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Kozier & Erb's Fundamentals of Nursing, 8eBerman, Snyder, Kozier, ErbCopyright 2008 by Pearson Education, Inc.

Chapter 2

!ita" Signs


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Copyright 2008 by Pearson Education, Inc.

!ita" Signs

# Body temperature, pu"se,respirations, and B"ood Pressure

#$onitor %unctions o% the body# Shou"d be a thought%u", scienti&cassessment


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'hen to (ssess !ita" Signs

# )n admission# Change in c"ient*s hea"th status# C"ient reports symptoms such as chest

pain, %ee"ing hot, or %aint# Pre and post surgery+in asi e procedure# Pre and post medication administration

that cou"d a-ect C! system# Pre and post nursing inter ention that

cou"d a-ect ita" signs


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Body emperature

# /e ects the ba"ance bet1een theheat produced and the heat "ost %romthe body

# $easured by heat units ca""eddegrees


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actors (-ectingBody emperature

# (ge# 3iurna" ariations

4circadian rhythms5# E6ercise# 7ormones

# Stress# En ironment


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("terations in Body emperature

# Pyre6ia, 7yperthermia, e er body temperature abo e the usua"

range

# ebri"e a c"ient 1ho has a %e er

# (%ebri"e

a c"ient 1ho does not ha e %e er# 7ypothermia

core body temperature be"o1 the "o1er"imit o% norma"


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Pu"se

# Is a 1a e o% b"ood created bycontraction o% the "e%t entric"e o% theheart

# /epresents the amount o% b"ood thatenters the arteries 1ith each entricu"arcontraction

# Periphera" pu"se a pu"se "ocated a1ay%rom the heart E6. oot or 1rist

# (pica" pu"se is the centra" pu"se that is"ocated at the ape6 o% the heart


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actors (-ectingPu"se

# (ge# 9ender# E6ercise# e er# $edications# 7ypo o"emia

# Stress# Position changes# Patho"ogy


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actors (-ecting/espirations

# E6ercise# Stress

# En ironmenta" temperature# $edications


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emperature: ;i%espanConsiderations

In%ants


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Pu"se: ;i%espanConsiderations

In%ants =e1borns may ha e heartmurmurs that are notpatho"ogica"

Chi"dren he ape6 o% the heart isnorma""y "ocated in the %ourthintercosta" space in youngchi"dren? &%th intercosta" spacein chi"dren @ years o"d and

o"derE"ders )%ten ha e decreased

periphera" circu"ation


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/espirations:;i%espan Considerations

In%ants Some ne1borns disp"ayAperiodic breathing

Chi"dren 3iaphragmatic breathers

E"ders (natomic and physio"ogicchanges cause respiratorysystem to be "ess e cient


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B"ood Pressure:;i%espan Considerations

In%ants (rm and thigh pressures areeDui a"ent under year o%age

Chi"dren high pressure is 0 mm 7ghigher than arm

E"ders C"ient*s medication maya-ect ho1 pressure is ta>en


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Sites %or $easuringBody emperature

# )ra"# /ecta"# (6i""ary# ympanic membrane# S>in+ empora" artery


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ypes o% hermometers

# E"ectronic# Chemica" disposab"e

# In%rared 4tympanic5# Scanning in%rared 4tempora" artery5# emperature sensiti e tape# 9"ass mercury


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=ursing Care %or e er

# $onitor ita" signs# (ssess s>in co"or and

temperature# $onitor "aboratory

resu"ts %or signs o%dehydration orin%ection

# /emo e e6cess

b"an>ets 1hen thec"ient %ee"s 1arm

# Pro ide adeDuatenutrition and uid

# $easure inta>e andoutput

# /educe physica"acti ity

# (dminister antipyreticas ordered

# Pro ide ora" hygiene

# Pro ide a tepid spongebath# Pro ide dry c"othing

and bed "inens


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=ursing Care %or 7ypothermia

# Pro ide 1arm en ironment# Pro ide dry c"othing

# (pp"y 1arm b"an>ets# Keep "imbs c"ose to body# Co er the c"ient*s sca"p

# Supp"y 1arm ora" or intra enous uids# (pp"y 1arming pads


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Pu"se Sites

/adia" /eadi"y accessib"e

empora" 'hen radia" pu"se is not accessib"e

Carotid 3uring cardiac arrest+shoc> inadu"ts3etermine circu"ation to the brain

(pica" In%ants and chi"dren up to F yearso% age

3iscrepancies 1ith radia" pu"se$onitor some medications


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Pu"se Sites

Brachia" B"ood pressureCardiac arrest in in%ants

emora" Cardiac arrest+shoc>Circu"ation to a "eg?

Pop"itea" Circu"ation to "o1er "eg

Posteriortibia"

Circu"ation to the %oot

3orsa"is

pedis

Circu"ation to the %oot


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Characteristics o% the Pu"se

# /atetachycardia o er 00 BP$bradycardia "ess than G0 BP$

# /hythmdysrhytmia or arrhythmia irregu"ar pu"se# !o"ume

%orce o% b"ood 1ith each beatabsent to bounding

# (rteria" 1a"" e"asticity# Bi"atera" eDua"ity


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Pu"se /ate and /hythm

# /ateH Beats per minuteH achycardia

H Bradycardia

# /hythmH EDua"ity o% beats

and inter a"s

bet1een beatsH 3ysrhythmiasH (rrhythmia


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Characteristics o% the Pu"se

# !o"umeHStrength or amp"itudeH(bsent to bounding

# (rteria" 1a"" e"asticityHE6pansibi"ity or de%ormity

#Presence or absence o% bi"atera"eDua"ityHCompare corresponding artery


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$easuring (pica" Pu"se


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(pica" /adia" Pu"se# ;ocate apica" and radia" sites# 1o nurse method:

H3ecide on starting timeH=urse counting radia" says AstartHBoth count %or G0 secondsH=urse counting radia" says AstopH/adia" can ne er be greater than apica"


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Inha"ation

# 3iaphragmcontracts 4 attens5

# /ibs mo e up1ard

and out1ard# Sternum mo es

out1ard

# En"arging the sizeo% the thora6


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E6ha"ation

# 3iaphragm re"a6es# /ibs mo e

do1n1ard and

in1ard# Sternum mo es

in1ard

# 3ecreasing the sizeo% the thora6


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/espiratory Contro"$echanisms

# /espiratory centersH$edu""a ob"ongataHPons


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Components o% /espiratory(ssessment

# /ate# 3epth

# /hythm# ua"ity# E-ecti eness


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/espiratory /ate and 3epth

# /ateH Breaths per minuteH (pnea H absence o%

breathingH Bradypnea

abnorma""y s"o1respirations

H achypneaabnorma""y %astrespirations

# 3epthH =orma"H 3eep

H Sha""o1


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Components o% /espiratory(ssessment

# /hythmH /egu"arH Irregu"ar

# ua"ityH E-ortH Sounds

# E-ecti enessH e and

transport o% ) 2

H ransport ande"imination o% C) 2


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("teratered BreathingPatterns

# /ateH achypnea H Duic>, sha""o1 breathsH Bradypnea abnorma""y sha""o1 breathing

H (pnea absence or cessation o% breathing# !o"ume

7yper enti"ation o ere6pansion o% the"ungs characterized by rapid and deepbreaths

7ypo enti"ation undere6pansion o% the"ungs characterized by sha""o1 respirations


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("teratered BreathingPatterns

# /hythmHCheyne Stro>e breathing rhythmic 1a6ing

and 1aning o% respirations, %rom ery deepto ery sha""o1 breathing and temporaryapnea

# Ease or E-ortH3yspnea di cu"t and "abored breathing

during 1hich the indi idua" has a persistent,unsatis&ed need %or air and %ee"s distressedH )rthopnea abi"ity to breathe on"y in upright

sitting or standing positions


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("teratered Breath Sounds

# Stridor H a shri"", harsh sound heardduring inspiration 1ith "aryngea"obstruction

# 'heeze continuous, high pitchedmusica" sDuea> or 1hist"ing soundoccuring on e6piration


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Systo"ic and 3iasto"ic B"oodPressure

# Systo"icH Contraction o% the

entric"es# 3iasto"ic

H !entric"es are at restH ;o1er pressure

present at a"" times# Pulse Pressure J

di-erence bet1eensysto"ic anddiasto"ic pressures

# $easured in mm7g

# /ecorded as a

%raction, e.g.20+80# Systo"ic J 20 and

3iasto"ic J 80


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Korot>o-*s Sounds


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Korot>o-*s Sounds

# Phase FH B"ood o1s %ree"yH Crisper and more intense soundH

humping Dua"ity but so%ter than in phase # Phase LH $u ed and ha e a so%t, b"o1ing sound

# Phase MH Pressure "e e" 1hen the "ast sound is heardH Period o% si"enceH 3iasto"ic pressure


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$easuring B"ood Pressure

# 3irect 4In asi e$onitoring5

# Indirect

H (uscu"tatoryH Pa"patory

# SitesH


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Pu"se )6imetry


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Pu"se )6imetry

# =onin asi e# Estimates arteria" b"ood o6ygen

saturation 4Sp) 25# =orma" Sp) 2 8M 00N? O @0N "i%e

threatening# 3etects hypo6emia be%ore c"inica" signs

and symptoms# Sensor, photodetector, pu"se o6imeter

unit


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Pu"se )6imetry

# actors that a-ect accuracy inc"ude:H7emog"obin "e e"HCircu"ationH(cti ityHCarbon mono6ide poisoning


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Pu"se )6imetry

# See S>i"" 2 @# Prepare site

# ("ign ;E3 and photodetector# Connect and set a"arms# Ensure c"ient sa%ety

# Ensure accuracy


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/esources# (udio 9"ossary# 7yper7E(/

Sho1s the heart pumping and ta">s aboutdiasto"ic and systo"ic cyc"es. 7as tutoria"s %oratria" systo"e and others. !ery %un site.

# Best Practice !ita" Signs/e ie1s research studies re"ated to ita" signs.Co ers a"" aspects o% ita" signs and e en gi esimp"ications %or practice and recommendations.

# he $edica" Center !ita" SignsPro ides an o er ie1 o% ita" signs. =ice"y done.


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