2011 EDITION

By Lemuel C. Macasa
CARDINAL SIGNS
body temperature
pulse
respirations
blood pressure
pain
reflects the body’s physiologic
status & ability to regulate
temperature, maintain local and
systemic blood flow, & oxygenate
tissues

VITAL SIGNS, what it is…

on admission

institution policy

before & after invasive procedure

before & after administration of medications

change in client’s condition

Before & after a nursing intervention

BODY TEMPERATURE
 reflects the balance between the heat produce and
heat loss
 measured in heat units called degrees
TYPES
1. CORE TEMPERATURE
2. SURFACE TEMPERATURE
BODY TEMPERATURE
TYPES
1. CORE TEMPERATURE
temperature of the deep
tissues in the body
i.e. abdominal cavity
pelvic cavity
BODY TEMPERATURE
TYPES
1. CORE TEMPERATURE
2. SURFACE TEMPERATURE
temperature of the skin, subcutaneous
tissue, & fats
CONTRIBUTING FACTORS
Basal Metabolic Rate (BMR)
rate of energy utilization
Muscle activity
Thyroxine output
effect: chemical thermogenesis
Stress
Fever
FACTORS AFFECTING HEAT LOSS
RADIATION
transfer of heat from one surface to
another without contact between the
two objects
i.e. use of infrared rays
sunlight exposure
RADIATION
 HEAT LOSS
FACTORS AFFECTING HEAT LOSS
CONDUCTION
transfer of heat
between two objects
in contact
 HEAT LOSS
FACTORS AFFECTING HEAT LOSS
CONVECTION
- dispersion of heat by air currents
- warm air rises and is replaced by
cooler air
 HEAT LOSS
FACTORS AFFECTING HEAT LOSS
VAPORIZATION
evaporation of moisture from body
surfaces
a. insensible water loss
b. insensible heat loss
Body temperature, WHAT AFFECTS?
1. AGE
young ↑ BMR = ↑ temp.
older ↓ BMR = ↓ temp
2. DIURNAL VARIATIONS (circadian
rhythms)
Highest - between 8:00 pm and midnight
Lowest - during sleep between 4:00 and
6:00 am
3. EXERCISE
Body temperature, WHAT AFFECTS?
4. HORMONES
epinephrine and norepinephrine
↑ BMR - ↑ temp.
progesterone
↑ BMR - ↑ temp.
5. STRESS
stimulation of the SNS
6. ENVIRONMENT
BODY TEMPERATURE alterations
PYREXIA
abnormally high body temperature
a.k.a. hyperthermia or fever
terminologies
Hyperpyrexia – a very high fever
Febrile – a client who has a fever
 FEVER and its types
INTERMITTENT FEVER
alternating temperature at regular
intervals between periods of fever and
periods of normal or subnormal
temperatures
 FEVER and its types
REMITTENT FEVER
wide range of temperature fluctuations
(more than 2°C [3.6°F]) occurs over the 24-hour
period, all of which are above normal
 FEVER and its types
RELAPSING FEVER
short febrile periods of a few days are
interspersed with periods of 1 or 2 days
of normal temperature
 FEVER and its types
CONSTANT FEVER
body temperature fluctuates minimally
but always remains above normal
FEVER SPIKES, what it is…
A temperature which rises to fever level
rapidly following a normal temperature
and then returns to normal within a few
hours
 FEVER resolution
TYPES
Resolution-by-crisis

Resolution-by-lysis
 HYPOTHERMIA
reflects body temperature that is lower
than normal
Types
1. Accidental
a. exposure to cold environment
b. immersion in cold water
c. lack of adequate clothing, shelter, or
heat
2. Induced
Key points:
• may be inaccurate if
client has ingested
hot or cold
food/fluid
• Thermometers can
break if bitten
Key points:
• Reliable
measurement
• C/I for clients with
MI, clotting d/o,
rectal surgery,
significant
hemorrhoids
• Least desirable in
infants
Key points:
• Preferred site for
measuring
temperature in
newborns
• However may not be
accurate to detect
fever in infants
Key points:
• Readily accessible
core temperature
assessment
• Involve risk of
injuring the
tympanic membrane
TYPES OF THERMOMETERS
a. Mercury-in-glass thermometers
b. Electronic thermometers
c. Chemical disposable thermometers
d. Temperature-sensitive tape
e. Infrared thermometers
f. Temporal artery thermometers
 TEMPERATURE SCALES
DEGREES
Celsius centigrade
Fahrenheit
HOW TO CONVERT?
Fahrenheit to Celsius
C = (Fahrenheit temperature – 32) x 5/9
Celsius to Fahrenheit
F = (Celsius temperature x 9/5) + 32
 PULSE, what it is…
Wave of blood created by contraction of
the left ventricle of the heart
represents the stroke volume output
and the amount of blood that enters the
arteries with each ventricular
contraction
expressed in beats per minute (bpm)
 PULSE, what it is…
DEFINITION OF TERMS
 Compliance - ability to contract and expand
 Cardiac output –the volume of blood
pumped into the arteries by the heart

CO = SV x HR
 Peripheral Pulse – a pulse located away
from the heart
 Apical Pulse – a central pulse located at
the apex of the heart
PULSE SITES
Temporal

Carotid

Brachial

Radial

Femoral

Popiteal

Posterior tibial

Dorsalis Pedis

Apical
REASONS FOR USING SITES
SITES
RADIAL Readily accessible
TEMPORAL Used when Radial is not accessible
CAROTID Cardiac arrest/Shock
Determine circulation to the brain
APICAL Children below 3 years of age
BRACHIAL Used to measure BP
Cardiac arrest for infants
FEMORAL Cardiac arrest/shock
Determine circulation of the leg
POPLITEAL Determine circulation of the LL
P. TIBIALIS Determine circulation of the foot
& D. PEDIS
 ASSESSING THE PULSE
1. Palpation
2. Auscultation
3. Doppler Ultrasound Stethoscope
DUS
 THINGS TO NOTE
1. Rate
2. Rhythm
3. Volume
4. Arterial wall elasticity
5. Presence or absence of bilateral
equality
 THINGS TO NOTE
RATE
tachycardia – excessively fast heart rate
bradycardia – decrease rate than normal
 THINGS TO NOTE
PULSE RHYTHM –pattern of the beats and the
intervals between the beats
Dysrhythmia or arrhythmia
an irregular rhythm
may consist of random, irregular beats or a
predictable pattern of irregular beats
ECG or EKG is necessary to define the
dysrhythmia further.
 THINGS TO NOTE
PULSE VOLUME – refers to the force of
blood with each beat
a.k.a. pulse strength or amplitude
Normal pulse – can be felt with moderate
pressure of the fingers
Full or bounding– a forceful or full blood
volume and difficult to obliterate
Weak, feeble or thready – a pulse that is
readily obliterated with pressure from
the fingers
 THINGS TO NOTE
ELASTICITY OF THE ARTERIAL WALL
- reflects its expansibility or deformities
- Normal artery feels straight, smooth, soft,
and pliable
APICAL PULSE ASSESSMENT
INDICATION
a. peripheral pulse is irregular
b. unavailable p. pulses
c. clients with known cardiovascular,
pulmonary, and renal diseases
d. commonly assess prior to administering
cardiotonics
e. newborns, infants, and children up to
2 to 3 years old.
 APICAL-RADIAL PULSE
NORMAL
apical and radial rates are identical
ABNORMAL
apical pulse rate greater than a radial
pulse rate
 Pulse deficit – any discrepancy
between the two pulse rates

NOTE: An apical pulse will never

be lower than the radial pulse
RESPIRATION, as defined…
Simply the act of breathing
VENTILATION
also used to refer to the movement of
air in and out of the lungs.
TYPES
1. EXTERNAL RESPIRATION
2. INTERNAL RESPIRATION
RESPIRATION, as defined…
PROCESSES
1. INHALATION or INSPIRATION
refers to the intake of air into the
lungs
2. EXHALATION or EXPIRATION
refers to breathing out or the
movement of gases from the lungs to
the atmosphere.
 TYPES OF BREATHING
a. costal (thoracic) breathing
involves the external intercostal
muscles and other accessory muscles,
such as the sternocleidomastoid
muscles
b. diaphragmatic (abdominal) breathing
involves the contraction and relaxation
of the diaphragm
INSPIRATION (active)
SIZE of the chest cavity

INTRATHORACIC pressure === NEGATIVE

AIR drawn into the LUNGS

EXPIRATION (passive)
RECOIL of stretched chest wall &
lung structures

CHEST CAVITY SIZE decreases

INTRATHORACIC pressure ===

INCREASES

Movement of AIR out of the LUNGS

 MECHANISMS OF BREATHING

LUNG PRESSURES
INHALATION = Negative (-) pressure
Lung expansion
EXPIRATION = Positive (+) pressure
Lung recoil,
decrease in size
 What to note?
a. rate
- normally described in breaths per
minute
b. depth
- established by watching the
movement of the chest
- generally described as normal, deep
or shallow
c. rhythm
d. quality and effectiveness
ABNORMAL PATTERNS
Rate
 Tachypnea
 Bradypnea
 Apnea
Volume
 Hyperventilation
 Hypoventilation
 ABNORMAL PATTERNS
Ease or Effort
 Dyspnea
 Orthopnea
Quality and character
 Stridor
 Stertor
 Wheeze
ABNORMAL PATTERNS
ANATOMY & PHYSIOLOGY
 ANATOMY & PHYSIOLOGY
CARDIOVASCULAR SYSTEM, What it is…
- Oxygen transport
- Nutrition
- Removal of the waste products

a hollow, cone-shaped organ about the size of

a fist
located in the mediastinum, between the lungs
& underlying the sternum
 CARDIAC CYCLE
a.k.a. HEARTBEAT
 SYSTOLE (Contraction)
- when the heart ejects the blood into the
pulmonary & systemic circulation

 DIASTOLE (Relaxation)
- when the ventricles fill with blood
 INDICATORS TO HEART FXN
 STROKE VOLUME
- amount of blood ejected from the heart with
each beat

 CARDIAC OUTPUT
- amount of blood ejected from the heart
each minute

CO = SV x HR
 INDICATORS TO HEART FXN
 HEART RATE
- number of beats each minute
- HR is directly proportional to CO
 PRELOAD
- left ventricular end diastolic volume; stretch
of the myocardium
 INDICATORS TO HEART FXN
 AFTERLOAD
- resistance against which the heart must
pump to eject the blood into the circulation
 CONTRACTILITY
- inotropic state of the myocardium, strength
of contraction
FXTORS AFFECTING ITS RATE
 Age  Stressors
 Gender  Positioning changes
 Exercise  Pathology
 Fever
 Medications
 Hypovolemia
ACTUAL SITE OF ASSESSMENT
at 4TH, 5TH, or 6TH intercostal
space, Left Midclavicular line
sinagXI
NORMAL RESULT

NORMAL
 S1 heard at all sites but louder at the
apex
 S2 heard at all sites but louder at the
base
 S3 in children and young adults
 S4 in many older adults

sinagXI
 BLOOD PRESSURE
- a measure of the pressure
exerted by the blood as it flows
through the arteries

a. Systolic Pressure
b. Diastolic Pressure
120 (SBP)
mmHg
80 (DBP)
 BLOOD PRESSURE
a. Systolic Pressure
b. Diastolic Pressure
 BLOOD PRESSURE
120 (SBP)
mmHg
80 (DBP)
PULSE PRESSURE
- the difference between the
DBP and SBP
NORMAL: 40-100mmHg
 DETERMINANTS OF BP
1. Cardiac Contractility
2. Peripheral Vascular Resistance
3. Blood Volume
4. Blood Viscosity
 BP SITES
Alternatives (Reasons)
1. BP cannot be measured on either
arm
2. BP comparison
3. Presence of bulky cast
4. Limb surgery
5. IVF infusion
6. AV fistula or shunt
 FXTORS AFFECTING BP
1. Age 7. Obesity
2. Exercise 8. Diurnal variations
3. Stress 9. Disease Process
4. Race
5. Gender
6. Medications
METHODS OF CHECKING BP
o DIRECT
- involves the insertion of a
catheter into the brachial, radial,
or femoral artery
o INDIRECTLY
a. Auscultatory
b. Palpatory
 KOROTKOFF’S SOUNDS
series of sounds heard during
auscultatory checking of the BP
PHASES
1. sharp tapping
2. swishing or whooshing
3. thump
4. muffled blowing
5. silence
KOROTKOFF’S SOUNDS
 ERRORS IN BP CHECKING
o BP cuff too narrow
o BP cuff too wide
o Arm unsupported
o Insufficient rest before checking
o Failure to use same arm
consistently
o Arm above level of the heart
o Arm below level of the heart
end