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PREPARED BY: J.A. TRIMOCHA,R.N
The vital signs are BODY TEMPERATURE, PULSE, RESPIRATIONS, AND BLOOD
PRESSURE. PAIN ASSESSMENT – recently considered as fifth vital signs
thoughtful, scientific assessement
Vital SIGNS reflect changes in function that otherwise might not be observed. Monitoring a client’s vital signs should not be automatic or routine procedure; it should be a
TIMES TO ASSESS VITAL SIGNS: On admission to health care agency to obtain baseline data When a client has change in health status or reports symptoms such as chest pain or feeling hot or faint. Before and/ or after the administration of a medication that could affect the respiratory or cardiovascular systems, for example, before giving digitalis preparation Before and after any nursing intervention that could affect the vital signs (e.g. ambulating a client who has been on bed rest)
Reflects the balance between the heat
production and the heat lost from the body, and is measured in heat units called degrees. There are two kinds of body temperature: CORE and SURFACE TEMPERATURE.
Core temperature is the temperature of deep
tissues of the body, such as abdominal cavity and pelvic cavity. It remains constant. Surface temperature is the temperature of the skin, the subcutaneous tissue, and fat. It, by contrast, rises and falls in response to the environment.
FACTORS affecting HEAT PRODUCTION
1.Basal Metabolic Rate(BMR) – is the rate of energy utilization in the body required to maintain essential activities such as breathing. 2.Muscle activity – including shivering = increase metabolic rate 3.Thyroxine output – increases thyroxine output increases the rate of cellular metabolism throughout the body.
Chemical thermogenesis – the stimulation of
heat production in the body through increased cellular metabolsism
4. Epinephrine, norepinephrine, and sympathetic stimulation stress response - these hormones immediately increase rate of cellular metabolism in many body tissue. 5. Fever – increases cellular metabolic rate and this increasing body temperature further.
How HEAT is lost?
Radiation – is the transfer of heat from the
surface of one object to the surface of another without a contact between two objects (infrared rays) Conduction – is the transfer of heat from one molecule to a molecule of lower temperature. (body is immersed in cold water) Convection – is the dispersion of heat by air currents. Vaporization – is continuous evaporation of moisture from the respiratory tract and from mucosa of the mouth and from the skin.
Insensible water loss and insensible heat loss
Factors affecting Body Temperature
Age Diurnal variations (circadian rhythms) 1600 – 1800 hours – highest body temp. 0400 – 0600 hours – lowest body temp. Exercise Hormones Stress Environment
Alterations in Body Temp.
Two primary alterations : PYREXIA and
PYREXIA – a body temp. that is above normal Hyperthermia and fever
Hyperpyrexia – a very high fever such as 41 C (1o5.8 F) Febrile and afebrile Intermittent – the body temp. alternates between periods of fever and periods of normal Remittent – a wide range of temperature fluctuations(more than 2C) occurs over 24 hour period , all of which are above normal Relapsing – short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temp.
Four common types of fever :
Hypothermia – is a core body temperature
below the lower limit of normal.
3 physiologic mechanisms of hypothermia 1.Excessive heat loss 2.Inadequate heat production to counteract heat loss 3.Impaired hypothalamic thermoregulation
Assessing body temperature
Site oral Advantages Accessible and convenient
Axillary Safe and noninvasive
Disadvantages Thermometers can break if bitten Inaccurate if client ingested hot or cold food or fluids Could injure the mouth following oral surgery Inconvenient and more unpleasant to client Presence of stool may interfere with thermometer placement The thermometer must be left in place for a long time to obtain accurate measurement
Tympanic membrane Temporal artery
Readily accessible, reflects the core Safe and temperature. Very noninvasive. Very fast fast
Can be uncomfortable and involveselectronicinjuring the Require risk if of equipment membrane ifexpensive or that may be the probe is inserted too far unavilable
Types of thermometers
Glass thermometers Electronic thermometers Chemical disposable thermometers Temperature – sensitive tape Infrared thermometers Temporal artery thermometers
Fahrenheit – celsius C = (Fahrenheit temp. – 32 ) X 5/9
Celsius – fahrenheit F = (Celsius temp. X 9/5) + 32
Is a wave of blood created by contraction o the
left ventricle of the heart Peripheral pulse – is a pulse located away from the heart Apical pulse – is a central pulse, that is, it is located at the apex of the heart. It is also referred to as the point of maximal impulse (PMI)
Factors affecting the Pulse
Age Gender Exercise Fever Medications Hypovolemia Stress Position changes Pathology
Temporal – site is superior(above) and lateral to
(away from the midline of) the eye Carotid- between trachea and sternocleidomastoid muscle Apical – 5th intercostal space(area between the ribs), left midclavicular area Brachial- inner aspect of the biceps muscle of the arm Radial- on the thumb side of the inner aspect of the wrist Femoral- alongside the inguinal ligament Popliteal- behind the knee Posterior tibial- medial surface of the ankle
Variations in Pulse by age
Age pulse average Newborn 130 (80 – 180) 1 year 120 (80 – 140) 5-8 years 100(75 – 120) 10 years 70 (50 – 90) Teen 75 (50-90) Adult 80 (60 – 100) Older adult 70 (60 – 100)
Is an act of breathing Inhalation or inspiration – refers to the intake of air in the lungs Exhalation or expiration – refers to the breathing out or the movement of gases from the lungs to the atmosphere. Ventilation – is also used to refer to the
movement of air in and out of the lungs.
Factors affecting respirations
Increase the respiratory rate Exercise Stress (fight or flight) Increased environmental temperature Lowered oxygen concentration Decrease the respiratory rate Decreased environmental temperature Certain medication (narcotics)
Altered breathing patterns
Rate Tachypnea – quick shallow breaths Bradypnea – abnormally slow breathing Apnea- cessation of breathing Volume Hyperventilation – overexpansion of the lungs characterized by rapid and deep breaths Hypoventilation – underexpansion of the lungs; characterized by shallow breaths
Rhythm Cheyne – stokes breathing – rhythmic waxing and waning of respirations, from a very deep to very shallow breathing and temporary apnea Ease and effort Dyspnea – difficult and labored breathing during which the individual has a persistent need for air and feels distressed Orthopnea – ability to breath in upright sitting or standing position
Audible without Amplification Stridor – a shrill, harsh sound heard during inspiration with laryngeal obstruction Stertor – snoring or sonorous respiration, usually due to partial obstruction of the upper airway Wheeze – continous, high pitched musical squeak or whistling sound occuring on expiration and sometimes on inspiration when air moves through a narrowed or partially obstructed airway Bubbling – gurgling sound heard as air passes through moist secretions in the respiratory tract
Chest movement Intercostal retraction – indrawing between the ribs Substernal retraction – indrawing beneath the breatstbone Suprasternal retraction – indrawing above the clavicles
Secretions and coughing Hemoptysis – the presence of blood in the sputum Productive cough – a cough accompanied by expectorated secretions Non productive cough – a dry, harsh cough without secretions
ARTERIAL BLOOD PRESSURE – is a measure 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, that is, the pressure of the height of the blood wave. Diastolic pressure – is the pressure when the ventricles are at rest. Present at all times within the arteries. It is the lower pressure
Pulse pressure – the difference between diastolic
and systolic pressures. Normal is about 40mmHg to 100mmHg.
Determinants of BP
Pumping action of the heart Peripheral vascular resistance Blood volume Blood viscosity
Factors affecting BP
Age Exercise Stress Race Gender Medications Diurnal variations Disease process
Classification of BP
systolicBP diastolicBP <120 and <80 and 80-89
Hypertension Stage 1 140-159 or 90-99 Stage 2 >160 or >100
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