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A.

Vital signs

I.

definition

a. a person's temperature, pulse, respiration, and blood pressure i.


normally regulated through homeostatic mechanisms to fall within certain normal ranges

b. some people consider pain the fifth vital sign II.


vital signs are commonly assessed:

a. during physical examinations b. at screenings or health fairs c. at clinic visits d. in the home e. upon admission to and before discharge from a health care facility f.
prior to administration of certain medications

g. before and after diagnostic and surgical procedures h. before and after certain nursing interventions i. j.
during emergency situations routinely during the patient's stay in a health care facility

k. when evaluating the effectiveness of a treatment plan l.


any time a patient's condition has changed

B. Temperature I.
the balance between the amount of heat produced by and heat lost from the body (thermoregulation)

II.

types of body temperature

a. core body temperature (C T) i.


temperature of the deep tissues of the body

a. e!g!, the cranium and thoracic, abdominal, and pelvic cavities ii.
fluctuates very little in healthy adults

a. critical range, or set point, is from "#!$% C (&'% () to "$% C (&'!#% () b. surface temperature ()T) i.
temperature of the surface of the body

a. e!g!, s*in, subcutaneous tissues, and fat ii.


fluctuates widely in healthy adults

a. ranges from +,% C (#'% () to -,% C (.,-% () II. a. developmental state i.


e!g!, an elderly individual, whose aging process has resulted in loss of subcutaneous tissue and fat and, conse/uently, the insulating effect of these substances, may experience alterations in thermoregulation (typically a decreased temperature) factors influencing body temperature

b. diurnal variations (circadian rhythms) i.


e!g!, a healthy individual, whose entrainment to +-0hour cycles in the environment has resulted in fluctuations of C T by as much as .!,% C (.!'% () throughout the day, may experience alterations in thermoregulation (typically lowest in the morning and higher in the late afternoon)

b. hormones i.
e!g!, a healthy woman, whose menstrual cycles result in the monthly secretion of a high level of progesterone during ovulation which raises C T by as much as ,!"% C (,!#% () to ,!1% C (.!,% (), may experience alterations in thermoregulation (typically an increased temperature)

b. stress i.
e!g!, an individual who is stressed, which results in stimulation of the sympathetic portion of the autonomic nervous system (23)) and, conse/uently, secretion of epinephrine and norepinephrine which increases basal metabolic rate and heat production, may experience alterations in thermoregulation (typically an increased temperature)

b. environment i.
e!g!, an individual living in the 2rtic, which has resulted in exposure to very cold environmental temperatures for an extended period of time, may experience alterations in thermoregulation (typically a decreased temperature)

ii.

e!g!, an individual living in the tropics, which has resulted in exposure to very high environmental temperatures for an extended period of time,

may experience alterations in thermoregulation (typically an increased temperature)

b. nervous system impairment i.


e!g!, an individual with /uadriplegia, which has resulted in poi*liothermia (ta*ing on the ambient environmental temperature as C T) due to the inability to vasoconstrict, shiver, or sweat, may experience alterations in thermoregulation (typically a decreased or an increased temperature depending on the environment)

ii.

e!g!, an individual with a head in4ury, which has resulted in damage to the hypothalamus, may experience alterations in thermoregulation (typically a decreased or an increased temperature)

b. genetic i.
e!g!, an individual with a genetic predisposition for malignant hyperthermia, which has resulted in a dangerously elevated temperature upon administration of general anesthetic agents, may experience alterations in thermoregulation (typically an increased temperature)

b. circulatory impairment i.
e!g!, an individual with peripheral vascular disease (5V6), which has resulted in the inability to constrict or dilate blood vessels in the periphery normally, may experience alterations in thermoregulation (typically a decreased or an increased temperature)

b. integumentary impairment i.
e!g!, an individual who is severely burned, which has resulted in extensive damage to and loss of large areas of s*in and blood vessels, may experience alterations in thermoregulation (typically a decreased temperature)

b. infection i.
e!g!, an individual who has an infectious process caused by bacteria, virus, fungi, and7or other microorganisms, which has resulted in the release of endogenous pyrogens, may experience alterations in thermoregulation (typically an increased temperature)

b. exercise i.
e!g!, an individual who exercises vigorously, which has resulted in increased muscular activity, metabolic rate and heat production, may experience alterations in thermoregulation (typically an increased temperature)

b. altered cognitive states i.


e!g!, an individual who is confused, which has resulted in an inability to interpret the ambient environmental temperature and the need to dress accordingly, may

experience alterations in thermoregulation (typically a decreased or an increased temperature)

b. altered nutrition i.
e!g!, an individual who is extremely thin, which has resulted in extensive loss of subcutaneous tissue and fat and, conse/uently, the insulating effect of these substances, may experience alterations in thermoregulation (typically a decreased temperature)

II.

body temperature regulation

a. control of body temperature occurs through balancing heat production and heat loss i.
methods of heat production by the body

a. physiologic mechanisms (primarily mediated by the sympathetic portion


of the 23)), e!g!:

i. ii. iii. iv. v. vi.

metabolism muscular activity increased sympathetic nervous system stimulation increased thyroxine secretion fever increased appetite

b. voluntary mechanisms, e!g!: i.


adding clothing (8bundling0up8)

ii. iii. iv. ii.

increasing physical activity (8*eep moving8) decreasing the amount of s*in surface available for heat loss (8curling up in a ball8) moving to a warmer environment methods of heat loss from the body

a. physiologic mechanisms (primarily mediated by the parasympathetic


portion of the 23))

i.

radiation

a. transfer of heat from one surface to another


without contact between the two surfaces, mostly in the form of infrared rays

i.

e!g!, #,9 of total heat lost from the body of a nude person at room temperature is the result of radiation of heat from the person into the room conduction

ii.

a. transfer of heat from one surface to another through


direct contact between the two surfaces

b. two types of conduction i.


conduction to ob4ects

a. e!g!, "9 of total heat lost from


the body of a nude person sitting in a chair at room temperature is the result of conduction of heat from the person to the chair

ii.

conduction to air

a. e!g!, .19 of total heat lost from the body


of a nude person sitting in a chair at room temperature is the result of conduction of heat from the person to the air

ii.

convection

a. dissipation of heat by air currents i.


e!g!, .19 of total heat lost from the body of a nude person at room temperature is the result of convection of heat away from the person after it has been conducted from the person to the air

ii.

evaporation

a. dissipation of heat by transformation of water to a gas i.


e!g!, ++9 of total heat lost from the body of a nude person at room temperature is the result of vapori:ation of moisture from mucus membranes, the mouth, and7or the s*in

ii. ii.

called insensible heat loss decreased appetite

b. behavioral mechanisms, e!g!:

i.

removing clothing (8dressing for warm weather8)

ii. iii. iv.

decreasing physical activity (8slow0down8) increasing the amount of s*in surface available for heat loss (8stretch out8) moving to a cooler environment

b. control of body temperature through regulation of heat


loss and production occurs as the result of the integrative function of the hypothalamus

i.

depends on three factors

a. thermal regulators b. a central integrator c. effectors ii.


thermal regulators

a. sensory receptors for cold and warmth b. two types: i.


peripheral tissue thermal receptors

a. located in the s*in b. send information regarding the external


environment to the central integrator

ii.

deep body tissue thermal receptors

a. located in the spinal cord, abdominal viscera, and in and


around great veins

b. send information regarding the internal


environment to the central integrator

ii.

both types have far more cold than warmth receptors

a. ., cold: . warmth b. seem to be more concerned with preventing


hypothermia

ii.

central integrator

a. the hypothalamus i.
a structure located in the diencephalon of the brainstem

ii.

called the 8body's thermostat8

b. posterior hypothalamus i.
receives input from peripheral and deep tissue thermal receptors that the C T is below the critical set point as a result of:

a. decreased heat production and7or b. increased heat loss ii.


stimulates effectors to return the C T to the critical set point by:

a. increasing heat production and7or b. decreasing heat loss b. preoptic area of the anterior hypothalamus i.
receives input from peripheral and deep tissue thermal receptors that the C T is above the critical set point as a result of:

a. increased heat production and7or b. decreased heat loss ii.


stimulates effectors to return the C T to the critical set point by:

a. decreasing heat production and7or b. increasing heat loss ii. a. blood vessels i.
vasodilation leads to a high rate of blood flow to the s*in from the core body causing heat to be conducted from the core body to the s*in surface effectors

ii.

vasoconstriction leads to a high rate of blood flow from the s*in to the core body preventing heat from being conducted from the core body to the s*in surface

b. sweat glands

i.

presence of stimulation of sweat glands increases the rate of evaporative heat loss from the core body

ii.

absence of stimulation of sweat glands decreases the rate of evaporative heat loss from the core body

b. s*eletal muscle i.
absence of the extra rate of metabolism caused by muscular activity decreases heat production

ii.

presence of the extra rate of metabolism caused by muscular activity, including muscular contraction caused by shivering, increases heat production normal temperature ranges at various ages

II. a. infant i.

"#!. 0 "$!$% C (&$ 0 .,,% ()

b. child i.
"$ 0 "$!#% C (&'!# 0 &&!#% ()

b. adult i.
"$ 0 "$!#% C (&'!# 0 &&!#% ()

b. older adult i.
"# 0 "#!&% C (&#!& 0 &'!"% ()

II.

abnormal body temperature

a. increased body temperature (fever; pyrexia) i.


the state in which an individual's C T is elevated above his7her normal range

ii.

severity of fever

a. low0grade fever i.
a fever between "$!.% C to "'!+% C (&'!'% ( to .,,!#% ()

b. high0grade fever i.
a fever between "'!"% C to -,!-% C (.,,!&% ( to .,-!$% ()

b. hyperpyrexia

i.

a fever over -.% C (.,1!'% ()

ii. a. constant fever i.

types of fever

rise in temperature above normal that remains consistently high with little fluctuation

a. e!g!, less than +% C ("!#% () b. intermittent fever i.


rises or spi*es in temperature above normal at some point during a +-0hour period

a. usually late0afternoon or evening b. remittent fever i.


rise in temperature that is always above normal during a +-0hour period, but the amount of elevation above normal fluctuates

a. e!g!, more than +% C ("!#% () b. relapsing fever i.


rises in temperature lasting for several days, alternating with several days of normal temperature

ii.

phases of fever

a. onset (cold or chill) phase i.


occurs when the body's heat0producing mechanisms are attempting to increase the C T to a higher set point due to development of a factor which causes a high temperature (e!g!, an infection)

ii.

clinical signs of the onset (cold or chill) phase include the following:

a. increased heart rate b. increased rate and depth of respiration c. shivering due to increased s*eletal muscle
tension and contractions

d. pallid, cold s*in due to vasoconstriction

e. complaints of feeling cold f.


cyanotic nail beds due to vasoconstriction contraction of the arectores pilorium muscles

g. 8gooseflesh8 appearance of the s*in due to h. cessation of sweating i.


rise in C T

b. course (fever) phase i.


occurs when the body's heat0producing mechanisms have reached the new, higher set point

ii.

clinical signs of the course (fever) phase include the following:

a. absence of chills b. s*in that feels warm c. feelings of neither hot nor cold d. increased pulse and respiratory rates e. increased thirst f.
mild to severe dehydration convulsions due to irritation of nerve cells

g. simple drowsiness, restlessness, or delirium and h. herpetic lesions of the mouth i. j.


loss of appetite (if the fever is prolonged) malaise, muscle wea*ness, and aching muscles due to protein catabolism

b. defervescence (flush or crisis) phase i.


occurs when the body's heat0loss mechanisms are attempting to decrease the C T to a new, lower set point due to the sudden removal of the cause of the high temperature (e!g!, an infection)

ii.

clinical signs of the defervescence (flush or crisis) phase include the following:

a. s*in that appears flushed and feels warm b. sweating

c. decreased shivering d. possible dehydration e. common interventions for fever f. i.


administer anti0pyretics as ordered decreases set0point to a lower level

b. administer antibiotics as ordered i.


destroys microorganisms which have increased the set0point to a higher level

b. administer oxygen i.
$9 increase in oxygen consumption for each degree in rise of temperature

b. apply hypothermia blan*et i.


body heat is transferred to the blan*et (conduction)

b. increase caloric inta*e i.


increased need for calories due to increased basal metabolic rate

b. increase cool fluid inta*e to +,,,, to


",,,, milliliters a day

c. measure inta*e and output d. maintain prescribed intravenous fluids e. reduce physical activity f.
apply lubricant to dried lips

g. *eep mucus membranes moist h. administer a tepid sponge bath to increase heat
loss through conduction

i. j.

administer an alcohol sponge bath to increase heat loss through evaporation increase air circulation to increase heat loss through convection

k. provide dry clothing and bed linens to increase


heat loss through conduction

b. decreased body temperature (hypothermia) i.


the state in which an individual's body temperature is reduced below normal range

ii.

types of hypothermia

a. induced hypothermia i.
deliberately lowering the C T to a range of ",% C to "+% C ('#% ( to '&!#% () to decrease the need for oxygen by the body tissues, metabolic rate, blood loss and, conse/uently, preserve vital organs during surgery

a. e!g!, cardiac or neurologic surgery b. accidental hypothermia i.


unintentional exposure to a cold environment or immersion in cold water

ii.

clinical signs of hypothermia

a. all cases of hypothermia i.


reduction of body temperature below normal range

b. at a C T of "1% C (&1% () i.
increased respirations, poor 4udgment, shivering

b. at a C T of "1% C to "-% C (&1% ( to &"!+% () i.


bradycardia or tachycardia, myocardial irritability7dysrhythmias, muscle rigidity, shivering, lethargy7confusion, decreased coordination

b. at a C T of "-% C to ",% C (&"!+% ( to '#% () i.


bradycardia, hypoventilation, generali:ed rigidity, metabolic acidosis, coma

b. at a C T of ",% C ('#% () i.
no apparent vital signs, heart rate unresponsive to drug therapy, coma, cyanosis, dilated pupils, areflexia, no shivering, appearance of death

ii.

common interventions for hypothermia

a. remove the patient from the cold b. apply blan*ets c. hyperthermia blan*ets d. warmed intravenous solutions e. remove wet clothing and *eep dry f.
*eep environment warm insulation

g. apply layers of clothing to trap air between them to act as h. warm gradually to prevent vasodilation which can lead to shoc* i. II. a. mercury0in0glass i.
what it consists of in severe cases, extracorporeal rewarming through hemodialysis or use of cardiopulmonary bypass may be needed types of thermometers used to measure body temperature

a. a hollow glass cylinder with a bulb filled with li/uid mercury at its base
mar*ed with (ahrenheit (() or Centigrade (C) calibrations

ii.

how it measures body temperature

a. when the bulb filled with li/uid mercury at the base is heated, the li/uid
mercury expands, forcing a column of li/uid mercury to rise in the hollow glass cylinder mar*ed with (ahrenheit (() or Centigrade (C) calibrations

b. the height that the li/uid mercury expands to on the hollow glass
cylinder mar*ed with (ahrenheit (() or Centigrade (C) calibrations is the patient's body temperature

ii.

length of time it ta*es to measure body temperature

a. oral, approximately " 0 1 minutes b. rectal, approximately + 0 " minutes c. axillary, approximately ., minutes ii.
used to measure body temperature in what routes

a. oral, axillary, rectal

i.

blue0tipped with a long, thin bulb of li/uid mercury at the base < oral, axillary

a. designed to allow for greater exposure of the bulb


against the blood vessels in the mouth or axilla

ii.

red0tipped with a short, blunt bulb of li/uid mercury at the base < rectal

a. designed to prevent trauma to rectal tissues during


insertion

ii. a. convenient

advantages

b. inexpensive to purchase c. easy to use d. accurate e. easy to disinfect f.


can be used multiple times for the same patient

g. can be used with isolation patients ii.


disadvantages

a. slow measurement time b. can brea* and release mercury, which is a poisonous substance c. difficult to read the small (ahrenheit (() or Centigrade
(C) calibrations

d. cannot be used with multiple patients b. digital electronic i.


what it consists of

a. a rechargeable, portable battery0powered electronic display unit, a thin


wire cord with a long, thin heat0sensitive probe that the nurse attaches to the unit, and a long, thin disposable probe cover that the nurse attaches to the long, thin heat0sensitive probe

ii.

how it measures body temperature

a. the heat0sensitive probe detects heat radiated from the oral cavity,
rectum, or axilla and displays it on the electronic display unit

ii.

length of time it ta*es to measure body temperature

a. approximately +1 0 1, seconds ii.


used to measure body temperature in what routes

a. oral, axillary, rectal i.


blue0tipped heat0sensitive probe < oral, axillary temperatures

ii. ii. a. convenient

red0tipped heat0sensitive probe < rectal temperatures advantages

b. easy to use
c! safe

d. accurate e. fast measurement time f.


easy to read

g. disposable probe covers minimi:e ris* for cross0infection h. can be used multiple times for the same patient i. ii.
can be used with multiple patients disadvantages

a. expensive to purchase b. cost of disposable probe covers c. re/uired maintenance d. should not be used with isolation patients b. tympanic membrane i.
consists of a rechargeable, portable battery0operated electronic display unit, an infrared sensor in an otoscope0li*e heat0sensitive probe, and an otoscope0li*e disposable probe cover that the nurse attaches to the otoscope0li*e heat0 sensitive probe

ii.

how it measures body temperature

a. the infrared sensor in the otoscope0li*e probe detects heat radiated from
the tympanic membrane and displays it on the electronic display unit

ii.

length of time it ta*es to measure body temperature

a. less than + seconds ii.


used to measure body temperature in what routes

a! tympanic membrane

ii.

advantages

a. convenient b. easy to use c. safe d. accurate e. fast measurement time f.


easy to read

g. disposable probe covers minimi:e ris* for cross0infection h. can be used multiple times for the same patient i. ii.
can be used with multiple patients disadvantages

a. expensive to purchase b. cost of disposable probe covers c. re/uired maintenance d. should not be used with isolation patients II. a. oral i.
advantages sites for assessing body temperature

a. easily accessible b. minimal, if any, patient repositioning re/uired c. not a source of embarrassment and anxiety

d. provides accurate surface temperature reading e. indicates rapid change in C T ii.


disadvantages

a. the patient must be able to close his7her mouth around the mercury0in0
glass thermometer or heat0sensitive probe

b. affected by ingestion of hot or cold food or fluids and smo*ing


(need to wait .1 0 ", minutes), chewing gum, and oxygen delivery by face mas*

c. contraindicated for use with the following patients: a.


unconscious

b. c. d. e.

irrational sei:ure0prone infants and young children with diseases or surgery of the nose or oral cavity

b. ris* of body fluid exposure b. rectal i.


advantages

a. considered a C T b. considered the most accurate (gold standard) ii.


disadvantages

a. not easily accessible b. patient repositioning re/uired c. may be a source of embarrassment and anxiety d. measurement may lag behind C T during rapid temperature
changes

e. contraindicated for use with the following patients: a.


newborns

b.

with diarrhea

c. d. e.

with diseases or surgery of the rectum with cardiac diseases or surgery bleeding tendencies

b. ris* of body fluid exposure c. re/uires lubrication b. axillary i.


advantages

a. convenient b. safest c. non0invasive d. can be used with newborns and uncooperative patients ii.
disadvantages

a. long measurement time b. re/uires continuous positioning by nurse c. measurement lags behind C T during rapid temperature
changes

d. re/uires exposure of thorax b. tympanic membrane i.


advantages

a. considered a C T b. easily accessible c. minimal, if any, patient repositioning re/uired d. not a source of embarrassment and anxiety e. provides accurate C T reading f.
very rapid measurement (+ 0 1 seconds)

g. can be obtained without disturbing or wa*ing the patient

h. tympanic membrane close to the hypothalamus, sensitive to C T


changes

ii.

disadvantages

a. expensive b. hearing aids must be removed before measurement c. should not be used with patients who have had surgery of the
ear or tympanic membrane

B. 5ulse I.
perceptible throbbing sensation (pulsation) felt over a peripheral artery as a wave of blood is created by contraction of the left ventricle of the heart or auscultated over the apex of the heart with a stethoscope

II.

factors influencing the pulse

a. developmental state i.
e!g!, an elderly individual whose aging process has resulted in a decreased metabolic rate and, conse/uently, a decreased demand for oxygenated blood to be supplied to the cells, may experience an alteration in the pulse (typically a decreased pulse rate)

b. gender i.
e!g!, a woman's heart, which is typically smaller and has a decreased stro*e volume when compared to a man's, may experience an alteration in the pulse to maintain the same cardiac output (typically an increased pulse rate)

b. exercise i.
e!g!, an individual who exercises vigorously, which results in stimulation of the sympathetic portion of the autonomic nervous system (23)) and, conse/uently, secretion of epinephrine and norepinephrine, may experience an alteration in the pulse (typically an increased pulse rate)

b. fever i.
e!g!, an individual who has a fever, which results in a $9 increase in metabolic rate for each ,!#% C (.% () increase in core body temperature and, conse/uently, a $9 increase for oxygenated blood to be supplied to the cells, may experience an alteration in the pulse (typically an increased pulse rate)

b. medications i.
e!g!, an individual who ta*es a cardiac glycoside such as digitalis, which results in negative dromotropic effect on the heart and, conse/uently, an increased refractory period and decreased conduction through the 2V node and 4unctional

tissue, may experience an alteration in the pulse (typically a decreased pulse rate)

b. hemorrhage i.
e!g!, an individual who has blood loss from a hemorrhage, which results in decreased blood volume and, conse/uently, decreased stro*e volume, may experience an alteration in the pulse to maintain the same cardiac output (typically an increased pulse rate)

b. stress i.
e!g!, an individual who is stressed, which results in stimulation of the sympathetic portion of the autonomic nervous system (23)) and, conse/uently, secretion of epinephrine and norepinephrine, may experience an alteration in the pulse (typically an increased pulse rate)

b. position changes i.
e!g!, an individual who assumes a sitting or standing position from a lying position, which results in blood pooling in the dependent vessels of the venous system and, conse/uently, a transient decrease in venous blood return to the heart and stro*e volume, may experience an alteration in the pulse to maintain the same cardiac output (typically an increased pulse rate)

II.

pulse regulation

a. regulated by the autonomic nervous system through the sinoatrial node (pacema*er) i.
parasympathetic nervous system stimulation decreases the heart rate

ii. II.

sympathetic nervous system stimulation increases the heart rate pulse rate

a. the number of perceptible throbbing sensations (pulsations) felt over a peripheral artery
as a wave of blood is created by contraction of the left ventricle of the heart, or auscultated over the apex of the heart, in one minute

b. expressed in beats per minute (bpm) c. normal pulse rates per minute at various ages i.
newborn to . month

a. approximate range < .+, 0 .#, bpm ii.


. to .+ months

a. approximate range < ', 0 .-, bpm ii.


.+ months to + years

a. approximate range < ', 0 .", bpm ii.


+ to # years

a. approximate range < $1 0 .+, bpm ii.


# to .+ years

a. approximate range < $1 0 .., bpm ii.


adolescence to adult

a. approximate range < #, 0 .,, bpm b. abnormal pulse rates per minute i.
tachydardia

a. a heart rate in an adult greater than .,, beats per minute ii.
bradycardia

a. a heart rate in an adult less than #, beats per minute II.


pulse rhythm

a. the pattern of, and intervals between, the perceptible throbbing sensations (pulsations)
felt over a peripheral artery as a wave of blood is created by contraction of the left ventricle of the heart, or auscultated over the apex of the heart with a stethoscope

b. normal pulse rhythms i.


have a regular pattern of, and intervals between, the pulsations, e!g!:

a. normal pulse i.
grade (amplitude)

a. "= (normal) ii.


description

a. the pulsation is easily felt; moderate pressure causes the


pulsation to disappear

ii.

rhythm

a. normal! b. thready pulse

i.

grade (amplitude)

a. .= (thready) ii.
description

a. the pulsation is not easily felt; slight pressure causes the


pulsation to disappear

ii.

rhythm

a. normal! b. wea* pulse i.


grade (amplitude)

a. += (wea*) ii.
description

a. the pulsation is stronger than a thready pulse; light


pressure causes the pulsation to disappear

ii.

rhythm

a. normal! b. bounding pulse i.


grade (amplitude)

a. -= (bounding) ii.
description

a. the pulsation is strong; moderate pressure does not


cause the pulsation to disappear

ii.

rhythm

a. normal! b. abnormal pulse rhythms (dysrhythmias) i.


have an irregular pattern of, and intervals between, the pulsations

ii.

regularly irregular abnormal pulse rhythms

a. pulse rhythm in which the irregular aspect of the pulse occurs at regular
intervals, e!g!:

i.

bisferins

a. pulse characteri:ed by two strong systolic pea*s


separated by a mid0systolic dip

ii.

pulsus alternans

a. pulse characteri:ed by alternation in amplitude from beat


to beat even though the rhythm is basically regular

ii.

paradoxical pulse

a. pulse characteri:ed by a decrease in the amplitude of


the pulse during inspiration

ii.

bigeminal

a. pulse characteri:ed by a normal beat alternating with a


premature ventricular contraction (5VC) whose stro*e volume is diminished in relation to that of the normal beats

ii.

irregularly irregular pulse rhythms

a! pulse rhythm in which the irregular aspect of the pulse occurs a irregular intervals, e!g!:

i.

atrial fibrillation

a. pulse characteri:ed by disorgani:ed electrical activity in


the atria accompanied by an irregular ventricular response that is usually rapid

b. if a dysrhythmia is detected i.
assess the apical pulse for one minute

ii. iii. II.

assess the apical0radial pulse to determine a pulse deficit electrocardiogram (>?@) pulse amplitude

a! the force of the perceptible throbbing sensation (pulsation) felt over a peripheral artery as a wave of blood is created by contraction of the left ventricle of the heart

b. normal pulse amplitude

i.

grade (amplitude)

a. "= (normal) ii.


description

a. the pulsation is easily felt; moderate pressure causes the pulsation to


disappear

ii.

amplitude

a. normal!

b. abnormal pulse amplitudes i.


absent

a. grade (amplitude) i.
, (absent)

b. description i.
no pulsation is felt despite extreme pressure

b. amplitude i.
absent!

ii.
a! grade

thready

i.

.= (thready)

b. description i.
the pulsation is not easily felt; slight pressure causes the pulsation to disappear

b. amplitude i.
very abnormally weak!

ii.
a! grade

wea*

i.

+= (wea*)

b. description i.
the pulsation is stronger than a thready pulse; light pressure causes the pulsation to disappear

b. amplitude i.
abnormally weak!

ii.
a! grade

bounding

i.

-= (bounding)

b. description i.
the pulsation is strong; moderate pressure does not cause the pulsation to disappear

b. amplitude i.
abnormally strong!

II. a. peripheral i.
palpation

methods of assessing the pulse

a. compressing a peripheral artery against an underlying bone with the tips


of the fingers

i.

not the thumb, which has its own pulse

b. peripheral pulse sites i.


temporal

a. where the temporal artery passes over the temporal


bone of the s*ull

ii.

carotid

a. where the carotid artery runs between the trachea and


sternocleiodomastoid muscle

ii.

brachial

a. at the inner aspect of the biceps muscle of the arm or


medially in the antecubital fossa

ii.

radial

a. where the radial artery passes alongside the radial bone ii.
femoral

a. where the femoral artery passes alongside the in/uinal


ligament

ii.

popliteal

a. where the popliteal artery passes behind the *nee ii.


posterior tibial

a. where the posterior tibial artery passes behind the


medial malleolus

ii.
the foot

dorsalis pedis

a. where the dorsalis pedis artery passes over the bones of ii.
6oppler ultrasound

a! assessing the pulse by auscultating a peripheral pulse using a device (doppler ultrasound) that detects the movement of blood flow through blood vessels and converts the velocity of the blood flow into sounds b! apical

i.

auscultation

a. assessing the pulse by auscultating the apical pulse located in the 1 th


intercostal space in the left mid0clavicular line (ABCA) in adults using a device (stethoscope) consisting of two earpieces connected by means of flexible tubing to a diaphragm that amplifies sounds

ii.

6oppler ultrasound

a! assessing the pulse by auscultating the apical pulse using a device (doppler ultrasound) that detects the movement of blood flow through blood vessels and converts the velocity of the blood flow into sounds ii! electrocardiogram (>?@)

a. assessing the apical pulse by recording the electrical activity of the


myocardium by using a device (>?@) to detect transmission of the cardiac impulse through conductive tissue of the muscle

B. Cespiration I.
the mechanism the body uses to exchange gases between the atmosphere and the cells

II.

summari:ation of three different, but related, physiologic processes

a. pulmonary ventilation i.
movement of air in and out of the lungs

a. inspiration (inhalation) i.
act of breathing in

b. expiration (exhalation) i.
act of breathing out

b. external respiration i.
the exchange of oxygen and carbon dioxide between the alveoli of the lungs and the circulating blood

b. internal respiration i.
the exchange of oxygen and carbon dioxide between the circulating blood and tissue cells

II.

factors influencing respiration

a. developmental state i.
e!g!, an elderly individual whose aging process has resulted in a decreased metabolic rate and, conse/uently, a decreased demand for oxygenated blood to be supplied to the cells, may experience an alteration in respirations (typically a decreased respiratory rate)

b. exercise i.
e!g!, an individual who exercises vigorously, which results in stimulation of the sympathetic portion of the autonomic nervous system (23)) and, conse/uently, secretion of epinephrine and norepinephrine, may experience an alteration in respirations (typically an increased respiratory rate)

b. stress i.
e!g!, an individual who is stressed, which results in stimulation of the sympathetic portion of the autonomic nervous system (23)) and, conse/uently, secretion of epinephrine and norepinephrine, may experience an alteration in respirations (typically an increased respiratory rate)

b. increased altitude i.
e!g!, an individual who lives at high altitude, which results in decreased partial pressure of oxygen in the atmosphere, may experience an alteration in respirations (typically an increased respiratory rate)

b. medications i.
e!g!, an individual who ta*es an opioid analgesic such a morphine sulphate, which results in decreased sensitivity of the chemosensitive area in the pons and medulla oblongata to CD+ levels, may experience an alteration in respirations (typically a decreased respiratory rate)

b. increased intracranial pressure


i! e!g!, an individual who has increased intracranial pressure, which results in pressure on the respiratory center in the brainstem, may experience an alteration in respirations (can be an increased or decreased respiratory rate)

II.

respiration regulation

a. chemosensitive area in the pons and medulla oblongata i.


highly sensitive to increases in 5aCD+

a. increased 5aCD+ (hypercarbia) and hydrogen ion concentration (acid pE;


acidosis) leads to increased rate and depth of respiration

b. decreased 5aCD+ (hypocarbia) and hydrogen ion concentration


(al*aline pE; al*alosis) leads to decreased rate and depth of respiration

b. chemoreceptors in the carotid and aortic bodies i.


highly sensitive to decreases in 5aD+

a. decreased 5aD+ (hypoxemia) leads to increased rate and depth of


respiration

b. increased 5D+ leads to decreased rate and depth of respiration II.


palpated in one minute respiratory rate

a. the number of full inspirations (inhalations) and expirations (exhalations) observed or b. expressed as breaths per minute (bpm) c. should be measured when the patient is at rest and unaware that the
measurement is being ta*en

d. normal respiratory rates ranges per age (eupnea)

i.

newborn

a. approximate range < "1 0 -, bpm


ii! infant (# months)

a. approximate range < ", 0 1, bpm ii.


toddler ( + years)

a. approximate range < +1 0 "+ bpm


ii! child

a. approximate range < +, 0 ", bpm ii.


adolescent

a. approximate range < .# 0 .& bpm ii.


adult

a. approximate range < .# 0 +, bpm b. abnormal respiratory rates per minute


i! tachypnea a! a respiratory rate in an adult greater than +- breaths per minute

ii.

bradypnea

a. a respiratory rate in an adult less than ., breaths per minute ii.


apnea

a. absence of breathing II.


respiratory volume

a. the volume of air exchanged with each full inspiration (inhalation) and expiration
(exhalation) (usually 1,, mAs)

b. normal respiratory volume i.


consists of a normal respiratory rate and a moderate amount of chest wall movement and volume of air inspired or expired during each full inspiration (inhalation) and expiration (exhalation)

b. abnormal respiratory volume

i.

hypoventilation

a. consists of a decreased respiratory rate and an decreased amount of


chest wall movement and volume of air inspired or expired during each full inspiration (inhalation) and expiration (exhalation)

ii.

hyperventilation

a. consists of an increased respiratory rate and an increased amount of


chest wall movement and volume of air inspired and expired during each full inspiration (inhalation) and expiration (exhalation)

II.

respiratory rhythm

a! the pattern of, and intervals between, each full inspiration (inhalation) and expiration (exhalation)

b. normal respiratory rhythm i.


has a regular pattern of, and intervals between, each full inspiration (inhalation) and expiration (exhalation)

b. abnormal respiratory rhythm i.


have an irregular pattern of, and intervals between, each full inspiration (inhalation) and expiration (exhalation), e!g!:

a. Cheyne0)to*es breathing i.
alternating periods of deep, rapid breathing followed by periods of apnea

b. i.

iot's respirations

varying depth and rate of breathing followed by periods of apnea

II.
expiration (exhalation)

respiratory ease or effort

a. the amount of effort a patient must exert during each full inspiration (inhalation) and b. normal respiratory ease or effort i.
the patient does not exert a noticeable amount of effort during each full inspiration (inhalation) and expiration (exhalation)

b. abnormal respiratory ease or effort i.


the patient does exert a noticeable effort during each full inspiration (inhalation) and expiration (exhalation), e!g!:

a. dyspnea i.
difficult or labored breathing

b. orthopnea a.
ability to breathe only in an upright sitting or standing position

II.

methods of assessing respirations

a. inspection of chest wall movement i.


assessing respirations by observation of chest wall movement

b. palpation of chest wall movement i.


assessing respirations by placing one hand on the diaphragm and palpating chest wall movement

b. apnea monitor i.
assessing respirations by application of a minimum of two electrodes to the abdomen, connecting them to wire leads, connecting the wire leads to a cable, and connecting the cable to a monitor that displays changes in thoracic or abdominal movements in a waveform and gives an audible alarm should any sudden change occur in thoracic or abdominal movement indicating the possible cessation of breathing

b. auscultation i.
assessing respirations by auscultating the chest using a device (stethoscope) consisting of two earpieces connected by means of flexible tubing to a diaphragm that amplifies sounds

B. I.

lood pressure

force of the blood against the arterial walls

a. systolic pressure i.
the highest pressure on the arterial walls when the left ventricle of the heart pushes blood through the aortic valve into the aorta during systole

a. measured in milliliters of mercury (mm Eg) b. recorded as the numerator of a fraction, e!g!: i.
the .+, in a blood pressure of .+,7',

b. diastolic pressure

i.

the lowest pressure on the arterial walls when the heart rests between beats (systole)

a. measured in milliliters of mercury (mm Eg) b. recorded as the denominator of a fraction, e!g!: i.
the ', in a blood pressure of .+,7',

b. pulse pressure i.
the difference between the systolic and diastolic pressures

II.

factors influencing blood pressure

a. developmental state i.
e!g!, an elderly individual whose aging process has resulted in decreased elasticity of the vessel walls and, conse/uently, an increased resistance to blood flow, may experience an alteration in the blood pressure (typically an increased blood pressure)

b. gender
i! e!g!, a woman aged 11 and younger, whose menopause process is not yet complete and, conse/uently, has a preponderance of the female hormone, estrogen, which tends to raise high density lipoproteins (E6As; the 8good cholesterol) and decrease total cholesterol may experience an alteration in the blood pressure (typically a decreased blood pressure compared to a man aged 11 and younger who has a preponderance of the male hormone, testosterone, which tends to raise low density lipoproteins FA6As; the 8bad8 cholesterolG and increase total cholesterol) ii! e!g!, a woman aged $1 and older, whose menopause process is complete and, conse/uently, lac*s a preponderance of the female hormone, estrogen, which tends to raise high density lipoproteins (E6As; the 8good cholesterol) and decrease total cholesterol may experience an alteration in the blood pressure (typically an increased blood pressure compared to a man aged $1 and older who lac*s a preponderance of the male hormone, testosterone, which tends to raise low density lipoproteins FA6As; the 8bad8 cholesterolG and increase total cholesterol)

b. stress i.
e!g!, an individual who is stressed, which results in stimulation of the sympathetic portion of the autonomic nervous system (23)) and, conse/uently, secretion of epinephrine and norepinephrine, may experience an alteration in the blood pressure (typically an increased blood pressure)

b. medication i.
e!g!, an individual who ta*es a beta adrenergic bloc*er such as propanolol, which results in bloc*ing of beta adrenergic innervation to the blood vessels and heart

and, conse/uently, vasodilation, may experience an alteration in blood pressure respirations (typically a decreased blood pressure)

b. diurnal variation (circadian rhythms) i.


e!g!, a healthy individual, whose entrainment to +-0hour cycles in the environment has resulted in fluctuations of blood pressure by as much as 1 0 ., mm Eg throughout the day, may experience and alteration in the blood pressure (typically lowest in the morning and higher in the late afternoon)

b. race i.
e!g!, an 2frican02merican man or woman, who is more li*ely to have genes that cause the body to precess salt differently ma*ing them more sensitive to the salty 2merican diet, may experience an alteration in blood pressure (typically an increased blood pressure compared to a Caucasian02merican man or woman of the same age)

b. exercise i.
e!g!, an individual who exercises vigorously, which results in stimulation of the sympathetic portion of the autonomic nervous system (23)) and, conse/uently, secretion of epinephrine and norepinephrine, may experience an alteration in the blood pressure (typically an increased blood pressure)

b. body position i.
e!g!, an individual who assumes a sitting or standing position from a lying position, which results in blood pooling in the dependent vessels of the venous system and, conse/uently, a transient decrease in venous blood return to the heart and stro*e volume, may experience an alteration in the blood pressure to maintain the same cardiac output (typically an increased blood pressure)

b. body weight a.
e!g!, an individual who is obese, which results in an increased peripheral resistance to blood flow in the peripheral arteries throughout the body as a result of the excess adipose (fat) tissue and a greater output of blood since the heart has to pump out more blood to supply the excess adipose (fat) tissue, may experience an alteration in blood pressure (typically an increased blood pressure)

b. blood volume i.
e!g!, an individual who has blood loss from a hemorrhage, which results in decreased blood volume and, conse/uently, decreased stro*e volume, may experience an alteration in blood pressure to maintain the same cardiac output (typically an increased blood pressure)

II.

blood pressure regulation

a. influenced by five factors

i.

peripheral resistance

a. resistance to blood flow determined by the tone of the vascular smooth


musculature and diameter of the blood vessels

i.

as arteries and arterioles surrounding blood vessels contract, the lumen of the blood vessels become smaller, peripheral vascular resistance increases and, conse/uently, blood pressure increases

ii.

as arteries and arterioles surrounding blood vessels relax, the lumen of the blood vessels become larger, peripheral vascular resistance decreases and, conse/uently, blood pressure decreases pumping action of the heart (cardiac output)

ii.

a. cardiac output is the volume of blood pumped by the heart (stro*e


volume) during . minute (heart rate) and is calculated as CD < EC x )V

i.

when cardiac output is increased, more blood is pumped against arteries and arterioles and, conse/uently, blood pressure is increased

ii.

when cardiac output is decreased, less blood is pumped against arteries and arterioles and, conse/uently, blood pressure is decreased blood volume

ii.

a. the amount of blood circulating within the vascular system i.


when blood volume is increased, more pressure is exerted against arteriole and arterial walls and, conse/uently, blood pressure increases

ii.

when blood volume is decreased, less pressure is exerted against arterial and arteriole walls and, conse/uently, blood pressure decreases viscosity of blood

ii.

a! the proportion of blood cells to plasma measured as the hematocrit

i.

as the hematocrit increases, blood becomes more viscous, the heart exerts greater force to move the viscous blood through the blood vessels and, conse/uently, blood pressure increases

ii.

as the hematocrit decreases, blood becomes less viscous, the heart exerts less force to move the less viscous blood through the blood vessels and, conse/uently, blood pressure decreases

ii.
(compliance)

elasticity of vessel walls

a. the ability of the arterioles and arteries to distend and contract i.


when arterial elasticity is reduced, resistance to blood flow is increased and, conse/uently, blood pressure increases

ii.

when arterial elasticity is increased, resistance to blood flow is decreased and, conse/uently, blood pressure decreases normal blood pressure at various ages (normotension)

II. a. newborn
i! -, (mean) b! . month i! '171-

b. . year
i! &17#1 b! # years i! .,17#1

b. ., 0 ." years
i! ..,7#1

b. .- 0 .$ years i.
.+,7$1

b. middle adult i.
.+,7',

b. older adult
i! .-, 0 #,7', 0&, HH! abnormal blood pressure

i.

hypertension

a.

blood pressure elevated above normal for a sustained period

b. i.

types of hypertension primary or essential

a.

hypertension without a *nown cause ii! secondary

a.

hypertension with a *nown cause

b. i.
normal

blood pressure classifications and follow0up criteria

a.

systolic less than .+,

b. c. i.

diastolic less than ', treatment without complications no anti0hypertensive Cx indicated

b. i.

treatment with complications

drugs for compelling indications (treat patients with chronic renal disease or diabetes to goal bp I .",7',) ii! pre0hypertension

a.

systolic .+, 0 ."&

b. c. i.

diastolic ', 0 '& treatment without complications no anti0hypertensive Cx indicated

b. i.

treatment with complications

drugs for compelling indications (treat patients with chronic renal disease or diabetes to goal bp I .",7',)

ii. a.

hypertension stage .

systolic .-, 0 .1&

b. c.

diastolic &, 0 && treatment without complications

i.

thia:ide diuretics for most

ii. b. i.

may consider 2C> inhibitors, 2C , combinations treatment with complications

, CC , or

drugs for compelling indications (treat patients with chronic renal disease or diabetes to goal bp I .",7',)

ii.
ii!

other anti0hypertensive drugs (diuretics, 2C> inhibitors, 2C , , CC ) as needed hypertension stage +

a.

systolic greater than .#,

b. c. i.

diastolic greater than .,, treatment without complications two0drug combo (usually thia:ide diuretic and 2C>0. or 2C or or CC )

b. i.

treatment with complications

drugs for compelling indications (treat patients with chronic renal disease or diabetes to goal bp I .",7',)

ii.
ii!

other anti0hypertensive drugs (diuretics, 2C> inhibitors, 2C , , CC ) as needed hypotension

a.

blood pressure decreased below normal for a sustained period


b. i.
type of hypotension orthostatic (postural)

a.

blood pressure decreased below normal associated with wea*ness or fainting when one rises to an erect position

b.

results when an individual assumes a sitting or standing position from a lying position, resulting in blood pooling in the dependent vessels of the venous system and a transient decrease in venous blood return to the heart and stro*e volume without a compensatory rise in blood pressure to maintain the same cardiac output methods of assessing blood pressure

i.

a.

directly (invasive)

i.

arterial line

i.

assessing blood pressure by insertion of a thin catheter directly into an artery that senses the pressure and transmits this information to a machine that displays the systolic and diastolic pressure in a waveform

b. i.
auscultation

indirectly (non0invasive)

a.

assessing blood pressure by auscultating the brachial or popliteal artery using a device (stethoscope) consisting of two earpieces connected by means of flexible tubing to a diaphragm that amplifies sounds

b. i.

e/uipment needed stethoscope

ii. a.

sphygmomanometer aneroid

b. b. i.
brachial

mercury sites used

ii. b. i.

popliteal sounds auscultated for

*orot*off sounds

a.

phase H < characteri:ed by the first appearance of faint but clear tapping sounds

i.

the onset of this phase is considered to be the systolic pressure

b. i.

phase HH < characteri:ed by muffled or swishing sounds

may temporarily disappear, especially in hypertensive patients

a. called the ausculatory gap

b. c. i.

phase HHH < characteri:ed by distinct, loud sounds

phase HV < characteri:ed by distinct, abrupt, muffling sound with a soft, blowing /uality the onset of this phase is considered to be the diastolic pressure

b.

phase V < characteri:ed by the last sound heart before a period of continuous silence

ii. a.

palpation

assessing the blood pressure by wrapping a sphygmomanometer around the arm, palpating the brachial pulse, inflating it ", mm Eg above the point at which the brachial pulse disappears, deflating it, palpating for the return of the brachial pulse, and noting the number on it when the brachial pulse returns

ii.
a!

doppler ultrasound

assessing the blood pressure by auscultating the brachial or popliteal pulse using a device (doppler ultrasound) that detects the movement of blood flow through blood vessels and converts the velocity of the blood flow into sounds

ii. a.

electronic indirect blood pressure meters

assessing the blood pressure by using a device (electronic indirect blood pressure meter) that senses vibrations within the artery wall, records the pressure readings, and displays them in digital numbers

ii. a.
falsely low readings

errors when assessing blood pressure

i.

hearing deficit

ii. iii. iv. v. vi. vii.

noise in the environment applying too wide a cuff inserting the eartips of the stethoscope incorrectly using crac*ed or *in*ed tubing releasing the valve too rapidly misplacing the bell beyond the direct area of the artery

viii. ix. b. i.

failing to pump the cuff +, 0 ", mm Eg above the disappearance of the pulse viewing the meniscus from above eye level falsely high readings

using a manometer not calibrated at the :ero mar*

ii. iii. iv. v. vi.

assessing the blood pressure immediately after exercise applying a cuff that is too narrow releasing the valve too slowly reinflating the bladder during auscultation viewing the meniscus from below eye level