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VITAL SIGNS I - ncreased thyroxin production

V - ital to a person’s physiologic status S - Screenings at health facilities and increased cellular metabolism is d/t inc
for it serves as indicators of body clinics thyroxine output from the thyroid gland,
function. this effect is called CHEMICAL
B - efore and after certain nursing THERMOGENESIS
I - ncludes Temperature, Pulse, interventions that could affect V/S (ex. C - hemical thermogenesis
Ambulating a client who has been on bed E - pinephrine, norepi, SNS stimulation –
Respiration and Blood Pressure and
rest, b/c he may have activity increases the rate of cellular metabolism
recently Pain as the fifth vital sign. intolerance PNS SNS
T - hey are checked to monitor the Decrease
I - n emergency situations or when client Increased
functions of the body, functions that has change in health status or reports Eye d Pupil Eye
Pupil Size
might not be observed. symptoms such as chest pain or feeling Size
hot or faint
A – lso known as Cardinal Signs Decrease Increased
PURPOSE OF ASSESSING VITAL d lacrimal lacrimal
L - isted and evaluated with reference secretion secretion
to the client’s present and prior health
status, are compared to the client’s T - o obtain baseline measurement of Increased
Oral d Salivary Oral
usual (if known) and accepted normal the patient’s vital signs salivary flow
standards. T - o assess patient’s response to
treatment or medication Decrease
T - o monitor patient’s condition after Hear Hea Increased
invasive procedures t rt heart rate

B- efore and after diagnostic and surgical BODY TEMPERATURE Vasodilati Vasoconstricti
procedures (there might be internal H - eat of the body measured in degrees on on
bleeding) D - ifference between production of heat
and loss of heat from the body Broncho
Lung Lun Bronchodilatio
U-pon admission to a healthcare setting s gs n
to obtain baseline data PROCESS OF HEAT PRODUCTION
OCCURS THROUGH: Inreased Decreased
W- When certain medications are given Gastric
(meds that F - ood Metabolism and Activity – basal GIT GIT Gastic Motility
could affect respi or cardio system ex. metabolic rate (BMR) or the rate of and and secretion
Digitalis). energy utilization in the body secretion
F - ever = inc metabolic rate
I - In the home M - uscle activity = inc metabolic rate

Keith Nester A. Lavin

Lavin .ost sensory receptors are in the skin tissue & fats.hivers to increase heat production FACTORS AFFECTING BODY therefore no contact (ex. E . sends out signals intended to E .8F) for a intestinal motility motility variety of reasons such as inadequeate Core Temperature diet. relatively constant T .ge – infant is greatly influenced by and cortisol) (vasoconstriction. and release the temperature of environment and of ephinephrine). immersion in cold V . shivering.3C to 40C (101-104F) rectally heat production and decrease heat loss (epinephrine A .asoconstriction decreases heat loss variations & understand the significance water) of the body temperature measurements C . Hypothalamic integrator. highest @ 8pm S . heat transfer to a surface of can recognize normal temperature lower temperature (ex.nvironment – extremes in pancreatic reduce temperature by decreasing heat environmental temp secretion production and increase heat loss S . Decreased H – eat. subcutaneous M .adiation: surface to surface by waves S .kin has more receptors for cold than and midnight. our body R . must be protected from extreme Decreased changes. loss of subcutaneous tissue. progesterone (sweating and peripheral vasodilation) pancreati Increased during ovulation rises body temperature c adrenal E .ome other factors such as food.xercise – can inc temp to as high as secretion C – old. women > men Increased hormone fluctuations.onduction : contact between 2 loss – nurses should be aware so that they surfaces. lack of T . lowest @ sleep between 4- warmth Surface Temperature 6 am T .motions/stress – stimulation of SNS from mucosa of mouth & from skin E .emperature of the deep tissues of the activity & decreased thermo-regulatory body such as abdominal cavity & pelvic efficiency REGULATION OF BODY cavity.emperature of the skin.vaporation – water to steam. people 75 y. the center continuous & unnoticed evaporation of that controls temperature is located in S . defecation Keith Nester A. rises and falls in response to the environment PROCESS OF HEAT LOSS OCCURS When the skin becomes chilled over the M .ex – d/t hormones.limination – urination. drugs moisture from the respiratory tract & the preoptic area of the hypothalamus.weating is inhibited to decrease heat C .ime of day – also “diurnal variations” TEMPERATURE M .easured thru tympanic and rectal or “circadian rhythms”.o & up are at risk Increased intestinal TYPES of TEMPERATURE for hypothermia (T < 36C or 96.easured thru oral and axillary routes THROUGH entire body. Nude person TEMPERATURE standing in room @ normal temperature) S . signals are sent out to increase secretion 38. @ 1C between routes early am and late pm.onvection – mov’t by air currents that deviate from normal E .

6F) T .6-100. Tympanic membrane – accessible.0-38.1C (98. Lavin . 1. Done Keith Nester A. nt fever normal or subnormal hot/cold fluids.1C (98. ORAL -Upon intake of R . S . wired 4 COMMON SITES FOR ASSESSING IC -Up/back for adult jaws.outh breathers and pts. CHF. for clients with oral TYMPAN -Within two seconds problem( oral inflammation.0. most convenient.6 C (97. but invasive and uncomfortable to SPECIAL Hyperpyr ROUTE BT above 41˚C patient. RECTAL matter could result to bradycardia fever but not reaching normal a false reading I .6-100.9 – 37. least less invasive.carred tympanic membrane during rectal temp assessment U .0C BODY TEMPERATURE Down/back for pedia (96.may inc risk -Lubricate tip prior to between fluctuations of infection inserting Clotting disorder Constant Consistently elevated and AXILLAR Y -Done for 10 minutes fever fluctuates very little 3.6-98.resence of ear ache I . least accurate.eeling lightheaded or passes out P . CONSIDERATIONS exia 38.atients with oral surgery S .emperature higher/lower than 36.4-37.iarrhea -Done for 2-3 minutes C .eizure-prone patients assess BP & HR. Within two seconds TEMPERATURE 3 minutes . oral surgery) -35. don’t take M .6F) 4. Oral – most frequently used.mmunosuppressed . done for blood supply.ertain heart conditions – ex.nfants and very young children S . pedia -37.ignificant ear drainage F . wait 30 Significant hemorroids temperature minutes D .ectal abnormalities – ex. has abundant arterial Unexpected Situations in assessing disruptive. for 10 minutes. Rectal – most accurate route.6F) CONTRAINDICATIONS: BT alternates regularly -Done for 3 minutes Intermitte between periods o fever. non-invasive. Down/back for or drank cold or hot food/fluids . wait 30 mins if client ate Up/back for adult . with oxygen another rectal temp) Pyrexia Elevated BT 2.6-99. done for 2-3 mins – 37. notify doctor. Axillary – safer than the oral method. Fluctuations of several -Presence of fecal may result to vagal stimulation = Remittent degrees above normal.6F) CONTRAINDICATIONS: expected based on how skin feels CONTRAINDICATIONS: (re-assess with new thermometer) P .nconscious or irrational patients (remove thermometer immediately.

w/ liquid crystals Adults 60-100 bpm fingers that change color. Temperature – sensitive Tape – does Weak. feeble. BRADYCARDIA simultaneously TEMPERATURE SCALES Rhythm – pattern or regularity of beats LOCATION OF PERIPHERAL PULSES C= (Farenheit temperature-32) x 5/9 and interval between each beat Keith Nester A. Tympanic Thermometer/infrared arterial circulation by the contraction of thermometer – senses body heat in form the left ventricle of infra red energy given off by the heat Volume/amplitude – also pulse strength.hrobbing sensation palpated over a Arrhythm n of Elevated BT returns to Irregular rhythm peripheral artery ia Pyrexia normal suddenly A . Electronic or Digital CHARACTERISTICS OF PULSE heartbeat Thermometer – can read temp in 2-60 Normal pulse – can be felt w/ moderate sec depending on manufacturer Rate – number of beats per minute pressure of the fingers & can be AGE obliterated w/ greater pressure PULSE RANGE Full or bounding pulse – forceful or full 3.iddle three fingertips are used for e beat normal beats palpating all pulse sites except the apex of the heart. GROUP “mercury-in-glass thermometers” blood volume that is obliterated only Newborn 80-180 bpm with difficulty 4.ssessed by palpation (feeling) or by crisis auscultation (hearing) Prematur Beat that occurs between M . Returns to normal for at F= (Celsius temperature x9/5) +32 Term Meaning Relapsing least a day then the fever fever Pulsus occurs Equal rhythm regularis Resolutio PULSE T . placed at forehead or abdomen Elderly 60-100 bpm Cardiac Output – 5-6 Liters of blood is 5. a stethoscope is used for Heart Time interval between each TYPES OF THERMOMETER assessing apical pulses & FHT rhythm heartbeat A . Glass Thermometer – traditional. source which is the ear canal (tympanic ASSESSMENT PARAMETERS / amount of blood pumped with each membrane) 2. Lavin . thready – pulse that is readily obliterated w/ pressure from the not indicate core temp. Chemical Thermometer – uses crystal forced out of the left ventricle per minute dots/bars or sensitive tape applied @ forehead Pulse Deficit – difference between the ASSESSMENT FINDINGS: apical and radial counts taken TACHYCARDIA.wave of blood being pumped into the 1.

Decreased BP – inc HR as arrest compensatory mechanism Femoral Used for infants and 9. Sex/gender – after puberty male’s CO2 between blood and tissue cells pulse is slightly lower than femlae’s Carotid Used in cases of cardiac 3.temporal – superior and lateral to the Used to determine 5. perception of pain) CHARACTERISTICS OF RESPIRATION Keith Nester A. quiet antecubital space yrs. anxiety.@ the thumb side of the inner Apical U . CHF – inc HR Used to determine to compensate Popliteal circulation to the lower leg RESPIRATION-ACT OF BREATHING REASONS FOR USING SPECIFIC Posterior Pulmonary ventilation –(breathing) PULSE SITE Used to determine movement of air in and out of the lungs tibial . Exercise – inc exercise. Prolonged heat application – inc eye circulation to the brain metabolic rate.Any conditions resulting to poor circulation to the leg oxygenation of blood ex.@ side of cheek 6.@ inguinal ligament pulse Irregular Abnormal politeal – behind the knee U .outinely used for muscle of the arm or medially in the infants 7 children up to 3 Regular Effortless. circulation to the foot Inspiration –(inhalation) act or breathing Pedal Pulse in Reasons for Use Site Expiration –(exhalation) act of breathing out Radial Readily accessible Factors Affecting Pulse Rate External respiration – exchange of O2 and CO2 between alveoli and blood Used when radial pulse is Internal respiration – exchange of O2 and Temporal 1. inc PR arrests ASSESSMENT PARAMETERS / 4. Emotions/stress – SNS stimulation (fear. Increased temperature – inc children metabolic rate Used to determine 10. Pain – d/t SNS stimulation Used in cases of cardiac 8.sed to determine aspect of the wrist discrepancies with radial femoral . radial .when sitting or brachial – inner aspect of the bicep R . inc PR carotid . Lavin . Body positions.sed in conjunction with posterior tibial – medial surface of the some medications ankle Used to measure blood standing. Age – inc age. dec PR not accessible 2. blood usually pools in dorsalis pedis/ pedal – over the bones of pressure dependent vessels of venous system Brachial Used during cardiac arrest  transient dec in venous return to the foot for infants the heart  inc HR to compensate 7.

alternate periods of accessory muscles.Prolonged grasping followed Stress – inc RR by extremely short insufficient 1.Rate – number of breaths per minute ASSESSMENT FINDINGS REGARDING AGE RESPIRATORY RESPIRATION GROUP RANGE Rhythm – regularity of respiration. inhalation and exhalation are evenly Eupnea Normal. effortless Newborn 30 – 60 bpm spaced. inspiration hypoventilation (underexpansion of Hyperpn Deeper respiration with Rales . Systole – the highest pressure. causing whistling Breath sounds – stridor. Inc ICP = dec RR exhalation pressure of the blood as a result of Dyspnea .Faster and deeper Age respiration without pauses in between Since blood moves in waves.F.DOB unless sitting Keith Nester A.difficulty of breathing contraction of ventricles Orthopnea . Narcotics Kussmaul’s .orce of the blood against the arterial walls FACTORS AFFECTING RESPIRATION M . bubbling.easured in millimeters of mercury A.sound caused by air passing thru lungs) ea normal rate fluid or mucus in the airways usually heard on inhalation 2 TYPES OF BREATHING Cheyne Resp. there are 2 Emotions – inc RR panting BP measures: Cardiac illness Apneustic . deep or Whee shallow Bradypn RR < 10 bpm zing Ease & effort – dyspnea. REGARDING RESPIRATION (mmHg) Exercise – inc RR Certain medications – eg. becomes faster and Rhonchi sound caused by air passing Costal/thoracic breathing – involves stokes deeper then slower with external intercostal muscles and other thru airways narrowed by fluids. – regular.high-pitched sounds heard on (overexpansion of lungs). orthopnea ea narrowing of airways. Observed thru muscle spasm usuallyheard during apnea(20-60sec) upward and outward movement of the exhalation chest Biot’s Faster and deeper than Diaphragmatic (abdominal) breathing – normal with abrupt involves contraction & relaxation of the diaphragm pauses in between each BLOOD PRESSURE breath F . Lavin . irregular breathing Tachypn RR > 24 bpm Adults 12-20 bpm Depth – assessed by watching the ea movement of the chest– normal. rales or sighing sounds Volume –: hyperventilation Apnea Absence of breathing Stridor . edema.

blood viscosity and arm (e. KOROTKOFF”S SOUND – SCHEMATIC of 2 or more diastolic readings on 2 visits knee. have just exercised. in pain rises w/ age b. dobutamine.uses sphygmomanometer. and a stethoscope PRESSURE Delay assessing if patient is: Palpatory – uses palpation Age – newborns systolic = 75mmHg. or Error Effect c. or ankle) is injured or diseased. because of burns and trauma) compliance of the arteries Hypertension – above 140/90 mmHg Blood pressure is not measure on a Hypotension – below 90/60 mmHg client’s arm or thigh in the following Orthostatic Hypotension – decrease in ASSESSMENT FINDINGS situations: Bp when changing position H . Direct invasive monitoring measurement contraction Blood Volume – adult has about 5-6 liters you must: – insertion of a catheter into the brachial.O. BP a. Emotions/stress – SNS stimulation = inc pressure of the blood when ventricles BP BLOOD PRESSURE SITES are at rest Exercise – inc cardiac output = inc BP Drugs – dopamine. upon systole and retracts upon minutes for routine assessment Non-invasive diastole Should not have ingested caffeine or nicotine 30 minutes before Auscultatory.ypertension – dx made when the ave The shoulder.ypotension = systolic pressure is The client has an intravenous infusion in FACTORS THAT CONTROL BLOOD consistently between 85-110 mmHg that limb O – rthostatic hypotension = a blood That client has an arteriovenous fistula PRESSURE pressure that falls when the client sits or ( for renal dialysis for that limb) stands METHODS Cardiac Output – amount of blood ejected from the heart per To ensure accuracy in taking the BP.. of circulating blood radial or femoral artery. The BP cannot be measured on either ABNORMAL FINDINGS blood volume. Diastole – the lowest pressure. Lavin . H . systolic BP readings is higher than The client has had removal of axilla (or 140mmHg hip) lymph nodes on that side. Bladder cuff to Erroneously high Keith Nester A..2. FACTORS AFFECTING BLOOD a cuff. represented by Elasticity of arterial walls – yields Let the patient rest for a minimum of 5 waves on an oscilloscope. DIAGRAM subsequent to initial assessment is 90 A cast or bulky bandage is on any part of mmHg or higher or ave of multiple the limb. emotionally upset. Assessment of BP in a client’s thigh is Pulse pressure – difference between the epinephrine usually indicated for: systole and diastole Obesity – predispose to hypertension Disease process – any dse affecting C.g. arm or hand (or the hip.

Lavin . narrow Bladder cuff Erroneously low too wide Cuff wrapped to loosely or Erroneously high unevenly Erroneously low Deflating cuff systolic and high to quickly diastolic readings Deflating cuff Erroneously high to slowly diastolic reading Failure to use Inconsistent the arm measurements consistently Arm above level of the Erroneously low heart Assessing immediately after a meal or Erroneously high while client smokes or has pain Keith Nester A.