Health Assessment Vital Signs

stable core of 37.2 celcius or 99 farenheit. Balance of heat production with heat loss. The normal range is 96.4 F to 99.1 F

trough occuring in early morning hours and peak occuring in late afternoon to early evening

place at base of tongue in either of posterior sublingual pockets; not in front of tongue.

Instruct person to keep his or her lips closed.

Leave in place 3 to 4 minutes if person is afebrile, and up to 8 minutes if febrile; take other vital signs during this time.

Wait 15 minutes if person has just taken hot or iced liquids and 2 minutes if he or she has just smoked.

Wear gloves and insert lubricated rectal probe cover on an electronic thermometer only 2 to 3 cm (1 in) into adult rectum, directed toward umbilicus.

Tympanic membrane thermometer (TMT) senses infrared emissions of tympanic membrane (eardrum).

Tympanic membrane shares same vascular supply that perfuses hypothalamus (internal carotid artery).

Gently place otoscope shaped covered probe tip in person’s ear canal; temperature can be read in 2 to 3 seconds.

Minimal chance of cross-contamination with tympanic thermometer because ear canal is lined with skin and not mucous membrane

Used with unconscious patients or with those who are unable or unwilling to cooperate with traditional techniques

Advantages of speed, convenience, safety, reduced risk for injury and infection, and noninvasiveness

palpable flow felt in the periphery as a result of pressure wave generation from stroke volume. Usually 60 to 100 bpm.

Force of pulse is strength of heart’s stroke volume.

Weak, thready pulse reflects a decreased stroke volume (e.g., as occurs with hemorrhagic shock).

Full, bounding pulse denotes increased stroke volume, as with anxiety, exercise, and some abnormal conditions.

Pulse force recorded using three-point scale

3+ Full, bounding

2+ Normal

1+ Weak, thready

0 Absent

pulse under 60bpm

pulse over 100bpm

Heart rate varies with respiratory cycle, speeding up at peak of inspiration and slowing to normal with expiration.

Inspiration momentarily causes a decreased stroke volume from left side of heart.

To compensate, heart rate increases.

count for 30 seconds 1 minute if theirs an anomaly

a noninvasive method to assess arterial oxygen saturation (SpO2). Attaches to person's finer or earlobe. Add on what air they are getting the reading

force of blood pushing against side of its container, vessel wall. average is 120/80 affected by age, gender, race, and dinural rhtyhm, weight, exercise, emotions, stress

maximum pressure felt on artery during left ventricular contraction, or systole

elastic recoil, or resting, pressure that blood exerts constantly between each contraction

difference between systolic and diastolic. Reflects stroke volume

pressure forcing blood into tissues, averaged over cardiac cycle

Phase 1: A sharp tapping.

This is the first sound heard as the cuff pressure is released. This sound provides the systolic pressure reading.

Phase 2: A swishing/whooshing sound.

Swishing sounds as the blood flows through blood vessels as the cuff is deflated.

Phase 3: A thump (softer than phase 1).

Intense thumping sounds that are softer than phase 1 as the blood flows through the artery but the cuff pressure is still inflated to occlude flow during diastole.

Phase 4: A softer, blowing, muffled sound that fades.

Softer and muffled sounds as the cuff pressure is released. The change from the thump of phase 3 to the muffled sound of phase 4 is known as the first diastolic reading.

Phase 5: Silence.

Leads to high readings

Taking when physiologically active, following activity, or emotionally labile

Narrow cuff size and/or applied too loose

Reinflating during procedure

Leads to low readings

Decreased inflation

Too large cuff size

Can lead to high or low readings—examiner/observer error

Position of arm or leg

Improper cuff size

Deflating cuff too quickly

is a narrowing, or constriction, in a portion of the aorta

higher than in arm, measured when arm is excessively high

BP is not normally checked in children less than 3 years of age.

Whenever possible, avoid rectal route and take a tympanic, inguinal, or axillary temperature.

Infant: reverse order of vital signs to respirations, pulse and temperature

Preschooler: consider normal fear of body mutilation may increase with any invasive procedure

School-age: Promote cooperation by explanation and participation in handling equipment

Adolescent: Same consideration as with adults

Temp: changes in body’s temp regulatory mechanism less likely to have fever but at greater risk for hypothermia

Temp is less reliable index of true health state; sweat gland activity is also diminished.

Pulse: rhythm may be slightly irregular

Radial artery may feel stiff, rigid, and tortuous in older person, although does not necessarily imply vascular disease in heart or brain.

rigid arterial wall needs faster upstroke of blood, so pulse is actually easier to palpate.

Resp.: decrease in vital capacity and decreased inspiratory reserve volume

note shallower inspiratory phase and an increased respiratory rate.

BP: aorta and major arteries tend to harden with age

heart pumps against a stiffer aorta, systolic pressure increases, leading to widened pulse pressure. Systolic and diastolic pressures increase, difficult to distinguish normal aging values from abnormal hypertension.

technique works by a principle that sound varies in pitch in relation to distance between sound source and listener: pitch is higher when distance is small, and pitch lowers as distance increases.

In this case, sound source is blood pumping through artery in rhythmic manner.

Handheld transducer picks up changes in sound frequency as blood flows and ebbs, and it amplifies them.

Instructions:

Apply coupling gel to transducer probe.

Turn Doppler flow meter on.

Touch probe to skin, holding probe perpendicular to artery.

A pulsatile whooshing sound indicates location of artery.

May need to rotate probe, but maintain contact with skin.

Do not push probe too hard or you will wipe out pulse.

Inflate cuff until sounds disappear; then proceed another 20 to 30 mm Hg beyond that point.

Slowly deflate cuff, noting point at which first whooshing sounds appear; this is systolic pressure.