Transcript Powerpoint
Body
temperature is the
balance between heat
produced in the body and
heat loss from the body.
Heat
Production
Heat Loss
Body
Temperature
Core Temperature – temperature of the deep
tissues of the body such as abdominal or pelvic
cavities. It is relatively constant
Surface Temperature – temperature of the skin
and subcutaneous tissue. It fluctuates
depending on the blood supply to the skin and
the amount of heat loss to the external
environment.
Physiologically
◦ Receptors in the skin, abdomen, and spinal cord send
messages to the autonomic nervous system that sends
the message to the hypothalamus.
◦ The hypothalamus acts as a central thermostat,
receiving input from sensors that detect hot or cold
temperatures and initiates body responses mainly in
the cardiovascular system via vasoconstriction or
vasodilation that decrease heat production and
increase heat loss.
Behavioral
◦ When an individual perceives he is hot or cold,
he changes his behavior such as: moves to the
shade or sun, regulates the thermostat, removes
extra clothes or puts on sweater.
Radiation
◦ Conduction
Evaporation
Convection
◦ Transfer of heat from the surface of one object to the
surface of another without contact
◦ Blood flows from the core internal organs carrying
heat to skin and surface blood vessels.
◦ Amount of heat carried to the surface depends on the
extent of vasoconstriction and vasodilation regulated
by hypothalamus.
◦ 85% of body heat is loss via radiation to the
environment
◦ Usually from the body to a cooler surface
Transfer of heat from one object to another with
direct contact.
When the warm skin touches a cooler object, the
heat is loss
Increase amount loss by applying a ice pack, bathing
with cool water
Decrease amount of heat loss by applying blankets
Gains heat via conduction when contact is made with
a warmer object
Transfer of heat when a liquid is changed to
a gas.
When body temperature rises,
hypothalamus signals the sweat glands to
release sweat. Sweat evaporates from the
skin, resulting in heat loss.
Transfer of heat away by air movements.
Air currents carry away the heat
An electric fan promotes heat loss
through convection
Vasoconstriction
◦ Decreases the amount of blood that reaches the surface
and thus is not lost.
Increase Basal Metabolism Rate
◦ Movement / exercise
◦ Shivering
Age
Activity / Exercise / Sleep
Hormones
Stress
Environment
Medication
Illness
Children: 98.60 - 99.60 F, oral
Adults:
Older Adults: 97.6 + / -1 degree F, oral
98.6 + /-1 degree F, oral
Rectal
temperature is usually 1
degree higher than oral
Axillary
temperature is usually 1
degree lower than oral
Pyrexia, hyperthermia, fever – an
elevation in body temperature
Hyperpyrexia – a very high fever such
as: 1050 F
Febrile – having a fever; Afebrile –
without a fever
Hypothermia – decreased body
temperature below 970 F
The nurse needs to look at the relationship of
the vital signs to each other, to previous
findings, and to other assessment data.
If the temperature is abnormal, the nurse
should notify the physician.
Reassess the temperature more often than
ordered – nursing intervention / judgment
Oral
◦ Rectal
Axillary
Tympanic
Temporal
Most common and convenient
Sublingual pocket very vascular and responds to
changes in core temperature
Disadvantage – varies with what the patient has
had in their mouth, mouth breathers
Not safe for infants, children, elderly,
disoriented, epileptic, or unconscious
Most reliable
Disadvantage– unpleasant for the patient and
inconvenient to gain access to the site
Does not respond to body temp changes
Cannot be used in rectal surgery, or stool in
bowel
Safest, Noninvasive, Easily accessible
Does not always give a true reading of core
temperature
Used for infants, children, patients with oral
problems or mouth breathers, and irrational
patients.
Utilizes the ear which is readily accessible,
minimal discomfort, and reflects core
temperature
Disadvantage – cost of the equipment and
inaccurate reading because of incorrect
positioning of the instrument.
One of the newer methods for evaluating a
person’s temperature is the temporal area of the
forehead.
The temporal artery is a branch of the internal
carotid artery, but courses within a millimeter or
two of the skin's surface over the lateral
forehead and is readily accessible.
Battery operated unit with an
attached heat sensitive probe and
disposable probe cover.
More rapid reading
Can be used in all methods of assessing
the temperature
Infrared light reflectance thermometer
determines the temperature of the
tympanic membrane by measuring heat
radiated as infrared energy from that
site
Tympanic membrane and hypothalamus
share the same vasculature—reflects
core temp
Accuracy depends on placement of the
device
Designed specifically to be
completely non-invasive
Scanner captures naturally
emitted infrared heat from the
arterial blood supply, locking in
the highest temperature it
senses
Measures the temperature by movement of
chemical through the calibrated glass.
Must be shaken down to 950 before taking a
reading.
Disadvantage – must follow hazard precautions if
it should break.
Shakes the thermometer to get below 960 or inserts
into probe cover
Places in posterior sublingual pocket
Remain in mouth for 3 - 5 minutes
Remove and wipe from stem to bulb (clean to dirty)
Reads at eye level, rotates slowly until mercury
visible and reads to nearest tenth of degree
Shakes the thermometer down, cleans with soapy
cold water, or pushes ejection button to release
probe cover
Preparation: same
Places the patient in Sim’s position and drape
Apply gloves
Prepares thermometer- lubricates tip
Dominant hand hold thermometer, other hand,
separate buttocks to expose anus
Instruct patient to take a deep breath. Insert the
thermometer gently into the anus: infant- ½ inch,
adult 1 ½ inches.
Do not force insertion
Hold in place for 3-5 minutes
Wipe secretions, and discard tissue, read temp
Gain access to the axillary area
Make sure area is dry
Place thermometer in the center of axilla. Fold
patients arm straight down and place arm across
chest
Leave in place 6-10 minutes
Remove, read, Write down
Easy way to remember how long to take a
temperature
5 min.
+3 min.
8 min.
= oral
= rectal
= axillary
Position patient upright or on their side
Attach probe cover to the unit
Turn head to one side and insert into ear canal
◦ Adult – pull pinna upward and back
◦ Child – pull pinna downward and back
Remove after reading displayed
Remove probe cover and place in storage unit
With just a light stroke across the
temporal artery area of the
forehead, an accurate
reproducible temperature is
measured in about 3 seconds eliminating any discomfort caused
by thermometer inserted into the
ear, mouth, or rectum.
A wave of blood created by contraction
of the left ventricle of the heart
Heart is a large pump that forces blood
to enter the arteries with each
heartbeat, causing pressure pulses or
pulse waves
The
heart pumps 4-6 liters each
minute.
This
volume is the cardiac output
Stroke volume- amount of blood that enters the
arteries with each ventricle contraction
◦ Normally heart empties about 70% of its volume with
each contraction. That is about 70 ml. of blood in an
adult
Heart rate- beats per minute
Rate of the ventricular contractions
of the heart
Normal rate if 60 – 90 BPM with an
extended range of 50- 100 BPM
Tachycardia
◦ Increased heart rate – over 100 BPM
◦ Usually occur when sympathetic nervous system is
stimulated
Bradycardia
◦ Decreased heart rate – below 60 BPM
◦ Usually occur with parasympathetic nervous system
is stimulated
Age
Sex
Exercise
Temperature
Medications
Emotions / Stress
Hemorrhage
Illness
Position
Pattern of the beats and the intervals between
the beats.
Equal time should lapse between beats of a
normal pulse making a normal rhythm
An irregular rhythm is dysrhythmia
May consist of an early beat, late beat, or
missed beat
Irregular rhythm may be random, irregular
rhythm or a predictable pattern of irregular
beats.
Threatens the heart’s ability to provide
adequate cardiac output.
Etiology = A contraction of the heart that fails to
transmit a pulse wave to the peripheral pulse
sites
Assess by apical – radial pulse simultaneously for
one minute, compare
Difference between the apical and radial pulse
rates is the pulse deficit.
Nurse A takes the apical pulse and gets
a rate of 88.
Nurse B takes the radial pulse and gets
a rate of 76.
The pulse deficit is 12.
88 – 76 = 12
Strength of the pulse reflects the volume of
blood ejected against the arterial wall with each
heartbeat.
Usually the volume / strength is the same with
each heartbeat.
Absent
◦ Not palpable
Weak, thready
◦ Difficult to feel, readily obliterated with pressure from
the fingers
Normal
◦ Easily detectable with moderate pressure
Bounding, full
◦ Obliterated, only with difficulty
A healthy normal artery should feel:
◦
◦
◦
◦
Straight
Smooth
Soft
Pliable
That makes it easy to assess the pulse
If
pulses on both sides of
the body are equal, they
are known as bilaterally
equal
Palpation
◦ Middle two - three fingers used
◦ Pads on fingers are sensitive areas for detecting a pulse
Auscultation
◦ Stethoscope used for auscultating
an apical pulse
Where arteries lie over bony surfaces:
◦ Temporal
◦ Carotid artery - in the neck
◦ Brachial – inner aspect of the elbow
◦ Radial – inner aspect of wrist on thumb side
◦ Ulnar – outer aspect of the arm
◦ Femoral- femoral artery passes along the inguinal
ligament
◦ Popliteal – behind the knee
◦ Posterior tibial – medial surface of the ankle
◦ Dorsalis pedis –upper surface of the foot
Taken with a stethoscope at apex
of the heart
S1- low pitched and dull, lub at apex of heart,
fifth intercostal space, just left of the
midclavicular line
S2 – Higher and shorter, dub at the base of
heart, second intercostal space, right or left
of sternal border
Each lub-dub is one heart beat
Counted for one full minute
Record characteristics and any abnormal
findings
◦
ie. Radial pulses strong, regular, equal bilaterally.
Apical / radial pulse unequal, with pulse deficit
of 12.
Radial pulse full, bounding at rate of 88.
Pedal pulses equal bilaterally.
The act of breathing
Supplying oxygen to the body cells and removing
carbon dioxide from the body cells
Inhalation of air into the lungs and exhalation of
gases from the lungs to the atmosphere
Three components:
1. Ventilation – mechanical movement of air in and out
of the lungs
2. Diffusion – movement of oxygen and carbon dioxide
between alveoli and RBC’s
3. Perfusion – distribution of blood to and from the
pulmonary capillaries in the lungs
Cellular level
Oxygen diffuses from hemoglobin in the RBC to
the cells of the body for use in production of
heat and energy
Carbon dioxide if given off from the body cell as
waste by-product of metabolism
Respiratory center in the brain stem and
chemoreceptors in the carotid artery and aorta.
◦ Regulated by levels of carbon dioxide, oxygen, and
hydrogen ion concentration (pH) in the arterial blood
◦ Most important is level of CO2. Elevation of carbon
dioxide causes the respiratory control system in the
brain to increase the rate and depth of breathing to
move out the carbon dioxide
If arterial oxygen levels drop, chemoreceptors signal
the brain to increase the rate and depth of ventilation
Accurate measurements requires observation
of the patient’s chest wall movement
Best to assess when resting
Prior data collection:
◦ Normal breathing pattern
◦ Health problems
◦ Medications or therapies
◦ Relationship of respirations to cardiovascular
function
Normally 12 – 20 breaths per minute
Terminology:
◦ Eupnea – normal rate and depth
◦ Bradypnea – abnormally slow respirations
◦ Tachypnea – abnormally fast respirations
◦ Apnea – cessation or absence of breathing
Exercise – increases the rate
Stress – increases the rate
Increased altitude – increases the rate
Medications – narcotics and analgesics lower the
rates
Regularity of expirations and inspirations
Normally, they are evenly spaced in an adult.
Normally, irregular in an infant
Irregular respirations in an adult should be
reported.
Degree of movement in the chest wall
Described as normal, deep, or shallow
Normal inspiration and expiration or volume of
air exchanges with each breath in an adult is
about 500 ml. of air. This in know as tidal
volume
Assess the chest
◦ Does it expand symmetrically with inspiration
◦ Is there retraction of intercostal spaces between the
ribs on inspiration
◦ Are the respirations diaphragmatic or costal
◦ Are accessory muscles used to augment
Difficulty with breathing is known as dyspnea
Respirations should be quiet
Abnormal breathing sounds are:
◦ Stridor – shrill, harsh, inspiratory crowing sounds that
occurs with upper airway obstruction
◦ Wheeze – high-pitched, musical, whistling sound that
occurs with partial obstruction in the smaller bronchi
◦ Stertor- snoring respiration produced by secretions in
the trachea and large bronchi
Hypoventilation – rate and depth decreased
Hyperventilation – rate and depth increased
Cheyne-Stokes – irregular, alternating
periods of apnea and hyperventilation
Kussmaul –abnormally deep, regular and
increased in rate.
Unobtrusively observes the patient’s respirations while
seeming to be involved in another activity
Counts the rate for 30 seconds unless otherwise
indicated
Washes hands if contact made with the patient or
furnishings in the room
Documents
Reports abnormalities
A
measure of the
pressure exerted by the
blood on the walls of an
artery as it flows through
the arteries.
Systolic Pressure
◦ The pressure of the blood as a result of contraction of
the ventricles, that is the pressure of the height of the
blood wave
Diastolic Pressure
◦ The pressure when the ventricles are at rest. Diastolic
pressure in the minimal pressure exerted against the
arterial walls at all times
The
difference between
the systolic and diastolic
pressure
Systolic 100 – 120 mm. Hg.
______________
Diastolic
60-80 mm. Hg.
The volume of blood pumped by the heart (stroke
volume) during one minute (heart rate).
The blood pressure depends on the cardiac
output and peripheral resistance
B/P = CO X R
Resistance
of blood flow
determined by the tone of
vascular musculature and
diameter of blood vessels
Volume of blood circulating with the vascular
system
Normal is about 5000 ml.
If volume increases, the B/P goes up; if volume
decreases, the B/P drops.
Thickness of blood
Hematocrit– percentage of RBC’s in blood
compared to plasma.
When hematocrit rises, the blood is thicker and
the heart must work harder to push it around.
This causes the B/P to go up.
Vessels walls normally have elasticity and can
adjust (dilate and constrict) to accommodate the
needs of the body.
When vessels lose their elasticity and is replaced
by fibrous tissue that does not stretch, there is
greater resistance to blood flow, and the B/P
rises.
1. Age
2. Stress and emotions
3. Gender
4. Medications
5. Disease / Illness
6. Body position and exercise
Hypertension is an elevated B/P
◦ Occurs on two or more occasions
◦ Diastolic pressure if 80 mm.Hg. or above
◦ Systolic pressure is 120 mm Hg or above
Hypotension is a lowered B/P
◦ Systolic pressure is 90 mm.Hg or below
Insertion of a thin catheter into an artery that is
connected to electronic monitoring equipment.
Mainly used in intensive care units
Measured
palpation
by auscultation or
Sphygmomanometer
Stethoscope
Cuff
Aneroid—glass enclosed circular gauge
containing a needle that registers
millimeters calibrations
Mercury – Upright tube containing
mercury. Pressure created by inflation of
cuff moves column of mercury upward
against gravity.
Cuff – come in various sizes and must
have the correct size
Used
to hear sounds on which you
base the B/P
Be
sure the earpieces point toward
the nose and not the back of the
head
Brachial is the most common
Alternative sites:
◦ Lower extremities—popliteal
artery behind the knee.
Electronic
pressure
machines
blood
Cuff too wide
Cuff too narrow
Cuff wrapped too
loosely
Deflating cuff too
slowly
Deflating cuff too
quickly
Stethoscope that fits
poorly
Inaccurate inflation
level
False low reading
False high reading
False high reading
False high diastolic
reading
False low systolic
and false high
diastolic
False low systolic
and false high
diastolic
False low systolic
reading
Assessment
◦ Reviews chart for data RT blood pressure
◦ Evaluates size of arm and accessibility
◦ Explains to patient
Washes hands
Positions patient and removes any
clothing
Extends the arm with palm facing up
Applies the cuff 1-2 inches above inner
aspect of elbow with bladder over
brachial artery
Palpates the brachial pulse, places the
stethoscope over the brachial pulse area
Tightens the valve on the cuff and inflates
about 30-40 mm. over normal or inflate to
about 180 –200 mm.
Releases valve slowly controlling rate of
descent which will deflate the cuff.
Watch the calibrations on the gauge as the
air is released and note changes in the
sounds.
Removes
the cuff
Assists patient to comfortable
position
Documents
Reports unusual findings