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Vital Signs

Module D Lee- 102 Vital Signs -Calhoun

96.8-100.4 Adult Temperature
98.6 Young Child
96.8 Older Adult
Labor-Delivery: T, P, R, B/P T=WNL, P=Increased, R=Increased, B/P=Slight Increase
Pregnancy: T, P, R, B/P T and P= Slight Increase, R and B/P= WNL
Post-Partum: T, P, R, B/P Increased up to 100.4, P= Transient, R and B/P= WNL
Newborns AX Temperture: 95.9-99.5
Newborns Pulse: 120-160
Newborns Respirations: 30-60
Newborns B/P: Systolic= 63/70 Diastolic= 40/50
F.H.R. Pulse: 120-160
Young Child/Pulse: Average 90
Young Child/Respirations: 20-30
Young Child B/P 95/65
Older Adult/Pulse: >80
Older Adult/Repirations: 12-20
Older Adult B/P Sysolic 140/160 Diastolic 80/90
Adult Pulse Pressure: 30-50 mm Hg
When should vital signs be taken? before, during, & after giving blood, ambulation, & change in mental status
If Md orders medications that effect cardiovascular system.. Nurse will need to... Monitor pulse or B/P & Teach patient how to take V/S & the importance
This is an essential ingredient to determine pts health status.. Vital Signs
Who teaches Techs about Vital Signs or other deligatable care for the patient... Nurse
Baseline measurement ... give us V/S we can compare future V/S with.
When would you have another nurse recheck V/S? If there abnormal
Report abnormal V/S to... MD or Charge Nurse
....cannot shiver!!! Neonate
Radiation Transfer of heat without direct contact of two surfaces.
Conduction Transfer of heat to another object during contact.
Convection Transfer of heat away by air movement.
Evaporation Conversion of liquid to a gas
Core Temperature Most accurate reading that comes from the deep tissues in the body.
Loss 30% of heat through head... Newborn's
Hypothermia Range for older adults ... 94 degrees & below
Vasomotor Controls Hot flashes, vasoconstriction & vasodialation
This can alter temperature set points... Disease
Temperature is lowest at... 1:00 AM To 4:00 AM
Temperature is highest at... 10:00 AM To 6:00 PM
Normally changes 0.9 to 1.8 degrees... In a 24 hour period
Rectal Temperature lubercate... 1 to 1 1/2" adult
Hold in place for 3 minutes.. Axillae thermometer
Tympanic Membrane taken with right hand in.. right ear or (left handed/left ear)Point speculum toward nose, small figure 8 in ear.
Pull ear pinna backward, up, & out... Adult
Pull pinna down & back... Child 3 or older
Pull pinna up & back... Child older than 3
Don't use Oral Temperature on these patient's.. Surgery, trauma, Epilepsy, Confused, Unconscious, Uncooperative, Shaking, Chills, Infants & Small children.
Temperature affected by theses... Ingestion of fluids/food, smoke, & oxygen delivery.
May lag behind core temperature during rapid temperature changes.... Rectal, Axillae, Cutaneous Temperatures
Not recommended to detect temperature in Infants & Young Children... Axillae
Not recommended to detect temperature in Infants & Young Children... Axillae
Not use for routine V/S in newborns (birth to 8 weeks) Rectal temperature
Axillae can be used for.. Newborns & uncooperative patients
Accurate Core Reading, very rapid measurement (2 to 5 secs), & can be used for tachypnea patients.... Tympanic Membrane
Not accurate core temp. after exercising... Tympanic Membrane
Cannot obtain continuous measurements... Tympanic Membrane
Provides continuous readings & can be used on neonates... Cutaneous Temp. Site
Sweating , environmental temp, chill phase of fever cause it to be unreliable... Cutaneous Temp. Site
Hypothalamus Controls body temperatures "Set Point"
Anterior Hypothalamus controls.. heat loss
Posterior Hypothalamus controls.. heat production
Hyperpyrexia Fever (not harmful if stays under 102.2 F)Pulse & Respirations increase
Malignant Hyperthermia: Hereditary, Uncontrolled heat production when susceptible people receive certain anestetics.
Heat Exhaustion: Environmental heat exposure, profuse diaphoresis excess loss of H20/Electrolytes, S/S:Increased heart rate, dry mucous membranes, thirst, lethargy, poor skin turgor, & confusion; Place in cooler environment, give fluids/elctrolytes.
Heat Stroke: Emergency!!! Treat Immediately!! S/S: hot, dry skin, confusion, delirium, incoherent, may be unresponsive; Place them out of the sun, fan person, pour cool water on them & PO fluids Call 911
Heat Stroke: Emergency!!! Treat Immediately!! S/S: hot, dry skin, confusion, delirium, incoherent, may be unresponsive; Place them out of the sun, fan person, pour cool water on them & PO fluids Call 911
Pulse Palpable bounding of blood flow in the peripheral arteries. Indicates circulatory status.
Assess pulse for... Rate, Rhythm, Strength, & Equality
Rate Beats per minute
Rhythm The pattern of the beats & the intervals between the beats (Regular or Irregular)
Strength The force of blood against the arterial wall with each beat.
Equality Compare one side to the other side (should be the same (Symmetrical)
Pulse site used in children when radial not accessible.. Temporal pulse
Pulse site used during physological shock or Cardiac arrest... Carotid pulse & (Femoral Pulse if Carotid not palpable)
Pulse site best for infants or young children up to age 3.... Brachial & Apical
This Pulse site is used to determine discrepancies with radial pulse.... Apical Pulse
If abnomal/intermittent, or inaccessible use this pulse site... Apical Pulse
Assessment of these two pulse sites reveal heart rate variations.... Peripheral & apical Pulse
This pulse site provides a more accurate assessment of heart functions when patient takes medications that effect the heart rate... Apical Pulse
Provides a more accurate assessment of cardiac contraction... Apical Pulse
Pulse sites used to Assess circulation to hand ... Radial & Ulnar Pulse
Pulse site routinely used... Radial Pulse
Pulse sites used to Assess circulation to hand ... Radial & Ulnar Pulse
Pulse site routinely used... Radial Pulse
How do you get a childs heart who has sinus dysrhythmia to become regular? Have child hold breath
Some Drugs, Anxiety, Fear, Stress, Fever, Heat, emotions, Hemorrhage, COPD, acute pain & standing or sitting cause the heart rate, cardiac output, Peripheral vascular resistance & Pulse to.... Increase
Some Drugs, Hypothermia, chronic pain & lying down causes the heart rate & pulse to... Decrease
Regular Pulse: is when a regular interval occurs between each pulse or heart beat (count for 60 sec or 30 sec x 2)
Tachycardia: Abnomally elevated heart rate, >100 beats per minute in adults
Bradycardia: Slow rate, < 60 beats per minute in adults
Pulse Deficit: is an inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site.(Frequently associated with dysrhythmias)
Nurse does what if there is a pulse deficit? Compare apical & radial rates simultaneously to determine if a pulse deficit exists (two nurse assessing at same time)
An Irregular heart rhythm has been detected what should the nurse do next no one else is available to help her... One examiner technique- Auscultate the apical pulse first & then the radial pulse immediately after. Report abnormal pulse rate to physician immediately!
Apical rate 90 & Radial rate is 70 what is the pulse deficit? 20 is the pulse deficit (90-70=20)
Scale for measuring pulse Volume 0-4+ 0- absent,not discernible, 1+ Pulse diminished, barely palpable, 2+ Normal, easily palpable, 3+ Full pulse, increased, 4+ Strong, Bounding, Cannot be obliterated
Respiration The exchange of Gases between the atmosphere & the blood, & the blood & the cells.
Diaphragmatic Abdominal or normal pattern of exhalation & inhalation in which the ventilatory works done in the diaphragm.
Dyspnea Breathing is difficult characterized by increased effort to inhale & exhale. (uses intercostal & accessory muscles)
Hyperpnea Increase in depth & rate >20/min
Bradypnea Regular, decreased < 12/min
Tachypnea Regular, > 20/min
Hyperventilation Increased depth & rate, (excessive intake of 02 & blowing off of Co2, seen with increased anxiety.)
hypoventilation rate is abnormally low & depth depressed
Kussmaul Abnormally deep, but regular, increased rate
Biot's Shallow breathing interrupted by irregular periods of apnea, condition of CNS, increased intracranial pressure followed by irregular period of apnea.
Cheyne Strokes Irregular rate, alternating periods of apnea & hyperventilation.
End of life breathing also known as... Cheyne stokes
Depth Deep or Shallow
Systolic Maximum pressure
Diastolic Minimum pressure
Systolic pressure 120 minus diastolic pressure 80 what is the pulse pressure? 40 mm/Hg (120-80= 40)
Peripheral Resistance The smaller the lumen the greater peripheral vascular resistance to blood flow. As resistances rises, arterial blood pressure rises. As vessels dilate & resistance falls, blood pressure drops.
Blood Volume If blood volume increases, more pressure is exerted against arterial walls & B/P increases.
Example of Blood Volume: Rapid infusion of IV fluids elevates blood pressure. When circulating blood volume falls, as in hmorrhage or dehydration, blood pressure falls.
Viscosity thickness of blood affects the ease with which blood flows thru small vessels. The hematocrit (HCT), or % of RBC's in the blood, determines blood viscosity.
Elasticity Normal wassl of the artery are elastic & easily distensible. As pressure within the arteries increases, the diameter of the vessel walls increase to accommodate the pressure changes.
Cardiac Cycle Consist of two phases.. Systole & Diastole
Systole The ventricles contract & eject blood from the left ventricle into the aorta & from the right ventricle into the pulmonary artery.
Diastole The ventricles relax & the atria contract to move blood into the ventricles & fill the coronary arteries.
Events on the.... of the heart have the most dramatic effect on assessment findings. left side
Body size & age would be considered with respect to... B/P level
Advancing age in adults causes B/P to... Increase
Hypertension is higher, genetically & environmentally related in.. African Americans
This med lowers B/P... Antihypertensive & Narcotic analgesics
Diural variation B/P gradually rises & falls throughout the day & night. No two persons have the same pattern or degree of variation.
Purberty & Menopause cause B/P readings to be... Higher
Most common B/P problem & considered the silent killer... Hypertension 140/90 & above
Prehypertension B/P... 128/84
Hypotension B/P... systolic 90 mm/Hg or below
S/S of Hypotension: Pallor, skin mottling, clamminess, confusion, increased heart rate, decreased urine output, Report to doctor immediatly
Orthostatics or (TILTS) measure B/P between each position change & document each. (1 to 3 minutes between each)LYING, SITTING, & STANDING
Stroke value times Heart Rate = Cardiac output 60x72= 4320
The amount of blood ejected from the left ventricle each minute at adult rest.. Cardiac Output
Created by: maliakaye5
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