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chapter 27 vital signs


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Describe the factors that affect the vital signs & accurate measurement of them.
Age: older people and infants are greatly influenced by temperature. People over 75 years are at the risk of hyperthermia (below 96.8 or 36o) for a vary reasons like inadequate diet loss of subcutaneous fat lack of activity etc.
Diurnal variations (circardian rhythms) temperature change through out the day. It is high in the morning and Afternoon and low at sleeping time (4-6Am).
Exercise: hard work or exercise increases the temperature.
Describe other factors that affect the vital signs & accurate measurement of them.
Hormones: women have a more fluctuations than men in there temperature due to hormones change. Secretion of hormones increases the temp.
Environment: if the room temperature is high the body temperature will be high and vice versa.
Measurement of vital signs: pulse, respiration, B/P,
PULSE: a wave of blood created by contraction of the left vertical of the heart
RESPIRATION: act of breathing
Blood PRESURE: the pressure excreted by the blood as it flows
Factors Influcing the body’s heat production & loss
Heat production: basal metabolic rate (BMR) rate of energy utilize in the body required to maintain esstentional activities such as breathing .BMR is decrease with the age.
Thyroxin output: stimulation of heat production in the body increase through the metabolism.
Hormones: increase rate of cellular metabolism.
Fever: increase in cellular metabolic rate increase the body temperature.
Heat Loss:
Radiation: transfer of heat from surface of one object to the other (ex nude person in room temperature loss 60% of body heat)
Conduction: transfer heat from one molecule to lower temperature (ex when body immersed in cold water.)
Convection: dispersion of heat by air current
Vapor ration: continues evaporation of moistures the respiratory tract mucosa of mouth & from the skin.
Name two kind of Body temperature
Core Temperature: is the Temp of the deep tissue of the body such as abdominal cavity pelvic it remains relatively constant.
Surface temperature: Temp of the skin the subcutaneous tissue and fat. It raises and falls in response to environment
Compare Oral, tympanic , axillary and rectal temperature .
Oral: refers more quickly affected by food, fluid and smoking.
Rectal: very accurate contradicted for diarrhea, rectal surgery clothing disorder or hemorrhoids
Axillary: referred for new born, inappropriate for adults with wired jaws oval surgery .
Tympanic : tissue of ear canal .core body temp. risk of injury
Explain how to measure the Appical Pulse?
1) Explain to client. 2) Observe infection control. 3) Provide a privacy. 4) Position the client appropriately in comfortable Supine position expose the area of the chest over the apex of the heart. 5) locate the apical impulse (PMI) 6) Insulate and count heart beats (S1 & S2) 7) if rhythm is regular count heart beats for 30 seconds & multiply by 2,if it is irregular count 60 complete sec.8) access the rhythm and strength of the heart beat. 9) document the pulse site ,rate ,rhythm,& volume .
Identify the 9 site to use asses the pulse & state the reason for their use
Temporal: where the temporal artery passes over the temporal bone. It is used when radial pulse is not accessible.
Carotid: neck, where the carotid artery . it is used in the case of cardiac arrest (CPR) and circulation
Apical: apex of the heart. (left side of the Chest abt 8 cms left of breast bone. Sternum. Used for infants & also used for discrepancies of radial pulse.
Popliteal: artires pass behind the knee. It is easy to check the circulation to the lower leg.
Pedal (Dorsal): where the dorsal of pedal artery passes over the bones of the foot . It is readily accessible determine the circulation to the foot.
Brachial: inner aspects of biceps muscles of the arm. Used in measured the B/P and cardiac arrest of infants
Posterior tibal: medial surface of the ankle where the tibial aretery passes. Easy to check circulation
List characteristics that should be included when accessing pulse .
Factors affecting the Pulse: AGE: increase in age lower the pulse rate is
Gender: after puberty male pulse lower than females.
Fever: pulse are high and B/P is lower vasodilatation high BMR.
Exercise: pulse are high due to activity, but athletes is less often than a normal person because of greater cardiac size and strength & efficiency
Medication: medications make the low pulse or it may be high
Hypovolemia: loss of blood cause the high pulse rate and high B/P.
Stress: sympathetic nervous stimulate high pulse; over activity of the heart.
Position change: sitting or standing pools the blood flow low and lower the pulse
Pathology: certain disease can cause lower pulse.. Impair the oxygen
Describe the mechanism of the breathing & control respiration
During inhalation : Diaphragm contracts & the ribs moves upward & downwards the sternum moves outward that enlarge the thorax and permit the lungs to expand.
Exhalation: diaphragm relaxes, the ribs moves downward and inwards and sternum moves inwards decrease the size of thorax.
Identify the components of a respiratory assessment.
Hyperventilation: refers to a very deep ,rapid respirations.
Hypoventiliation: refers to vary shallow respiration
Respiratory rhythm:
: refers to very deep ,rapid respiration and the inspiration
Respiratory quality
refers to those aspects of breathing that are different from the normal ,effortless breathing , using breathing does not required efforts but it does than it is known as Labored breathing.
Breathing Patterns:
Rate, Volume, Rhythm, Ease or effort, Breath Sounds Chest movement.
quick shallow breathing.
abnormal slow breathing
: cessation of breathing
Cheyne stokes breathing:
: rhythmic waxing and waning of respirations, from very deep to very shallow breathing and temporary apnea.
: difficult or labored breathing during which the individual has a persistent, unsatisfied need for air and feels distressed
ability to breath in upright sitting or standing positions.
: a shrill harsh sound heard during inspiration with larygeal obstruction.
: snoring. Usually due to partial obstruction of the upper airway
: continuous high pitched musical squeak or whistling sound occurring on expiration and sometimes on inspiration when air moves through a narrow obstructed airway.
gurgling sounds as air passes through the moist secretions in the respiratory tract.
intercostals retraction: in drawing between the ribs.
Substernal retraction:
: in drawing beneath the breastbone.
indrawing above the clavicles.
Hemoptysis: the presence of the blood in the sputum.
PRODUCTIVE COUGH: a cough accompany by expectorated secretions
NONPRODUCTIVE COUGH: a dry harsh cough without secretions.
is a measure of the pressure expected by the blood as it flows through the arteries.
SYSTOLIC B/P: is the pressure of the blood as a result of contraction of the ventricles and it is the height of the blood wave.
DIASTOLIC: is the pressure which is the pressure when ventricles rest.
PULSE PRESSURE: the difference between the diastolic and systolic pressure
Describe the various site and methods of Blood Pressure
The blood pressure is usually assessed in the client’s arm using the brachial artery and a std. stethoscope .the following are the conditions when B/P can be asses on the pt. THIGH: if can’t be measured on any arm (due to burns or other trauma) , it can not be measured on thigh in following condition: the shoulder, arm, or hand (the hip, knee or ankle ) is injured or ceased ; a cast or the bandage is on any part of the limb. The client had a removal of the axilla or hip or lymph nodes. The client has a infusion in the limb
Methods of the assessing the B/P
Direct: (invasive monitoring) measurements involves the insertion of the of a catheter in to the brachial or radial or femoral artery.
Two invasive indirect methods of B/P anscultatory:is most common method used in the hospitals ,a sphygmonometer a cuff and a stethoscope . it is most accurate way of assessing the B/P.
Phase 1: A SHARP TAPPING the pressure level is first faint, clear tapping or thumping sounds that heard.
Phase 2 A SWISHING WHOOSHING SOUND the period during deflation when the sounds have a muffled whooshing or swishing quality
Phase 3: A THUMP SOFTER THAN A TAPPING the period during the blood flows freely through an increasingly open artery, & sound become more crisper and intense.
Phase 4: A SOFTER BLOWING the time when sounds become modified and have a soft , blowing quality.
Phase 5: the pressure level when the sound is heard and is follow by a silence.
Age, Exercise, Stress, Race, gender, medications, Diurnal variations, diseases process.
Factors that affect 02 saturations
Hemoglobin: if the hemoglobin is fully saturated with o2, the SAO2 will appear normal even if the total hemoglobin level is low if the pt is anemic and has an inadequate. 02 supply to the tissue but pulse oximeter would return a normal value.
Circulation: the oximeter will not return accurate reading if the area under the sensor has impaired circulation.
Activity: shivering or excessive movement of the sensor site may interfere with accurate readings.

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