Chapter 11 Vital sign TTV NORMAL Tekanan Darah (TD) : 120/80 mmHg Spesifikasi Jenis Normal Perhipertensi Hipertensi

staium 1 Hipertensi stadium 2 Sistole < 120 120 - 129 140 - 149 > 160 Diastole < 80 80 - 90 90 - 99 > 100

Words to Know
afebrile afterload antipyretics apical heart rate apical-radial rate apnea arrhythmia auscultatory gap automated monitoring devices blood pressure bradycardia bradypnea cardiac output centigrade scale cerumen clinical thermometers core temperature diastolic pressure Doppler stethoscope drawdown effect dyspnea dysrhythmia Fahrenheit scale febrile fever frenulum hypertension hyperthermia hyperventilation hypotension hypothalamus hypothermia hypoventilation Korotkoff sounds metabolic rate offsets orthopnea orthostatic hypotension palpitation piloerection postural hypotension preload pulse pulse deficit pulse pressure pulse rate pulse rhythm pulse volume pyrexia respiration

respiratory rate set point shell temperature speculum sphygmomanometer stertorous breathing stethoscope stridor systolic pressure tachycardia tachypnea temperature translation thermistor catheter thermogenesis training effect ventilation vital signs whitecoat hypertension

Learning Objectives
On completion of this chapter, the reader will List four physiologic components measured during assessment of vital signs. Differentiate between shell and core body temperature. Identify the two scales used to measure temperature. List four temperature assessment sites and indicate the site considered the closest to core temperature. Name four types of clinical thermometers. Discuss the difference between fever and hyperthermia. Name the four phases of a fever. List at least four signs or symptoms that accompany a fever. Give two reasons for using an infrared tympanic thermometer when body temperature is subnormal. List at least four signs and symptoms that accompany subnormal body temperature. Identify three characteristics noted when assessing a clients pulse. Name the most commonly used site for pulse assessment and three other assessment techniques that may be used. Explain the difference between systolic and diastolic blood pressure. Name and explain at least four terms used to describe abnormal breathing characteristics. Discuss the physiologic data that can be inferred from a blood pressure assessment. Explain the difference between systolic and diastolic blood pressure. Name three pieces of equipment for assessing blood pressure. Describe the five phases of Korotkoff sounds. Identify three alternative techniques for assessing blood pressure.

Vital signs (body temperature, pulse rate, respiratory

rate, and blood pressure) are four objective assessment data that indicate how well or poorly the body is functioning. Vital signs are very sensitive to alterations in physiology; therefore, nurses measure them at regular intervals (Box 11-1) or whenever they determine it is appropriate to assess a clients health status. This chapter describes how to obtain each component of the vital signs and explains what findings indicate based on established norms. Recommendations for Measuring Vital Signs

Recommendations for Measuring Vital Signs.

Vital signs are taken On admission, when obtaining data base assessments According to written medical orders Once per day when a client is stable At least every 4 hours when one or more vital signs is abnormal Every 5 to 15 minutes when a client is unstable or at risk for rapid physiologic changes such as after surgery Whenever a clients condition appears to have changed A second time, or more frequently, when there is a significant difference from the previous measurement When a client is feeling unusual Before, during, and after a blood transfusion Before administering medications that affect any of the vital signs and after to monitor the drugs effect

BODY TEMPERATURE
Body temperature refers to the warmth of the human body. Body heat is produced primarily from exercise and metabolism of food. Heat is lost through the skin, the lungs, and the bodys waste products through the processes of radiation, conduction, convection, and evaporation (Table 11-1). The bodys shell temperature (warmth at the skin surface) is usually lower than its core temperature (warmth in deeper sites within the body like the brain and heart). Core temperature is much more significantthan shell temperature because there is a narrow range within which core temperature can fluctuate without resulting in negative outcome

Temperature Measurement
Physicists studying thermokinetics, or heat in motion, have developed various scales for measuring heat and cold. Some examples include Kelvin (K), Rankine (R), Fahrenheit (F), and centigrade (C) scales, all of which are based on increments at which water freezes and boils. The centigrade temperature scale is also known as Celsius. Health care professionals commonly use the Fahrenheit and centigrade scales. The Fahrenheit scale (scale that uses 32F as the temperature at which water freezes and 212F as the point at which it boils) generally is used in the United States to measure and report body temperature. The centigrade scale (scale that uses 0C as the temperature at which water freezes and 100C as the point at which it boils) is used more often in scientific research and in countries that follow the metric system. Nurses are required to use both scales occasionally and to convert between the two measurements (Box 11-2).

Normal Body Temperature

In normal, healthy adults, shell temperature generally ranges from 96.6 to 99.3F or 35.8 to 37.4C (Porth, 2002). Core body temperature, according to Nicholl