HA LEC M2

• Vital signs


  Considered to be the signs of life, important body functions such as breathing and heartbeat that are measured to see if someone is alive or healthy
• Body temperature


  Reflects the balance between the heat produced and the heat lost from the body, and is measured in heat units called degrees
• Temperature measurement


  Measured in Celsius or Fahrenheit, with a fever defined as greater than 38-38.5 C or 101-101.5 F
• Two kinds of body temperature

  • Core temperature
  • Surface temperature
• Core temperature


  • The temperature of the deep tissues of the body, such as the abdominal cavity and pelvic cavity
  • Rises and falls in response to the environment
• Surface temperature


  • The temperature of the skin, the subcutaneous tissue, and fat
  • Remains relatively constant
• The normal core body temperature is a range of temperatures
• Factors that affect the body's heat production

  • BMR
  • Exercise
  • Secretion of Thyroxine
  • Epinephrine/norepinephrine
  • Inflammation/Fever
• Heat loss


  • Radiation
  • Conduction
  • Convection
  • Evaporation
• Factors affecting body temperature

  • Age
  • Diurnal Variations (Circadian Rhythms)
  • Exercise
  • Hormones
  • Stress
  • Environment
• Variances in temperature


  • Fever (pyrexia)
  • Hyperpyrexia
• Fever (pyrexia) is an abnormally high body temperature (>100.4 or 38.0 C) that occurs in response to pyrogens (bacteria)
• Pyrogens induce secretion of prostaglandin that reset the hypothalamic thermostat to a higher temperature
• Physiologic responses to temperature increases

  • Immune system stimulates hypothalamus to new set point
  • Chills, shivers
  • Metabolism increases
  • O2 consumption increases
  • HR and RR increase
  • Energy stores are used
  • Dehydration and confusion
  • Vasodilation
  • Warm flushed skin and diaphoresis
• When the cause is removed, the set point drops
• Fever activates the immune system, stimulates antibody production, and fights viruses by stimulating interleukin
• Fever serves as a diagnostic tool
• Serious variations in temperature

  • Heat stroke
  • Hypothermia
• Heat stroke is caused by prolonged exposure to heat and depression of the hypothalamus, and is an emergency with symptoms of hot, dry skin, confusion, and delirium
• Hypothermia is below 95 degrees, with uncontrolled shivering, loss of memory, and loss of consciousness
• The normal temperature range is 77-109 degrees F or 25-42.77 C
• Pulse


  The wave felt caused by the expansion and distention of the arterial walls as the blood is forced into the aorta and then into the smaller arteries each time heart beats
• Pulse


  A wave of blood created by contraction of the left ventricle of the heart
• Pulse


  1. The wave begins when the left ventricle contracts and ends when the ventricle relaxes

  2. Indirect measure of cardiac output
• Systole


  Peak of the wave; contraction of the heart
• Diastole


  Resting phase of the heart
• Pulse Characteristics


  • Rate
  • Rhythm
  • Volume
  • Tension
• Pulse Rate


  The number of beats per minute (60-100 beats/min.)
• Tachycardia


  Over 100 beats/minute
• Bradycardia


  Below 60 beats per minute
• Pulse Rhythm


  • Regular - time between beats is essentially the same
  • Arrhythmia - interval between beats is irregular
• Pulse Volume


  • Normal - if compressed artery is full to touch and pulsations are strong
  • Imperceptible - if pulsations cannot be felt
  • Thready/Feeble - if pulsations can be easily obliterated
  • Bounding - if pulsations reaches a higher level than normal then disappears again
• Pulse Tension


  • High tension - obliterated only by relatively great pressure
  • Low tension - easily obliterated, even under slight pressure
• Obtaining Pulse Rate


  1. Apical is most accurate

  2. Use a standard stethoscope to auscultate the number of heartbeats at the apex of the heart

  3. A heartbeat is one series of the LUB and DUB sounds
• Pulse Sites


  • Radial - inner aspect of the wrist on the thumb side
  • Temporal - superior and lateral to the eye
  • Carotid - side of the neck, near the angle of the jaw
  • Brachial - inner aspect of the biceps muscle, a few centimeter below the axilla on the inner aspect of the arm
  • Femoral - middle of the groin
  • Popliteal - behind the knee, along the center of the popliteal space
  • Posterior tibial - the groove between the achilles tendon and the tibia just above the medial malleolus then pressing toward the tibia
  • Dorsalis pedis - pedal pulse; at the instep of the foot on an imaginary line drawn from the middle of the ankle to the interdigital space between the big and second toe
• Common Pulse Points


  • Temporal
  • Apical: at the apex of the heart
  • Carotid: between midline and side of neck
  • Brachial: medially in the antecubital space
  • Radial: laterally on the anterior wrist
  • Femoral: in the groin fold
  • Popliteal: behind the knee
  • Post tibial
  • Dorsalis pedis
• Variances in Pulse Rate

  1. Apical –Radial Pulse: Apical Pulse is counted at the apex of the heart while another nurse counts the radial pulse. This is done simultaneously for one full minute

  2. Pulse Deficit: the difference between the apical and radial pulse
• Bradycardia


  Rate less than 60 bpm
• Tachycardia


  Rate more than 100 bpm
• Variances in Pulse Rate

  • Is the rate regular?
  • What is the quality? - Bounding?
  • - Thready?