1 chapter 8 vital signs. 2 t--temperature p--pulse r--respiration bp--blood pressure

11

Chapter 8Chapter 8

Vital SignsVital Signs

22

Vital Signs

T--temperature

P--pulse

R--respiration

Bp--blood pressure

33

vital signsvital signs

reflect the body’s physiological statusreflect the body’s physiological status

present conditionpresent condition

provide information to evaluate homeostatic provide information to evaluate homeostatic

balance in statusbalance in status

be a quick and efficient waybe a quick and efficient way

to monitor a patient’s condition to monitor a patient’s condition

to identify problems to identify problems

to evaluate the patient’s response to interventionto evaluate the patient’s response to intervention

44

vital signsvital signs Vital signs and other physiological Vital signs and other physiological

measurements are the basis for clinical measurements are the basis for clinical

problem solving. problem solving. An alteration in vital signs may signal the An alteration in vital signs may signal the

need for medical or nursing intervention.need for medical or nursing intervention.

--Vital signs should be taken at regular intervals. --Vital signs should be taken at regular intervals.

--As nurses we should--As nurses we should

know the relevant knowledge about vital signsknow the relevant knowledge about vital signs

be able to measure vital signs accuratelybe able to measure vital signs accurately

interpret their significanceinterpret their significance

make decisions about interventionsmake decisions about interventions

55

SectionSectionⅠⅠ Guidelines for Taking Vital SignsGuidelines for Taking Vital Signs

1. select equipment :1. select equipment : be functional and appropriate be functional and appropriate based on the patient’s condition and characteristicsbased on the patient’s condition and characteristics

2. know the patient’s normal range of vital 2. know the patient’s normal range of vital

signssigns ---serve as a baseline for comparison with ---serve as a baseline for comparison with findings taken later findings taken later

3. know the patient’s medical history, 3. know the patient’s medical history, therapies, and prescribed medicationstherapies, and prescribed medications

Some illnesses or treatments cause predictable vital Some illnesses or treatments cause predictable vital sign changes. sign changes.

Most medications affect at least one of the vital signs.Most medications affect at least one of the vital signs.

66


4. control or minimize environmental factors 4. control or minimize environmental factors

may affect vital signs may affect vital signs

5. use an organized, systematic approach 5. use an organized, systematic approach

when taking vital signswhen taking vital signs

---each procedure requires following a step-by-step ---each procedure requires following a step-by-step

approach to ensure accuracyapproach to ensure accuracy

6. the frequency of vital signs assessment6. the frequency of vital signs assessment --based on the physician and the patient’s condition--based on the physician and the patient’s condition

77


7. use vital sign assessment to determine 7. use vital sign assessment to determine

indications for medication administrationindications for medication administration

----cardiac drugs----cardiac drugs

8. analyze the results of vital sign 8. analyze the results of vital sign

measurementmeasurement--not interpret them in isolation--not interpret them in isolation

9. verify and communicate significant changes 9. verify and communicate significant changes

in vital signsin vital signs

88

SectionSectionⅡⅡ Body Temperature Body Temperature

Physiology of Body TemperaturePhysiology of Body Temperature

Factors Affecting Body Temperature Factors Affecting Body Temperature

Alterations in Body TemperatureAlterations in Body Temperature

Nursing Process and Nursing Process and

ThermoregulationThermoregulation

99

Physiology of Body TemperaturePhysiology of Body Temperature

Definition of body temperatureDefinition of body temperature

Heat production and heat lossHeat production and heat loss

Regulation of body temperatureRegulation of body temperature

Average temperature and normal ranAverage temperature and normal ran

ge of adultge of adult

1010


Body temperature is the heat of the Body temperature is the heat of the

bodybody..-- reflects the balance between -- reflects the balance between

the amount of heat produced by body the amount of heat produced by body

processes processes

the amount of heat lost to the external the amount of heat lost to the external

environmentenvironment

1111


core temperature :core temperature : temperature of deep temperature of deep

tissues (cranium, thorax, abdominal and tissues (cranium, thorax, abdominal and

pelvic cavity ), relatively constant pelvic cavity ), relatively constant

Surface temperature :Surface temperature :the temperature of the the temperature of the

skin, the subcutaneous and the fat tissue , skin, the subcutaneous and the fat tissue ,

fluctuates from 36fluctuates from 36℃℃ to 38 to 38℃℃

1212

Heat ProductionHeat Production

Heat is produced in the body through Heat is produced in the body through

metabolism. metabolism.

The main heat production organs of the The main heat production organs of the

body are liver and skeletal muscles.body are liver and skeletal muscles.

Heat production occurs duringHeat production occurs during rest, voluntary rest, voluntary

movements, involuntary shivering, and nonshivering movements, involuntary shivering, and nonshivering

thermogenesis(brown adipose).thermogenesis(brown adipose).

1313

Heat LossHeat Loss

Heat is lost through physical mode. The main Heat is lost through physical mode. The main

heat loss part of the body is skin.heat loss part of the body is skin. (70%)(70%)

(R29%,elimination1%)(R29%,elimination1%)

RadiationRadiation

ConductionConduction

ConvectionConvection

EvaporationEvaporation

1414

RadiationRadiation

Radiation is the transfer of heat between Radiation is the transfer of heat between

two objects without direct contact by two objects without direct contact by

electromagnetic waves.electromagnetic waves. Heat radiates from the skin to any Heat radiates from the skin to any

surrounding cooler object.surrounding cooler object. increase T difference between two objects increase T difference between two objects

Increase radiating surface area heat loss Increase radiating surface area heat loss

Increase the extent of vasodilationIncrease the extent of vasodilation

1515

ConductionConduction

Conduction is the transfer of heat from one Conduction is the transfer of heat from one

object to another with direct contact. object to another with direct contact.

When the warm skin touches a cooler When the warm skin touches a cooler

object(solid; gas; liquid), heat is lost.object(solid; gas; liquid), heat is lost.

Heat loss velocity depends onHeat loss velocity depends on

Heat conducting capabilityHeat conducting capability T difference between the two objectsT difference between the two objects Contacting areaContacting area

1616

ConvectionConvection Convection is the transfer of heat away by Convection is the transfer of heat away by

air or liquid movement. air or liquid movement.

Heat is first transferred to air or liquid Heat is first transferred to air or liquid

molecules directly in contact with the molecules directly in contact with the

skin. Air or liquid currents carry away the skin. Air or liquid currents carry away the

warmed air or liquid. warmed air or liquid.

Heat loss velocity depends onHeat loss velocity depends on current velocity current velocity

T difference between the object and air or liquidT difference between the object and air or liquid

1717

EvaporationEvaporation

Evaporation is the transfer of heat energy Evaporation is the transfer of heat energy

when a liquid is changed to a gas. when a liquid is changed to a gas.

The body continuously loses heat by The body continuously loses heat by

evaporation. --evaporation. --R;skin 300-400ml/dR;skin 300-400ml/d

By regulating sweating, the body promotes By regulating sweating, the body promotes

additional evaporative heat loss. --additional evaporative heat loss. --febricidefebricide

Evaporation is the main heat loss mode Evaporation is the main heat loss mode

when environment temperature is higher when environment temperature is higher

than body temperature.than body temperature.

1818

Regulation of Body TemperatureRegulation of Body Temperature

Neural and Vascular Control Neural and Vascular Control

Behavioral ControlBehavioral Control

1919

Neural and Vascular ControlNeural and Vascular Control

T regulation centerT regulation center :the hypothalamus , :the hypothalamus ,

controls body temperature the same way a controls body temperature the same way a

thermostat works in the home thermostat works in the home ((reflex arcreflex arc))

the anterior hypothalamusthe anterior hypothalamus controls heat controls heat

loss loss Via sweating, vasodilation, inhibition of heat Via sweating, vasodilation, inhibition of heat

productionproduction

the posterior hypothalamusthe posterior hypothalamus controls heat controls heat

production production via muscle shivering , heat via muscle shivering , heat

conservation by vasoconstriction of surface blood conservation by vasoconstriction of surface blood

vesselsvessels

2020

Normal Blood Temperature(37℃ )

Factors which

increase metabolic rate or

Environmental temperature

Increased blood temperatureabove level at which “thermostat”

in hypothalamus is set (37℃ )

Stimulated thermal receptorsOf heat-dissipating center

in hypothalamus, initiatingimpulses that lead to

Increased sweatsecretion

Dilation of skin blood vessels

Increased heat Loss by radiation

Increased heatLoss by evaporation

Decreased bloodtemperature

(to or toward)

Heat loss mechanisms to maintain normal body temperature

2121


environmental temperature fall:environmental temperature fall:

add clothingadd clothing

move to a warmer placemove to a warmer place

raise the thermostat settingraise the thermostat setting

increase muscular activity by running increase muscular activity by running

sit with arms and legs tightly wrapped togethersit with arms and legs tightly wrapped together

2222


The ability of a person to control body The ability of a person to control body

temperature depends ontemperature depends on

the degree of temperature extremethe degree of temperature extreme

the person’s ability to sense feeling the person’s ability to sense feeling

comfortable or uncomfortable--infants, older comfortable or uncomfortable--infants, older

adultsadults

thought processes or emotions--depressionthought processes or emotions--depression

the person’s ability to remove or add clothesthe person’s ability to remove or add clothes

— —infants, childreninfants, children

2323

Average Temperature Average Temperature

and Normal Range of Adultand Normal Range of Adult

site average temperature normal rangesite average temperature normal range

oral 37oral 37℃℃ 36.3-37.2 36.3-37.2℃℃

rectal 37.5rectal 37.5℃℃ 36.5-37.7 36.5-37.7℃℃

axillary 36.5axillary 36.5℃℃ 36.0-37.0 36.0-37.0℃℃

2424

Factors Affecting Body TemperatureFactors Affecting Body Temperature

Measurement siteMeasurement site Circadian rhythms :Circadian rhythms : drops between 2 and 6 AM drops between 2 and 6 AM peaks between 1 and 6PMpeaks between 1 and 6PM

Age:Age: With age,T tends to fall .With age,T tends to fall .

infancy: temperature regulation is labile infancy: temperature regulation is labile

aging: control mechanisms deteriorateaging: control mechanisms deteriorate

2525


Hormonal influences :Hormonal influences : progesterone: raise the body temperatureprogesterone: raise the body temperature

Exercise :Exercise :increase body temperatureincrease body temperature

Medications:Medications:

anaesthetic: depress T regulation centeranaesthetic: depress T regulation center

promote vasodilation promote vasodilation

febrifuge: Tfebrifuge: T

T

2626


Stress:Stress: Stimulate sympathetic nervous system Stimulate sympathetic nervous system

-- epinephrine and norepinephrine production , -- epinephrine and norepinephrine production ,

-- metabolic activity heat production --T-- metabolic activity heat production --T

Environment:Environment: the extent of exposure, the extent of exposure,

air temperature and humidityair temperature and humidity

the presence of convection currentsthe presence of convection currents

Ingestion of hot/cold liquidsIngestion of hot/cold liquids

Smoking:Smoking: increase body temperatureincrease body temperature

2727

Alterations in Body TemperatureAlterations in Body Temperature

Fever or Hyperthermia Fever or Hyperthermia

HypothermiaHypothermia

2828

Fever or HyperthermiaFever or Hyperthermia

A body temperature above the usual range A body temperature above the usual range

is called fever. is called fever.

A true fever results from an alteration in A true fever results from an alteration in

the hypothalamic set point. the hypothalamic set point.

Pyrogens such as bacteria and virus cause Pyrogens such as bacteria and virus cause

a rise in body temperature. a rise in body temperature.

Fever is an important defense mechanism.Fever is an important defense mechanism.

2929

Fever process and manifestationFever process and manifestation

Fever-chill phase:Fever-chill phase: heat productionheat production>heat loss;>heat loss;

experience tiredness, paleness, dryness, chills, experience tiredness, paleness, dryness, chills,

shivers, and feels coldshivers, and feels cold (2 patterns)(2 patterns)

plateau phase :plateau phase : heat productionheat production=heat loss;=heat loss;

warm , dry, R , P , headache, faint, inappetencewarm , dry, R , P , headache, faint, inappetence

fever break phase:fever break phase: heat productionheat production<heat loss;<heat loss;

skin -- warm, flushed, diaphoresis skin -- warm, flushed, diaphoresis (2 patterns)(2 patterns)

3030

Hyperthermia Hyperthermia (clinical)(clinical)

An elevated body temperature related to the An elevated body temperature related to the

body’s inability to promote heat loss or body’s inability to promote heat loss or

reduce heat production is hyperthermia. reduce heat production is hyperthermia.

Any disease or trauma to the hypothalamus Any disease or trauma to the hypothalamus

can impair heat loss mechanisms.can impair heat loss mechanisms.

3131

Classification of Fever (Oral)Classification of Fever (Oral)

℃℃ ℉℉

Mild 37.5Mild 37.5℃℃ --37.937.9℃℃ 99.5 99.5 -℉-℉ 100.2100.2℉℉

Moderate 38.0Moderate 38.0℃℃ --38.938.9℃℃ 100.4 100.4 -℉-℉ 102.0102.0℉℉

Severe 39.0Severe 39.0℃℃ --39.939.9℃℃ 102.2 102.2 -℉-℉ 105.6105.6℉℉

Profound >41Profound >41℃℃ >105.8 >105.8℉℉

3232

Patterns of FeverPatterns of Fever is the modality of a temperature curve. is the modality of a temperature curve.

differ depending on the causative pyrogen. differ depending on the causative pyrogen.

The increase or decrease in the amount of The increase or decrease in the amount of

pyrogens results in fever spikes and pyrogens results in fever spikes and

declines at different times of the day. declines at different times of the day.

The duration and degree of fever depends The duration and degree of fever depends

on the pyrogen’s strength and the ability of on the pyrogen’s strength and the ability of

the individual to responds.the individual to responds.

----serve a diagnostic purpose.----serve a diagnostic purpose.

3333

Patterns of FeverPatterns of Fever

Constant Fever Constant Fever

Remittent Fever Remittent Fever

Intermittent fever Intermittent fever

Irregular FeverIrregular Fever

3434

Constant FeverConstant Fever

sustains between 39~40sustains between 39~40℃℃

demonstrates little demonstrates little

fluctuation of less than fluctuation of less than

11℃℃ within 24 hours. within 24 hours.

( pneumonia , typhoid)( pneumonia , typhoid)

3535

Remittent FeverRemittent Fever

has great fluctuation has great fluctuation

above the normal with above the normal with

more than 1more than 1℃℃ in 24 hours in 24 hours

and cannot return to and cannot return to

normal temperature normal temperature

level. (septicemia , level. (septicemia ,

rheumatic fever)rheumatic fever)

3636

Intermittent feverIntermittent fever

fluctuates greatly in 24 hours, fluctuates greatly in 24 hours,

may suddenly rise above the may suddenly rise above the

normal then suddenly fall to or normal then suddenly fall to or

below the normal below the normal

alternates regularly between a alternates regularly between a

period of fever and a period of period of fever and a period of

normal temperature levelsnormal temperature levels

(malaria, tuberculosis)(malaria, tuberculosis)

3737

Irregular FeverIrregular Fever

irregularity alternates irregularity alternates

between a period of fever between a period of fever

and a period of normal and a period of normal

temperature values. temperature values.

( influenza , cancer)( influenza , cancer)

3838

HypothermiaHypothermia A body temperature below the lower limit A body temperature below the lower limit

of normal 35of normal 35℃℃ is called hypothermia is called hypothermia ．． Heat loss during prolonged exposure to Heat loss during prolonged exposure to

cold overwhelms the body’s ability to cold overwhelms the body’s ability to

produce heatproduce heat ，， causing hypothermiacausing hypothermia ．． Hypothermia may be intentionally induced Hypothermia may be intentionally induced

during surgical procedures to reduce during surgical procedures to reduce

metabolic demand and the body’s need for metabolic demand and the body’s need for

oxygenoxygen ．．

3939

Classification of HypothermiaClassification of Hypothermia

℃℃ ℉℉

Mild 33.1Mild 33.1℃℃ --3636℃℃ 91.5 91.5 -℉-℉ 96.896.8℉℉

Moderate 30.0Moderate 30.0℃℃ --3333℃℃ 86.1 86.1 -℉-℉ 91.491.4℉℉

Severe 27Severe 27℃℃ --3030℃℃ 80.6 80.6 -℉-℉ 86.086.0℉℉

Profound <27Profound <27℃℃ <80.6 <80.6℉℉

4040

Manifestation of HypothermiaManifestation of Hypothermia 34.4-3534.4-35 :℃:℃ uncontrolled shiveringuncontrolled shivering ，， loss loss

of memoryof memory ，， depression, poor judgmentdepression, poor judgment

falls below 34.4falls below 34.4℃℃

heart and respiratory rates heart and respiratory rates

blood pressure fall skin ---- cyanoticblood pressure fall skin ---- cyanotic

progressprogress------ cardiac dysrhythmiascardiac dysrhythmias ，，

loss of consciousnessloss of consciousness ，，

unresponsive to painful stimuliunresponsive to painful stimuli

4141

Nursing Process Nursing Process

and Thermoregulation and Thermoregulation

Assessment Assessment

Nursing Diagnosis Nursing Diagnosis

Planning Planning

Implementation Implementation

InterventionIntervention

4242

AssessmentAssessment

Sites:Sites: mouthmouth ，， rectum, axillary rectum, axillary

tympanic membranetympanic membrane

ThermometersThermometers

Glass Thermometer Glass Thermometer

Electronic Thermometer Electronic Thermometer

Disposable ThermometerDisposable Thermometer

4343

Glass ThermometerGlass Thermometer

VCD

4444

Electronic ThermometerElectronic Thermometer

4545

Disposable ThermometerDisposable Thermometer

4646

Nursing DiagnosisNursing Diagnosis

Nursing diagnosis DiagnosticNursing diagnosis Diagnostic foundationfoundation

Hyperthermia Increase body temperature above usual rangeHyperthermia Increase body temperature above usual range

Flushed skin, skin warm to touchFlushed skin, skin warm to touch

Increased pulse and respiratory rateIncreased pulse and respiratory rate

Herpetic lesions of the mouthHerpetic lesions of the mouth

Hypothermia Decreased body temperatureHypothermia Decreased body temperature

Pale, cool skinPale, cool skin

Decreased pulse and respiratory rateDecreased pulse and respiratory rate

Feelings of cold and chillFeelings of cold and chill

Ineffective Older adults or infants, weak inability to adaptIneffective Older adults or infants, weak inability to adapt

thermoregulation to environmental temperaturethermoregulation to environmental temperature

4747

Planning Planning

require an individualized care planrequire an individualized care plan -- -- maintaining normothermia and reducing risk maintaining normothermia and reducing risk

factorsfactors ．．

education is importanteducation is important

Objects:Objects: restoring normothermiarestoring normothermia

minimizing complicationsminimizing complications

promoting comfortpromoting comfort care plan should support goalscare plan should support goals

4848

Examples for goals and outcomesExamples for goals and outcomes

GoalGoal

Restore and maintain normothermia.Restore and maintain normothermia.

OutcomeOutcome

Temperature maintained within normal Temperature maintained within normal

range during environment changes.range during environment changes.

4949


Goal Goal Minimize complications of altered body Minimize complications of altered body temperature.temperature.

OutcomesOutcomes

patient’s blood pressure, pulse, and respirationspatient’s blood pressure, pulse, and respirations

are within normal limitsare within normal limits

patient’s skin integrity maintainedpatient’s skin integrity maintained

patient’s nutritional intake meets body needspatient’s nutritional intake meets body needs

patient’s mucous membranes are moistpatient’s mucous membranes are moist

patient is able to participate in ADL activitiespatient is able to participate in ADL activities

patient’s skin is warm and pinkpatient’s skin is warm and pink

patient reports sense of rest and comfortpatient reports sense of rest and comfort

5050


GoalGoal

Reduce risk of altered body temperatureReduce risk of altered body temperature..

OutcomesOutcomes

patient identifies risk factors for alteredpatient identifies risk factors for altered

body temperaturebody temperature

patient practices measures to prevent patient practices measures to prevent

bodybody

temperature alterationtemperature alteration

5151


Nursing measures for patient Nursing measures for patient

with a fever with a fever

Nursing Interventions for patient Nursing Interventions for patient

With HypothermiaWith Hypothermia

5252

Nursing measures Nursing measures for patient with a fever for patient with a fever

AssessmentAssessment •• Obtain body temperature during each phase of febrile Obtain body temperature during each phase of febrile

episodeepisode ．．••Assess for contributing factors such as Assess for contributing factors such as

dehydrationdehydration ，， infectioninfection ，， or environmental or environmental temperaturetemperature ．．

••Identify physiological response to temperature.Identify physiological response to temperature.

Obtain a11 vital signsObtain a11 vital signs ．． Observe skin colorObserve skin color ．． Assess skin temperatureAssess skin temperature ．． Observe for shivering and diaphoresisObserve for shivering and diaphoresis ．． Assess patient comfort and well-beingAssess patient comfort and well-being ．．••Determine phase of fever--chillDetermine phase of fever--chill ，， plateauplateau ，， fever breakfever break ．．

5353

Nursing measures Nursing measures for patient with a fever for patient with a fever

InterventionIntervention 1.Promote heat loss and lower the 1.Promote heat loss and lower the

temperature. temperature.

Limit physical activity--heat production Limit physical activity--heat production

reduce external covering--heat loss reduce external covering--heat loss

physical therapies:ice packs ; bathing with alcohol- physical therapies:ice packs ; bathing with alcohol-

water solutions water solutions

medicationmedication

Take temperature after lowering the temperature Take temperature after lowering the temperature

physically for 30 minutes, record the readings.physically for 30 minutes, record the readings.

5454

2.Intensify observation of the patient’s 2.Intensify observation of the patient’s conditions.conditions.

•• take temperature take temperature

1 time/4h--severe fever, 1 time/4h--severe fever,

4 time/day T4 time/day T<<38.538.5℃℃

1-2 times/day for three days after body temperature 1-2 times/day for three days after body temperature returns normal. returns normal.

•• Observe patient’s face color, pulse, respiration, Observe patient’s face color, pulse, respiration, diaphoresis and other signs when taking patient’s diaphoresis and other signs when taking patient’s temperature. temperature.

•• Assess for contributing factors such as Assess for contributing factors such as dehydrationdehydration ，， infectioninfection ，， or environmental or environmental temperaturetemperature ．．

•• Observe therapeutic effect.Observe therapeutic effect.

•• Observe the intake of liquids and the output of urine.Observe the intake of liquids and the output of urine.

•• Contact physicians promptly when find abnormal Contact physicians promptly when find abnormal conditions.conditions.

5555

3. Provide nutrients to meet increased 3. Provide nutrients to meet increased

energy needsenergy needs

•• Provide measures to stimulate appetiteProvide measures to stimulate appetite ，， and offer and offer

well-balanced mealswell-balanced meals ．．

•• Provide fluids at least 3000ml per day for patient with Provide fluids at least 3000ml per day for patient with

normal cardiac and renal functional to compensate normal cardiac and renal functional to compensate

fluids lost through insensible water loss and sweatingfluids lost through insensible water loss and sweating ．．

5656

4.Promote comfort and prevent 4.Promote comfort and prevent

complications.complications.

•• Allow rest periods. Allow rest periods.

•• Control temperature of the environment without Control temperature of the environment without

inducing shiveringinducing shivering ．．

•• Provide oral hygiene and keep oral moist to prevent Provide oral hygiene and keep oral moist to prevent

oral infection. oral infection.

•• Keep clothing and bed sheet dry to increase comfort Keep clothing and bed sheet dry to increase comfort

and heat loss through conduction and convectionand heat loss through conduction and convection ．．

5757

5.Provide psychological care. 5.Provide psychological care.

•• Meet patient’s reasonable requirements.Meet patient’s reasonable requirements.

• • Provide health education about fever.Provide health education about fever.

6.Obtain blood cultures when ordered.6.Obtain blood cultures when ordered.

7.Provide supplemental oxygen therapy as 7.Provide supplemental oxygen therapy as

ordered to improve oxygen delivery to body ordered to improve oxygen delivery to body

cells when ordered cells when ordered ．．

5858

Nursing Interventions Nursing Interventions

for patient With Hypothermia for patient With Hypothermia • • Control environment temperature at 22~24Control environment temperature at 22~24℃℃. .

•• Elevate body temperature. Elevate body temperature.

• • patients are monitored closely for cardiac patients are monitored closely for cardiac irregularities and electrolyte imbalances. irregularities and electrolyte imbalances. Observe the vital signs, take temperature Observe the vital signs, take temperature once at least per hour until the temperature once at least per hour until the temperature returned normal and stability. returned normal and stability.

• • Eliminate pathogeny. Eliminate pathogeny.

• • Health education.Health education.

5959

EvaluationEvaluation

all nursing goals have been metall nursing goals have been met

use other evaluative measures such as use other evaluative measures such as

palpation of the skin and assessment of palpation of the skin and assessment of

pulse and respirationspulse and respirations

If therapies are effectiveIf therapies are effective ，， body body

temperature will return to a normal temperature will return to a normal

rangerange ，， other vital signs will stabilize and other vital signs will stabilize and

the patient will report a sense of the patient will report a sense of

comfortcomfort ．．

6060

Section PulseⅢSection PulseⅢ

Physiology and RegulationPhysiology and Regulation

Character of The Pulse and Character of The Pulse and

Observation of Abnormal PulseObservation of Abnormal Pulse

Nursing process and Pulse Nursing process and Pulse

DeterminationDetermination

6161

Physiology and RegulationPhysiology and Regulation

The The pulsepulse is the rhythmical throbbing of is the rhythmical throbbing of

arteries produced by the regular arteries produced by the regular

contraction of the heart. contraction of the heart.

The number of pulsing sensations The number of pulsing sensations

occurring in 1 minute is the occurring in 1 minute is the pulse ratepulse rate ．．

Healthy adult pulse rate can range Healthy adult pulse rate can range

between between 60-100 beats per minute60-100 beats per minute in in

quiet state.quiet state.

6262

Forming of PulseForming of Pulse Electrical impulses from the sinoatrial node travel Electrical impulses from the sinoatrial node travel

through heart muscle to stimulate cardiac through heart muscle to stimulate cardiac

contractioncontraction ．．

Approximately 60 to 70 ml (stroke volume) of blood Approximately 60 to 70 ml (stroke volume) of blood

enters the aorta with each ventricular contractionenters the aorta with each ventricular contraction ．．

The arterial walls expand to compensate for the The arterial walls expand to compensate for the

increase in pressure. As the ventricle of the heart is increase in pressure. As the ventricle of the heart is

in diastole, arterial walls return to original status in diastole, arterial walls return to original status

by its own elasticity and peripheral resistance. by its own elasticity and peripheral resistance.

6363

Forming of PulseForming of Pulse

The expansion and retraction of the aorta The expansion and retraction of the aorta

sends a wave through the walls of the sends a wave through the walls of the

arterial system that can be felt as a light arterial system that can be felt as a light

tap on palpation. The pulse is the palpable tap on palpation. The pulse is the palpable

bounding of the blood flowbounding of the blood flow ．．

6464

Factors Influencing Pulse RateFactors Influencing Pulse Rate Age Age Normally Pulse Rates at Varies AgesNormally Pulse Rates at Varies Ages

Age normal range of pulse rate (beats/min) Age normal range of pulse rate (beats/min)

Infants 120-160 Infants 120-160

Toddlers 90-140 Toddlers 90-140

Preschoolers 80-110 Preschoolers 80-110

School ages 75-100 School ages 75-100

Adolescent 60-90Adolescent 60-90

Adult 60-100Adult 60-100

6565

Sex : Sex : After puberty, the average male pulse rate is After puberty, the average male pulse rate is

slightly lower than the female. 5 times/minslightly lower than the female. 5 times/min

Exercise Exercise Temperature: Temperature: Fever ; HypothermiaFever ; Hypothermia Emotions: Emotions: Acute pain ,anxiety -- pulse rateAcute pain ,anxiety -- pulse rate

Unrelieved severe pain--Unrelieved severe pain-- pulse ratepulse rate Drugs : Drugs : atropine digitalisatropine digitalis

Postural changes: Postural changes: Standing or sitting , Lying Standing or sitting , Lying

downdown Hemorrhage:Hemorrhage: Pulmonary conditions: Pulmonary conditions: poor oxygenationpoor oxygenation

6666

Character of The Pulse and Character of The Pulse and

Observation of Abnormal PulseObservation of Abnormal Pulse Pulse Rate Pulse Rate

Pulse Rhythm Pulse Rhythm

Strength Strength

EqualityEquality

6767

Abnormal Pulse RateAbnormal Pulse Rate

TachycardiaTachycardia is an abnormally elevated heart is an abnormally elevated heart

raterate ，， above 100 beats per minute in adultsabove 100 beats per minute in adults ．．

(fever, anemia, hemorrhage, hyperthyroidism) (fever, anemia, hemorrhage, hyperthyroidism)

BradycardiaBradycardia is a slow rate, below 60 beats per is a slow rate, below 60 beats per

minute in adultsminute in adults ．． (atrioventricular block, (atrioventricular block,

increased intracranial pressure, hypothyroidism ) increased intracranial pressure, hypothyroidism )

6868

Pulse RhythmPulse Rhythm

Normally a regular interval of time occurs Normally a regular interval of time occurs

between each pulse or heart beatbetween each pulse or heart beat ．． An An

interval interrupted by an early or late beat interval interrupted by an early or late beat

or a missed beat indicates an abnormal or a missed beat indicates an abnormal

rhythm or rhythm or dysrhythmiadysrhythmia ．．

6969

Abnormal Pulse RhythmAbnormal Pulse Rhythm

Intermittent PulseIntermittent Pulse

Pulse DeficitPulse Deficit

7070


one pulse missing during regular or one pulse missing during regular or

irregular pulse patternsirregular pulse patterns

one pulse absents every one pulse-one pulse absents every one pulse-bigeminybigeminy

one pulse absents two normal pulses be one pulse absents two normal pulses be

called -- called -- trigeminy trigeminy

occur in cardiomyopathy, myocardial occur in cardiomyopathy, myocardial

infarction, digitalis intoxication, and infarction, digitalis intoxication, and

transient symptoms caused by excited transient symptoms caused by excited

emotion or fearemotion or fear

7171


threatens the heart ability to provide threatens the heart ability to provide

adequate cardiac outputadequate cardiac output

An electrocardiogram (ECG) is necessary to An electrocardiogram (ECG) is necessary to

define the pulse dysrhythmia.define the pulse dysrhythmia.

Children often have a sinus dysrhythmia, Children often have a sinus dysrhythmia,

which is an irregular heartbeat that speeds which is an irregular heartbeat that speeds

up with inspiration and slows down with up with inspiration and slows down with

expiration.expiration.

7272

Pulse DeficitPulse Deficit Refers to pulse rate is less than heart rateRefers to pulse rate is less than heart rate

An inefficient contraction of the heart An inefficient contraction of the heart

--fails to transmit a pulse wave to the --fails to transmit a pulse wave to the

peripheral pulse site --creates a pulse peripheral pulse site --creates a pulse

deficitdeficit ．． To assess a pulse deficit To assess a pulse deficit simultaneouslysimultaneously

--one nurse assess radial rates--one nurse assess radial rates

--a colleague assess apical rates--a colleague assess apical rates

It can be seen in patients with atria It can be seen in patients with atria fibrillation.fibrillation.

7373

StrengthStrength reflects the volume of blood ejected against reflects the volume of blood ejected against

the arterial wall with each heart contraction the arterial wall with each heart contraction

and the condition of the arterial vascular and the condition of the arterial vascular

system leading to the pulse sitesystem leading to the pulse site

normally remains the same with each normally remains the same with each

heartbeatheartbeat

may be graded or described as may be graded or described as

strongstrong ，， weakweak ，， threadythready ，， or boundingor bounding

7474

Abnormal StrengthAbnormal Strength

Bounding PulseBounding Pulse

Thready PulseThready Pulse

Alternating pulseAlternating pulse

Water Hammer PulseWater Hammer Pulse

Paradoxical PulseParadoxical Pulse

7575

Bounding PulseBounding Pulse

an increased stroke volume, which can be an increased stroke volume, which can be

palpated by fingertips slightlypalpated by fingertips slightly

often be seen with fever, hyperthyroidism, often be seen with fever, hyperthyroidism,

and aortic valve incompetence.and aortic valve incompetence.

7676

Thready PulseThready Pulse

weak and diminished, which is barely by weak and diminished, which is barely by

fingertipsfingertips

often occurs with massive hemorrhage, often occurs with massive hemorrhage,

shock, and aortic stenosisshock, and aortic stenosis

7777

Alternating pulseAlternating pulse

alternates between increased and alternates between increased and

diminished patterns along with strong and diminished patterns along with strong and

weak contraction of the ventriclesweak contraction of the ventricles

common causes are hypertensive heart common causes are hypertensive heart

disease, myocardial infarctiondisease, myocardial infarction

7878

Water Hammer PulseWater Hammer Pulse

The abrupt distension and quick collapse The abrupt distension and quick collapse

of the pulse is palpated following the of the pulse is palpated following the

increased cardiac output with resultant increased cardiac output with resultant

pulse pressure surges. pulse pressure surges.

It often occurs with hyperthyroidism, It often occurs with hyperthyroidism,

aortic valve incompetence.aortic valve incompetence.

7979

Paradoxical PulseParadoxical Pulse

The pulse is obviously weak or not The pulse is obviously weak or not

palpable on inspiration. It results from palpable on inspiration. It results from

the declined strokes by the left ventricle the declined strokes by the left ventricle

on inspiration. on inspiration.

Common causes are pericardial effusion Common causes are pericardial effusion

and constrictive pericarditis.and constrictive pericarditis.

8080

Equality Equality The nurse should assess both radial pulses The nurse should assess both radial pulses

to compare the characteristics of each. A to compare the characteristics of each. A

pulse in one extremity may be unequal in pulse in one extremity may be unequal in

strength or absent in many diseases, such strength or absent in many diseases, such

as thrombosis, aberrant blood vessels, or as thrombosis, aberrant blood vessels, or

aortic dissection. aortic dissection.

The carotid pulse should not be measured The carotid pulse should not be measured

simultaneously because excessive pressure simultaneously because excessive pressure

may stop blood supply to the brain.may stop blood supply to the brain.

8181

Nursing process and Nursing process and

Pulse DeterminationPulse Determination Assessment Assessment

Nursing Diagnosis Nursing Diagnosis

Nursing Plan Nursing Plan



8282

AssessmentAssessment

the nurse should collect the following data: the nurse should collect the following data:

the patient’s general condition, such as the patient’s general condition, such as

age , sex, status of an illness and age , sex, status of an illness and

treatment; treatment;

the pulse rate, rhythm, strength, equality the pulse rate, rhythm, strength, equality

and factors influencing pulseand factors influencing pulse

arterial wall elasticityarterial wall elasticity

8383

Nursing DiagnosisNursing Diagnosis

TachycardiaTachycardia; ; bradycardiabradycardia; ;

dysrhythmias ; activity intolerance; dysrhythmias ; activity intolerance;

anxiety; fear; fluid volume deficit; anxiety; fear; fluid volume deficit;

gas exchange impaired; gas exchange impaired;

Hyperthermia; and hypothermiaHyperthermia; and hypothermia

8484

Nursing PlanNursing Plan

interventions based on the nursing interventions based on the nursing

diagnosis identified and the related factors; diagnosis identified and the related factors;

the expected outcomes generally:the expected outcomes generally:

patients can tell the normal range and physiological patients can tell the normal range and physiological

changes of the pulse; changes of the pulse;

patients can cooperate with the treatment and care.patients can cooperate with the treatment and care.

8585

ImplementationImplementation

Instruct the patients to rest to decrease Instruct the patients to rest to decrease

heart energy consuming. heart energy consuming.

Oxygen administration is provided, Oxygen administration is provided,

according to the patient’s condition.according to the patient’s condition.

Observe the patients’ condition closely.Observe the patients’ condition closely.

8686

ImplementationImplementation

Instruct the patients to take medicine on Instruct the patients to take medicine on

time and observe the effect and side effect time and observe the effect and side effect

of the medicine. of the medicine.

Tell the patients to keep first-aid medicine Tell the patients to keep first-aid medicine

along with them.along with them.

Provide mental support, let the patients to Provide mental support, let the patients to

keep steady mood.keep steady mood.

8787

ImplementationImplementation Health education: Health education: stop smoking and drinkingstop smoking and drinking take light and digestible diet, keep bowels take light and digestible diet, keep bowels

smooth; smooth; teach the patients to monitor the pulse prior teach the patients to monitor the pulse prior

to taking medicines that affect the heart rate.to taking medicines that affect the heart rate. Tell the patients to report any notable Tell the patients to report any notable

changes of heart rate or rhythm to health changes of heart rate or rhythm to health care provider. care provider.

Teach the patients and family members the Teach the patients and family members the basic first-aid skills.basic first-aid skills.

8888


evaluate the therapeutic effect by evaluate the therapeutic effect by

assessing the pulse rate, rhythm, strength, assessing the pulse rate, rhythm, strength,

and equality; and equality;

evaluate the patients’ mental status, evaluate the patients’ mental status,

cooperation with treatment and nursing; cooperation with treatment and nursing;

evaluate the patients’ knowledge about evaluate the patients’ knowledge about

healthhealth ．．

1 chapter 8 vital signs. 2 t--temperature p--pulse r--respiration bp--blood pressure

Documents

vital signs vital signs

vital signs slide

body temperature alterations

vital sign assessment

predictable vital sign

patient s condition

thermoregulation slide

intervention slide