Copyright © Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 26: Vital Sign Assessment

Copyright © <2008> Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 26:

Vital Sign Assessment


Body Temperature 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 TemperatureBody Temperature

•Heat production

– Metabolism

– Heat is lost through four processes:

•Radiation; Conduction

•Convection; Evaporation



•Factors affecting body temperature

– Age; Environment

– Time of day

– Exercise

– Stress

– Hormones



•Factors affecting body temperature measurement

– Smoking

– Oxygen administered by mask or cannula

– Intake of hot or cold liquids



•Assessing body temperature

– Sites

•Oral; Rectal; Ear

•Temporal artery (forehead)

•Axillary



•Equipment

– Electronic thermometers

– Tympanic membrane thermometer

– Temporal artery thermometer

– Disposable paper thermometers

– Temperature-sensitive strips

– Glass mercury thermometer



•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


QuestionQuestion

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

a. Eupnea

b. Apnea

c. Bradypnea

d. Tachypnea


AnswerAnswer

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.


PulsePulse

•Characteristics

– Rate or frequency; Rhythm; Quality

•Factors affecting pulse rate

– Age

– Autonomic nervous system

– Medications


PulsePulse

•Assessing the pulse

– Sites

•Temporal; Carotid

•Apical; Brachial

•Radial; Popliteal

•Pedal; Posterior tibial


PulsePulse

•Equipment

– Stethoscope

– Doppler

•Methods

– Palpation

– Auscultation


PulsePulse

•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


PulsePulse

•Assessing pulse characteristics (cont’d)

– Rhythm

– Quality

– Pulse deficits


QuestionQuestion

Tell whether the following statement is True or False.

Cardiac medications like digoxin increase pulse rate in clients.


AnswerAnswer

False.

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


RespirationsRespirations

•External respiration

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



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



•Assessing respirations

– Rate

– Rhythm and depth

– Quality: Usually automatic, quiet, and effortless



•Dyspnea

•Methods: Perform the respiratory assessment without clients being aware of the assessment


Blood PressureBlood Pressure

•Physiologic factors determining blood pressure

– Systolic blood pressure

– Diastolic blood pressure

– Pulse pressure

– Blood flow

– Resistance



•Factors affecting blood pressure

– Age

– Autonomic nervous system

– Circulating volume

– Medications

– Normal fluctuations



•Assessing blood pressure

– Sites

•Upper extremity

•Lower extremity



•Equipment

– Sphygmomanometer

– Stethoscope

– Doppler

– Electronic 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 clients 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 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 SignsDocumenting Vital Signs

•Vital signs

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


Lifespan ConsiderationsLifespan Considerations

•Newborn and infant

•Toddler and preschooler

•School-age child and adolescent

•Adult and older adult

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Copyright © Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 26: Vital Sign Assessment