Vital Signs Fundamentals Unit 5 Vital Signs Temperature

Vital Signs Fundamentals Unit 5

Vital Signs- Temperature o Temperature terms: n Afebrile-not having elevated temperature n Cardinal symptoms- Vital Signs n Febrile- having as elevated body temperature n Hypothermia- decreased body temperature n Hyperthermia- elevated body temperature

Vital Signs n Body temperature is a balance between heat lost and heat produced, controlled by the hypothalamus n What influences temperature? o Age o Time of day o Exercise o Hormones o Stress o Environment o Illness

Vital Signs o Sx of high temperature include… n n n Flushed Glassy eyes Rapid breathing and heart rate Unusual thirst, anorexia, nausea Changes in mental status o Sx of subnormal temperature include… n Pale n Cold n Clammy

Vital Signs o An abnormally high or low temperature is a medical emergency o Normal body temperature is 98. 6 degrees Fahrenheit or 37 degrees Centigrade (Celsius). o A normal range is about 1 degree above or below a Fahrenheit reading or 0. 5 degrees above or below a Centigrade reading

Vital Signs o Celsius (Centigrade) vs. Fahrenheit o Conversion Formulas n Celsius = F – 32 x 5/9 OR Celsius = F – 32 / 1. 8 n Fahrenheit = C x 9/5 + 32 OR Fahrenheit = 1. 8 x C + 32

Vital Signs o Thermometer o The oldstyle mercury thermometer o Taking the temperature…some general rules n Oral n Rectal n Axillary

Vital Signs o There are different characteristics for each site you’d take a temperature… n Oral-keep mouth closed n Rectal-longer time for accurate measurement n Axillary- longest period of time n Tympanic- registers in less than 2 seconds n Temporal-infared, measures temperature of temporal artery

Vital Signs-Pulse o The 3 pulse assessments n Rate- 60 -100 Ø Tachycardia-greater than 100 beats per minute Ø Bradycardia-less than 60 beats a minute n Rhythm- regular or irregular Ø Dysrhythmia=irregular pulse n Quality (Volume)- amount of blood pushing against artery

Vital Signs o What factors influence pulse rate? o Age-decreases birth to adulthood o Activity and position- exercise and laying down = lower heart rate o Gender- males are lower o Body temperature- increase=increase o Blood volume and circulating components-decrease volume, increase rate o Stress, emotion, pain-increase rate o Drugs

Vital Signs o What factors influence pulse? n When I feel the rhythm…(spacing of beats) n When I note the quality/volume… (strength of beats) o Normal o Thready or Weak-difficult to feel o Full or bounding- strong even with pressure n What is a doppler?

Vital Signs Where can I feel pulses at?

Vital Signs o Which sites are best used for… n n An emergency- Carotid Convenience- Radial Most accurate- Apical Circulation assessment- Dorsalis Pedis

Vital Signs o Assessing the Radial Pulse o Assessing the Apical Pulse n The heart sounds… n Let’s look at the stethoscope… o Assessing an Apical/Radial Pulse n Pulse Deficit-difference between Apical and Radial Pulses

Vital Signs-Respirations o Did you know there are 2 parts to 1 respiration? n Inspiration-chest rise, lungs expand n Expiration- chest decreases, air forced out o Organs of respiration- lungs, chest muscles, diaphragm o Did you know there are 2 types of respiration? n External-use of lungs for gas exchange n Internal- exchange of gases between the blood and tissue cells

Vital Signs o The respiratory center is located in the brain and stimulated by CO 2 o Respirations increase or decrease in direct relationship with the CO 2 in the blood.

Vital Signs o We need to consider several factors with our respiratory assessment. n n Rate-influenced by many factors Rhythm- regular or irregular Depth- chest movement seen or felt Quality- chest movement, skin color, noise, symmetry, restlessness, disorientation

Vital Signs o What influences each of these factors? n n n n Age- faster when younger in age Disease- chronic or acute Gender- females slightly faster Exercise-increase activity, increase rate Body position- affects depth Stress- increase rate and depth Drugs- depressants=depress, stimulants=increse o Assessing respirations…

Vital Signs-Blood Pressure o Let’s talk about terms and equipment. n Blood pressure- measure of blood against the walls of arteries n Hypertension- Elevated blood pressure n Hypotension- Low blood pressure n Sphygmomanometer- instrument for measuring blood pressure n Pulse pressure-Difference between Systolic and Diastolic readings n Korotkoff’s sounds- "tapping" sounds heard with a stethoscope as the cuff is gradually deflated.

Vital Signs q Systolic Pressure- the upper number § The pressure present when the left ventricle of the heart contracts and forces blood to the arteries. q Diastolic Pressure- the lower number § The relaxation of the left ventricle allowing blood to refill

Vital Signs o Types of sphygmomanometers n Mercury n Aneroid n Electronic o The brachial artery is most commonly used o Site contraindications are… n n n IV fluids are infusing Shunt Cast or bulky dressing Trauma or paralysis Side of breast or axillary surgery

Vital Signs o Where is the brachial artery? o Assessing the blood pressure… n Systolic and diastolic n The standard of measurement is millimeters of mercury or mm. Hg

Vital Signs o Heart Rate x Stroke Volume = Cardiac Output (reflected in systolic reading) o Peripheral vascular resistance is reflected in the diastolic reading o MAP = systolic + (2 x diastolic) 3

Vital Signs o Some factors influence blood pressure… n Circulating blood volume-increase volume, increase pressure n Age- younger=lower n Exercise-increases blood pressure n Time of day-lower BP earlier in the day n Sex-females have lower n Stress, anxiety, fear, pain-raise BP n Medications-antihistamines, steroids, caffeine, nicotine n Race- Caucasian males have lower BP n Cardiac disease- n Obesity-Higher BP

Vital Signs o How do I take a blood pressure? o How do I document the blood pressure, and the other vital signs? o Practice your vital signs assessment in total.

Vital Signs. Terms to know o o o Height-ht Inch-in or “ Centimeter-cm Foot-ft Meter-m o o o Weight- wt Ounce- oz Pound- lb Kilogram-kg Gram- g

Vital Signs o Types of scales n n n Bed scale Standing scale Wheelchair scales Bariatric scales Pediatric scales

Vital Signs o Why do daily weights? n Fluid balance indicator n Calculating medications n Nutritional status o Rules for daily weights n n Same scale Same time Same clothing Same bed linens and pillows (if bed scale)

Vital Signs o Important conversions n n 2. 2 pounds=1 kilogram 1000 grams=1 kilogram 12 inches=1 foot 2. 5 centimeter= inch