NCM 103L- FUNDAMENTALS OF NUSING BS NURSING (1ST YEAR – 2ND SEMESTER)

BATANGAS STATE UNIVERSITY – THE NATIONAL ENGINEERING UNIVERSITY

 The average normal body temperature is

VITAL SIGNS ASSESSMENT
Vital Signs
 Temperature, pulse, respiration and blood
pressure are collectively termed vital signs
, also called cardinal signs.
 In health, their values are so constant that
any marked deviation from normal is
looked upon as a symptom of disease.
Vital Signs or Cardinal Signs Taking – is the
measurement of physiologic functioning,
specifically body temperature, blood pressure
pulse and respiration.
VITAL SIGNS ASSESSMENT
Purposes of Vital Signs Taking
generally accepted as 98.6°F (37°C), can
have a wide range, from 97°F (36.1°C) to
99°F (37.2°C)
Alterations in Body Temperature
1. PYREXIA
 A body temperature above the usual range
is called pyrexia, hyperthermia, or (in lay
terms) fever.
 A very high fever, such as 41C ( 105.8F),
is called hyperpyrexia.
 The client who has a fever is referred to as

 Serves as guide in meeting the needs of

the client (to determine the course of
illness)
 Aids in the planning of care for the client
(to aid the physician in making his
diagnosis and planning patient’s care)
 Establish baseline values of the client’s
cardio respiratory integrity (to afford an
opportunity to observe the general
condition of the client)
febrile; the one who does not is afebrile.
Time to Assess Vital Signs
2. HYPOTHERMIA
 On admission to a health care agency to
obtain baseline data  It occurs when you lose more heat than
 When a client has a change in health your body can produce and you feel very
status or reports symptoms such as chest cold.
pain or feeling hot or faint
 Before and after surgery or an invasive Purpose of Temperature Taking
procedure  To establish baseline data or subsequent
 Before or/and after the administration of a evaluation
medication that could affect the  To identify whether the core temperature
respiratory or cardiovascular systems; for is within normal range
example giving digitalis preparation.  To determine changes in the core
 Before and after any nursing intervention temperature in response to specific
that could affect the vital signs(e.g., therapies (e.g., antipyretic medication,
ambulating a client who has been on bed immunosuppressive therapy, invasive
rest. procedure)
Temperature Taking  To monitor clients at risk for imbalanced
body temperature (e.g., clients at risk for
DEFINITION infection, or diagnosis of infection; those
who have been exposed to temperature
 Reflects the balance between the heat
extremes)
produced and the heat lost from the body,
and is measured in heat units called
degrees.
ORAL METHOD EQUIPMENT
Normal Value
 Thermometer – oral
 Alcohol, cotton balls
  Watch with second hand PULSE RATE
 Paper and pen
 The speed of the heartbeat measured by
AXILLARY METHOD EQUIPMENT the number of contractions (beats) of the
heart per minute (bpm).
 Digital Thermometer  vary according to the body's physical
 Alcohol and cotton balls needs, including the need to absorb
 Watch with a second hand oxygen and excrete carbon dioxide.
 Paper and pen  Activities that can provoke change include
physical exercise, sleep, anxiety, stress,
illness, and ingestion of drugs.

RECTAL METHOD EQUIPMENT

 Rectal thermometer
PULSE SITES
 Alcohol and cotton balls
 Watch with second hand
 Paper and pen
PULSE TAKING
DEFINITION
Pulse
 It is a wave of blood created by
contraction of the left ventricle of the
heart?
 Expansion of the arterial walls occurring
with each ventricular contraction.
 To feel the pulse is to feel the distention or
pulsation of the arteries, each time the
ventricle contracts blood is forced into the
aorta and the arteries pulsate.
Arteries
 Blood vessels that deliver oxygen
 Rich blood from the heart to the tissues of
the body.
NORMAL VALUE
 Temporal – where the temporal artery
passes over the temporal bone of the head.
 Carotid – at the side of the neck where
the carotid artery runs between the trachea
and the sternocleidomastoid muscle.
 Apical – at the apex of the heart. Located
on the left side of the chest, about 8cm (3
inches)to the left of the sternum
(breastbone) at the fifth intercostal space
(area between the ribs).
 Brachial – the inner aspect of the biceps
muscle of the arm or medially in the
antecubital space.
 Radial- where the radial artery runs along
the radial bone, on the thumb side of the
inner aspect of the wrist.
 Femoral – where the femoral artery
passes alongside the inguinal ligament.
 Popliteal- where the popliteal artery
passes behind the knee.
 Posterior tibial- on the medial surface of
the ankle where the posterior tibial artery
passes behind the medial malleolus.
 Dorsalis pedis- where the dorsalis pedis
artery passes over the bones of the foot
(the space between the big and the second
toes).

 Adults: 60-100 beats per minute

 Athlete: 40-60 beats per minute
(American Heart Association)
 Children :
o 3-4 years old: 80-120 beats per
minute
o 5-6 years old: 75-115 beats per
minute
o 7-9 years old: 70-110 beats per
minute
 Newborn: 120-160 beats per minute
 maximum heart rate = subtract your age
from 220 x 50% and 85%
TERMS USED TO DESCRIBED THE
CHARACTER OF PULSE
 Arrhythmias –means irregularities of
rhythm, intervals between beats are of
different lengths or the beats are of
unequal force.
 Tachycardia- refers to a pulse rate higher
than 150 per minute
 Bradycardia- means a very slow pulse
rate( usually lower than 60 beats per
minute)which indicates slow heart action.
 Bounding- describes a pulse that reaches
a higher level than normal, then
disappears quickly.
 Running pulse- describes a pulse rate that
is too fast to be counted.
 Feeble, weak or thready- are terms used
whose volume is small and can be readily
obliterated.
 Water hammer pulse or Corrigan’s
pulse- is a pulse with a very forceful beat,
with the artery falling away very quickly.
 Dicrotic pulse- means one heart beat for
two arterial pulsations, giving the
sensation of a double beat.
 Intermittent pulse- refers to a pulse that
occasionally skips a beat.
 Weak or absent pulses – in normally
palpable arteries in the lower extremities
reflect diminished, thus poor circulation in
these areas.
PURPOSES
 To establish baseline data for subsequent
evaluation
 To identify whether the pulse rate is
within normal range
 To determine the pulse volume and
whether the pulse rhythm is regular.
 To determine the equality of
corresponding peripheral pulses on each
side of the body.
 To monitor and assess changes in the
client’s health status
 To monitor client’s at risk for pulse
alterations (e.g., those with a history of
heart disease are experiencing cardiac
arrhythmias, hemorrhage, acute pain,
infusion of large volumes of fluids, or
fever)
 To evaluate blood perfusion to the
extremities
EQUIPMENT
 Watch with second hand
Respiration Taking
Respiratory Rate
 Usually determined by counting the
number of times the chest rises or falls per
minute.
 The number of breaths per minute or,
more formally, the number of movements
indicative of inspiration and expiration per
unit time.
Normal Values
 Adults: 12-20 breaths/cycles per minute
 School age: 18-30 cycles per minute
 Pre-school: 22-34 cycles per minute
 Toddler: 24-40 cycles per minute
 Infant: 30-60 cycles per minute
Factors affecting respiratory rate
 Asthma
 Anxiety
 Pneumonia
 congestive heart failure
 lung disease
 use of narcotics
 Drug overdose.
Two Types of Breathing
 Costal (thoracic) breathing involves the
external intercostal muscles and other
accessory muscles, such as the
sternocleidomastoid muscles. It can be
observed by movement of the chest
upward and outward.
 Diaphragmatic (abdominal) breathing
involves the contraction and relaxation of
the diaphragm, and it is observed by the
movement of the abdomen, which occurs
as a result of the diaphragm’s contraction
and downward movement.
PURPOSES OF RESPIRATION TAKING
 To acquire baseline data against which
future measurements can be compared
 To monitor abnormal respirations and
respiratory patterns and identify changes
 To monitor respirations before or after the
administration of general anesthetic or any
medication that influences respirations
 To monitor clients at risk for respiratory
alterations (e.g., those with fever, pain,
acute anxiety , chronic obstructive
pulmonary disease, asthma, respiratory
infection, pulmonary edema or emboli,
chest trauma or constriction, brainstem
injury)
EQUIPMENT
 Watch with a second hand
Blood Pressure Taking
  Arterial Blood Pressure - is the measure  Paper and Pen
of the pressure exerted by the blood as it
flows through the arteries.
 Systolic Pressure - is the pressure of the
blood as a result of contraction of the
ventricles, the pressure of the height of the
blood wave.
 Diastolic Pressure is the pressure when
the ventricles are at rest.
 Pulse Pressure is the difference between
the diastolic and the systolic pressures.
Factors Affecting BP

 Stress
 Smoking
 Cold temperatures
 Exercise
 A full stomach
 Full bladder
 Caffeine, alcohol consumption
 Certain medicines
 Gaining or losing weight
 Salt intake

Normal Values
Age Systolic Diastolic
Pressure Pressure
Preschooler 89-112 46-72
(3-5 y)
School-age 97-115 57-76
(6-9 y)
Preadolescent 102-120 61-80
(10-11 y)
Adult 100-120 60-80

PURPOSE

 To obtain baseline measurement of arterial

blood pressure for subsequent evaluation
 To determine the clients hemodynamic
status(e.g., cardiac output: stroke volume
of the heart and blood vessel resistance).
 To identify and monitor changes in blood
pressure resulting from a disease process
or medical therapy (ex: presence or
history of cardiovascular disease, renal
disease, circulatory shock or acute pain;
rapid infusion of fluids or blood products).
EQUIPMENT

 Blood Pressure Apparatus

 Sphygmomanometer
 Stethoscope