1. Chapter 26: Vital Sign Assessment

2. 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

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

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

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

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

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

8. 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

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

10. 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.

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

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

13. Pulse
Equipment
Stethoscope
Doppler
Methods
Palpation
Auscultation

14. 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

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

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

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

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

19. Respirations
Factors affecting respirations
Age
Medications
Stress
Exercise
Altitude
Gender

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

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

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

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

24. Blood Pressure
Assessing blood pressure
Sites
Upper extremity
Lower extremity

25. Blood Pressure
Equipment
Sphygmomanometer
Stethoscope
Doppler
Electronic devices

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

27. 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

28. Blood Pressure
Abnormalities
Hypertension
Prehypertension
Hypotension
Orthostatic hypotension

29. 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

30. 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.

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

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