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Kozier & Erb's Fundamentals of Nursing, 8eBerman, Snyder, Kozier, ErbCopyright 2008 by Pearson Education, Inc.
Chapter 2
!ita" Signs
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!ita" Signs
# Body temperature, pu"se,respirations, and B"ood Pressure
#$onitor %unctions o% the body# Shou"d be a thought%u", scienti&cassessment
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'hen to (ssess !ita" Signs
# )n admission# Change in c"ient*s hea"th status# C"ient reports symptoms such as chest
pain, %ee"ing hot, or %aint# Pre and post surgery+in asi e procedure# Pre and post medication administration
that cou"d a-ect C! system# Pre and post nursing inter ention that
cou"d a-ect ita" signs
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Body emperature
# /e ects the ba"ance bet1een theheat produced and the heat "ost %romthe body
# $easured by heat units ca""eddegrees
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actors (-ectingBody emperature
# (ge# 3iurna" ariations
4circadian rhythms5# E6ercise# 7ormones
# Stress# En ironment
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("terations in Body emperature
# Pyre6ia, 7yperthermia, e er body temperature abo e the usua"
range
# ebri"e a c"ient 1ho has a %e er
# (%ebri"e
a c"ient 1ho does not ha e %e er# 7ypothermia
core body temperature be"o1 the "o1er"imit o% norma"
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Pu"se
# Is a 1a e o% b"ood created bycontraction o% the "e%t entric"e o% theheart
# /epresents the amount o% b"ood thatenters the arteries 1ith each entricu"arcontraction
# Periphera" pu"se a pu"se "ocated a1ay%rom the heart E6. oot or 1rist
# (pica" pu"se is the centra" pu"se that is"ocated at the ape6 o% the heart
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actors (-ectingPu"se
# (ge# 9ender# E6ercise# e er# $edications# 7ypo o"emia
# Stress# Position changes# Patho"ogy
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actors (-ecting/espirations
# E6ercise# Stress
# En ironmenta" temperature# $edications
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emperature: ;i%espanConsiderations
In%ants
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Pu"se: ;i%espanConsiderations
In%ants =e1borns may ha e heartmurmurs that are notpatho"ogica"
Chi"dren he ape6 o% the heart isnorma""y "ocated in the %ourthintercosta" space in youngchi"dren? &%th intercosta" spacein chi"dren @ years o"d and
o"derE"ders )%ten ha e decreased
periphera" circu"ation
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/espirations:;i%espan Considerations
In%ants Some ne1borns disp"ayAperiodic breathing
Chi"dren 3iaphragmatic breathers
E"ders (natomic and physio"ogicchanges cause respiratorysystem to be "ess e cient
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B"ood Pressure:;i%espan Considerations
In%ants (rm and thigh pressures areeDui a"ent under year o%age
Chi"dren high pressure is 0 mm 7ghigher than arm
E"ders C"ient*s medication maya-ect ho1 pressure is ta>en
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Sites %or $easuringBody emperature
# )ra"# /ecta"# (6i""ary# ympanic membrane# S>in+ empora" artery
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ypes o% hermometers
# E"ectronic# Chemica" disposab"e
# In%rared 4tympanic5# Scanning in%rared 4tempora" artery5# emperature sensiti e tape# 9"ass mercury
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=ursing Care %or e er
# $onitor ita" signs# (ssess s>in co"or and
temperature# $onitor "aboratory
resu"ts %or signs o%dehydration orin%ection
# /emo e e6cess
b"an>ets 1hen thec"ient %ee"s 1arm
# Pro ide adeDuatenutrition and uid
# $easure inta>e andoutput
# /educe physica"acti ity
# (dminister antipyreticas ordered
# Pro ide ora" hygiene
# Pro ide a tepid spongebath# Pro ide dry c"othing
and bed "inens
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=ursing Care %or 7ypothermia
# Pro ide 1arm en ironment# Pro ide dry c"othing
# (pp"y 1arm b"an>ets# Keep "imbs c"ose to body# Co er the c"ient*s sca"p
# Supp"y 1arm ora" or intra enous uids# (pp"y 1arming pads
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Pu"se Sites
/adia" /eadi"y accessib"e
empora" 'hen radia" pu"se is not accessib"e
Carotid 3uring cardiac arrest+shoc> inadu"ts3etermine circu"ation to the brain
(pica" In%ants and chi"dren up to F yearso% age
3iscrepancies 1ith radia" pu"se$onitor some medications
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Pu"se Sites
Brachia" B"ood pressureCardiac arrest in in%ants
emora" Cardiac arrest+shoc>Circu"ation to a "eg?
Pop"itea" Circu"ation to "o1er "eg
Posteriortibia"
Circu"ation to the %oot
3orsa"is
pedis
Circu"ation to the %oot
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Characteristics o% the Pu"se
# /atetachycardia o er 00 BP$bradycardia "ess than G0 BP$
# /hythmdysrhytmia or arrhythmia irregu"ar pu"se# !o"ume
%orce o% b"ood 1ith each beatabsent to bounding
# (rteria" 1a"" e"asticity# Bi"atera" eDua"ity
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Pu"se /ate and /hythm
# /ateH Beats per minuteH achycardia
H Bradycardia
# /hythmH EDua"ity o% beats
and inter a"s
bet1een beatsH 3ysrhythmiasH (rrhythmia
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Characteristics o% the Pu"se
# !o"umeHStrength or amp"itudeH(bsent to bounding
# (rteria" 1a"" e"asticityHE6pansibi"ity or de%ormity
#Presence or absence o% bi"atera"eDua"ityHCompare corresponding artery
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$easuring (pica" Pu"se
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(pica" /adia" Pu"se# ;ocate apica" and radia" sites# 1o nurse method:
H3ecide on starting timeH=urse counting radia" says AstartHBoth count %or G0 secondsH=urse counting radia" says AstopH/adia" can ne er be greater than apica"
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Inha"ation
# 3iaphragmcontracts 4 attens5
# /ibs mo e up1ard
and out1ard# Sternum mo es
out1ard
# En"arging the sizeo% the thora6
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E6ha"ation
# 3iaphragm re"a6es# /ibs mo e
do1n1ard and
in1ard# Sternum mo es
in1ard
# 3ecreasing the sizeo% the thora6
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/espiratory Contro"$echanisms
# /espiratory centersH$edu""a ob"ongataHPons
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Components o% /espiratory(ssessment
# /ate# 3epth
# /hythm# ua"ity# E-ecti eness
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/espiratory /ate and 3epth
# /ateH Breaths per minuteH (pnea H absence o%
breathingH Bradypnea
abnorma""y s"o1respirations
H achypneaabnorma""y %astrespirations
# 3epthH =orma"H 3eep
H Sha""o1
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Components o% /espiratory(ssessment
# /hythmH /egu"arH Irregu"ar
# ua"ityH E-ortH Sounds
# E-ecti enessH e and
transport o% ) 2
H ransport ande"imination o% C) 2
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("teratered BreathingPatterns
# /ateH achypnea H Duic>, sha""o1 breathsH Bradypnea abnorma""y sha""o1 breathing
H (pnea absence or cessation o% breathing# !o"ume
7yper enti"ation o ere6pansion o% the"ungs characterized by rapid and deepbreaths
7ypo enti"ation undere6pansion o% the"ungs characterized by sha""o1 respirations
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("teratered BreathingPatterns
# /hythmHCheyne Stro>e breathing rhythmic 1a6ing
and 1aning o% respirations, %rom ery deepto ery sha""o1 breathing and temporaryapnea
# Ease or E-ortH3yspnea di cu"t and "abored breathing
during 1hich the indi idua" has a persistent,unsatis&ed need %or air and %ee"s distressedH )rthopnea abi"ity to breathe on"y in upright
sitting or standing positions
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("teratered Breath Sounds
# Stridor H a shri"", harsh sound heardduring inspiration 1ith "aryngea"obstruction
# 'heeze continuous, high pitchedmusica" sDuea> or 1hist"ing soundoccuring on e6piration
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Systo"ic and 3iasto"ic B"oodPressure
# Systo"icH Contraction o% the
entric"es# 3iasto"ic
H !entric"es are at restH ;o1er pressure
present at a"" times# Pulse Pressure J
di-erence bet1eensysto"ic anddiasto"ic pressures
# $easured in mm7g
# /ecorded as a
%raction, e.g.20+80# Systo"ic J 20 and
3iasto"ic J 80
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Korot>o-*s Sounds
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Korot>o-*s Sounds
# Phase FH B"ood o1s %ree"yH Crisper and more intense soundH
humping Dua"ity but so%ter than in phase # Phase LH $u ed and ha e a so%t, b"o1ing sound
# Phase MH Pressure "e e" 1hen the "ast sound is heardH Period o% si"enceH 3iasto"ic pressure
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$easuring B"ood Pressure
# 3irect 4In asi e$onitoring5
# Indirect
H (uscu"tatoryH Pa"patory
# SitesH
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Pu"se )6imetry
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Pu"se )6imetry
# =onin asi e# Estimates arteria" b"ood o6ygen
saturation 4Sp) 25# =orma" Sp) 2 8M 00N? O @0N "i%e
threatening# 3etects hypo6emia be%ore c"inica" signs
and symptoms# Sensor, photodetector, pu"se o6imeter
unit
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Pu"se )6imetry
# actors that a-ect accuracy inc"ude:H7emog"obin "e e"HCircu"ationH(cti ityHCarbon mono6ide poisoning
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Pu"se )6imetry
# See S>i"" 2 @# Prepare site
# ("ign ;E3 and photodetector# Connect and set a"arms# Ensure c"ient sa%ety
# Ensure accuracy
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/esources# (udio 9"ossary# 7yper7E(/
Sho1s the heart pumping and ta">s aboutdiasto"ic and systo"ic cyc"es. 7as tutoria"s %oratria" systo"e and others. !ery %un site.
# Best Practice !ita" Signs/e ie1s research studies re"ated to ita" signs.Co ers a"" aspects o% ita" signs and e en gi esimp"ications %or practice and recommendations.
# he $edica" Center !ita" SignsPro ides an o er ie1 o% ita" signs. =ice"y done.
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