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Temperature
Pulse
Respirations
Blood Pressure
The fifth vital sign
Pain
Oxygen Saturation
Body Temperature
Body temperature reflects the balance between
the heat produced and the heat lost from the
body, and is measured in heat units called
degrees.
There are two kinds of body temperature:
Core temperature is the temperature of the deep
tissues of the body such as abdominal cavity
and pelvic cavity; it remains relatively constant.
The surface temperature is the temperature of the
skin, the subcutaneous tissue, and fat. It rises
and falls in response to the environment. When
the amount of heat produced by the body equals
the amount of heat loss, the person is in heat
balance.
Evaporation
Administer antipyretic
Provide oral hygiene to keep the mucous
membrane moist.
Provide a tepid sponge bath to increase heat
loss through conduction.
Provide dry clothing and bed linens.
Oral
Rectal thermometer
Axillary temperature
Tympanic
Pulse
Pulse; is a wave of blood created by contraction of
the left ventricle of the heart.
Cardiac output; is the volume of blood pumped
into the arteries by the heart and equals the
result of the stroke volume times the heart rate.
A peripheral pulse; is a pulse located away from
the heart such as in the foot, wrist neck.
Apical pulse; is a central pulse; that is, located at
the apex of the heart.
Pulse Sites
Temporal; passes over the temporal bone of the
head. The site is superior and lateral to the eye.
Carotid; at the side of the neck between the
trachea and the sternocleiodomastoid muscle.
Apical; at the apex of the hearty. About 8cm to
the left of the sternum and at the fourth and
sixth intercostals space.
Brachial; at the inner aspect of the biceps
muscle of the arm
Respirations
Mechanics and regulation of breathing
During inhalation, the diaphragm contracts the ribs
move upward and outward, and the sternum
moves outward, thus enlarging the thorax and
permitting the lungs to expand.
During exhalation. The diaphragm relaxes, the
ribs move downward and inward, and the
sternum moves inward, thus decreasing the size
of the thorax as the lungs are compressed.
Assessing Respiration
Nurses should be aware of the following before
having respiration rate:
The clients normal breathing pattern
The influence of the clients health problems on
respirations
Any medications or therapies that might affect
respirations
The relationship of the clients respiration to
cardiovascular function
Breath sounds
- Stridor, harsh sound heard during inspiration
with laryngeal obstruction
- Stertor, snoring respiration usually due to a
partial obstruction of the upper airway.
- Wheeze, continuous, high pitched musical sound
occurring on expiration when air moves through
narrowed or partially obstructed air way.
Blood Pressure
Blood pressure is referred to the force of the
blood against arterial walls. Maximum blood
pressure is exerted on the walls of arteries when
the left ventricles of the heart pushes blood
through the aortic valve into the aortas during
contraction, the highest pressure thus called
systolic pressure.
Medications.
Obesity; predispose to high blood pressure
Diurnal variations; pressure is usually lowest early
in the morning when metabolic rate is low.
Disease process; any condition affecting the
cardiac output, blood volume, blood viscosity,
and compliance of the arteries has a direct effect
on the blood pressure.
Hypertension:
Hypertension; an abnormally high blood
pressure, over 140mm Hg systolic and 90 mm
Hg diastolic.
Factors associated with hypertension
Thickening of the arterial walls, which reduces
the size of the arterial lumen
Elasticity of the arteries
Lifestyle as cigarette smoking
Obesity
Lack of physical exercise
High blood cholesterol level
Continued exposure to stress
Hypotension
Hypotension; blood pressure below normal that
is systolic reading between 85-110mm Hg. It
occurs as a result of peripheral vasodilatation in
which blood leaves the central body organs
especially the brain and moves to the periphery
Factors associated with hypotension
Analgesics
Bleeding
Severe burn
Dehydration.
Oxygen Saturation
A pulse oximeter; is a non invasive device that
measures a client's arterial blood oxygen
saturation by means of a sensor attached to the
client's finger, toe, nose, earlobe, or forehead.
The pulse oximeter can detect hypoxemia
before clinical signs and symptoms such as
dusky skin color and dusky nailbed color.
PAIN SCALE
5TH OR 6TH VITAL SIGN.
MONITOR ON A REGULAR BASIS.
ASSESS PATINETS SELF-REPORT OF PAIN
LEVEL. USING SCALE OF 0-10.
OBSERVE FOR NON-VERBAL CUES.
DOCUMENT.
1 to 3mild pain.
4 to 6---moderate pain
7 to 10severe pain
Pain vs. pain and inflammation.
max
For children:
Visual Analog Scale
VAS
NAS
Verbal Rating Scale:
extreme
very strong
strong
mild
no pain at all
0 1
2 3
7 8 9 10