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Hayden S. Ganta
5 Vital Signs
• vPulse vTemperature vRespiration vBlood Pressure vPain
When to take VS?
• On the client admission. • Before and after surgery. • Before and after a diagnostic procedure. • Before and after giving certain medications. • A complaint of pain. • A complaint of loss of consciousness.
• It is the balance between the heat produced by the body and the heat lost from the body.
KINDS: Core Temperature – is the temperature of the deep tissues of the body such as the cranium, thorax, abdominal cavity and pelvic cavity. Surface Temperature – it rises and falls
Newborn – 1 year old 2 – 4 years old 6 years old to adult Elderly (over 70 years old)
36.1°C to 37.7°C (97.0°F to 100.0°F) 37.2°C (98.9°F) 37.0°C ( 98.6°F) 36.0°C ( 96.8°F)
Factors affecting Heat Production
• Basal Metabolic Rate - the rate of energy utilization in the body required to maintain essential activities such as breathing.
• Muscular Activities
• Thyroxine Output - increased thyroxine output increased thyroxine output increases the rate of cellular metabolism throughout the body. This effect is called chemical thermogenesis.
• Epinephrine, norepinephrine, and sympathetic stimulation.
• Fever – it increases the cellular metabolic rate and thus increases the body’s temperature further.
Modes of Heat Loss
v Radiation- transfer of heat from the surface of one object to the surface of another without the contact between the two objects, mostly in the form of infrared rays.
• • •
v Conduction – it is a transfer of heat from one molecule to another.
v Convection – dispersion of heat by air currents.
v Vaporization – it is the continuous evaporation of moisture from the respiratory tract and from the mucosa of the mouth and from the skin.
Factors affecting Body Temperature
v Age (Infants and Elderly) v Circadian Rhythms v Exercise v Hormones v Stress v Environment
Alterations in Thermoregulation
v Pyrexia/Febrile A temperature that is above the normal range
v Hyperthermia/Hyperpyrexia – a very high fever.
v Hypothermia – a temperature that is below the normal range
Fever is not an illness but a natural reaction to a number of illnesses.
Characteristics of FEVER
v Intermittent – a period of fever and a period of normal/subnormal temperature. v Remittent – a wide range of temp fluctuation over the 24 hour period, all of which are above normal. v Relapsing – short febrile for few days and followed by a day or two of normal temperature. v Constant – temperature fluctuates minimally but always remains above normal.
Types of Thermometer
ØMercury ØElectronic ØDisposable ØTympanic
Table of Comparison
Site Oral Advantages Most accessible and convenient Disadvantages Can break if bitten. C/I for kids under 6 years old, with nasal/oral surgery, and clients who are confused or who have convulsive disorder. Inaccurate for patients who just eaten hot/cold
Advantages Safe and most noninvasive
Disadvantages The thermometer must be left in place a long time to obtain an accurate measurement.
Readily accessible and Equipment is expensive. reflects core Puts risks of injuring the temperature. tympanic membrane if probe is inserted too far. Most reliable measurement Inconvenient and more unpleasant to the patient.
Can cause trauma to the area especially for newborns and infants.
To convert from Fahrenheit to Celsius:
°C = (°F – 32) x 5/9
Ex:Convert 98.6°F (Normal Body Temperature!) to Celsius First: 98.6° - 32 = 66.6 Then: 66.6 × 5/9 = 333/9 = 37° C
To convert from Celsius to Fahrenheit:
°F = (°C x 9/5) + 32 Ex: Convert 26° Celsius (A nice warm day!) to Fahrenheit First: 26° × 9/5 = 234/5 = 46.8 Then: 46.8 + 32 = 78.8° F
It is a wave of blood created by contraction of the left ventricle of the heart. It can be palpated (fingers) at sites where an artery passes alongside or over a bone, by placing slight pressure on the artery.
Stroke Volume - is the amount of blood ejected from the left ventricle of the heart during contraction. Cardiac Output – it is the volume of blood pumped into the arteries by the heart.
Factors Affecting Pulse Rate
v AGE v Gender v Exercise v Fever v Medications v Hemorrhage v Stress v Position Changes
Ways to assess pulse:
• Palpation – with the use of 3 middle fingers. • Stethoscope – for apical pulse and FHT. • Doppler UTZ – pulses that are difficult to assess. • Cardiac Monitor
Always note for the rate, rhythm, strength and equality.
Newborn 1 – 3 years old 6 – 8 years old Adult/Elderly (Healthy)
80 - 180 bpm 80 – 140 bpm 75 – 120 bpm 60 – 100 bpm
It is the act of “breathing”. It involves the intake of oxygen through “inhalation” and expels carbon dioxide through “exhalation”.
NURSES MUST OBSERVE FOR:
Ø Costal (Thoracic) Breathing It involves the external intercostal muscles and other accessory muscles such as the sternocleidomastoid muscle.
Ø Diaphragmatic (Abdominal) Breathing
It involves the contraction and relaxation of the diaphragm. It is observed by the rise and fall movement of the abdomen.
q Eupnea – normal respiration that is quiet, rhythmic, and effortless. q Tachypnea – rapid respiration marked by quick , shallow breaths. q Bradypnea – abnormally slow breathing. q Apnea – cessation of breathing.
qHyperventilation – an increase amount of air in the lungs. q qHypoventilation – a reduction of air in the lungs.
Newborn 1 – 3 years old 8 – 16 years old Adult
30 – 80 cpm 20 – 30 cpm 15 – 25 cpm 12 – 20 cpm
It is the measure of pressure exerted by the blood as it flows through the arteries. It is measured in millimeters of mercury (mmHg) and recorded as a fraction.
Systolic Pressure – the pressure of the blood as a result of contraction of the ventricles. Diastolic Pressure – the pressure when the ventricles are at rest. Pulse Pressure – the difference
PHASE Phase I Phase II Phase III Phase IV Phase V DESCRIPTION CLINICAL OF SOUND of IMPLICATION Appearance Correlates with clear tapping Sounds become systolic blood No clinical sound and longer pressure softer become significance Sounds No clinical crisper and louder significance Sounds become Correlates as muffleddisappear alternate measure Sounds and softer Correlates with of DBP completely DBP
Factors affecting BP
Ø Age Ø Gender Ø Blood Volume Ø Stress Ø Pain Ø Exercise Ø Weight Ø Race Ø Diet ØM e d i ti n s ca o ØPo si o n ti ØA l h o l co ØS m o ki g n ØD i rn a lV a ri ti n s u a o ØD i a se Pro ce ss se
Aneroid Sphygmomanometer Mercurial Sphygmomanometer
Age Newborn 1 year 2 years 4 years 6 years 8 years 10 years Teenager Adult Elderly Mean BP (mmHg) 78/42 96/65 100/63 97/64 98/65 106/70 110/72 125/79 120/80 120/80
Common Errors in BP taking
• Too narrow bladder cuff - erroneously high • Too wide bladder cuff - erroneously low • Arm unsupported - erroneously high • Insufficient rest before the assessment - erroneously high • Repeating assessment too quickly erroneously high or low diastolic readings • Cuff wrapped too loosely or unevenly - erroneously high
• Deflating cuff too quickly erroneously slow systolic and high diastolic readings • Deflating cuff too slowly - erroneously high diastolic reading • Failure to use the same arm consistently – inconsistent measurements • Arm above level of the heart erroneously low • Assessing immediately after a meal or while client smokes or has pain or has pain - erroneously high • Failure to identify auscultatory gap erroneously low systolic pressure
Guidelines in BP taking
• Let the person rest for 10--20 minutes before measuring BP. • Do not take BP on an arm with an IV infusion, a cast, or a dialysis access site. If a person has had breast surgery, BP is not taken on that side. Also avoid taking BP on an injured arm. • Measure BP with the person sitting or lying. Sometimes the doctor orders measurement of BP in the standing position.
• Apply the cuff on the bare upper arm. Clothing can affect the measurement. Do not apply the cuff over clothing. • Make sure the cuff is snug. Loose cuff can cause inaccurate readings. • Place the diaphragm of the stethoscope firmly over artery. The entire diaphragm must be in contact with the skin. • Make sure the room is quiet. Talking, TV, radio, and sounds from the hallway can affect an accurate reading.
• Have the sphygmomanometer clearly visible. • Locate the radial artery, and then inflate the cuff. When you no longer feel the pulse, inflate the cuff another 30mmHg . This prevents cuff inflation to an unnecessarily high pressure which is painful to the person. (You can deflate the cuff at this time and note the point where you feel a pulse. Wait 30seconds and inflate the cuff 30mmHg above point. • Measure the systolic and diastolic pressure. Expect To hear the 1st BP sound at the point where you felt radial pulse. The 1st sound is the systolic pressure. The point where the sound disappears is the diastolic pressure. • Take the BP again if you are not sure of an accurate measurement. Wait 30-
• Whatever the patient says it is, existing whenever when the patient says it exists
• Beliefs about pain and how to respond to it differ between cultures.
P (Provokes) Q (Quality) What provokes the pain? (exertion, spontaneous onset, stress)
Is it dull, achy, sharp, stabbing, pressing, deep, surface, etc.? Similar to pain you’ve had before? Does it travel anywhere (to the jaw,back, arms, etc.)? What makes it better (position, being still)? What makes it worse (inspiration, movement)?
Explain the pain scale and have Pt rate pain. Are there any associated signs or symptoms (nausea, vomiting, dizziness, diaphoresis, pallor, shortness of breath [SOB], dyspnea, abnormal vital signs, etc.)? When did it start? Is it constant or intermittent? How long does it last? Sudden or gradual onset? Does it start after you’ve eaten? Frequency?
T (Time; Onset and Duration)
Wong-Baker Faces Pain Rating Scale
Refer red Pain
Characteristic of different Types of Pain
Acute Pain Onset Duration Current < 6 months Chronic Pain Cancer Pain Continuous or May be acute Intermittent or chronic > 6 months Pain maybe associated with cancer itself or the treatment
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