Fundamental Nursing Skills and Concepts

Fundamental Nursing Skills and Concepts

Vital Signs

• Body temperature

• Pulse rate

• Respiratory rate

• Blood pressure

Body Temperature

• Warmth of the human body

• Body’s shell temperature is lower than the core temperature

• Measured in the Fahrenheit or Centigrade scale

• Normal body temperature 96.6 to 99.3 Fahrenheit or 35.8 to 37.4 Centigrade

 

Factors Affecting Body Temperature

• Food intake

• Age

• Climate

• Gender

• Exercise and activity

• Circadian rhythm

• Emotions

• Illness or injury

• Medications

 

Assessment Sites

• Thermistor catheter (heat sensing device at the tip of internally placed tube)

• Oral site

• Rectal site

• Axillary site

• Ear

 

Phases of a Fever

• Prodromal Phase: The client has nonspecific symptoms just before the temperature rises.

• Onset or Invasion Phase: Obvious mechanism for increasing body temperature, such as shivering develops.

• Stationary phase: The fever is sustained.

• Resolution or defervescence phase: Temperature returns to normal

 

Subnormal Temperature

• Hypothermia-core temperature less than 95 degrees

• Mild hypothermia-temperature 95 to 93.2 degrees

• Moderate hypothermia-93 to 86 degrees

• Severe hypothermia-below 86 degrees

 

Pulse

• A wavelike sensation that can be palpated in a peripheral artery, produced by the movement of blood during the heart’s contraction.

• Normal heart rate is 60-100 beats per minute at rest

• Pulse rate (number of peripheral pulsations palpated in 1 minute) is counted by compressing a superficial artery against an underlying bone with the tips of the fingers.

 

Factors Affecting Pulse and Heart Rates

• Age

• Circadian Rhythm

• Gender

• Body build

• Exercise and activity

• Stress and emotions

• Body temperature

• Blood volume

• Drugs

 

Alterations in Pulse Rate

• Tachycardia-100-150 bpm

• Palpitation-Awareness of one’s heart contraction without having to feel the pulse.

• Bradycardia-<60 bpm

• Arrhythmia or dysrhythmia-irregular pattern of heartbeats

 

Pulse Assessment Sites

• Peripheral pulses-radial artery

• Apical heart rate-number of ventricular contractions per minute

• Apical-radial heart rate-number of sounds heard at the heart’s apex and the rate of the radial pulse during the same period

 

Respiration

• Exchange of oxygen and carbon dioxide

• Ventilation-movement of air in and out of the chest

• Inhalation-breathing in

• Exhalation-breathing out

• Respiratory rate-number of ventilations per minute

 

Breathing Patterns and Abnormal Characteristics

• Cheyne-Stokes Respiration-Breathing pattern in which the depth of the respirations gradually increases followed by gradual decrease, and then a period when breathing stops before resuming again

• Hyperventilation-Rapid or deep breathing

• Hypoventilation-Diminished breathing

• Dyspnea-Difficult or labored breathing

• Orthopnea-Breathing facilitated by sitting or standing up

• Apnea-Absence of breathing

 

Blood Pressure

• Force that the blood exerts within the arteries

• Circulating blood volume averages 4.5 to 5.5 L in adult men

• Contractility of the heart is influenced by the stretch of cardiac muscle fibers

• Cardiac output-volume of blood ejected from the left ventricle per minute

 

Factors Affecting Blood Pressure

• Age

• Circadian rhythm

• Gender

• Exercise and activity

• Emotions and pain

 

Blood Pressure Measurements

• Systolic pressure-Pressure within the arterial system with the heart contracts

• Diastolic pressure-Pressure within the arterial system when the heart relaxes and fills with blood

• Pulse pressure-Difference between systolic and diastolic pressure measurements

 

Assessment of the Blood Pressure

• Over the brachial artery at the inner aspect of the elbow

• It is possible to use the lower arm and radial artery

• Equipment for Measuring Blood Pressure: Sphygomomanometer

 

Abnormal Pressure Measurements

• Hypertension-High blood pressure

• Whitecoat Hypertension-Condition in which the blood pressure is elevated when taken by a health care worker

• Hypotension-Low blood pressure

• Postural or orthostatic hypotension-Sudden temporary drop in blood pressure when rising from a reclining position

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