Chapter 26: Vital Sign Assessment

Body Temperature Humans maintain a consistent internal body temperature. Core temperature: Temperature inside the body; normal body temperature ranges between 36.5º and 37.5ºC (97.6º and 99.6ºF) Regulation of core body temperature

Body Temperature Heat production Metabolism Heat is lost through four processes: Radiation; Conduction Convection; Evaporation

Body Temperature Factors affecting body temperature Age; Environment Time of day Exercise Stress Hormones

Body Temperature Factors affecting body temperature measurement Smoking Oxygen administered by mask or cannula Intake of hot or cold liquids

Body Temperature Assessing body temperature Sites Oral; Rectal; Ear Temporal artery (forehead) Axillary

Body Temperature Equipment Electronic thermometers Tympanic membrane thermometer Temporal artery thermometer Disposable paper thermometers Temperature-sensitive strips Glass mercury thermometer

Body Temperature 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

Question What is the term used for normal respiratory rhythm and depth in a client? a. Eupnea b. Apnea c. Bradypnea d. Tachypnea

Answer a. Eupnea Rationale: Eupnea is the term used for normal respiratory rhythm and depth in a client. Apnea is the absence of respirations in a client. Tachypnea is an abnormally fast respiratory rate and bradypnea is an abnormally slow respiratory rate in an adult client.

Pulse Characteristics Rate or frequency; Rhythm; Quality Factors affecting pulse rate Age Autonomic nervous system Medications

Pulse Assessing the pulse Sites Temporal; Carotid Apical; Brachial Radial; Popliteal Pedal; Posterior tibial

Pulse Equipment Stethoscope Doppler Methods Palpation Auscultation

Pulse Assessing pulse characteristics Dysrhythmic: Any pulse out of the range of normal rate or rhythm Rate: Normal adult pulse rate; 60 to 100 pulsations per minute Tachycardia; Bradycardia

Pulse Assessing pulse characteristics (cont’d) Rhythm Quality Pulse deficits

Question Tell whether the following statement is True or False. Cardiac medications like digoxin increase pulse rate in clients.

Answer False. Cardiac medications like digoxin decrease pulse rate, whereas atropine inhibits parasympathetic input, causing increased pulse rate in clients.

Respirations External respiration Tidal volume: Amount of air moving in and out with each breath

Respirations Factors affecting respirations Age Medications Stress Exercise Altitude Gender

Respirations Assessing respirations Rate Rhythm and depth Quality: Usually automatic, quiet, and effortless

Respirations Dyspnea Methods: Perform the respiratory assessment without clients being aware of the assessment

Blood Pressure Physiologic factors determining blood pressure Systolic blood pressure Diastolic blood pressure Pulse pressure Blood flow Resistance

Blood Pressure Factors affecting blood pressure Age Autonomic nervous system Circulating volume Medications Normal fluctuations

Blood Pressure Assessing blood pressure Sites Upper extremity Lower extremity

Blood Pressure Equipment Sphygmomanometer Stethoscope Doppler Electronic devices

Blood Pressure Methods Proper cuff size Proper positioning Correlation with the respiratory cycle Proper inflation and deflation

Blood Pressure 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

Blood Pressure Abnormalities Hypertension Prehypertension Hypotension Orthostatic hypotension

Question What is the term used for a high-pitched musical sound in clients during a respiratory assessment? a. Crowing b. Wheezing c. Stridor d. Sigh

Answer b. Wheezing Rationale: The term used for a high- pitched musical sound in clients is wheezing. Stridor is a harsh inspiratory sound that may also be compared to crowing. Sighs are breaths of deep inspiration and prolonged expiration.

Documenting Vital Signs Documented in a graph format, with time as the horizontal axis and the measured value as the vertical axis

Lifespan Considerations Newborn and infant Toddler and preschooler School-age child and adolescent Adult and older adult