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    Vital Signs

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    Bryan Lloyd Rayat
    - Cardinal signs refer to the basic body functions that health professionals measure, including body temperature, pulse rate, blood pressure, and respiratory rate. - There are two main types of thermoregulation: internal thermoregulation through metabolic heat production and external thermoregulation through heat exchange with the environment via radiation, conduction, convection, and evaporation. - The normal body temperature range varies slightly based on age, time of day, activity level, and other factors but typically remains between 36.5-37.5°C when measured orally.

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    Vital Signs

    Uploaded by

    Bryan Lloyd Rayat
    41 views91 pages
    - Cardinal signs refer to the basic body functions that health professionals measure, including body temperature, pulse rate, blood pressure, and respiratory rate. - There are two main types of thermoregulation: internal thermoregulation through metabolic heat production and external thermoregulation through heat exchange with the environment via radiation, conduction, convection, and evaporation. - The normal body temperature range varies slightly based on age, time of day, activity level, and other factors but typically remains between 36.5-37.5°C when measured orally.

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    - Cardinal signs refer to the basic body functions that health professionals measure, including body temperature, pulse rate, blood pressure, and respiratory rate. - There are two main types of thermoregulation: internal thermoregulation through metabolic heat production and external thermoregulation through heat exchange with the environment via radiation, conduction, convection, and evaporation. - The normal body temperature range varies slightly based on age, time of day, activity level, and other factors but typically remains between 36.5-37.5°C when measured orally.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    41 views91 pages

    Vital Signs

    Uploaded by

    Bryan Lloyd Rayat
    - Cardinal signs refer to the basic body functions that health professionals measure, including body temperature, pulse rate, blood pressure, and respiratory rate. - There are two main types of thermoregulation: internal thermoregulation through metabolic heat production and external thermoregulation through heat exchange with the environment via radiation, conduction, convection, and evaporation. - The normal body temperature range varies slightly based on age, time of day, activity level, and other factors but typically remains between 36.5-37.5°C when measured orally.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 91

    • CARDINAL SIGNS

    • MEASURES OF PHYSIOLOGICAL STATISTICS


    • TAKEN BY HEALTH PROFESSIONALS
    • ASSESS THE MOST BASIC BODY
    FUNCTIONS
    •Body Temperature
    •Pulse rate (or heart rate)
    •Blood pressure
    •Respiratory rate
    2 Types:
    I. __________________

    II. __________________
    • BMR
    • Muscle activity
    • Thyroxine
    • Epi. Norepi, SNS,
    Stress response
    • Fever
    •RADIATION
    •CONDUCTION
    •CONVECTION
    •EVAPORATION
    • transfer of heat from the
    surface of one object to the
    surface of another without
    contact between the two
    objects, mostly in the form of
    infrared rays.
    • transfer of heat from one
    molecule to a molecule of
    lower temperature.
    • Dispersion of heat by air
    currents.
    • continuous vaporization of
    moisture from the respiratory
    tract and from the mucosa
    of the mouth and from the
    skin.
    Three Main Parts:
    1. Sensors in the
    periphery and in the
    core,
    2. An integrator in the
    hypothalamus,
    3. An effector system
    • Most sensors or sensory
    receptors are in the skin.
    • The skin has more
    receptors for cold than
    warmth.
    1. Shivering
    • increases heat production.
    2. Sweating
    • is inhibited to decrease heat loss.
    3. Vasoconstriction
    • decreases heat loss
    • Hypothalamic integrator
    controls the core
    temperature.
    • Detects heat
    • Sends out signals intended
    to reduce the temperature
    • Infants- greatly influenced by the temperature of
    the environment
    • Children- vary more than those of adults until
    puberty.
    • over 75 years- risk of hypothermia (temperatures
    below 36°C, or 96.8°F)
    • Older adults -sensitive to extremes in the
    environmental temperature due to decreased
    thermoregulatory controls.
    • varying as much as 1.0°C (1.8°F) between the early
    morning and the late afternoon
    • The point of highest body temperature is usually
    reached between 1600 and 1800 hours (4:00 PM
    and 6:00 PM)
    • lowest point is reached during sleep between 0400
    and 0600 hours (4:00 AM and 6:00 AM)
    Hard work or strenuous
    exercise can increase body
    temperature to as high as
    38.3°C to 40°C (101°F to
    104°F) measured rectally.
    ovulation raises body
    temperature by about
    0.3°C to 0.6°C (0.5°F to 1.0°F)
    above basal temperature
    • Stimulation of the sympathetic
    nervous system can increase the
    production of epinephrine and
    norepinephrine, thereby
    increasing metabolic activity
    and heat production.
    • If the temperature is assessed in
    a very warm room and the body
    temperature cannot be
    modified by convection,
    conduction, or radiation, the
    temperature will be elevated
    • Increased heart rate
    • Increased respiratory rate and depth
    • Shivering
    • Pallid, cold skin
    • Complaints of feeling cold
    • Cyanotic nail beds
    • “Gooseflesh” appearance of the skin
    • Cessation of sweating
    • help the client decrease heat loss. At this
    time, the body’s physiological processes
    are attempting to raise the core
    temperature to the new set-point
    temperature
    • Absence of chills
    • Skin that feels warm
    • Photosensitivity
    • Glassy-eyed appearance
    • Increased pulse and respiratory rates
    • Increased thirst
    • Mild to severe dehydration
    • Drowsiness, restlessness, delirium, or convulsions
    • Herpetic lesions of the mouth
    • Loss of appetite (if the fever is prolonged)
    • Malaise, weakness, and aching muscles
    • Skin that appears flushed and feels
    warm
    • Sweating
    • Decreased shivering
    • Possible dehydration
    • VS
    • Assess skin color and temperature.
    • Monitor laboratory reports
    • Remove excess blankets when the client feels
    warm, but provide extra warmth when the client
    feels chilled.
    • Provide adequate nutrition and fluids (e.g., 2,500–
    3,000 mL per day)
    • Intake and output.
    • Reduce physical activity to limit heat production,
    especially during the flush stage.
    • Antipyretics as ordered.
    • Oral hygiene.
    • Tsb
    • Dry clothing and bed linens.
    •Intermittent
    •Remittent
    •Relapsing
    •Constant
    alternates at regular
    intervals between periods
    of fever and periods of
    normal or subnormal
    temperatures.
    wide range of
    temperature fluctuations
    (more than 2°C [3.6°F])
    over a 24-hour period, all
    of which are above
    normal.
    short febrile periods of
    a few days are
    interspersed with
    periods of 1 or 2 days
    of normal temperature.
    fluctuates minimally but
    always remains above
    normal. This can occur
    with typhoid fever.
    A temperature that rises to
    fever level rapidly following
    a normal temperature and
    then returns to normal within
    a few hours .
    • ____________ – most
    common (accessible and
    convenient)

    • ____________– most accurate


    (reliable)

    • ____________– least accurate


    but most safe (noninvasive)

    • ____________– most quick

    • ____________– safe non-


    invasive, very fast
    1. Apply disposable gloves.
    Lubricate (2 inches)
    2. Instruct the client to take a slow
    deep breath during insertion.
    3. Never force the thermometer if
    resistance is felt.
    4. Insert in a rotating motion.
    5. 1 ½ inches for adults, 1 inch for
    child and ½ inch for infant.
    • Pat the axilla dry if
    very moist. The bulb
    is placed in the
    center of the axilla
    • Rectal – 37 – 38.1 C (1-2
    mins)
    • Oral – 36.5 – 37.5 C (3-5 mins)
    • Axilla – 35.8 – 37 C (5-10
    mins)
    • Tympanic Membrane – 37 C
    (2-5 secs)
    •Extremely labile
    •Hold arms against chest – axillary
    •Axillary not as accurate
    •Tympanic route- fast and convenient
    • Supine
    • Stabile head
    • Pull pinna STRAIGHT BACK AND SLIGHTLY
    DOWN (3 yrs below)
    • Direct probe anteriorly seal canal but do not
    touch tympanic membrane
    • Avoid Tympanic Route when + Ear Infections
    or Drainage Tube
    • More Accurate in Febrile Px
    • When Temporal Artery Thermometer-
    Touching only the Forehead or Behind Ear is
    Needed
    • Rectal Route is Least Desirable
    • It is a wave of blood created
    by contraction of the left
    ventricle of the heart.
    • It is expressed in bpm.
    2 Types:
    - Central
    - Peripheral
    • When assessing the pulse, there
    is a need to take note of the
    following:
    • Rate (tachycardia/bradycardia)
    • Rhythm – patterns of beat and
    interval between beats
    (dysrhythmia/arrhythmia)
    Temporal – superior and lateral to the eye.
    Carotid – side of the neck below the lobe of
    ear.
    Apical – left of sternum at the 5th intercostal
    space
    Brachial – inner aspect of biceps of arm or
    medially in the antecubital space.
    Radial – thumb side of the inner aspect of
    the wrist.
    Femoral – inguinal ligament.
    Popliteal – behind the knee
    Posterior Tibial – medial surface of ankle
    Dorsalis Pedis – dorsum of the foot on an
    imaginary line from the middle of ankle
    to the space between big toe and
    second toe.
    Respiration
    • It is the act of breathing; it includes
    the intake of oxygen and output of
    carbon dioxide.
    • Inhalation/ Inspiration
    • Exhalation/ Expiration
    • Ventilation
    • Eupnea
    • Tachypnea
    • Bradypnea
    • Apnea
    • Dyspnea
    • Orthopnea
    • Cheyne-Stokes breathing/
    respiration
    Measure of the force blood
    exerts against the blood vessel
    walls.
    Systolic pressure
    • maximum (VC)
    Diastolic pressure
    • minimum (VR)
    Mercury (Hg) manometer/
    sphygmomanometer
    1. Auscultatory
    2. Palpatory
    • Signs and symptoms of
    hypertension
    • Signs and symptoms of
    hypotension
    • Factors affecting blood pressure
    • Some blood pressure cuffs
    contain latex.
    • Pediatric Stethoscope
    • antecubital space of
    an infant.
    • Systolic 50 and 80
    mmHg
    • Diastolic 25 and 55
    mmHg
    CATEGORY SYSTOLIC DIASTOLIC
    Normal <120 <80

    Prehypertension 120-139 80-89

    Hypertension Stage 1 140-159 90-99

    Hypertension Stage 2 >160 >100


    • The percent of all
    hemoglobin binding sites
    that are occupied by
    oxygen.
    • 95-100%
    • Pulse oximeter
    • Best Location
    • Overall Condition
    • Baseline data
    • Adhesive allergy
    AGE PULSE RESPIRATION
    Newborn 130 (80-180) 35 (30-80)

    1 year 120 (80-140) 30 (20-40)

    5-8 years 100 (75-120) 20 (15-25)

    10 years 70 (50-90) 19 (15-25)

    Teen 75 (50-90) 18 (15-20)

    Adult 80 (60-100) 16 (12-20)

    Older Adult 70 (60-100) 16 (15-20)


    • Earlobe or
    Forehead
    • SpO2 Levels
    • Pulse Rate
    • Keep it in Place.
    • The phrase "fifth vital sign"
    usually refers to pain, as
    perceived by the patient
    on a pain scale of 0–10.
    Based on Etiology
    1. Nociceptive Pain (experienced
    when an intact, properly
    functioning nervous system sends
    signals that tissues are damaged,
    requiring attention and proper
    care)
    a. Somatic
    b. Visceral
    2. Neuropathic Pain -
    associated with damaged or
    malfunctioning nerves due to
    illness
    a. Peripheral Neuropathic
    b. Central Neuropathic
    11-point rating scale
    1. The client’s temperature at 8:00 AM using an
    oral electronic thermometer is 36.1°C (97.2°F). If
    the respiration, pulse, and blood pressure were
    within normal range, what would the nurse do
    next?
    A.Wait 15 minutes and retake it.
    B. Check what the client’s temperature was the
    last time it was taken.
    C.Retake it using a different thermometer.
    D.Chart the temperature; it is normal.
    2. Which client meets the criteria for
    selection of the apical site for assessment
    of the pulse rather than a radial pulse?
    A.A client who is in shock
    B.The pulse changes with body position
    changes
    C.A client with an arrhythmia
    D.It is less than 24 hours since a client’s
    surgical operation
    3. When the nurse enters the room to measure vital
    signs in preparing the client for a diagnostic test, the
    client is on the phone. What technique should the nurse
    use to determine the respiratory rate?
    A. Count the respirations during conversational pauses.
    B. Ask the client to end the phone call now and resume
    it at a later time.
    C.Wait at the client’s bedside until the phone call is
    completed and then count respirations.
    D.Since there is no evidence of distress or urgency,
    defer the measurement.
    4. For a client with a previous blood pressure
    of 138/74 and pulse of 64, approximately
    how long should the nurse take to release
    the blood pressure cuff in order to obtain an
    accurate reading?
    A.10–20 seconds
    B.30–45 seconds
    C.1–1.5 minutes
    D.3–3.5 minutes
    5. It would be appropriate to delegate the taking
    of vital signs of which client to unlicensed
    assistive personnel?
    A. A client being prepared for elective facial
    surgery with a history of stable hypertension
    B. A client receiving a blood transfusion with a
    history of transfusion reactions
    C. A client recently started on a new
    antiarrhythmic agent
    D. A client who is admitted frequently with
    asthma attacks
    6. An 85-year-old client has had a stroke
    resulting in right-sided facial drooping, difficulty
    swallowing, and the inability to move self or
    maintain position unaided. The nurse determines
    that which sites are appropriate for taking the
    temperature? Select all that apply
    A.Oral
    B. Rectal
    C.Axillary
    D.Tympanic
    E. Temporal artery
    7. A nursing diagnosis of Ineffective
    Peripheral Tissue Perfusion would be
    validated by which one of the following?
    A.Bounding radial pulse
    B.Irregular apical pulse
    C.Carotid pulse stronger on the left side
    than the right
    D.Absent posterior tibial and pedal pulses
    8. The nurse reports that the client has
    dyspnea when ambulating. The nurse is
    most likely to have assessed which of
    the following?
    A.Shallow respirations
    B.Wheezing
    C.Shortness of breath
    D.Coughing up blood
    9. When auscultating the blood pressure, the
    nurse hears: From 200 mmHg to 180 mmHg:
    silence; then: a thumping sound continuing
    down to 150 mmHg: muffled sounds continuing
    down to 130 mmHg; soft thumping sounds
    continuing down to 105 mmHg; muffled sounds
    continuing down to 95 mmHg; then silence

    A.The nurse records the blood pressure as


    _____________.

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