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Ppt chapter 12
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Ppt chapter 12

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  • 1. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 12 Vital Signs
  • 2. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins • Body temperature • Pulse • Respiratory rate • Blood pressure • Pain – Fifth vital sign Vital Signs
  • 3. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Question •Is the following statement true or false? Pain is considered as the fifth vital sign.
  • 4. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True. Pain is considered the fifth vital sign. The other vital signs include body temperature, pulse, respiratory rate, and blood pressure.
  • 5. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessing a Client’s Health Status
  • 6. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Body Temperature • Shell temperature: the warmth at the skin surface • Core temperature: the warmth in deeper sites within the body like the brain and heart
  • 7. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Factors Affecting Body Temperature • Food intake, age, gender • Climate, exercise and activity • Circadian rhythm • Emotions • Illness or injury • Medications
  • 8. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Temperature Measurement • Fahrenheit scale: uses 32˚F as the temperature at which water freezes and 212˚F as the point at which it boils • Centigrade scale: uses 0˚C as the temperature at which water freezes and 100˚C as the point at which it boils
  • 9. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Normal Body Temperature • In normal, healthy adults, shell temperature generally ranges from 96.6˚F to 99.3˚F or 35.8˚C to 37.4˚C • Chances of survival diminish if body temperatures exceed 110˚F (43.3˚C) or fall below 84˚F (28.8˚C)
  • 10. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Normal Body Temperature (cont’d) • Based on temperature, animals are either: – Poikilothermic: temperature fluctuates depending on environmental temperature – Homeothermic: structural and physiologic adaptations keep body temperature within a narrow stable range
  • 11. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment Sites • Accurate assessment site: Brain, heart, lower third of the esophagus, and urinary bladder • Practical and convenient assessment sites: – Ear, temporal artery (on forehead or behind ear lobe), mouth, rectum, and axilla – Ear, temporal artery provide the temperature closest to the core temperature
  • 12. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Clinical Thermometers • Instruments used to measure body temperature – Electronic – Infrared – Chemical – Digital – Glass
  • 13. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Clinical Thermometers (Refer to Table 12-3 in the textbook.)
  • 14. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Electronic Thermometers
  • 15. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Infrared Tympanic Thermometer
  • 16. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Chemical Thermometer
  • 17. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Automated Monitoring Devices • Equipment that allows for the simultaneous collection of multiple data • Measure the temperature, blood pressure, pulse, heart rhythm, and pulse oximetry • Portable to save time and money
  • 18. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Continuous Monitoring Devices • Used primarily in critical care areas • Measure body temperature using internal thermistor probes within the esophagus of anesthetized clients, inside the bladder, or attached to a pulmonary artery catheter
  • 19. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Elevated Body Temperature • Fever is a condition in which the body temperature exceeds 99.3˚F (37.4˚C) • Pyrexia is a condition in which the temperature is warmer than the normal set point • Hyperthermia is a condition in which core temperature is excessively high and the temperature exceeds 105.8˚F (40.6˚C)
  • 20. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Symptoms of Fever • Pinkish, red (flushed) skin that is warm to the touch • Restlessness in some; excessive sleepiness in others • Irritability; poor appetite • Glassy eyes and sensitivity to light • Increased perspiration • Headache
  • 21. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Symptoms of Fever (cont’d) • Above-normal pulse and respiratory rates • Disorientation and confusion (when the temperature is high) • Convulsions in infants and children (when the temperature is high) • Fever blisters about the nose or lips in clients who harbor the herpes simplex virus
  • 22. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Phases of Fever • Prodromal phase • Onset or invasion phase • Stationary phase • Resolution or defervescence phase
  • 23. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Phases of Fever and Physiologic Changes
  • 24. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Question •Is the following statement true or false? Fever is a condition where the body temperature exceeds 105.8˚F.
  • 25. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False. Fever is a condition where the body temperature exceeds 99.3˚F.
  • 26. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Hypothermia • Core body temperature less than 95˚F (35˚C) • Mildly hypothermic: 95˚F to 93.2˚F (35˚C to 34˚C) • Moderately hypothermic: 93˚F to 86˚F (33.8˚C to 30˚C) • Severely hypothermic: below 86˚F (30˚C)
  • 27. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Symptoms of Hypothermia • Shivering until body temperature is extremely low • Pale, cool, and puffy skin • Impaired muscle coordination • Listlessness and irregular heart rhythm • Slow pulse and respiratory rates • Incoherent thinking and diminished pain sensation
  • 28. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Pulse • Produced by the movement of blood during the heart’s contraction • In most adults, the heart contracts 60 to 100 times per minute at rest – Pulse rhythm – Pulse volume – Pulse rate
  • 29. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Pulse Assessment Techniques • Primary pulse assessment site: radial artery located at inner (thumb) side of the wrist • Alternate assessment techniques – Counting the apical heart rate – Obtaining an apical–radial rate – Using a Doppler ultrasound device over a peripheral artery
  • 30. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Peripheral Pulse Sites
  • 31. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins • Exchange of oxygen and carbon dioxide • Respiratory rate is the number of ventilations per minute • Cheyne-Stokes respiration: a breathing pattern in which the depth of respirations gradually increases, followed by a gradual decrease, and then a period when breathing stops briefly before resuming again Respiration
  • 32. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins • Rapid respiratory rate – Tachypnea accompanies elevated temperature or diseases affecting cardiac and respiratory systems • Slow respiratory rate – Bradypnea can result from medications; observed in clients with neurologic disorders or hypothermia Respiratory Rate
  • 33. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins • Hyperventilation • Hypoventilation • Dyspnea • Orthopnea • Apnea • Stertorous breathing • Stridor Abnormal Breathing Characteristics
  • 34. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Blood Pressure • Force that the blood exerts within the arteries • Lower-than-normal volumes of circulating blood cause a decrease in blood pressure • Excess volumes cause an increase in blood pressure • Regular aerobic exercise increases tone of heart muscle and increases efficiency • Cardiac output
  • 35. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Blood Pressure (cont’d) • Cardiac output is approximately 5 to 6 L in adults at rest • Blood pressure measurements provide physiologic data about: – Ability of arteries to stretch – Volume of circulating blood – Amount of resistance heart must overcome when it pumps blood
  • 36. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Factors Affecting Blood Pressure • Age • Circadian rhythm • Gender • Exercise and activity • Emotions and pain
  • 37. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Factors Affecting Blood Pressure (cont’d) • Lower blood pressure – Lower when lying down than when sitting or standing • Higher blood pressure – When urinary bladder is full, when the legs are crossed, when the person is cold – When drugs that stimulate the heart are taken
  • 38. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Pressure Measurements • Systolic pressure • Diastolic pressure • Blood pressure is expressed in millimeters of mercury (mm Hg) as a fraction; systolic pressure/diastolic pressure • Pulse pressure: difference between systolic and diastolic blood pressure measurements
  • 39. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment Sites • Usually assessed over the brachial artery • Lower arm and radial artery • Measured over the popliteal artery behind the knee in case: – Client’s arms are missing – Both of a client’s breasts have been removed – Client has had vascular surgery
  • 40. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Equipments for Measuring Blood Pressure • Sphygmomanometer • Aneroid manometer • Electronic oscillometric manometer • Inflatable cuff • Stethoscope
  • 41. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Aneroid and Electronic Oscillometric Manometer
  • 42. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Measuring Blood Pressure • Phase I: first faint but clear tapping sound that follows a period of silence as pressure is released from the cuff • Phase II: change from tapping sounds to swishing sounds • Phase III: change to loud and distinct sounds—crisp knocking sounds
  • 43. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Measuring Blood Pressure (cont’d) • Phase IV: sounds muffled and has a blowing quality—first diastolic pressure measurement • Phase V: point at which the last sound is heard—second diastolic pressure measurement
  • 44. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Characteristics of Korotkoff Sounds
  • 45. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Question •Is the following statement true or false? First diastolic pressure measurement is taken at phase III of Korotkoff sounds.
  • 46. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False. First diastolic pressure measurement is taken at phase IV of Korotkoff sounds.
  • 47. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Alternate Techniques for Assessing Blood Pressure • Palpation • Using a Doppler stethoscope • Automatic blood pressure monitoring • Measuring thigh blood pressure
  • 48. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Abnormal Blood Pressure Measurements • Blood pressures above or below normal ranges indicate significant health problems • Hypertension: high blood pressure • Hypotension: low blood pressure • Postural or orthostatic hypotension: sudden but temporary drop in blood pressure when rising from a reclining position
  • 49. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Abnormal Blood Pressure Measurements (cont’d) • Hypertension or high blood pressure is associated with: – Anxiety – Obesity – Vascular diseases – Stroke, heart failure – Kidney diseases
  • 50. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Documenting Vital Signs • Once vital sign measurements are obtained: – Document the data in medical record for analysis of patterns and trends – Enter the data, along with any other subjective or objective information in narrative nursing notes
  • 51. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Implications • Vital sign assessment is the basis for identifying problems • Nurses identify from the nursing diagnoses: – Hyperthermia, hypothermia, ineffective thermoregulation, decreased cardiac output, risk for injury, or ineffective breathing pattern
  • 52. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Gerontologic Considerations • Lower “normal” or baseline temperature • Changes in thermoregulation system • Delayed or diminished febrile response to illnesses • Change in cognitive function, restlessness, or anxiety may be initial sign of illness
  • 53. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Gerontologic Considerations (cont’d) • Susceptible to hypothermia and heat- related conditions; elevated blood pressure readings in clinical settings • Blood pressure assessment in bilateral arms; document subsequent trends • Older adults are more susceptible to arrhythmias and postural and postprandial hypotension
  • 54. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Gerontologic Considerations (cont’d) • If older client is hypotensive, plan for limited activities during the hour following eating or for frequent smaller food consumption throughout the day • More profound responses to cardiovascular medications than younger adults

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