Vital Signs I (Temperature & Pulse) PDF

VITAL SIGNS (TEMPERATUREI & PULSE)  OBJECTIVES ▪ After completing this lecture, each student will be able to: Define body temperature Identify the types of body temperature List the factors that influence the body temperature Describe appropriate temperature....

VITAL SIGNS (TEMPERATUREI & PULSE)  OBJECTIVES ▪ After completing this lecture, each student will be able to: Define body temperature Identify the types of body temperature List the factors that influence the body temperature Describe appropriate temperature. nursing care for alterations in Identify nine sites used reasons for their use. to assess the pulse and state the List the pulses characteristics that should be included when assessing  INTRODUCTION ▪ The traditional vital signs are Body temperature Pulse Respirations Blood pressure ▪ Many agencies such as American Pain Society and The Joint Commission have designated pain as a fifth vital sign, to be assessed at the same time as each of the other four  INTRODUCTION ▪ Vital signs, which should be looked at in total, are checked to monitor the functions of the body. ▪ The signs reflect changes in function that otherwise might not be observed. ▪ Vital signs should be evaluated with reference to clients’ present and prior health status, their usual vital sign results (if known), and accepted normal standards.  INTRODUCTION ▪ When and how often to assess a specific client’s vital signs are chiefly nursing judgments, depending on the client’s health status. ▪ Some agencies have policies about when to take clients’ vital signs. The primary care provider may specifically order a vital sign (e.g., “Blood pressure q2h”). INTRODUCTION  BODY TEMPERATURE ▪ Body temperature reflects the balance between the heat produced and the heat lost from the body, and is measured in heat units called degrees. ▪ There are two kinds of body temperature: Core temperature Surface temperature.  BODY TEMPERATURE ▪ Core temperature Is the temperature of the deep tissues of the body, such as the abdominal cavity and pelvic cavity. It remains relatively constant. The normal core body temperature is a range of temperatures ▪ The surface temperature Is the temperature of the skin, the subcutaneous tissue, and fat. It, by contrast, rises and falls in response to the environment.  BODY TEMPERATURE ▪ The body metabolism.continually produces heat as a by-product of ▪ When the amount of heat produced by the body amount of heat lost, the person is in heat balance equals the ▪ Aimportant number are of factors affect these five: the body’s heat production. The most ▪ Basal metabolic rate ▪ Muscle activity ▪ Thyroxine output ▪ Epinephrine, response norepinephrine, and sympathetic stimulation/ stress ▪ Fever  BODY TEMPERATURE ▪ Basal metabolic rate. The basal metabolic rate (BMR) is the rate of energy utilization in the body required to maintain essential activities such as breathing. Metabolic rates decrease with age. In general, the younger the person, the higher the BMR. ▪ Muscle activity. Muscle activity, including shivering, increases the metabolic rate. ▪ Thyroxine output. Increased thyroxine output increases the rate of cellular metabolism throughout the body  BODY TEMPERATURE ▪ Epinephrine, norepinephrine, and sympathetic stimulation/ stress response. These hormones immediately increase the rate of cellular metabolism in many body tissues. ▪ Fever. Fever increases the cellular metabolic rate and thus increases the body’s temperature further.  BODY TEMPERATURE ▪ Heat is lost from the body through Radiation Conduction Convection Evaporation  BODY TEMPERATURE ▪ Radiation ▪ Is the transfer of heat from the surface of one object to the surface of another without contact between the two objects, mostly in the form of infrared rays. ▪ Conduction ▪ is the transfer of heat from one molecule to a molecule of lower temperature. ▪ Conductive transfer cannot take place without contact between the molecules and normally accounts for minimal heat loss except, for example, when a body is immersed in cold water. ▪ The amount of heat transferred depends on the temperature difference and the amount and duration of the contact.  BODY TEMPERATURE ▪ Convection ▪ Is the dispersion of heat by air currents. The body usually has a small amount of warm air adjacent to it. This warm air rises and is replaced by cooler air, so people always lose a small amount of heat through convection.  BODY TEMPERATURE ▪ Evaporation ▪ Is continuous vaporization of moisture from the respiratory tract and from the mucosa of the mouth and from the skin. ▪ This continuous and unnoticed water loss is called insensible water loss, and the accompanying heat loss is called insensible heat loss. ▪ Insensible heat loss accounts for about 10% of basal heat loss. When the body temperature increases, vaporization accounts for greater heat loss.  BODY TEMPERATURE ▪ Regulation of Body Temperature ▪ The hypothalamic integrator is the center that controls the core temperature. ▪ When the integrator detects heat, it sends out signals intended to reduce the temperature, that is, to decrease heat production and increase heat loss. ▪ In contrast, when the cold sensors are stimulated, the integrator sends out signals to increase heat production and decrease heat loss.  BODY TEMPERATURE ▪ The signals from the cold-sensitive receptors of the hypothalamus initiate effectors, such as Vasoconstriction Shivering, Release of epinephrine, which increases cellular metabolism and hence heat production.  BODY TEMPERATURE ▪ When the warmth-sensitive receptors in the hypothalamus are stimulated, the effector system sends out signals that: Initiate sweating Peripheral vasodilation ▪ When this system is stimulated, the person consciously makes appropriate adjustments, such as putting on additional clothing in response to cold or turning on a fan in response to heat.  BODY TEMPERATURE ▪ Factors Affecting Body Temperature Age Diurnal variations (circadian rhythms) Exercise. Hormones Stress Environment  BODY TEMPERATURE ▪ Age Infants are greatly influenced by the temperature environment and must be protected from extreme changes. of the Children’ s temperatures until puberty. vary more than those of adults do Many older people, particularly those over 75 years, risk of hypothermia (temperatures below 36°C, or 96.8°F). are at Older the adults are environmental also particularly temperature sensitive due to to extremes decreased in thermoregulatory controls.  BODY TEMPERATURE ▪ Diurnal variations (circadian rhythms) ▪ Body temperatures normally change throughout the day, varying as much as 1.0°C (1.8°F) between the early morning and the late afternoon. ▪ The point of highest body temperature is usually reached between 1600 and 1800 hours (4:00 pm and 6:00 pm), and the lowest point is reached during sleep between 0400 and 0600 hours (4:00 am and 6:00 am)  BODY TEMPERATURE ▪ Exercise. Hard work or strenuous exercise can increase body temperature to as high as 38.3°C to 40°C (101°F to 104°F) measured rectally. ▪ Hormones. Women usually experience more hormone fluctuations than men. In women, progesterone secretion at the time of ovulation raises body temperature by about 0.3°C to 0.6°C (0.5°F to 1.0°F) above basal temperature.  BODY TEMPERATURE ▪ Stress. ▪ Stimulation of the sympathetic nervous system can increase the production of epinephrine and norepinephrine, thereby increasing metabolic activity and heat production. ▪ Nurses should anticipate that a highly stressed or anxious client could have an elevated body temperature for that reason.  BODY TEMPERATURE ▪ Environment. ▪ Extremes in environmental temperatures can affect a person’s temperature regulatory systems. ▪ If the temperature is assessed in a very warm room and the body temperature cannot be modified by convection, conduction, or radiation, the temperature will be elevated. ▪ Similarly, if the client has been outside in cold weather without suitable clothing, or if a medical condition prevents the client from controlling the temperature in the environment (e.g., the client has altered mental status or cannot dress self), the body temperature may be low.  BODY TEMPERATURE ▪ Alterations in Body Temperature ▪ The normal range for adults is considered to be between 36°C and 37.5°C (96.8°F to 99.5°F). ▪ There are two primary alterations in body temperature: Pyrexia Hypothermia  BODY TEMPERATURE ▪ A body temperature above the usual range is called pyrexia, hyperthermia, or (in lay terms) fever. ▪ A very high fever, such as 41°C (105.8°F), is called hyperpyrexia. ▪ The client who has a fever is referred to as febrile; the one who does not is afebrile.  BODY TEMPERATURE ▪ Four common types of fevers are: Intermittent Remittent Relapsing Constant.  BODY TEMPERATURE ▪ During an intermittent fever, the body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperatures. ▪ An example is with the disease malaria. ▪ During a remittent fever, such as with a cold or influenza, a wide range of temperature fluctuations (more than 2°C [3.6°F]) occurs over a 24-hour period, all of which are above normal.  BODY TEMPERATURE ▪ Relapsing fever, short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature. ▪ During a constant fever, the body temperature fluctuates minimally but always remains above normal. This can occur with typhoid fever. ▪ A temperature that rises to fever level rapidly following a normal temperature and then returns to normal within a few hours is called a fever spike. Bacterial blood infections often cause fever spikes. BODY TEMPERATURE ▪ BODY TEMPERATURE Clinical manifestations of fever ▪ Fever ONSET (COLD OR CHILL PHASE) Increased heart rate Increased respiratory rate and depth Shivering Pallid, cold skin Complaints of feeling cold Cyanotic nail beds “Gooseflesh” appearance of the skin Cessation of sweating ▪ BODY TEMPERATURE COURSE (PLATEAU PHASE) Absence of chills Skin that feels warm Photosensitivity Glassy-eyed appearance Increased pulse and respiratory rates Increased thirst Mild to severe dehydration Drowsiness, restlessness, delirium, or convulsions Herpetic lesions of the mouth Loss of appetite (if the fever is prolonged) Malaise, weakness, and aching muscles  BODY TEMPERATURE ▪ DEFERVESCENCE (FEVER ABATEMENT/FLUSH PHASE) Skin that appears flushed and feels warm Sweating Decreased shivering Possible dehydration  BODY TEMPERATURE ▪ HYPOTHERMIA ▪ The three physiological mechanisms of hypothermia are (a) excessive heat loss, (b) inadequate heat production to counteract heat loss, and (c) impaired hypothalamic thermoregulation. ▪ Hypothermia may be induced or accidental ▪ Induced hypothermia is the deliberate lowering of the body temperature to decrease the need for oxygen by the body tissues such as during certain surgeries.  BODY TEMPERATURE ▪ Accidental hypothermia can occur as a result of (a) exposure to a cold environment, (b) immersion in cold water, and (c) lack of adequate clothing, shelter, or heat ▪ BODY TEMPERATURE CLINICAL MANIFESTATIONS Hypothermia Decreased body temperature, pulse, and respirations Severe shivering (initially) Feelings of cold and chills Pale, cool, waxy skin Frostbite (discolored, blistered nose, fingers, toes) Hypotension Decreased urinary output Lack of muscle coordination Disorientation Drowsiness progressing to coma  PULSE ▪ The pulse is a wave of blood created by contraction of the left ventricle of the heart ▪ Generally, the pulse wave represents the stroke volume output or the amount of blood that enters the arteries with each ventricular contraction. ▪ Compliance of the arteries is their ability to contract and expand. ▪ When a person’s arteries lose their distensibility, as can happen with age, greater pressure is required to pump the blood into the arteries.  PULSE ▪ Cardiac output is the volume of blood pumped into the arteries by the heart and equals the result of the stroke volume (SV) times the heart rate (HR) per minute. ▪ For example, 65 mL * 70 beats per minute 5 4.55 L per minute. When an adult is resting, the heart pumps about 5 liters of blood each minute.  PULSE ▪ A peripheral pulse is a pulse located away from the heart, for example, in the foot or wrist. ▪ The apical pulse, in contrast, is a central pulse; that is, it is located at the apex of the heart. It is also referred to as the point of maximal impulse (PMI). ▪ The rate of the pulse is expressed in beats per minute (beats/min).  PULSE ▪ Factors Affecting the Pulse ▪ Age. As age increases, the pulse rate gradually decreases overall.  PULSE ▪ Sex. After puberty, the lower than the female’s. average male’ s pulse rate is slightly ▪ Exercise. The rate ofThe pulse increase rate in thenormally increases professional with athlete is activity. often less than in the average person strength, and efficiency. because of greater cardiac size, ▪ Fever. lowered The pulse blood rate pressureincreases that (a) results in response from to peripheralthe vasodilation associated with elevated body and (b) because of the increased metabolic rate. temperature  PULSE ▪ Medications. Some medications decrease the pulse rate, and others increase it. For example, cardiotonics (e.g., digitalis preparations) decrease the heart rate, whereas epinephrine increases it. ▪ Hypovolemia/dehydration. Loss of blood from the vascular system increases the pulse rate. In adults, the loss of circulating volume results in an adjustment of the heart rate to increase blood pressure as the body compensates for the lost blood volume.  PULSE ▪ Stress. In response to stress, sympathetic nervous stimulation increases the overall activity of the heart. Stress increases the rate as well as the force of the heartbeat. Fear and anxiety as well as the perception of severe pain stimulate the sympathetic system. ▪ Position. When a person is sitting or standing, blood usually pools in dependent vessels of the venous system. Pooling results in a transient decrease in the venous blood return to the heart and a subsequent reduction in blood pressure and increase in heart rate.  PULSE ▪ Pathology. Certain diseases such as some heart conditions or those that impair oxygenation can alter the resting pulse rate.  PULSE ▪ Pulse sites  PULSE ▪ Pulse sites ▪ A pulse may be measured in nine sites Temporal, temporal where bone of the the temporal head. The artery site is passes over superior the (above) and lateral to (away from the midline of) the eye. ▪ Carotid, runs at between the side the of the trachea neck and where the the carotid artery sternocleidomastoid muscle. because (Never this canpress cause both a carotids reflex dropat the in same blood time pressure or pulse rate)  PULSE ▪ Apical, at the apex of the heart. In an adult, this is located on the left side of the chest, about 8 cm (3 in.) to the left of the sternum (breastbone) at the fifth intercostal space (area between the ribs). In older adults, the apex may be further left if conditions are present that have led to an enlarged heart. Before 4 years of age, the apex is left of the midclavicular line (MCL); between 4 and 6 years, it is at the MCL. For a child 7 to 9 years of age, the apical pulse is located at the fourth or fifth intercostal space.  PULSE ▪ Brachial, at the inner aspect of the biceps muscle of the arm or medially in the antecubital space. ▪ Radial, where the radial artery runs along the radial bone, on the thumb side of the inner aspect of the wrist. ▪ Femoral, where the femoral artery passes alongside the inguinal ligament. ▪ Popliteal, where the popliteal artery passes behind the knee. ▪ Posterior tibial, on the medial surface of the ankle where the posterior tibial artery passes behind the medial malleolus.  PULSE ▪ Dorsalis pedis, where the dorsalis pedis artery passes over the bones of the foot, on an imaginary line drawn from the middle of the ankle to the space between the big and second toes. ▪ The radial site is most commonly used in adults. It is easily found in most people and readily accessible  ASSESSING THE PULSE ▪ A pulse is commonly assessed by palpation (feeling) or auscultation (hearing). ▪ The middle three fingertips are used for palpating all pulse sites except the apex of the heart. ▪ A stethoscope is used for assessing apical pulses  ASSESSING THE PULSE ▪ Before the nurse assesses the resting pulse, the client should assume a comfortable position. The nurse should also be aware of the following: Any medication that could affect the heart rate. Whether the client has been physically active. If so, wait 10 to 15 minutes until the client has rested and the pulse has slowed to its usual rate. ASSESSING THE PULSE Any baseline data about the normal heart rate for the client. For example, a physically fit athlete may have a resting heart rate below 60 beats/min. Whether the client should assume a particular position (e. g., sitting). In some clients, the rate changes with the position because of changes in blood flow volume and autonomic nervous system activity.  ASSESSING THE PULSE ▪ When assessing the pulse, the nurse collects the following data: the rate, rhythm, volume, arterial wall elasticity, and presence or absence of bilateral equality. ▪ An excessively fast heart rate (e.g., over 100 beats/min in an adult) is referred to as tachycardia. ▪ A heart rate in an adult of less than 60 beats/min is called bradycardia. ▪ If a client has either tachycardia or bradycardia, the apical pulse should be assessed.  ASSESSING THE PULSE ▪ The pulse rhythm is the pattern of the beats and the intervals between the beats. ▪ Equal time elapses between beats of a normal pulse. ▪ A pulse with an irregular rhythm is referred to as a dysrhythmia or arrhythmia.  ASSESSING THE PULSE ▪ Pulse volume, also called the pulse strength amplitude, refers to the force of blood with each beat. or ▪ Usually, range the from pulse absent volume to is the bounding. same A with normal each pulsebeat. can It be can felt with moderate pressure obliterated with greater pressure of the fingers and can be ▪ Awithforceful or full blood volume that is obliterated difficulty is called a full or bounding pulse. only ▪ Athepulse that is readily obliterated with pressure fingers is referred to as weak, feeble, or thready. from  ASSESSING THE PULSE ▪ The elasticity of the arterial wall reflects its expansibility or its deformities. ▪ A healthy, normal artery feels straight, smooth, soft, and pliable. Older adults often have inelastic arteries that feel twisted (tortuous) and irregular on palpation.  ASSESSING THE PULSE ▪ When assessing a peripheral pulse to determine the adequacy of blood flow to a particular area of the body (perfusion), the nurse should also assess the corresponding pulse on the other side of the body. ▪ The second assessment gives the nurse data with which to compare the pulses. ▪ For example, when assessing the blood flow to the right foot, the nurse assesses the right dorsalis pedis pulse and then the left dorsalis pedis pulse.  ASSESSING THE PULSE ▪ If the client’s right and left pulses are the same volume and elasticity, the client’s dorsalis pedis pulses are bilaterally equal.