fever. Treatment of fever - If the fever is the result of a bacterial or other type of microbial infection, the appropriate antibiotic or anti-infective may be prescribed. o Antipyretic (fever-reducing) drugs, such as aspirin, ibuprofen, or acetaminophen, may be administered in certain circumstances. These drugs reset the elevated set point regulated by the hypothalamus. - Recommended by the FDA, CDC, WHO, and AAP aspirin and combination products containing aspirin not be taken by anyone younger than 19 years during fever-causing or flu-like illnesses - Oral fluids are increased to maintain cellular and intravascular status and prevent dehydration.

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Simple carbohydrates are included in the diet to prevent tissue breakdown from the hypermetabolic state. Modifications of the external environment o use of cool sponge baths, cool packs, and hypothermia (cooling) blankets.

Review USING A HYPOTHERMIA BLANKET TO REGULATE BODY TEMPERATURE o pg 649

Decreased In body temperature - Hypothermia is a body temperature below the lower limit of normal - occurs when compensatory physiologic responses meant to produce and retain heat are overwhelmed by unprotected exposure to cold environments. o accidental exposure or impaired perception of cold, which occurs particularly in older adults or the disabled. - Chronic conditions—such as alcoholism, malnutrition, and hypothyroidism—increase the risk of hypothermia - Death may occur if body temp falls below 95F o Survival is possible since the chemical rxns of the body are lowered. - Therapeutic hypothermia, the purposeful lowering of the core body temperature, has been used to improve outcomes after cardiac arrest Physical effects of hypothermia - Patients with hypothermia may experience poor coordination, slurred speech, poor judgment, amnesia, hallucinations, and stupor. - Respirations decrease, pulse becomes weak, and irregular lowering of bp. Treatment of hypothermia - Rewarming the patient o Blankets and clothing o Heating pads and radiant warmers o Warm fluid- orally or intravenous route Assessing Temperature o Proper equipment, which site, and appropriate method o nurse is responsible for assessing the findings, assessing the effect of changes in body temperature, and implementing appropriate interventions. o nurse is also responsible for teaching the patient and caregiver(s) about methods of temperature measurement, normal values, and the need to report abnormal findings.

Body temperature is documented in either Celsius or Fahrenheit degrees.

Tympanic membrane thermometers - heat given off by the tympanic membrane, reflecting the temperature of the blood flowing in the carotid artery - reading takes from 1 to 3 seconds - Studies conflict regarding the accuracy of this method o As such, it is important to use proper technique and adhere to manufacturer’s guidelines for use. Temporal artery thermometers - measure body temperature by capturing the heat emitted by the skin over the temporal artery. - Can be an accurate method for temperature reading but operator technique and cleanliness of the thermometer lens can influence Disposable Single-Use thermometers

Sites and Methods Assessing Body Temperature - Policies will specify which site to assess for temperature first. However, the nurse is expected to choose an alternate route. - Factors affecting site selection include the patient’s age, state of consciousness, amount of pain, and other care or treatments (such as oxygen administration) being provided. - If temp reading is obtained other than the oral route, it must be documented along with the result to ensure accurate comparison of data. If no site is listed, it is assumed it was through the oral route - Commonly used site for assessing temperature oral (sublingual), tympanic, temporal artery, rectal, and axillary o Electronic probe is used for oral, rectal, and axillary. o Temporal probe is placed in ear for tympanic o Thermometers swiped of skin for temporal - Comparing the recordings using two different sites is a method for double-checking the validity of an unusual measurement. Assessing Oral Temperature - Pt must be able to open and close mouth o Not suitable for children less than 5 years or with developmental delay who are unable to follow directions.

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If pt drank something hot or cold, smoked, or chewed gum- wait 15-30 minutes to allow oral temperature to return to normal temp Oral temperatures should not be taken with pt with oral cavity disease, surgery in nose or mouth, or when at risk for seizure Place it in sublingual pocket o Normal oral temp 97.7 to 99.5F (36.5 to 37.5C)

Assessing a Temporal Artery temperature - Right or left ear are equally effective - Assess for head coverings o Anything covering would insulate the area causing a false high temp reading - If patient is laying on the side, use ear that is exposed to the environment - Do not measure if there is scar tissue, open lesions, or abrasions. - Move thermometer across the forehead slowly and remain in contact with skin exposure - More accurate than axillary readings o Normal readings are 98.7 to 100.5F (37.1 to 38.1C) Assessing an Axillary temperature - Axillary readings are affected by ambient temperature, local blood flow, placement of the probe, and closure of the axillary cavity - May be used when oral & rectal are inaccessible or contraindicated o BUT should not be used when accurate temp is needed - Commonly used in neonate - Normal axillary temperature readings range from 35.9° to 36.9°C (96.7° to 98.5°F) Assessing a rectal temperature - Aka core temperature - Most accurate o Not be used in newborns, children w/ diarrhea, and in pt who have undergo rectal surgery or have disease in rectum o In some places it may not be allowed for pt with heart disease or after cardiac surgery, bc insertion of the thermometer into the rectum can slow the heart rate by stimulating the vagus nerve o Do not insert in pt with low platelet count -rectal thermom could cause bleeding o Normal reading 37.1° to 38.1°C (98.7° to 100.5°F)

Pulse - A peripheral pulse is a throbbing sensation that can be palpated (felt) over a peripheral artery o Radial and carotid artery - Wave of blood being pumped into the arterial circulation by the contraction of the left ventricle. Heat contract – ejects blood-smooth muscle in artery expands to compensate for the increase in pressure of the blood - Characteristics of peripheral pulse: o Rate, rhythm, and amplitude (quality; strong or weak)

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o Characteristics indicate the effectiveness of the heart as a pump and adequacy of blood flow heart rate affects the amount of blood ejected by the heart with each beat and is determined by the frequency with which the ventricle contracts. quality and rhythm affect how much blood is ejected and whether the beat is regular in rhythm. apical pulse may be auscultated (listened to) over the apex of the heart as the heart beats. o apical pulse - closure of the mitral and tricuspid valves (“lub”) and aortic and pulmonic valves (“dub”). The combination is counted as one beat.

Physiology of the pulse - regulated by the autonomic NS through the SA node (the pacemaker) - PNS stimulate SA Node via vagus nerve – decrease HR - SNS stimulate SA Node – increase HR and force of contraction - Pulse rate is the number of the pulsations felt over a peripheral artery or heard of the apex in one minute o Rate=beat in normal conditions Factors affecting the pulse - Age and biological sex o Women have slightly higher pulse rate (PR) than men o PR decrease as we get older due to metabolic rate decreasing - Physical activity o PR increase w/ exercise o Athletes may have slightly decreased PR due to greater efficiency and strength of heart - Fever and stress o Elevated body temp= increase PR o Increase stress= increase PR (fear, anxiety, pain) - Medications o Some meds can cause alterations in PR  Some can increase or decrease PR  Can be intended or unintended effects - Disease o Acute or chronic health affect PR Normal PR - 60-100 BPM o Changes across the life span Increased PR - Tachycardia o Rapid HR, decreasing cardiac filling time, which decreases stroke volume and cardiac output  Adult is tachycardic when PR is at 100 to 180 bpm - Bradycardia o HR below 60 BPM o PR is normally slower during sleep in men and in people who are thin

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o Slows in hypothermia due to metabolic decrease o PR becomes slower as we age o Sinus bradycardia results when the SA node generates a slower-than-normal impulse rate.  Occurs during sleep, in hypothermia, athletes, etc. For more examples for tachycardia and bradycardia read page 655

Pulse Amplitude (Quality) - The quality of the pulse in terms of fullness and reflects the strength of the L ventricle contraction - Scales are used to describe the amplitude. Grade 0 +1 +2 +3

Description absent, unable to palpate diminished, weaker than expected brisk, expected (normal) bounding

Pulse Rhythm - Pattern of the beats and the pauses between them o Normally regular = regular intervals o Irregular = irregular intervals - Irregular pattern= dysrhythmia Assessing the pulse - Assessed by palpating peripheral arteries or auscultating the apical pulse with a stethoscope Equipment - Stethoscope o Diaphragm- large flat disk  Useful for hearing higher frequency, such as respiratory  Screens out low frequency sounds o Bell – hollowed, upright, curved  Screens out high frequency sounds  More useful for low freq sounds – heart and blood vessels and veins - Doppler US o May be used to assess pulse that are difficult to palpate or auscultate  (read guidelines on pg 655) - Assessing peripheral areterial pulses o Radial pulse site is assessed most often in children and adults  Skill 25-2 (on pages 677–679) o Circulation to the legs and feet may be assessed at the femoral, popliteal, posterior tibial, or dorsalis pedis sites. o Carotid pulse site is used during emergency assessments, such as for patients who are in shock or have had a cardiac arrest.  Lightly palpate carotid  Brachial Pulse is used more often for infants in these situations

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Assessing the Apical Pulse o If peripheral pulse is difficult to assess because it or irregular, weak, or very rapid – apical rate can be used o Also assessed with giving medications that can alter heart rate and rhythm o Preferred method for pulse assessment for infants and children less than 2 y/o o count for one full minute Assessing the Apical – Radial Pulse o Counting of the pulse at the apex of the heart and at the radial artery simultaneously is used to assess the apical–radial pulse rate. o A difference between the two is called pulse deficit  This indicates that the heartbeats are not reaching the peripheral arteries or are too weak to be palpated Respirations Involves ventilation, diffusion, and perfusion o Ventilation (breathing)  Inhale and exhale  Has both voluntary and involuntary control  Measured as respirations o Diffusion  Exchange of oxygen and carbon dioxide b/w alveoli of the lungs and the circulating blood o Perfusion  Exchange of oxygen and carbon dioxide between the circulating blood and tissue cells Abnormalities can be indications of cardiac arrest

Physiology of Respirations - rate and depth of breathing can change in response to tissue demands. - Activation of the respiratory centers occurs via impulses from chemoreceptors located in the aortic arch and carotid arteries, via stretch and irritant receptors in the lungs, and via receptors in muscles and joints Factor Affecting Respirations - Exercise, respiratory and cardiovascular disease; alterations in fluid, electrolyte, and acid–base balances; medications; trauma; infection; pain; and emotions Normal Respirations - Healthy respirations are between 12-20 per min o Infants and young children breathe more Increased Respiration Rate - Tachypnea: increased respiratory rate – increased metabolic rate (such a person has a fever) - Increase in co2 and decrease in o2 in the blood increases the rate and depth of respirations causing – hyperventilation - Respiratory disease such as Acute pneumonia may cause tachypnea or hyperventilation

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Age: The respiratory rate decreases with age, ranging from a normal range of 30 to 55 breaths/min in a newborn to 12 to 20 breaths/min in an adult. Exercise: Exercise increases respiratory rate and depth. Acid–base balance: Alterations in acid–base balance (especially acidosis) commonly result in increased rate and depth of respirations (hyperventilation). Brain lesions: Lesions of the brain (such as hemorrhage or tumors) or brainstem can cause a change in both the depth and rate of respirations, most commonly manifested as Cheyne–Stokes respirations. Increased altitude: As an adaptation to higher altitudes, healthy people may exhibit Cheyne–Stokes respirations, especially when asleep. Higher altitudes also increase respiratory rate and depth prior to adaptation by increasing hemoglobin levels. Respiratory diseases: Any alterations in the normal respiratory structures may result in changes in respiratory rate, depth, and patterns, most often manifested as difficult breathing, using accessory muscles of respiration (such as the intercostal muscles), and increased rate. The depth may be shallower. Smoking can alter the pulmonary airways, resulting in an increase in respiratory rate at rest. Anemia: Anemia, a decrease in oxygen-carrying hemoglobin, may result in an increased rate of respirations. Anxiety: Anxiety can cause sighing type respirations (increased depth) and increased rate. Medications: Medications—such as narcotics, sedatives, and general anesthetics—slow respiratory rate and depth. Other drugs, including amphetamines and cocaine, may increase rate and depth. Acute pain: Acute pain increases respiratory rate but may decrease respiratory depth....