Vital Signs

Vital Signs 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. during emergency situations j. 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 (CBT) 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 36.7° C (98° F) to 37° C (98.6° F) b. surface temperature (ST) i. temperature of the surface of the body a. e.g., skin, subcutaneous tissues, and fat ii. fluctuates widely in healthy adults a. ranges from 20° C (68° F) to 40° C (104° F) III. factors influencing body temperature a. developmental state i. e.g., an elderly individual, whose aging process has resulted in loss of subcutaneous tissue and fat and, consequently, the insulating effect of these substances, may experience alterations in thermoregulation (typically a decreased temperature)

b. diurnal variations (circadian rhythms) i. e.g., a healthy individual, whose entrainment to 24-hour cycles in the environment has resulted in fluctuations of CBT by as much as 1.0° C (1.8° F)  throughout the day, may experience alterations in thermoregulation (typically lowest in the morning and higher in the late afternoon)

c. 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 CBT by as much as 0.3° C (0.6° F) to 0.5° C (1.0° F), may experience alterations in thermoregulation (typically an increased temperature)

d. stress i. e.g., an individual who is stressed, which results in stimulation of the sympathetic portion of the autonomic nervous system (ANS) and, consequently, e.

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i.

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secretion of epinephrine and norepinephrine which increases basal metabolic rate and heat production, may experience alterations in thermoregulation (typically an increased temperature) environment i. e.g., an individual living in the Artic, 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) nervous system impairment i. e.g., an individual with quadriplegia, which has resulted in poikliothermia (taking on the ambient environmental temperature as CBT) 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 injury, which has resulted in damage to the hypothalamus, may experience alterations in thermoregulation (typically a decreased or an increased temperature) 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) circulatory impairment i. e.g., an individual with peripheral vascular disease (PVD), 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) integumentary impairment i. e.g., an individual who is severely burned, which has resulted in extensive damage to and loss of large areas of skin and blood vessels, may experience alterations in thermoregulation (typically a decreased temperature) infection i. e.g., an individual who has an infectious process caused by bacteria, virus, fungi, and/or other microorganisms, which has resulted in the release of endogenous pyrogens, may experience alterations in thermoregulation (typically an increased temperature) 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) 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)

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

IV. 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 ANS), e.g.: i. metabolism ii. muscular activity iii. increased sympathetic nervous system stimulation iv. increased thyroxine secretion v. fever vi. increased appetite b. voluntary mechanisms, e.g.: i. adding clothing ("bundling-up") ii. increasing physical activity ("keep moving") iii. decreasing the amount of skin surface available for heat loss ("curling up in a ball") iv. moving to a warmer environment ii. methods of heat loss from the body a. physiologic mechanisms (primarily mediated by the parasympathetic portion of the ANS) 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., 60% 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

ii. conduction a. transfer of heat from one surface to another through direct contact between the two surfaces b. two types of conduction i. conduction to objects a. e.g., 3% 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., 15% 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

iii. convection a. dissipation of heat by air currents i. e.g., 15% 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

iv. evaporation a. dissipation of heat by transformation of water to a gas i. e.g., 22% of total heat lost from the body of a nude person at room temperature is the result of vaporization of moisture from mucus membranes, the mouth, and/or the skin

ii. called insensible heat loss v. decreased appetite b. behavioral mechanisms, e.g.: i. removing clothing ("dressing for warm weather") ii. decreasing physical activity ("slow-down") iii. increasing the amount of skin surface available for heat loss ("stretch out") iv. 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 skin 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 iii. both types have far more cold than warmth receptors a. 10 cold: 1 warmth b. seem to be more concerned with preventing hypothermia iii. central integrator a. the hypothalamus i. a structure located in the diencephalon of the brainstem ii. called the "body's thermostat" b. posterior hypothalamus i. receives input from peripheral and deep tissue thermal receptors that the CBT is below the critical set point as a result of: a. decreased heat production and/or b. increased heat loss ii. stimulates effectors to return the CBT to the critical set point by: a. increasing heat production and/or

b. decreasing heat loss c. preoptic area of the anterior hypothalamus i. receives input from peripheral and deep tissue thermal receptors that the CBT is above the critical set point as a result of: a. increased heat production and/or b. decreased heat loss ii. stimulates effectors to return the CBT to the critical set point by: a. decreasing heat production and/or b. increasing heat loss iv. effectors a. blood vessels i. vasodilation leads to a high rate of blood flow to the skin from the core body causing heat to be conducted from the core body to the skin surface

ii. vasoconstriction leads to a high rate of blood flow from the skin to the core body preventing heat from being conducted from the core body to the skin 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 c. skeletal 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

V. normal temperature ranges at various ages a. infant i. 36.1 - 37.7° C (97 - 100° F) b. child i. 37 - 37.6° C (98.6 - 99.6° F) c. adult i. 37 - 37.6° C (98.6 - 99.6° F) d. older adult i. 36 - 36.9° C (96.9 - 98.3° F) VI. abnormal body temperature a. increased body temperature (fever; pyrexia) i. the state in which an individual's CBT is elevated above his/her normal range ii. severity of fever a. low-grade fever i. a fever between 37.1° C to 38.2° C (98.8° F to 100.6° F) b. high-grade fever i. a fever between 38.3° C to 40.4° C (100.9° F to 104.7° F) c. hyperpyrexia i. a fever over 41° C (105.8° F) iii. types of fever a. constant fever i. rise in temperature above normal that remains consistently high with little fluctuation a. e.g., less than 2° C (3.6° F) b. intermittent fever i. rises or spikes in temperature above normal at some point during a 24-hour period a. usually late-afternoon or evening c. remittent fever i. rise in temperature that is always above normal during a 24-hour period, but the amount of elevation above normal fluctuates a. e.g., more than 2° C (3.6° F) d. relapsing fever i. rises in temperature lasting for several days, alternating with several days of normal temperature iv. phases of fever a. onset (cold or chill) phase i. occurs when the body's heat-producing mechanisms are attempting to increase the CBT 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 skeletal muscle tension and contractions d. pallid, cold skin due to vasoconstriction e. complaints of feeling cold f. cyanotic nail beds due to vasoconstriction g. "gooseflesh" appearance of the skin due to contraction of the arectores pilorium muscles h. cessation of sweating i. rise in CBT b. course (fever) phase i. occurs when the body's heat-producing mechanisms have reached the new, higher set point ii. clinical signs of the course (fever) phase include the following: a. absence of chills b. skin that feels warm c. feelings of neither hot nor cold d. increased pulse and respiratory rates e. increased thirst f. mild to severe dehydration g. simple drowsiness, restlessness, or delirium and convulsions due to irritation of nerve cells h. herpetic lesions of the mouth

i. loss of appetite (if the fever is prolonged) j. malaise, muscle weakness, and aching muscles due to protein catabolism c. defervescence (flush or crisis) phase i. occurs when the body's heat-loss mechanisms are attempting to decrease the CBT 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. skin that appears flushed and feels warm b. sweating c. decreased shivering d. possible dehydration e. common interventions for fever f. administer anti-pyretics as ordered i. decreases set-point to a lower level g. administer antibiotics as ordered i. destroys microorganisms which have increased the set-point to a higher level h. administer oxygen i. 7% increase in oxygen consumption for each degree in rise of temperature i. apply hypothermia blanket i. body heat is transferred to the blanket (conduction) j. increase caloric intake i. increased need for calories due to increased basal metabolic rate k. increase cool fluid intake to 2,000 to 3,000 milliliters a day l. measure intake and output m. maintain prescribed intravenous fluids n. reduce physical activity o. apply lubricant to dried lips p. keep mucus membranes moist q. administer a tepid sponge bath to increase heat loss through conduction r. administer an alcohol sponge bath to increase heat loss through evaporation s. increase air circulation to increase heat loss through convection t. 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 CBT to a range of 30° C to 32° C (86° F to 89.6° F) to decrease the need for oxygen by the body tissues, 

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metabolic rate, blood loss and, consequently, 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 iii. clinical signs of hypothermia a. all cases of hypothermia i. reduction of body temperature below normal range b. at a CBT of 35° C (95° F) i. increased respirations, poor judgment, shivering c. at a CBT of 35° C to 34° C (95° F to 93.2° F) i. bradycardia or tachycardia, myocardial irritability/dysrhythmias, muscle rigidity, shivering, lethargy/confusion, decreased coordination d. at a CBT of 34° C to 30° C (93.2° F to 86° F) i. bradycardia, hypoventilation, generalized rigidity, metabolic acidosis, coma e. at a CBT of 30° C (86° F) i. no apparent vital signs, heart rate unresponsive to drug therapy, coma, cyanosis, dilated pupils, areflexia, no shivering, appearance of death iv. common interventions for hypothermia a. remove the patient from the cold b. apply blankets c. hyperthermia blankets d. warmed intravenous solutions e. remove wet clothing and keep dry f. keep environment warm g. apply layers of clothing to trap air between them to act as insulation h. warm gradually to prevent vasodilation which can lead to shock i. in severe cases, extracorporeal rewarming through hemodialysis or use of cardiopulmonary bypass may be needed types of thermometers used to measure body temperature a. mercury-in-glass i. what it consists of a. a hollow glass cylinder with a bulb filled with liquid mercury at its base marked with Fahrenheit (F) or Centigrade (C) calibrations ii. how it measures body temperature a. when the bulb filled with liquid mercury at the base is heated, the liquid mercury expands, forcing a column of liquid mercury to rise in the hollow glass cylinder marked with Fahrenheit (F) or Centigrade (C) calibrations b. the height that the liquid mercury expands to on the hollow glass cylinder marked with Fahrenheit (F) or Centigrade (C) calibrations is the patient's body temperature iii. length of time it takes to measure body temperature a. oral, approximately 3 - 5 minutes b. rectal, approximately 2 - 3 minutes c. axillary, approximately 10 minutes iv. used to measure body temperature in what routes a. oral, axillary, rectal

i. blue-tipped with a long, thin bulb of liquid 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. red-tipped with a short, blunt bulb of liquid mercury at the base = rectal a. designed to prevent trauma to rectal tissues during insertion v. advantages a. convenient 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 vi. disadvantages a. slow measurement time b. can break and release mercury, which is a poisonous substance c. difficult to read the small Fahrenheit (F) or Centigrade (C) calibrations d. cannot be used with multiple patients b. digital electronic i. what it consists of a. a rechargeable, portable battery-powered electronic display unit, a thin wire cord with a long, thin heat -sensitive probe that the nurse attaches to the unit, and a long, thin disposable probe cover that the nurse attaches to the long, thin heat-sensitive probe

ii. how it measures body temperature a. the heat-sensitive probe detects heat radiated from the oral cavity, rectum, or axilla and displays it on the electronic display unit iii. length of time it takes to measure body temperature a. approximately 25 - 50 seconds iv. used to measure body temperature in what routes a. oral, axillary, rectal i. blue-tipped heat-sensitive probe = oral, axillary temperatures ii. red-tipped heat-sensitive probe = rectal temperatures v. advantages a. convenient b. easy to use c. safe d. accurate e. fast measurement time f. easy to read g. disposable probe covers minimize risk for cross-infection h. can be used multiple times for the same patient i. can be used with multiple patients vi. disadvantages a. expensive to purchase b. cost of disposable probe covers c. required maintenance d. should not be used with isolation patients c. tympanic membrane i. consists of a rechargeable, portable battery-operated electronic display unit, an infrared sensor in an otoscope -like heat-sensitive probe, and an otoscope-like disposable probe cover that the nurse attaches to the otoscope-like heat-sensitive probe

ii. how it measures body temperature a. the infrared sensor in the otoscope-like probe detects heat radiated from the tympanic membrane and displays it on the electronic display unit iii. length of time it takes to measure body temperature a. less than 2 seconds iv. used to measure body temperature in what routes a. tympanic membrane v. advantages a. convenient b. easy to use c. safe d. accurate e. fast measurement time f. easy to read g. disposable probe covers minimize risk for cross-infection h. can be used multiple times for the same patient i. can be used with multiple patients vi. disadvantages a. expensive to purchase b. cost of disposable probe covers c. required maintenance d. should not be used with isolation patients VIII. sites for assessing body temperature a. oral i. advantages a. easily accessible b. minimal, if any, patient repositioning required c. not a source of embarrassment and anxiety d. provides accurate surface temperature reading e. indicates rapid change in CBT ii. disadvantages

a. the patient must be able to close his/her mouth around the mercury-in-glass thermometer or heat-sensitive probe b. affected by ingestion of hot or cold food or fluids and smoking (need to wait 15 - 30 minutes), chewing gum, and oxygen delivery by face mask c. contraindicated for use with the following patients: a. unconscious b. irrational c. seizure-prone d. infants and young children e. with diseases or surgery of the nose or oral cavity d. risk of body fluid exposure b. rectal i. advantages a. considered a CBT b. considered the most accurate (gold standard) ii. disadvantages a. not easily accessible b. patient repositioning required c. may be a source of embarrassment and anxiety d. measurement may lag behind CBT during rapid temperature changes e. contraindicated for use with the following patients: a. newborns b. with diarrhea c. with diseases or surgery of the rectum d. with cardiac diseases or surgery e. bleeding tendencies f. risk of body fluid exposure g. requires lubrication c. axillary i. advantages a. convenient b. safest c. non-invasive d. can be used with newborns and uncooperative patients ii. disadvantages a. long measurement time b. requires continuous positioning by nurse c. measurement lags behind CBT during rapid temperature changes d. requires exposure of thorax d. tympanic membrane i. advantages a. considered a CBT b. easily accessible c. minimal, if any, patient repositioning required d. not a source of embarrassment and anxiety e. provides accurate CBT reading f. very rapid measurement (2 - 5 seconds) g. can be obtained without disturbing or waking the patient h. tympanic membrane close to the hypothalamus, sensitive to CBT 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 C. Pulse 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, consequently, 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 stroke 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)

c. exercise i. e.g., an individual who exercises vigorously, which results in stimulation of the sympathetic portion of the autonomic nervous system (ANS) and, consequently, secretion of epinephrine and norepinephrine, may experience an alteration in the pulse (typically an increased pulse rate)

d. fever i. e.g., an individual who has a fever, which results in a 7% increase in metabolic rate for each 0.6° C (1° F) increase in core body temperature and,  e.

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consequently, a 7% increase for oxygenated blood to be supplied to the cells, may experience an alteration in the pulse (typically an increased pulse rate) medications i. e.g., an individual who takes a cardiac glycoside such as digitalis, which results in negative dromotropic effect on the heart and, consequently, an increased refractory period and decreased conduction through the AV node and junctional tissue, may experience an alteration in the pulse (typically a decreased pulse rate) hemorrhage i. e.g., an individual who has blood loss from a hemorrhage, which results in decreased blood volume and, consequently, decreased stroke volume, may experience an alteration in the pulse to maintain the same cardiac output (typically an increased pulse rate) stress i. e.g., an individual who is stressed, which results in stimulation of the sympathetic portion of the autonomic nervous system (ANS) and, consequently, secretion of epinephrine and norepinephrine, may experience an alteration in the pulse (typically an increased pulse rate)

h. 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 III.

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venous system and, consequently, a transient decrease in venous blood return to the heart and stroke volume, may experience an alteration in the pulse to maintain the same cardiac output (typically an increased pulse rate) pulse regulation a. regulated by the autonomic nervous system through the sinoatrial node (pacemaker) i. parasympathetic nervous system stimulation decreases the heart rate 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 1 month a. approximate range = 120 - 160 bpm ii. 1 to 12 months a. approximate range = 80 - 140 bpm iii. 12 months to 2 years a. approximate range = 80 - 130 bpm iv. 2 to 6 years a. approximate range = 75 - 120 bpm v. 6 to 12 years a. approximate range = 75 - 110 bpm vi. adolescence to adult a. approximate range = 60 - 100 bpm d. abnormal pulse rates per minute i. tachydardia a. a heart rate in an adult greater than 100 beats per minute ii. bradycardia a. a heart rate in an adult less than 60 beats per minute 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. 3+ (normal) ii. description a. the pulsation is easily felt; moderate pressure causes the pulsation to disappear iii. rhythm a. normal! b. thready pulse i. grade (amplitude) a. 1+ (thready) ii. description a. the pulsation is not easily felt; slight pressure causes the pulsation to disappear iii. rhythm a. normal! c. weak pulse i. grade (amplitude) a. 2+ (weak) ii. description a. the pulsation is stronger than a thready pulse; light pressure causes the pulsation to disappear iii. rhythm a. normal! d. bounding pulse i. grade (amplitude) a. 4+ (bounding) ii. description a. the pulsation is strong; moderate pressure does not cause the pulsation to disappear iii. rhythm a. normal! c. 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 characterized by two strong systolic peaks separated by a mid-systolic dip ii. pulsus alternans a. pulse characterized by alternation in amplitude from beat to beat even though the rhythm is basically regular iii. paradoxical pulse a. pulse characterized by a decrease in the amplitude of the pulse during inspiration iv. bigeminal a. pulse characterized by a normal beat alternating with a premature ventricular contraction (PVC) whose stroke volume is diminished in relation to that of the normal beats iii. 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 characterized by disorganized electrical activity in the atria accompanied by an irregular ventricular response that is usually rapid

d. if a dysrhythmia is detected i. assess the apical pulse for one minute ii. assess the apical-radial pulse to determine a pulse deficit iii. electrocardiogram (EKG) VI. 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. 3+ (normal) ii. description a. the pulsation is easily felt; moderate pressure causes the pulsation to disappear iii. amplitude a. normal! c. abnormal pulse amplitudes i. absent a. grade (amplitude) i. 0 (absent) b. description i. no pulsation is felt despite extreme pressure c. amplitude i. absent! ii. thready a. grade i. 1+ (thready) b. description i. the pulsation is not easily felt; slight pressure causes the pulsation to disappear c. amplitude i. very abnormally weak! iii. weak a. grade i. 2+ (weak) b. description i. the pulsation is stronger than a thready pulse; light pressure causes the pulsation to disappear c. amplitude i. abnormally weak! iv. bounding a. grade i. 4+ (bounding) b. description i. the pulsation is strong; moderate pressure does not cause the pulsation to disappear c. amplitude i. abnormally strong! VII. methods of assessing the pulse a. peripheral i. palpation 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 skull ii. carotid a. where the carotid artery runs between the trachea and sternocleiodomastoid muscle iii. brachial a. at the inner aspect of the biceps muscle of the arm or medially in the antecubital fossa iv. radial a. where the radial artery passes alongside the radial bone v. femoral a. where the femoral artery passes alongside the inquinal ligament vi. popliteal a. where the popliteal artery passes behind the knee vii. posterior tibial a. where the posterior tibial artery passes behind the medial malleolus viii. dorsalis pedis a. where the dorsalis pedis artery passes over the bones of the foot ii. Doppler 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 5 th intercostal space in the left mid-clavicular line (LMCL) in adults using a device (stethoscope) consisting of two earpieces connected by means of flexible tubing to a diaphragm that amplifies sounds

ii. Doppler ultrasound a. assessing the pulse by auscultating the apical pulse using a device (doppler ultrasound) that detects the movement of blood flow through blood

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

iii. electrocardiogram (EKG) a. assessing the apical pulse by recording the electrical activity of the myocardium by using a device (EKG) to detect transmission of the cardiac impulse through conductive tissue of the muscle

D. Respiration I. the mechanism the body uses to exchange gases between the atmosphere and the cells II. summarization 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 c. internal respiration i. the exchange of oxygen and carbon dioxide between the circulating blood and tissue cells III. factors influencing respiration a. developmental state i. e.g., an elderly individual whose aging process has resulted in a decreased metabolic rate and, consequently, 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 (ANS) and, consequently, secretion of epinephrine and norepinephrine, may experience an alteration in respirations (typically an increased respiratory rate)

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

d. 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)

e. medications i. e.g., an individual who takes an opioid analgesic such a morphine sulphate, which results in decreased sensitivity of the chemosensitive area in the pons and medulla oblongata to CO 2 levels, may experience an alteration in respirations (typically a decreased respiratory rate)

f. 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)

IV. respiration regulation a. chemosensitive area in the pons and medulla oblongata i. highly sensitive to increases in PaCO 2 a. increased PaCO 2 (hypercarbia) and hydrogen ion concentration (acid pH; acidosis) leads to increased rate and depth of respiration b. decreased PaCO 2 (hypocarbia) and hydrogen ion concentration (alkaline pH; alkalosis) leads to decreased rate and depth of respiration b. chemoreceptors in the carotid and aortic bodies i. highly sensitive to decreases in PaO 2 a. decreased PaO 2 (hypoxemia) leads to increased rate and depth of respiration b. increased PO 2 leads to decreased rate and depth of respiration V. respiratory rate a. the number of full inspirations (inhalations) and expirations (exhalations) observed or palpated in one minute b. expressed as breaths per minute (bpm) c. should be measured when the patient is at rest and unaware that the measurement is being taken d. normal respiratory rates ranges per age (eupnea) i. newborn a. approximate range = 35 - 40 bpm ii. infant (6 months) a. approximate range = 30 - 50 bpm iii. toddler ( 2 years) a. approximate range = 25 - 32 bpm iv. child a. approximate range = 20 - 30 bpm v. adolescent a. approximate range = 16 - 19 bpm vi. adult a. approximate range = 16 - 20 bpm e. abnormal respiratory rates per minute i. tachypnea a. a respiratory rate in an adult greater than 24 breaths per minute ii. bradypnea a. a respiratory rate in an adult less than 10 breaths per minute iii. apnea a. absence of breathing VI. respiratory volume a. the volume of air exchanged with each full inspiration (inhalation) and expiration (exhalation) (usually 500 mLs) 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)

c. 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)

VII. 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) c. abnormal respiratory rhythm i. have an irregular pattern of, and intervals between, each full inspiration (inhalation) and expiration (exhalation), e.g.: a. Cheyne-Stokes breathing i. alternating periods of deep, rapid breathing followed by periods of apnea b. Biot's respirations i. varying depth and rate of breathing followed by periods of apnea VIII. respiratory ease or effort a. the amount of effort a patient must exert during each full inspiration (inhalation) and expiration (exhalation) 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) c. 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 IX. 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 c. 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

E.

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 d. 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 Blood pressure I. 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 Hg) b. recorded as the numerator of a fraction, e.g.: i. the 120 in a blood pressure of 120/80 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 Hg) b. recorded as the denominator of a fraction, e.g.: i. the 80 in a blood pressure of 120/80 c. 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, consequently, 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 55 and younger, whose menopause process is not yet complete and, consequently, has a preponderance of the female hormone, estrogen, which tends to raise high density lipoproteins (HDLs; the "good cholesterol) and decrease total cholesterol may experience an alteration in the blood pressure (typically a decreased blood pressure compared to a man aged 55 and younger who has a preponderance of the male hormone, testosterone, which tends to raise low density lipoproteins [LDLs; the "bad" cholesterol] and increase total cholesterol) ii. e.g., a woman aged 75 and older, whose menopause process is complete and, consequently, lacks a preponderance of the female hormone, estrogen, which tends to raise high density lipoproteins (HDLs; the "good cholesterol) and decrease total cholesterol may experience an alteration in the blood pressure (typically an increased blood pressure compared to a man aged 75 and older who lacks a preponderance of the male hormone, testosterone, which tends to raise low density lipoproteins [LDLs; the "bad" cholesterol] and increase total cholesterol) c. stress i. e.g., an individual who is stressed, which results in stimulation of the sympathetic portion of the autonomic nervous system (ANS) and, consequently, secretion of epinephrine and norepinephrine, may experience an alteration in the blood pressure (typically an increased blood pressure) d. medication i. e.g., an individual who takes a beta adrenergic blocker such as propanolol, which results in blocking of beta adrenergic innervation to the blood vessels and heart and, consequently, vasodilation, may experience an alteration in blood pressure respirations (typically a decreased blood pressure) e. diurnal variation (circadian rhythms) i. e.g., a healthy individual, whose entrainment to 24-hour cycles in the environment has resulted in fluctuations of blood pressure by as much as 5 - 10 mm Hg throughout the day, may experience and alteration in the blood pressure (typically lowest in the morning and higher in the late afternoon) f. race i. e.g., an African-American man or woman, who is more likely to have genes that cause the body to precess salt differently making them more sensitive to the salty American diet, may experience an alteration in blood pressure (typically an increased blood pressure compared to a CaucasianAmerican man or woman of the same age) g. exercise

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

h. 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

III.

IV.

V.

venous system and, consequently, a transient decrease in venous blood return to the heart and stroke volume, may experience an alteration in the blood pressure to maintain the same cardiac output (typically an increased blood pressure) i. 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) j. blood volume i. e.g., an individual who has blood loss from a hemorrhage, which results in decreased blood volume and, consequently, decreased stroke volume, may experience an alteration in blood pressure to maintain the same cardiac output (typically an increased blood pressure) 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, consequently, 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, consequently, blood pressure decreases ii. pumping action of the heart (cardiac output) a. cardiac output is the volume of blood pumped by the heart (stroke volume) during 1 minute (heart rate) and is calculated as CO = HR x SV i. when cardiac output is increased, more blood is pumped against arteries and arterioles and, consequently, blood pressure is increased ii. when cardiac output is decreased, less blood is pumped against arteries and arterioles and, consequently, blood pressure is decreased iii. blood volume 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, consequently, blood pressure increases ii. when blood volume is decreased, less pressure is exerted against arterial and arteriole walls and, consequently, blood pressure decreases iv. viscosity of blood 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, consequently, 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, consequently, blood pressure decreases v. elasticity of vessel walls a. the ability of the arterioles and arteries to distend and contract (compliance) i. when arterial elasticity is reduced, resistance to blood flow is increased and, consequently, blood pressure increases ii. when arterial elasticity is increased, resistance to blood flow is decreased and, consequently, blood pressure decreases normal blood pressure at various ages (normotension) a. newborn i. 40 (mean) b. 1 month i. 85/54 c. 1 year i. 95/65 d. 6 years i. 105/65 e. 10 - 13 years i. 110/65 f. 14 - 17 years i. 120/75 g. middle adult i. 120/80 h. older adult i. 140 - 60/80 -90 abnormal blood pressure i. hypertension a. blood pressure elevated above normal for a sustained period b. types of hypertension i. primary or essential a. hypertension without a known cause ii. secondary a. hypertension with a known cause c. blood pressure classifications and follow-up criteria i. normal a. systolic less than 120 b. diastolic less than 80 c. treatment without complications i. no anti-hypertensive Rx indicated d. treatment with complications i. drugs for compelling indications (treat patients with chronic renal disease or diabetes to goal bp < 130/80) ii. pre-hypertension a. systolic 120 - 139 b. diastolic 80 - 89

b. diastolic 80 - 89 c. treatment without complications i. no anti-hypertensive Rx indicated d. treatment with complications i. drugs for compelling indications (treat patients with chronic renal disease or diabetes to goal bp < 130/80) iii. hypertension stage 1 a. systolic 140 - 159 b. diastolic 90 - 99 c. treatment without complications i. thiazide diuretics for most ii. may consider ACE inhibitors, ARB, BB, CCB, or combinations d. treatment with complications i. drugs for compelling indications (treat patients with chronic renal disease or diabetes to goal bp < 130/80) ii. other anti-hypertensive drugs (diuretics, ACE inhibitors, ARB, BB, CCB) as needed iv. hypertension stage 2 a. systolic greater than 160 b. diastolic greater than 100 c. treatment without complications i. two-drug combo (usually thiazide diuretic and ACE-1 or ARB or BB or CCB) d. treatment with complications i. drugs for compelling indications (treat patients with chronic renal disease or diabetes to goal bp < 130/80) ii. other anti-hypertensive drugs (diuretics, ACE inhibitors, ARB, BB, CCB) as needed ii. hypotension a. blood pressure decreased below normal for a sustained period b. type of hypotension i. orthostatic (postural) a. blood pressure decreased below normal associated with weakness 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 vi.

vii.

vessels of the venous system and a transient decrease in venous blood return to the heart and stroke volume without a compensatory rise in blood pressure to maintain the same cardiac output methods of assessing blood pressure 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. indirectly (non-invasive) i. auscultation 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. equipment needed i. stethoscope ii. sphygmomanometer a. aneroid b. mercury c. sites used i. brachial ii. popliteal d. sounds auscultated for i. korotkoff sounds a. phase I = characterized by the first appearance of faint but clear tapping sounds i. the onset of this phase is considered to be the systolic pressure b. phase II = characterized by muffled or swishing sounds i. may temporarily disappear, especially in hypertensive patients a. called the ausculatory gap c. phase III = characterized by distinct, loud sounds d. phase IV = characterized by distinct, abrupt, muffling sound with a soft, blowing quality i. the onset of this phase is considered to be the diastolic pressure e. phase V = characterized by the last sound heart before a period of continuous silence ii. palpation a. assessing the blood pressure by wrapping a sphygmomanometer around the arm, palpating the brachial pulse, inflating it 30 mm Hg 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 iii. doppler ultrasound a. 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 iv. electronic indirect blood pressure meters a. 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 errors when assessing blood pressure a. falsely low readings i. hearing deficit ii. noise in the environment iii. applying too wide a cuff iv. inserting the eartips of the stethoscope incorrectly v. using cracked or kinked tubing vi. releasing the valve too rapidly vii. misplacing the bell beyond the direct area of the artery viii. failing to pump the cuff 20 - 30 mm Hg above the disappearance of the pulse

ix. viewing the meniscus from above eye level b. falsely high readings i. using a manometer not calibrated at the zero mark ii. assessing the blood pressure immediately after exercise iii. applying a cuff that is too narrow iv. releasing the valve too slowly v. reinflating the bladder during auscultation vi. viewing the meniscus from below eye level end