vital signs
are a means of assessing vital or critical physiological functions
the six vital signs to check
body temperature, pulse rate, respiration rate, oxygenation saturation, blood pressure, pain
definition of body temperature
-Degree of heat maintained by the body-Difference between heat produced by the body and heat lost to the environment
definition of thermoregulation
Process of maintaining a stable temperature
center of control for body temperature
hypothalamus
hyperpyrexia
high fever
pyrexia
fever
methods of measuring temperature
tympanic, oral, axillary, rectal
shows 1 degree higher
rectal temperature
shows 1 degree lower
axillary temperature
definition of pulse
The rhythmic expansion of an artery produced when a bolus of oxygenated blood is forced into it by a contraction of the heart
average pulse
70-80 bpm
systole definition
Measure of pressure when left ventricle contracts
diastole definiton
resting phase of the heart
what happens physiologically to create a pulse?
-The "wave" that begins when the left ventricle contracts and ends when the ventricle relaxes-Each contraction forces blood into the already-filled aorta, causing increased pressure within the arterial system
increase pulse rate
-being a newborn-being a woman-ingestion of a meal-stress-fever-disease-blood loss-standing and sitting-stimulant drugs
why does a fever increase pulse
-metabolic rate increases-peripheral vasodilation occurs which decreases BP, body causes heart to beat faster to compensate lower BP
most accurate way to obtain a pulse
apical (we learned radial)
common pulse points
radial, brachial, carotid, temporal, dorsalis pedis, femoral, popliteal, apical
when to measure apical pulse
-radial pulse is weak or irregular-patient is taking cardiac meds-infant or children (peripheral pulses can be difficult to palpate)
when measuring an apical pulse, what intercostal space is the stethoscope put at?
intercostal space 5
intercostal space (ICS)
space between the ribs
what does PMI stand for?
point of maximal impulse
what valve can you hear when taking an apical pulse
mitral
mitral valve shoots blood out to:
the body
data from three characteristics of a patient's pulse are needed; what are they?
-pulse RATE-pulse RHYTHM-pulse QUALITY
pulse quality characteristics
0- absent, pulse can't be felt1- weak or thready, pulse is barely felt 2- normal quality, pulse is easily palpated (not weak or bounding3- bounding or full (pulse easily felt), can almost see it pulsating through skin
pulse deficit
Hear a heartbeat but do not feel a beat at a pulse point
bradycardia
rate less than 60
tachycardia
rater greater than 100
pallor
paleness
cyanosis
bluish discoloration of the skin
respiration
the exchange of oxygen and carbon dioxide in the body
two separate processes of respiration
mechanical and chemical
Mechanical Respiration
The active movement of air into and out of the respiratory system
chemical respiration
external respiration, gas transport, internal respiration
external respiration (chemical respiration)
The exchange of oxygen and carbon dioxide between the alveoli and the pulmonary blood supply
gas transport (chemical respiration)
transport of O2 and CO2 throughout the body
internal respiration (chemical respiration)
the exchange of O2 and CO2 between capillaries and body tissue cells
regulators of respiration
-level of CO2 in blood-central chemoreceptors (located in respiratory centers, are sensitive to CO2 and hydrogen ion concentrations)-peripheral chemoreceptors (located in carotid and aortic bodies)
inspiration
breathing in-Involves the ribs and diaphragm, creating negative pressure and allowing air to flow into the lungs
expiration
breathing out-Relaxation of thoracic muscles and diaphragm-passive process
what factors influence respiration
-developmental level-exercise-pain-stress-smoking-fever-hemoglobin-disease-medications-position
respiratory rate
number of breaths per minute
respiratory depth
movement of chest wall (deep, normal or shallow)
respiratory rhythm
the regular or irregular spacing of breaths
respiratory effort
amount of effort (effortless, dyspnea, orthopnea)
4 characteristics to gauge for respiration
-respiratory rate-respiratory depth-respiratory rhythm-respiratory effort
variations in respiration assessment findings
-apnea-bradypnea-tachypnea-hyperventilation-hypoventilation
apnea
absence of breathing
bradypnea
slow breathing
tachypnea
rapid breathing
Hyperventilation
increased breathing
hypoventilation
decreased breathing
abnormal signs concerning respiration
-hypoxia-cyanosis-cough-irritability and anxiety
hypoxia
low oxygen
blood pressure
pressure of the blood as it it forced against arterial walls during cardiac contraction
systolic pressure
peak pressure exerted against arterial walls as the ventricles contract and eject blood
diastolic pressure
Minimum pressure exerted against arterial walls between cardiac contractions when the heart is at rest
factors that influence blood pressure
-developmental stage-sex-family history-exercise-body position-pain-race-obesity-diurnal variations-medications-diseases-genetic variations/genes
equipment for BP
sphygmomanometer and stethoscope
auscultatory gap
a brief period when Korotkoff sounds disappear during auscultation of blood pressure; common with hypertension
first sound of korotkoff
-As you deflate the cuff, a sound that occurs during systole (systolic blood pressure)-It is a tapping sound that corresponds to a palpable pulse
Second sound of Korotkoff
As you further deflate the cuff, a soft swishing sound caused by blood turbulence
third sound of korotkoff
Begins midway through the blood pressure and is a sharp, loud rhythmic tapping sound
fourth sound of Korotkoff
Similar to the third sound, but softer, fading, and muffled
fifth sound of Korotkoff
Silence, corresponding with diastole (diastolic blood pressure)