measuring vital sign
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CHAPTER 21CHAPTER 21
Measuring Vital SignsMeasuring Vital Signs
CHAPTER 21CHAPTER 21
Measuring Vital SignsMeasuring Vital Signs
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Production of Body HeatProduction of Body HeatProduction of Body HeatProduction of Body Heat
� Heat is a by-product of normal body metabolism
� As metabolism increases, heat increases.
� When the body is invaded by pathogens, thebody elevates the temperature to elevate thebasal metabolic rate in an effort to destroypathogens.
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Factors Affecting Body Heat ProductionFactors Affecting Body Heat ProductionFactors Affecting Body Heat ProductionFactors Affecting Body Heat Production
(«Cont¶d)
� Other hormones affecting metabolic rate:
Epinephrine
Norepinephrine Testosterone
� Men have a higher BMR than women because of testosterone.
� Voluntary muscle movement causes increasedheat production.
� Shivering can increase heat production up to fivetimes normal.
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Body Temperature RegulationBody Temperature RegulationBody Temperature RegulationBody Temperature Regulation
� Hypothalamus acts as the thermostat to controlbody temperature.
� Pyrogens may increase the thermostat¶s set point(pyrexia).
� A decrease in body temperature results inperipheral vasoconstriction and shivering.
� An increase in body temperature results inperipheral vasodilatation and diaphoresis.
(Cont¶d«)
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Body Temperature RegulationBody Temperature RegulationBody Temperature RegulationBody Temperature Regulation
(«Cont¶d)
� Heat loss occurs through the skin¶s exposure tothe environment through:
Radiation
Conduction
Convection
Evaporation
� Heat being lost by evaporation results in 800-mLloss of water each day.
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Body Temperature MeasurementsBody Temperature MeasurementsBody Temperature MeasurementsBody Temperature Measurements
� Temperature measurements vary depending onsite used.
� Rectal temperatures are approximately1° F higher than oral temperatures.
� Axillary temperatures are approximately1° F lower than oral temperatures.
� Tympanic membrane measurementapproximates core body temperature.
(Cont¶d«)
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Body Temperature MeasurementsBody Temperature MeasurementsBody Temperature MeasurementsBody Temperature Measurements
(«Cont¶d)
� Other factors affecting temperaturemeasurements:
Time of day
Environmental temperature
Age of the patient
Physical exercise
Menstrual cycle or stress Eating, drinking, mouth-breathing
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PyrexiaPyrexiaPyrexiaPyrexia
Temperature higher than 100.2° F
� Pyrexia (fever) occurs when normal regulationmechanisms cannot keep up with heat producedby the body.
� Pyrogens such as bacteria cause an increasedbody temperature.
� Diaphoresis is excessive sweat production in aneffort to cool the body.
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Nursing Interventions to Reduce Fever Nursing Interventions to Reduce Fever Nursing Interventions to Reduce Fever Nursing Interventions to Reduce Fever
� Increase patient¶s fluid intake
� Lower room temperature
� Increase the rate of circulating air
� Remove excessive clothing or bed covers� Control or reduce the amount of body activity
� Provide sponge bath or cooling blanket
� Antipyretics (ASA, acetaminophen)
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HypothermiaHypothermiaHypothermiaHypothermia
Body temperature lower than 94° F
� People at risk for hypothermia:
Infants
Surgical patients in the operating room
Elderly exposed to cold for prolonged periods
People exposed to extreme cold weather
People exposed to cold water immersion
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PulsePulsePulsePulse
� Pulse is produced by cardiac contractionscausing a pressure wave against the walls of arteries
� Cardiac contractions are normally initiated by the
sinoatrial node.� Each contraction propels 60 to 70 mL of blood
into the aorta (stroke volume).
� Stroke volume affects pulse character.
� Stroke volume x heart rate = Cardiac output(approximately 5 L/min for the average adult)
(Cont¶d«)
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PulsePulsePulsePulse
(«Cont¶d)
� Normally found by palpation or by auscultation
� Strength is determined by force of cardiaccontraction and circulating volume.
� Rate is affected by fever, pain, hypoxia, anxiety,exercise and cardiac disease
� Rate does not normally change with age, butarrythmias are common in the elderly.
(Cont¶d«)
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PulsePulsePulsePulse
(«Cont¶d)
Common pulse points:
� Radial artery in the wrist at the base of the thumb
� Temporal artery just in front of the ear � Carotid artery on the front side of the neck
� Femoral artery in the groin
� Apical pulse over the apex of the heart
� Popliteal pulse just behind the knee� Pedal pulse
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Factors Affecting Pulse RateFactors Affecting Pulse RateFactors Affecting Pulse RateFactors Affecting Pulse Rate
� Age� Body build and size
� Blood pressure
� Drugs� Emotions
� Blood loss
� Exercise
� Increased body temperature� Pain
� Hypoxia
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RespirationsRespirationsRespirationsRespirations
� An involuntary autonomic function� Controlled by respiratory center in the pons and
medulla in the brainstem
� Triggered by increased levels of CO2 or serumhydrogen ion concentration or by decreasedlevels of O2
� Organs of respiration
Nose, pharynx, larynx, trachea, bronchi, lungs
(Cont¶d«)
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RespirationsRespirationsRespirationsRespirations
(«Cont¶d)
� Respiratory center works with feedbackmechanisms.
� The carotid body receptors alter rate and depth of respiration based on CO2 content of the blood.
� O2 and CO2 are diffused across capillaries in thelungs to maintain normal O2, CO2 and H+ levels.
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Terms Used to Describe RespirationsTerms Used to Describe RespirationsTerms Used to Describe RespirationsTerms Used to Describe Respirations
� Eupnea� Dyspnea
� Tachypnea
� Hyperventilation� Cheyne-Stokes
� Apnea
� Kussmaul¶s
� Biot¶s
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Blood PressureBlood PressureBlood PressureBlood Pressure
The pressure exerted on the arterial walls by thepumping action of the heart
� Affected by the condition of the vascular bed,circulating blood volume, and
cardiac output
� Changes with aging are normal
(Cont¶d«)
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Blood PressureBlood PressureBlood PressureBlood Pressure
(«Cont¶d)
� Systolic pressure: The pressure exerted on thearterial wall during cardiac contraction
� Diastolic Pressure: The pressure exerted on thearterial wall between contractions
� Blood pressure is affected by cardiac output.
� Blood pressure increases with increases incirculating blood volume.
(Cont¶d«)
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Blood PressureBlood PressureBlood PressureBlood Pressure
(«Cont¶d)
� If blood volume decreases beyond the vascular beds ability to compensate, blood pressure maydecrease.
Causes
� Dehydration
� Hemorrhage
� Vasoconstriction and vasodilatation alter blood
pressure to compensate for changes incirculating volume.
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Changes in Vital Signs Occurring withChanges in Vital Signs Occurring with
AgingAging
Changes in Vital Signs Occurring withChanges in Vital Signs Occurring with
AgingAging
� Temperature: Heat loss may lead to hypothermiain the elderly.
� Lower metabolic rate may also result inhypothermia in the elderly.
� Respiratory rates may vary with decreases in vitalcapacity in the elderly.
� Systolic and diastolic blood pressure may risewith hardening of the arteries.
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PainPainPainPain
� Pain is recognized by the JCAHO as the fifth vitalsign.
� Assessment should include:
Location
Intensity
Character
Frequency
Duration
� Pain should be measured using a standardizedpain scale.