Quiz

• Vital Signs


  Includes a person's temperature, pulse, respiration, and blood pressure
• Vital Signs


  • They are the signs reflecting the physiologic state which governed the body's vital organs such as the heart, lungs & brain necessary to sustain life
  • They are called "vital" because of the importance of these indicators in predicting the effectiveness of body functions
  • Health status is reflected in these indicators of body functions and regulated through homeostatic mechanisms and falling within the normal range
  • A change in VS indicates a change in physiological functioning or a change in comfort signaling the need for medical or nursing interventions
• When to Measure Vital Signs

  1. Upon admission to a health care facility

  2. When assessing the patient during home visits

  3. Before and after a surgical procedure or invasive diagnostic procedure

  4. Before, during, and after a transfusion of blood products

  5. Before, during, and after the administration of medications or applications of therapies that affect cardiovascular, respiratory, or temperature- control functions

  6. When the patient's general condition changes (loss of consciousness or increased intensity of pain)

  7. Before and after nursing interventions that influence a VS (ROM exercises, and ambulating a client who has been on bed rest)

  8. When the patient reports nonspecific symptoms of physical distress
• Body Temperature


  • It reflects the balance between the heat produced and the heat lost from the body
  • The heat of the body is measured in degrees
  • The difference between the amount of heat produced by the body processes & the amount of heat lost to the external environment
• Types of Body Temperature

  • Core Temperature
  • Surface Temperature
• Core Temperature


  • Temperature of the deep tissues of the body such as abdominal and pelvic cavity
  • Remains relatively constant within a range of 36 C – 37 .4 C
  • Higher than surface temperature
  • Measured @ tympanic or rectal sites, but they may also be measured in the esophagus, pulmonary artery or bladder by invasive monitoring devices
• Surface Temperature


  • Temperature of the skin, subcutaneous tissue and fat
  • Measured at oral and axillary sites
  • Rises and falls in response to the environment
• Body Temperature Assessment Sites

  • Oral
  • Rectal
  • Axillary
  • Tympanic membrane
• Oral Temperature


  • Accessible and convenient
  • Generally measures 0.5 – 0.6 C below core temperature
  • The area under the tongue is in direct proximity to the sublingual artery
  • The most practical clinically preferred method because oral temperature fluctuates more accurately in response to alteration in body heat balance than does rectal temperature
  • Reflects changing body temperature more quickly than the rectal method
  • Contraindications: uncooperative, very young, unconscious, shivering, prone to seizures, or mouth breathers or oral surgery
• Rectal Temperature


  • Most accurate and reliable measurement
  • Rectal temp. differs about 0.1 C from core temperature
  • This can be embarrassing and emotionally traumatic for alert clients and difficult for client who cannot turn to side
  • Used to check for imperforate anus in newborns
  • Contraindications: rectal surgery, diarrhea or hemorrhoids and other diseases of the rectum
• Axillary Temperature


  • Safe and noninvasive
  • Preferred site for the newborns because it is safe and accessible
  • Less potential for spreading microorganisms than oral and rectal sites
  • Some research indicates that this method is inaccurate when assessing fever
  • The thermometer must be left in place longer to obtain an accurate measurement
  • Make sure that the area is dry and not wet with perspiration, deodorants, cream, or the like; do not rub the area dry vigorously as friction will increase the temperature
• Tympanic/Infrared Thermometer


  • Use infrared sensors to detect heat given off by the tympanic membrane
  • The probe is covered w/ a probe cover and inserted into the ear canal tightly enough to seal the opening
  • The reading takes from 1-3 seconds, depending on the product
  • The probe contains an infrared sensor that detects the warmth radiating from the tympanic membrane and converts the heat into a temperature measurement
• Normal Range of Body Temperature by Site


  • Oral: 97.6 - 99.6 F (36.5 – 37.4 C)
  • Rectal: 98.6 – 100.6 F (37.0 – 38.1 C)
  • Axilla: 96.6 – 98.6 F (36.0 – 37.0 C)
• Digital Thermometer


  • Works by using heat sensors that determine body temperature
  • Looks similar to a glass thermometer & can be used at oral, axillary, and rectal sites
  • It has an on/off button, and a display that lights up during use
  • The battery used to operate the thermometer requires occasional replacement
  • It takes 1-60 seconds to measure body temperature, depending on the site and product used
  • Requires cleansing similar to glass thermometer except that it is wiped rather than soaked w/ alcohol
• Fever/Pyrexia/Hyperthermia


  • Body temperature above the usual range
  • Occurs because heat loss mechanisms are unable to keep pace w/ excess heat production
  • Not harmful if it stays below 39 C in adults or 40 C in children
  • Results from a response to bacterial or viral infection and in response to tissue injury
  • Febrile - client's w/ fever
  • Afebrile - clients without fever
  • Hyperpyrexia - a very high fever with body temperature of 41 ºC
• Hypothermia


  • Core body temperature below the lower limit
  • Physiologic mechanisms: excessive heat loss, inadequate heat production to counteract heat loss, impaired hypothalamic thermoregulation
• Types of Fever


  • Intermittent fever
  • Remittent fever
  • Continuous fever
• Fever/pyrexia/hyperthermia


  Body temperature above the usual range
• Fever


  • Occurs because heat loss mechanisms are unable to keep pace with excess heat production
  • Not harmful if it stays below 39 C in adults or 40 C in children
  • Results from a response to bacterial or viral infection and in response to tissue injury
• Febrile


  Client's with fever
• Afebrile


  Clients without fever
• Hyperpyrexia


  A very high fever with body temperature of 41 ºC
• Hypothermia


  Core body temperature below the lower limit
• Hypothermia


  • Physiologic mechanisms: excessive heat loss, inadequate heat production to counteract heat loss, impaired hypothalamic thermoregulation
• Pulse


  • A wave of blood created by contraction of the left ventricle of the heart
  • A throbbing sensation that can be palpated over a peripheral artery or auscultated over the apex of the heart
  • Produced by the movement of blood during heart's contraction
  • The distention or pulsation of arteries produced by the wave of blood forced into them by the heart's left ventricular contraction or by the pumping action of the heart
• Pulse Sites


  • Temporal
  • Carotid
  • Apical
  • Brachial
  • Radial
  • Femoral
  • Popliteal
  • Posterior Tibial
  • Dorsalis Pedis/Pedal
• Pulse Rate


  • The number of pulsations felt over a peripheral artery or normally heard over the apex of the heart per min
  • Normally corresponds to the same rate at which the heart is beating
  • Normal range = 60-100 beats/min (adult & adolescence at rest)
• Tachycardia


  Rapid pulse rate, a pulse rate of an adult that exceeds 100 beats/min at rest, can exceed 150 beats/min during exercise
• Palpitation


  Awareness of one's own heart contraction and can accompany tachycardia
• Bradycardia


  Slow pulse rate, a pulse rate of an adult less than 60 beats/min
• Rhythm/Regularity


  The pattern by which the heart beats are spaced, normally regular with each beat
• Dysrhythmia/arrhythmia


  An irregular pattern/rhythm of heartbeats
• Bigeminal


  Pulse has occasional premature beats, resulting in a shorter interval between beats followed by a longer interval
• Pulse Volume/Amplitude


  Reflects the strength of left ventricular contraction, quality of pulsation felt usually is related to the amount of blood pumped with each heartbeat, or the force of heart contraction
• Types of Pulse Volume

  • Absent pulse
  • Thready pulse
  • Weak pulse
  • Normal pulse
  • Bounding pulse
• Pulse Oximeter


  A non-invasive device that measures a client's arterial blood oxygen saturation by means of sensor attached to the client's finger, toe, nose or forehead. It indicates oxygen saturation measurement and pulse rate.