vital signs
clinical measurements that include blood pressure, pulse, oxygen, body temperature, and respiration.
Blood pressure
is a measurement of the amount of pressure exerted by the blood within the circulatory system. Measured in millimeters of mercury
systolic blood pressure
maximum amount of pressure exerted when the heart contracts and forces blood into the aorta
Diastolic blood pressure
minimum amount of pressure exerted when the heart is relaxed
cardiac output
amount of blood pumped into the circulatory system by the hear within one minute
stroke volume (SV)
the amount of blood ejected by the ventricle during one heart contraction. CO is the product of this and the pulse rate of the heart HRCO=SV+HR
blood pressure
increased viscosity increases resistance flow and increases what?
Elasticity
ability of the vessel to stretch and compress, then return to their original shape
decrease in elasticity
what causes and increase in rigidity of vessel wall which causes an increase in blood pressure
peripheral vascular resistance
ability of the vessels to accommodate increased blood flow without also increasing resistance or blood pressure
atherosclerosis
hardening of arteries
contractility
hearts ability to contract efficiently, indicated by the ejection fraction and generally measured in the left ventricle via echocardiogram
decreased CO
decreased contractility causes and decrease in what and blood pressure?
preload
the amount of blood inside the ventricles before they contract
impair contractility
excess preload within the ventricles can cause what and decrease stroke volue?
afterload
amount of resistance or constriction that the heart must overcome to eject the blood into the systemic circulation
hypertrophy
an increase in afterload causes what in the heart and decrease of contractility? Hypertension can also occur
sphygmomanometer (blood pressure cuff)
a tool used to measure blood pressure with a stethoscope (manually done)
manual measurements
are manual measurements of electronic device bp cuffs more accurate
korotkoff sounds
series of sounds created by movement of blood through a partially compressed vessel during a manual bp assessment
thigh
if a nurse cannot use the arm for bp this part of the body is used and a certain bp can be used for it if available. Usually bp higher here than in the arm
falsely high reading
a cuff to tight or small can cause what?
falsely low reading
a cuff to loose or large can cause what?
white coat syndrome
phenomenon where a clients bp increases due to anxiety from health care worker
Extrinsic BP factors
weight; use of stimulants (caffeine and nicotine), medications, sodium, intake, stress, and activity level, emotions can cause temp. elevation
Intrinsic BP factors
Not modifiable such as age, ethnicity, genetics, and natural hormonal variations
A factor that can cause low BP (hypoglycemia)
heart failure
factors that can increase bp
pain and fever;
hypertension
bp that is above the expected reference range, most common. Increases a clients health in heart attack and stroke
causes of hypertension
thickening of arterial vessels walls and a decrease in elasticity which increases peripheral vascular resistance
diagnosis of hypertension
need two elevated readings taken two or more seperate occasion
Elevated
systolic: 120-129diastolic: less than 80
Normal
systolic: less than 120diastolic: less than 80
hypertension stage 1
Systolic: 130-139Diastolic: 80-89
hypertension stage 2
Systolic: 140 or higherDiastolic: 90 or higher
hypertensive crisis
Systolic over 180 or Diastolic over 120
Newborn (full term) BP
64/41
Toddler BP
85-91/37-46 (male)86-89/40-49 (female)
Toddler hypertension
Greater than 103-109/56-65 (male)Greater than 104-107/58-67 (female)
Preschooler BP
91-98/46-53 (male)89-93/49-54 (female)
Preschooler Hypertension
Greater than 109 to 112 / 65 to 72 (male)Greater than 107 to 110 / 67 to 72 (female)
School-age BP
96-106/55-62 (male)94-105/56-62 (female)
School age hypertension
greater than 114-123/74-81 (male)greater than 111-123/74-80 (female)
adolescents BP
Less than 120/80
hypotension
a blood pressure that is below the expected reference range: below 90/60
causes for low blood pressure
dehydration, blood loss, shock, significant illness
symptoms of hypotension
dizziness, nausea, blurred vision, increased pulse, and fatigue
shock
not enough blood circulating around your body; symptoms include cold, pale-skin, rapid breathing and a weak rapid pulse
orthostatic hypotension
drop in blood pressure that occurs when a client rises to a sitting or standing position; caused by dehydration, hypotension, heart failure, or a disorder of the central nervous system. Symptoms include faintness and dizziness
Assessment if a patient has orthostatic hypotension
a nurse takes the patients bp while lying/sitting and then again while standing after 3 min have passed; must have a drop of at lease 20mm Hg in systolic or a 10mm Hg drop in diastolic pressure
interventions for orthostatic hypotension
increase fluid intake orally or via intravenous fluids or compression stockings. Patients should change positions slowly, slightly elevate bed when sleeping and avoid lying or a seated position for an extended period of time.
chest pain
decreased cardiac output resulting from hypotension can cause what?
falsely low measurement
Applying the blood pressure cuff to tightly; using a cuff too large and applying the cuff to loosely on the arm
Falsely high measurement
applying a cuff to small; using a cuff that is too small based on the clients arm circumference; leaving the clients arm unsupported while obtaining the reading:;obtaining the measurement immediately after a client has smoked a cigarette
pulse
rhythmic dilation of the arteries and pulsation of blood flow that occurs with each contraction of the left ventricle.
Sinoatrial (SA) node
intrinsic pacemaker if the heart consisting of a small group of special cells in the right atrium;
Newborn (full term; birth to 28 days) pulse
110 to 160/min
Infant (1 month to 1 year) pulse
90 to 160/min
Toddler (1 to 3 years) pulse
80 to 140/min
Preschooler (3 to 6 years) pulse
70 to 120/min
School-age (6 to 12 years) pulse
60 to 110/min
Adolescent (12 to 20 years) pulse
50 to 100/min
Adult (20 years and older) pulse
60 to 100/min
tachycardia
pulse greater than 100/min; due to exercise, anxiety, certain medications, or use of caffeine/nicotine
managing tachycardia
relaxation techniques such as meditation, yoga, or guided imagery`
The Valsava maneuver
the action of attempting to exhale with the nostrils and mouth, or the glottis increasing pressure in the middle ear nd the chest. As well as pushing on bowel movements to stimulate the parasympathetic nervous system, decreasing the heart rate.
Bradycardia
A pulse that is less that 60/min; usually occurs in people that are physically fit because the heart pumps blood effectively causing for less contraction; if not physically fit, this can cause dizziness, fatigue, shortness of air, chest pain, or confusion
causes of bradycardia
cardiac abnormalities, heart failure, heart muscle, damage, or hypothyroidism
ways to limit physical manifestation within bradycardia
client should change positions slowly; take medications exactly prescribed; keep all scheduled medical appointments, and notify the provider of any changes in health status
Arrythmia
an irregular rhythm or pulse rate outside of the expected reference range
apical pulse
the heart rate that is heard or felt at the apex of the heart, which is located medially to the midclavicular line at the fifth intercostal
children younger that 7 years apical pulse location
fourth intercostal space to left of the sternum
peripheral pulses
palpating areas on the body such as: temporal, carotid, brachial, radial, femoral, popliteal, dorsalis pedis and posterior tibial pulses.
radial pulse
most common area to palpate pulse rate
Assessment of other peripheral pulse rates when...
the client is undergoing a procedure that could affect circulation or the client has manifestations of impaired peripheral blood flow such as cool skin temperature on palpation or an alteration in skin color.
pulse deficit
a difference between the apical and radial pulse rates. This difference indicates a decrease in ventricular contraction or peripheral perfusion
abnormal pulse deficits
aortic rupture, coronary artery disease, or atrial fibrillation can all be causes for what?
How to assess for a pulse deficient
one nurse is taking the apical pulse for a minute while the other nurse takes the radial pulse. Then compare the findings and determine pulse deficit
factors that increase heart rate and affect the pulse deficit
smoking and exercise
Pulse ratings: 0
absent/ nonpalpable pulse
Pulse ratings: +1
weak/diminished pulse
Pulse ratings: +2
normal pulse
Pulse ratings: +3
increased/ strong pulse
Pulse ratings: +4
bounding pulse
Doppler ultrasound stethoscope (DUS)
when a peripheral pulse is nonpalpable or difficult to palpate, this tool is used to auscultate the pulse; a stethoscope fitted with an audio unit and a transducer that amplifies the vascular or other sounds of the body
Body temperature
measurement of the balance of the hear produced by the body and the heat lost to the environment; measured in degrees
core temperature
temperature of the deep tissues within the body
surface temperature
temperature of the skin, fat, and subcutaneous tissue
Normal body temperature
36-38 degrees Celsius (96.8-100.4 degrees F)
thermoregulation
body's natural mechanism for balancing body temperature
conduction
loss of heat due to direct contact with a cooler surface
convection
loss of heat due to air currents
radiation
loss of heat due to indirect contact with, or being in close proximity to, a cooler surface
evaporation
loss of heat via gases due to indirect contact with, or being in close proximity to, a cooler surface
hypothalamus gland
fever is an increase in body temperature above the expected reference range due to an upward shift of the body's natural set point in the what?
fever
temperature of 100.4 F or 38 celcius; considered febrile
afebrile
body temperature within the normal range
hyperthermia
increase in temperature due to the body's inability to stop heat production or to stimulate heat loss; caused by the inability of the hypothalamus ro regulate and maintain temperature
hyperthermia interventions
moving the client to a cooler environment; cold packs; IV fluids
hypothermia
decrease in core body temperature due to extended exposure to cold or the inability of the body to produce heat
Oral Body temperature limitations
Risk of exposure to body fluids; inaccurate if the client, ate, drank, or smoked in the previous 30 min; unusable site for newborns, infants, and young children due to safety concern
Oral body temperature advantages
easily accessible despite client position; accurately measures body surface temperature
Tumpanic membrane body temperature advantages
Easily accessible; rapid results, available in less than 5 seconds; accurately measures core body temperature; result is not altered by the environmental temperature
Temporal artery body temperature limitations
reading is affected by moisture on the skin, such as sweat; inaccurate reading if the client has a head covering or hair on the forehead
Tumpanic membrane body temperature limitations
measurement is inaccurate in clients who have cerumen or ear infection; difficult to obtain accurate result in newborns, infants, and children younger than 3 years due to angle of the eustachian tube; required removal of hearing aids
Temporal artery body temperature advantages
easily accessible despite client position; rapid result' no risk of injury; accurate for all age groups; reflects rapid changes in the body's core temperature
Axillary body temperature advantages
accurate for all age groups; no risk of injury
Axillary body temperature limitations
takes more time to obtain a reading than with other methods; temperature does not reflect rapid changes in core temperature; result may be altered by the environmental temperature
Rectal body temperature advantages
reliable results
Rectal body temperature limitations
risk for injury to rectal mucosa; result can be altered due to presence of stool; generally unpleasant for clients; should not be used for clients who have diarrhea, hemorrhoids', rectal surgery or coagulation disorders
tympanic thermometer
type of electronic thermometer that measure the amount of heat radiating from the tympanic membrane
temporal thermometer
contains infrared sensor tip that measure the temperature of blood flow through the temporal artery
chemical dot thermometer
thin strip of plastics with small dots filled with chemical that when sensitive to temperature changes
temperature sensitive patch or tape
contains liquid crystals that change color based on temperature. Applied directly on dry skin
sublingual
route of medication administration is placed under the tongue and allowed to dissolve
Respiration
the act of breathing consisting of inspiration and expiration
Inspiration
intake of air by the lungs during so as to oxygenate body tissue and support cellular function
expiration
exhale of carbon dioxide' relaxation of the diaphragm and muscles relax
Expansion of the lungs occurs when the
diaphragm contracts and intercostal muscles, pushing the ribs outward and up
respiratory rate
number of breaths taken per minute
eupnea
respiratory rate and rhythm that are within the expected reference range
Newborn (full term; birth to 28 days) respiratory rate
30 to 60/min
Infant (1 month to 1 year) respiratory rate
25 to 30/min
Toddler (1 to 3 years) respiratory rate
25 to 30/min
Preschooler (3 to 6 years) respiratory rate
20 to 25/min
School-age (6 to 12 years) respiratory rate
20 to 25/min
Adolescent (12 to 20 years) respiratory rate
16 to 20/min
Adult (20 years and older) respiratory rate
12 to 20/min
tachypnea
respiratory rate that is a higher than the expected reference range
tachypnea due to pain may be alleviated by
administration of an analgesic with position change and application of ice or heat
Tachypnea due to an exacerbation of asthma
treatment via medication such as a bronchodilator and by maintaining the client in an upright position
bradypnea
respiratory rate lower than the expected reference range; may experience weakness, fatigue, confusion, and impaired coordination
causes of bradypnea
increased intracranial pressure, hypothyroidism, shock, alcohol toxicity, use of opiods/ sedative, and morbid obesity
drug used to help bradypnea due to opioid toxicity
naloxone
apnea
absence of spontaneous respirations; can occur due to opioid toxicity, trauma, or neurologic dysfunction
Cheyne-stokes
irregular respirations and consist of a cycling pattern of breaths ranging from shallow to deep, followed by periods of hyperventilation and episodes of apnea
causes of Cheyne-stokes
increased intracranial pressure, brain tumor, stroke, and heart failure
Kussmaul respirations
regular in rhythm but abnormally deep and rapid
Causes of Kussmaul's
severe metabolic acidosis, commonly diabetic ketoacidosis, or severe kidney disease
retractions
use of accessory muscles in the neck causing tissue to be pulled inward during inspiration
oxygen saturation (SpO2)
percentage of hemoglobin that is saturated with oxygen; indication of the amount of oxygen being transported to body tissues and expressed as a percentage
normal oxygen saturation range
95-100%
pulse oximeter
device used to measure oxygen saturation
ear lobe
are more reliable to get oxygen range within a person who has decreased peripheral perfusion
decreased oxygen saturation levels can be caused by
chronic ling disease, hypothermia, or a decrease in perfusion due to poor cardiac output
dyspnea
sensation of difficult or labored breathing
hypoxia
occurs when not enough oxygen is being supplied to the body's tissues; can cause a decrease in mental alertness and confusion
(DUS) Doppler ultrasonography
a tool to check for a peripheral pulse that is nonpalpable
Altercations that can affect peripheral pulse
hemoglobin and Hct below the reference range; wbc count above the expected range; electrolyte balance which regulate water and acid--based balance
Point of maximal impulse (PMI)
physical location of the apex of the heart and is where the apical pulse is the most audible
blood pressure (BP)
measurement of the amount of pressure exerted by the blood within the circulatory system; mm Hg
low circulating blood volume and is at risk for hypotension
a client who has high HgB and Hct levels is at risk for which of the following?
decrease in clients blood pressure
severe infection (WBC) can cause what?
pulse oximetry (SpO2)
determines the amount of oxygen being transported in arterial blood
can alter pulse oximetry
dark nail polish, acrylic nails, and possibly dark skin
coughing
promotes the expectoration of secretion from the lungs and may improve oxygenation
low oxygenation can lead to what?
respiratory arrest
Assessment/ Data collection
review the clients medical record; allergies, medical history, medications, previous vital signs data, pertinent laboratory values (including arterial blood gasses and hemoglobin and hematocrit levels)
ABG (Arterial Blood Gas)
a blood test that requires a sample from an artery in your body to measure the levels of oxygen and carbon dioxide in your blood, checks for acids and bases known as the pH balance in your blood
hemoglobin and hematocrit levels
provide data about the transport of oxygen within the bloodstream; decreased levels can have a direct effect on the clients respiratory and oxygenation status
indications of altered oxygenation and respiratory status
labored breathing, chest wall retractions, pain with breathing, and the need to sot upright to breathe
environmental factors within a home-care setting
tobacco smoke, allergens, pollutants, and the presence of mold that can affect a clients respirations and respiratory health
positions the client in an upright or elevating the head of the bed allows what?
maximum expansion of the clients thoracic cavity
presence of hypoxia
restlessness, irritability, dizziness, tingling in the hands, confusion, impaired coordination, and cyanosis
temporary elevations in the clients respiratory rate
pain, anxiety, recent physical activity, nicotine, and caffeine
tympanica on an adult
pull the pinna up and back
hot or cold drinks/ food can do what?
fluctuate the temperature within an oral
tympanic on a child less than 3
pull the pinna back and down
capillary refill needs to be less than what?
2 seconds; indicates good perfusion
a cold hand or finger can impede the reading because it would be to ?
low