Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Fundamentals of Nursing:...

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fundamentals of Nursing: Human Health and FunctionFundamentals of Nursing:

Human Health and Function

Chapter 17: Vital Signs


Body Temperature 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)


Body Temperature (Cont’d)Body Temperature (Cont’d)

• Regulation of body temperature– Heat production

• Metabolism– Heat loss

• Heat is lost through four processes: Radiation; conduction; convection; evaporation



• Factors affecting body temperature– Age – Environment – Time of day– Exercise– Stress– Hormones



• Factors affecting oral body temperature measurement

– Smoking; chewing gum

– Oxygen administered by mask or cannula

– Intake of hot or cold liquid drinks


Body Temperature (Cont’d)Body Temperature (Cont’d)• Assessing body temperature

– Sites• Oral • Rectal • Ear• Forehead (temporal artery)• Axillary



• Assessing body temperature (cont’d)– Equipment

• Electronic thermometers • Tympanic membrane thermometers • Temporal artery thermometers• Disposable paper (chemical)

thermometers• Glass mercury thermometers



• 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


PulsePulse

• Characteristics– Rate or frequency; rhythm; quality

• Factors affecting pulse rate– Age– Autonomic nervous system– Medications


Pulse (Cont’d)Pulse (Cont’d)

• Assessing the pulse– Sites

• Temporal; carotid• Apical; brachial• Radial; femoral; popliteal• Pedal; posterior tibial



• Equipment– Stethoscope– Doppler ultrasound device

• Methods– Palpation– Auscultation



• 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



• Assessing pulse characteristics (cont’d)

– Rhythm

– Quality

– Pulse deficits


QuestionQuestion

Tell whether the following statement is true or false:

Cardiac medications such as digoxin increase pulse rate in patients.


AnswerAnswer

False.

Rationale: Cardiac medications such as digoxin decrease pulse rate, whereas atropine inhibits parasympathetic input, causing increased pulse rate in patients.


RespirationsRespirations

• External respiration; internal respiration

• Tidal volume: Amount of air moving in and out with each breath


Respirations (Cont’d)Respirations (Cont’d)

• Factors affecting respirations– Age– Medications– Stress– Exercise– Altitude– Gender



• Assessing respirations

– Rate

– Rhythm and depth

– Quality: Usually automatic, quiet, and effortless



• Assessing respirations (cont’d)– Quality

• Dyspnea– Methods: Perform the respiratory

assessment without patients being aware of the assessment


QuestionQuestion

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

a. Eupnea

b. Apnea

c. Bradypnea

d. Tachypnea


AnswerAnswera. 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.


Blood PressureBlood Pressure

• Physiologic factors determining blood pressure– Systolic blood pressure– Diastolic blood pressure– Pulse pressure– Blood flow– Resistance


Blood Pressure (Cont’d)Blood Pressure (Cont’d)

• Factors affecting blood pressure– Age– Autonomic nervous system– Circulating volume– Medications– Normal fluctuations



• Assessing blood pressure

– Sites

• Upper extremity

• Lower extremity



• Assessing blood pressure (cont’d)

– Equipment

• Sphygmomanometer

• Stethoscope

• Doppler ultrasound

• Automated devices




– Methods

• Proper cuff size

• Proper positioning

• Correlation with the respiratory cycle

• Proper inflation and deflation




– 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




– Abnormalities

• Hypertension; prehypertension

• Hypotension

• Orthostatic hypotension


QuestionQuestion

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


AnswerAnswer

b. Wheezing

Rationale: The term used for a high-pitched 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.


Documenting Vital SignsDocumenting 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


Lifespan ConsiderationsLifespan Considerations

• Newborn and infant

• Toddler and preschooler

• School-age child and adolescent

• Adult and older adult

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Fundamentals of Nursing:...

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