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Times to Assess
On admission to a health care agency to obtain baseline data
When a client has a change in health status or report symptoms
Before and after surgery
Before and/or after the administration of a medication that could affect
respiratory or cardiovascular system
Before and after any nursing intervention that could affect vital signs (e.g
ambulating a client who has been on bed rest)
Reflects the balance bet. the heat produced and the heat lost from the body
Measured in heat units called degrees
Heat is by-product of metabolism
Heat balance is When the amount of heat produced by the body equals the
amount of heat loss
Radiation
Kinds
Core temperature
Decrease w/ age
Muscle activity
Directly affect the liver and muscle cells, thereby increasing cellular
metabolism
Fever
Hypothalamic integrator
3. Exercise
Hard work or strenuous exercise can increase body temp. to as high as 38.3
degree C to 40 degree C measured rectally
4. Hormones
Women usually experience more hormone fluctuations than men
In women, progesterone secretion at the time of ovulation raises body temp.
by about 0.3 degree C to 0.6 degree C above basal temp.
5. Stress
Stimulation of sympathetic NS can increase production of epinephrine and
norepinephrine thereby increasing metabolic activity and heat production
6. Environment
Signs :
o
Paleness
o
Fainting
o
Dizziness
o
Moderately increased temp.
o
N/V
Heat stroke
Remove excess blankets when client feels warm but provide extra warmth
when the client feels chilled
Provide adequate nutrition and fluids to meet the increased metabolic
demands and prevent dehydration
Measure I and O
Reduce physical activity to limit heat production , esp. during the flush stage
Administer antipyretics as ordered
Provide oral hygiene to keep the mucous membranes moist
Provide TSB to increase heat loss through conduction
Provide dry clothing and bed linens
Hypothermia
Induced hypothermia
o
Lowering of the body temp. to decrease the need of oxygen
by the body tissues such as during certain surgeries
Accidental hypothermia
o
Exposure to cold environment
o
Immersion in cold water
o
Lack of adequate clothing , shelter or heat
use of sedatives
Frostbite
o
If skin and underlying tissues are damaged by freezing cold
o
Most commonly occurs in hands, feet, nose and ears
Disorientation
Hypotension
I. Oral
Nurse should wait 30 min. if client has been taking cold or hot food or fluids
or smoking to ensure that temp. of mouth is not affected by the temp.
of the food or warm smoke.
Advantages :
Accessible and convenient
Disadvantages :
Can break if bitten
Inaccurate if pt has just ingested hot or cold flood, etc.
Could injure the mouth following oral surgery
II. Rectal
Considered to be very accurate
Contraindicated for clients who are undergoing :
o
Rectal surgery
o
Immunosuppression
o
Diarrhea
o
Clotting disorder
o
Disease of the rectum
o
Hemorrhoids
Advantages :
Reliable measurement
Disadvantages :
Inconvenient
Could injure the rectum ff rectal surgery
More unpleasant for pt
Presence of stool may interfere w/ thermometer placement
Difficult for pt who cannot turn to the side
III. Axilla
Preferred site for measuring temp. in newborns because it is accessible and
safe
Advantages :
Safe and noninvasive
Disadvantages :
Thermometer must be left in place a long time to obtain an accurate
measurement
IV. Tympanic membrane
Nearby tissue in the ear canal
Frequent site for estimating core body temp.
Has an abundant arterial blood supply , primarily from the branches of
external carotid artery
Advantages :
Readily accessible
Reflects the core temp.
Very fast
Disadvantages :
Can be uncomfortable
Involves risk of injuring the membrane if the probe is inserted too far
Repeated measurements may vary
R and L measurements can differ
Presence of cerumen can affect the reading
V. Temporal artery
Using a chemical thermometer or a temporal artery thermometer
Most useful for infants and children
Advantages :
Safe and noninvasive
Very fast
Disadvantages :
Requires electronic equipment that may be expensive or unavailable
Variation in technique needed if the pt has perspiration on the forehead
Lifespan considerations
Infants
Children
For a rectal temperature , place the child prone across your lap
or in a side lying position w/ the knees flexed. Insert
thermometer 1 inch from the rectum
Pinna back and up children over 3 years of age
Pinna back and down children under 3 years of age
Elders
Pulse
heart
Represents the Stroke volume output , the amount of blood that
Compliance
Apical
Cardiac Output
S1 (lub)
Occurs when AV valves close after the ventricles have been
sufficiently filled
S2 (dub)
When the SV valves close after the ventricles empty
Peripheral pulse
Central pulse
Age
Gender
After puberty, average males pulse rate is slightly lower than the females
Exercise
Fever
Radial
Cardiotonics (e.g digitalis preparations) decrease the heart rate
Epinephrine increases heart rate
Where the radial artery runs along the radial bone on the
thumb side of the inner aspect of the wrist
Femoral
Loss of blood from the vascular system normally increases pulse rate
Medications
Hypovolemia
Stress
Position changes
Pathology
Pulse Sites
Variations in Pulse and Resp by Age
Temporal
Carotid
Pulse Average
(and ranges)
130 (80-180)
Respirations
average (and
ranges)
35 (30-80)
120 (80-140)
30 (20-40)
100 (75-120)
20 (15-25)
10 years
70 (50-90)
19 (15-25)
Teen
75 (50-90)
18 (15-20)
Adult
80 (60-100)
16 (12-20)
Older Adult
70 (60-100)
16 (15-20)
Assessing pulse
Presence or absence of Nurse should also assess the corresponding pulse on the oth
the bilateral equality
vessel
Pulse is normally palpated by applying moderate pressure w/ the 3
middle fingers of the hand
o
W/ Excessive pressure one can obliterate a pulse
o
W/ Too little pressure one may not be able to detect it
Any baseline data about the normal heart rate for the pt
Lifespan considerations
Infants
Rate
Tachycardia
Excessively fast heart rate
Over 100 BPM
Bradycardia
Less than 60 BPM
Children
Rhythm
Normal pulse
Has equal time periods bet. beats
Volume
Use the apical pulse for the heart rate of newborns , infants, and
children 2 to 3 years old
Place a baby in supine position , and offer pacifier if the baby is
crying or restless . Crying and physical activity will increase the
pulse rate
Locate the apical pulse in the 4th ICS , lateral to the MCL during
infancy
Brachial, popliteal, and femoral pulses may be palpated . Due to
normally low BP and rapid heart rate , infants other distal pulses
may hard to feel
May have heart murmurs that are not pathological but reflect
functional incomplete closure of fetal heart structures
Dysrhythmia/ Arrhythmia
Pulse w/ an irregular rhythm
Elders
May consist of random , irregular beats or a predictable pattern of irregular
beats
If the pt
has severe hand or arm tremors , the radial pulse may
(regularly irregular)
be difficult to count
When detected , apical pulse should be assessed
Normal pulse
Can be felt w/ moderate pressure of the fingers
Can be obliterated w/ greater pressure
Pressure is equal w/ each beat
Full /bounding pulse
A forceful or full blood volume that is obliterated only w/ difficulty
Weak, feeble, or thready
A pulse that is readily obliterated w/ the pressure from the fingers
Respirations
Respiration
Act of breathing
Inhalation / Inspiration
Types
Costal (thoracic) breathing
Involves external intercostal muscles and other accessory muscles such as
the sternocleidomastoid muscles
Can be observed by the movement of the chest upward and outward
Diaphragmatic breathing
Involves contraction and relaxation of the diaphragm
Can be observed by the movement of abdomen
Increase :
Audible w/o
Amplification
Respiratory depth
Gen. described as normal, deep, or shallow
Deep respiration
Shallow
respiration
Tidal volume
Supine position
Hyperventilation
Secretions and
Coughing
Breathing Patterns
Rate
Hypoventilation
Resp. rhythm
Volume
than an adults
Rhythm
( Regularity of the
expirations and
inspirations )
Assessing Respirations
Exercise and Anxiety
Ease or effort
Blood Pressure
Lifespan considerations
Infants
Children
Elders
arteries
Measured in millimeters of mercury (mm Hg)
Can vary considerably among individuals
It is important for nurse to know a specific pts baseline BP
Pulse pressure :
Difference bet. the diastolic and systolic pressure
Normal is about 40 mm Hg
A consistently elevated pulse pressure occurs in arteriosclerosis
Low pulse pressure occurs in conditions such as severe heart failure
Determinants
Pumping Action
of the heart
Peripheral
Vascular
Resistance
Blood Volume
Blood Viscosity
Factors affecting BP
Primary hypertension
Elevated BP of unknown cause
Age
Exercise
Stress
Race
Gender
Assessing BP
Medications
BP is measured with :
Blood pressure cuff consists of a rubber bag that can be inflated w/ air
called bladder
Obesity
Both childhood and adult obesity predispose to hypertension
One tube connects to a rubber bulb that inflates the bladder
A small valve on the side of the bulb traps and releases the air in the
bladder
Diurnal variations Pressure is lowest early in the morning , when the metabolic rate is lowest
Other tube is attached to a sphygmomanometer w/c indicates pressure of
Pressure rises throughout the day and peaks in the late afternoon or early in the
the air within the bladder
evening
Doppler Ultrasound stethoscopes are also used when BP sounds are difficult
to hear such as in infants, obese clients, and clients in shock
Disease process
Any condition affecting CO, blood volume, blood viscosity and/or compliance
of sphygmomanometer :
2 Types of
arteries has a direct effect on BP
Aneroid sphygmomanometer
A calibrated dial w/ a needle that points to the calibrations
Classification of BP
Category
Systolic BP mm Hg
Normal
<120
< 80
Prehypertension
120-139
80-89
Hypertension , stage 1
140-159
90-99
Hypertension , stage 2
> 160
>100
Hypertension
BP that is persistently above normal
Diagnosed as an elevated BP w/c is measured twice at diff times
Factors associated :
o
Thickening of the arterial walls w/c reduces the size of the
arterial lumen
o
Inelasticity of the arteries
o
Lifestyle factors :
Cigarette smoking
Methods
Direct (invasive Involves insertion of a catheter into the brachial, radial, or femoral artery
monitoring)
Arterial pressure is represented as wavelike forms displayed on a monitor
With correct placement, this pressure reading is highly accurate
1 . Auscultatory method
Most commonly used in hospitals, clinics, and homes
Error
Required equipment is a sphygmomanometer , a cuff and a stethoscope
Korotkoffs sound
Deflating cuff too quickly
When taking a BP using a stethoscope , nurse identifies phases in the series of sounds
First the nurse pumps the cuff up to about 30 mm Hg above the point where the pulse is
no longer felt that is point when the blood flow in the artery is stopped
Then the pressure is released slowly (2 to 3 mm Hg per sec. )
Deflating cuff too slowly
Nurse observes the readings on the manometer and relates them to the sounds heard
through stethoscope
Five phases occur but may not always audible
Phase 1
The pressure level at w/c the first faint , clear tapping or thumping sounds are
heard
Arm above level of the heart
These sounds gradually become more intense
To ensure that they are not extraneous sounds, the nurse should identify at least 2
consecutive tapping sounds
Assessing immediately after a meal
The first tapping sound heard during deflation of cuff is the systolic BP
or while pt smokes or has pain
Phase 2
Period during deflation when the sounds have a muffled, whooshing, or swishing quality
Failure to identify auscultatory gap
Phase 3
Period during w/c the blood flows freely through an increasingly open artery
Sounds become crisper and more intense
Assume a thumping quality but softer than in phase 1
Phase 4
Phase 5
Effect
Erroneously high
Erroneously low
Erroneously high
Erroneously high
Erroneously high
Inconsistent measurements
Erroneously low
Erroneously high