Fundamentals of Nursing Human Health and Function Chapter

Body Temperature • Humans maintain a consistent internal body temperature • Core temperature: Temperature

Body Temperature (Cont’d) • Regulation of body temperature – Heat production • Metabolism –

Body Temperature (Cont’d) • Factors affecting body temperature – Age – Environment – Time

Body Temperature (Cont’d) • Factors affecting oral body temperature measurement – Smoking; chewing gum

Body Temperature (Cont’d) • Assessing body temperature – Sites • Oral • Rectal •

Body Temperature (Cont’d) • Assessing body temperature (cont’d) – Equipment • Electronic thermometers •

Body Temperature (Cont’d) • Assessing body temperature (cont’d) – Scales: Temperature can be measured

Pulse • Characteristics – Rate or frequency; rhythm; quality • Factors affecting pulse rate

Pulse (Cont’d) • Assessing the pulse – Sites • Temporal; carotid • Apical; brachial

Pulse (Cont’d) • Equipment – Stethoscope – Doppler ultrasound device • Methods – Palpation

Pulse (Cont’d) • Assessing pulse characteristics – Dysrhythmic: Any pulse out of the range

Pulse (Cont’d) • Assessing pulse characteristics (cont’d) – Rhythm – Quality – Pulse deficits

Question Tell whether the following statement is true or false: Cardiac medications such as

Answer False. Rationale: Cardiac medications such as digoxin decrease pulse rate, whereas atropine inhibits

Respirations • External respiration; internal respiration • Tidal volume: Amount of air moving in

Respirations (Cont’d) • Factors affecting respirations – Age – Medications – Stress – Exercise

Respirations (Cont’d) • Assessing respirations – Rate – Rhythm and depth – Quality: Usually

Respirations (Cont’d) • Assessing respirations (cont’d) – Quality • Dyspnea – Methods: Perform the

Question What is the term used for normal respiratory rhythm and depth in a

Answer a. Eupnea Rationale: Eupnea is the term used for normal respiratory rhythm and

Blood Pressure • Physiologic factors determining blood pressure – Systolic blood pressure – Diastolic

Blood Pressure (Cont’d) • Factors affecting blood pressure – Age – Autonomic nervous system

Blood Pressure (Cont’d) • Assessing blood pressure – Sites • Upper extremity • Lower

Blood Pressure (Cont’d) • Assessing blood pressure (cont’d) – Equipment • Sphygmomanometer • Stethoscope

Blood Pressure (Cont’d) • Assessing blood pressure (cont’d) – Methods • Proper cuff size

Blood Pressure (Cont’d) • Assessing blood pressure (cont’d) – Methods (cont’d) • Auscultation: Korotkoff

Blood Pressure (Cont’d) • Assessing blood pressure (cont’d) – Abnormalities • Hypertension; prehypertension •

Question What is the term used for a high-pitched musical sound in patients during

Answer b. Wheezing Rationale: The term used for a highpitched musical sound in patients

Documenting Vital Signs • Data entered into an EMR may be viewed in a

Lifespan Considerations • Newborn and infant • Toddler and preschooler • School-age child and

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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) • 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) • 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) • 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) • 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

Pulse • 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) • 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) • 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

Question 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

Answer 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

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

Answer a. 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 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) • 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) • Assessing blood pressure (cont’d) – Equipment • Sphygmomanometer • Stethoscope • Doppler ultrasound • Automated devices Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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) • 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) • Assessing blood pressure (cont’d) – Abnormalities • Hypertension; prehypertension • Hypotension • Orthostatic hypotension Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question 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

Answer b. Wheezing Rationale: The term used for a highpitched 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 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