copyright © 2013 wolters kluwer health | lippincott williams & wilkins fundamentals of nursing:...
TRANSCRIPT
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Fundamentals of Nursing: Human Health and FunctionFundamentals of Nursing:
Human Health and Function
Chapter 17: Vital Signs
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Body Temperature Body Temperature
• Humans maintain a consistent internal body temperature
• Core temperature: Temperature inside the body; normal body temperature when measured orally ranges between 36.5º and 37.5ºC (97.6º and 99.6ºF)
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Body Temperature (Cont’d)Body Temperature (Cont’d)
• Regulation of body temperature– Heat production
• Metabolism– Heat loss
• Heat is lost through four processes: Radiation; conduction; convection; evaporation
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Body Temperature (Cont’d)Body Temperature (Cont’d)
• Factors affecting body temperature– Age – Environment – Time of day– Exercise– Stress– Hormones
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Body Temperature (Cont’d)Body Temperature (Cont’d)
• Factors affecting oral body temperature measurement
– Smoking; chewing gum
– Oxygen administered by mask or cannula
– Intake of hot or cold liquid drinks
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Body Temperature (Cont’d)Body Temperature (Cont’d)• Assessing body temperature
– Sites• Oral • Rectal • Ear• Forehead (temporal artery)• Axillary
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Body Temperature (Cont’d)Body Temperature (Cont’d)
• Assessing body temperature (cont’d)– Equipment
• Electronic thermometers • Tympanic membrane thermometers • Temporal artery thermometers• Disposable paper (chemical)
thermometers• Glass mercury thermometers
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Body Temperature (Cont’d)Body Temperature (Cont’d)
• Assessing body temperature (cont’d)
– Scales: Temperature can be measured on the Celsius or Fahrenheit scale
– Methods: Nurses use critical thinking to interpret temperature measurements, document the results, and report abnormal values
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
PulsePulse
• Characteristics– Rate or frequency; rhythm; quality
• Factors affecting pulse rate– Age– Autonomic nervous system– Medications
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Pulse (Cont’d)Pulse (Cont’d)
• Assessing the pulse– Sites
• Temporal; carotid• Apical; brachial• Radial; femoral; popliteal• Pedal; posterior tibial
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Pulse (Cont’d)Pulse (Cont’d)
• Equipment– Stethoscope– Doppler ultrasound device
• Methods– Palpation– Auscultation
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Pulse (Cont’d)Pulse (Cont’d)
• Assessing pulse characteristics
– Dysrhythmic: Any pulse out of the range of normal rate or rhythm
– Rate: Normal adult pulse rate is 60 to 100 pulsations per minute
• Tachycardia; bradycardia
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Pulse (Cont’d)Pulse (Cont’d)
• Assessing pulse characteristics (cont’d)
– Rhythm
– Quality
– Pulse deficits
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
QuestionQuestion
Tell whether the following statement is true or false:
Cardiac medications such as digoxin increase pulse rate in patients.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
AnswerAnswer
False.
Rationale: Cardiac medications such as digoxin decrease pulse rate, whereas atropine inhibits parasympathetic input, causing increased pulse rate in patients.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
RespirationsRespirations
• External respiration; internal respiration
• Tidal volume: Amount of air moving in and out with each breath
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Respirations (Cont’d)Respirations (Cont’d)
• Factors affecting respirations– Age– Medications– Stress– Exercise– Altitude– Gender
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Respirations (Cont’d)Respirations (Cont’d)
• Assessing respirations
– Rate
– Rhythm and depth
– Quality: Usually automatic, quiet, and effortless
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Respirations (Cont’d)Respirations (Cont’d)
• Assessing respirations (cont’d)– Quality
• Dyspnea– Methods: Perform the respiratory
assessment without patients being aware of the assessment
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
QuestionQuestion
What is the term used for normal respiratory rhythm and depth in a patient?
a. Eupnea
b. Apnea
c. Bradypnea
d. Tachypnea
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
AnswerAnswera. Eupnea
Rationale: Eupnea is the term used for normal respiratory rhythm and depth in a patient. Apnea is the absence of respirations in a patient. Tachypnea is an abnormally fast respiratory rate, and bradypnea is an abnormally slow respiratory rate in an adult patient.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Blood PressureBlood Pressure
• Physiologic factors determining blood pressure– Systolic blood pressure– Diastolic blood pressure– Pulse pressure– Blood flow– Resistance
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Blood Pressure (Cont’d)Blood Pressure (Cont’d)
• Factors affecting blood pressure– Age– Autonomic nervous system– Circulating volume– Medications– Normal fluctuations
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Blood Pressure (Cont’d)Blood Pressure (Cont’d)
• Assessing blood pressure
– Sites
• Upper extremity
• Lower extremity
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Blood Pressure (Cont’d)Blood Pressure (Cont’d)
• Assessing blood pressure (cont’d)
– Equipment
• Sphygmomanometer
• Stethoscope
• Doppler ultrasound
• Automated devices
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Blood Pressure (Cont’d)Blood Pressure (Cont’d)
• Assessing blood pressure (cont’d)
– Methods
• Proper cuff size
• Proper positioning
• Correlation with the respiratory cycle
• Proper inflation and deflation
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Blood Pressure (Cont’d)Blood Pressure (Cont’d)
• Assessing blood pressure (cont’d)
– Methods (cont’d)
• Auscultation: Korotkoff sounds can be heard with a stethoscope placed over the artery
• Palpation: When Korotkoff sounds are inaudible, blood pressure may be estimated by palpation
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Blood Pressure (Cont’d)Blood Pressure (Cont’d)
• Assessing blood pressure (cont’d)
– Abnormalities
• Hypertension; prehypertension
• Hypotension
• Orthostatic hypotension
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
QuestionQuestion
What is the term used for a high-pitched musical sound in patients during a respiratory assessment?
a. Crowing
b. Wheezing
c. Stridor
d. Sigh
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
AnswerAnswer
b. Wheezing
Rationale: The term used for a high-pitched musical sound in patients is wheezing. Stridor is a harsh inspiratory sound, which may also be compared to crowing. Sighs are breaths of deep inspiration and prolonged expiration.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Documenting Vital SignsDocumenting Vital Signs
• Data entered into an EMR may be viewed in a graph format that allows vital sign trends to be seen easily
• Trends may reflect normal variations or a change in response to disease or therapy
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Lifespan ConsiderationsLifespan Considerations
• Newborn and infant
• Toddler and preschooler
• School-age child and adolescent
• Adult and older adult