VITAL SIGNS (cardinal signs) BASIC 1. 2. 3. 4. 5. 6.

MEASUREMENT Temperature Pulse Rate Respiration Rate Blood pressure Oxygen Saturation Assessment Pain

FUNCTIONS OF VITAL SIGNS 1. Patients condition 2. Response to your intervention (ex. He has a fever, and then youll wait for response/effect.) 3. Identifying problems (high adrenaline , high vital signs) 4. Base-line data of the client (usual state of the client) ex. High BP is normal to others * Independent function of the nurse, dont need to wait for the doctors order. GUIDELINES IN TAKING VITAL SIGNS: 1. Nurses responsibility 2. Make sure that the equipment are properly functioning and using it appropriately. 3. You need to know the usual baseline data of the patient. 4. You need to know the patients medical history, medication, therapist hes receiving. To know the effect Not prescribe medicine 5. 6. Make predictable to the effect. Control or Minimize environmental factor that affects vital signs. Ex. Temperature When and how to assessment of vital signs are chiefly nursing judgement. Ex. You dont need to wait the doctor. *Every 4hours (routine) 8am, 12pm, 4pm, 8pm, 12am, 4am... ***Supposed surgery*** More check up is needed. (depends to the condition) Ex. Every 1 hour in 3 hours (depends in nurses judgement) During medication administration, before enduring drug Ex. Cardiac drugs Digitalis (monitor the pulse rate not above 60 dont give) You need to verify significant changes in vital signs. Dont forget to document any changes of the vital signs.

7. 8. 9.

WHEN TO MEASURE VITAL SIGNS 1. During admission (to give baseline data when it changes) 2. Before and after surgical procedure (it changes during surgical) If its high (make low first) 3. 4. Complication after Before and after invasive(entry) diagnostic procedure Before during and after administration of medication that affect cardiovascular, respiratory, temperature control function. To check the effect of the medication When the patient general conditions changes.

5.

TEMPERATURE It is the balance between heat production and heat loss. Unit is in (o) degrees oC or oF Hypothalamus (located at the cerebral hemisphere) It controls the body temperature It receives a message (warm or cold) When it response Warm It produces heat (high temp.) Cold Heat loss

WARM Perspiration Vasodilatation (dilation of blood vessels) COLD Vasoconstriction Shiver of muscle

2 TYPES OF TEMPERATURE 1. Core temperature It measures the deep tissues of the body. (CONSTANT. Cannot be altered by environmental factors) a. Rectal route b. Tympanic route Monitoring device is used at: Bladder 2. Pulmonary artery Esophagus

Surface temperature can be altered by environmental factors. (Temperature of the skin, SQ tissues, Fats) a. Oral route b. Axillary route

A. HEAT PRODUCTION Metabolism primary source of heat Energy utilization of the body required to maintain bodily functions (FAST or SLOW) Required essential activities May be affected by food intake, exercise and hormones [thyroid gland] *Metabolism transfer to skin = heat loss. B. HEAT LOSS Skin- primary source of heat loss 4 PHYSICAL PROCESS 1. Radiation transfer of heat through electromagnetic wave. transfer of heat of 2 objects without physical contact Uncovered surface of body exposed without physical contact Example: Ear 2. Conduction transfer of heat from one object to another with direct contact. Example: Ice pack to head Baby to weighing scale 3. Convection transfer of heat through air movements Example: Air condition or Electric fan 4. Evaporation transfer of heat through sweating *600-900ml being evaporated during respiration FACTORS AFFECTING TEMPERATURE 1. Season / Environment blood vessels - vasomotor nerves cold - blood vessel constrict hot - dilation Age Infants are still immature so they have less activities or less metabolism and less temperature Sex or Gender Increase in progesterone level for female during ovulation, increases temperature Hormonal Activity During extreme stress (adrenaline works)

2. 3. 4.

5.

6. 7. 8.

Diurnal Variation occurring each day Lowest early morning.. (6oC) Peak (highest temperature at 4pm-7pm) Exercise Stress Food Intake the more you eat = the higher the temperature (vice versa)

DEVIATION OR ALTERATION IN BODY TEMPERATURE 1. Afebrile absence of fever normal body temperature 36.4oC - 37.4oC

2.

3.

97.6oF - 99.3oF Fever / Febrile / Pyrexia Elevation or increase in Body Temperature 38oC - 40oC Hyper Pyrexia very high fever Elevation in Body Temperature above 40 oC 41oC - 42oC Hypothermia extremely low Body Temperature Neurogenic Fever Results from problems in hypothalamus Intracranial trauma Intracranial bleeding High intracranial pressure

4. 5.

TYPES OF FEVER 1. Intermittent - On and Off fever - the body temperature alternates at regular intervals between periods of fever and periods of normal to subnormal temperatures 2. Remittent - wide range of temperature fluctuation in 24 hours. - There is an increase of 2oC within 24 hours 3. Relapsing [pabalikbalik] - short febrile periods followed by afebrile periods for 1-2 days 4. Constant - Febrile periods - Minimal increase in temperature 5. Fever Spike - sudden increase of fever then sudden decrease of fever or afebrile - one time big time 6. Crisis Fever - fever suddenly returns to normal 7. Lysis - fever gradually returns to normal MEASUREMENT OF TEMPERATURE Thermometer device used to measure body temperature 42oC [highest] 35 oC [lowest]

TYPES OF THERMOMETER 1. Standard Glass consist of Bulb, Graduated scale, Stem 3 class of standard glass Oral glass thermometer (longer and slender bulb) Rectal glass thermometer (pear-shape bulb) 2. 3. Multi use thermometer (stubby tip) Electronic Thermometer stainless probe [digital] Tympanic Thermometer less than 10seconds

SITES or ROUTES 1. Oral or Sublingual Route most convenient 35.7oC 37.4oC 3-5 minutes Wait for 30 minutes if the client smoked or drank cold or hot beverages

2.

not recommended for young/newborn , with cough, with disease/had surgery in the mouth, irrational/crazy, with clogged nose Rectal route most accurate most inconvenient 1-3 minutes 0.4 oC higher [NORMAL: 36.5oC 37.8oC] Used when oral route is not accessible usually used for newly borns to check for imperforate anus (no hole in anus) PROCEDURE a. provide privacy b. Lubricate the thermometer [no pressure/no friction] c. Sims position [side lying with upper leg flexed] d. bulb end inserted about 1.5 inches or 3-8 cm or 1/3 of the thermometer

3.

Axillary least desirable site (no major blood vessels) safest way 5-10 minutes Ear canal Readily accessible 10 seconds

4.

CONVERSION o C to oF = oC x (9/5) +32

o

F to oC = oF -32 x (5/9)

PULSE is the wave felt caused by the expansion and distention of the arterial walls as the blood is forced into the aorta and then into the small arteries each time the heart beats. A clients pulse can be felt [palpated] or heard [auscultated] each time the hearts left ventricle contracts and forces blood into the aorta.

PURPOSES To obtain the baseline measurement of the clients heart rate and rhythm To monitor the changes in the clients cardiovascular status To monitor the hearts response to a disease, procedure or therapy To assess blood flow to specific body part

CHARACTERISTICS 1. Rate- the number of beats per minute [ normal: 60-80 bpm ] a. Tachycardia b. 2. over 100bpm caused by stress, strenuous exercise, fever, hemorrhage, shock, congestive heart disease below 60bpm

Bradycardia - caused by moderate exercise, certain drug, therapies, pathogenic condition

Rhythm- pattern of beats; interval beats a. b. Regular- time between beats is essentially the same Arrhythmia- interval between beats is irregular Normal- if compressed artery is full to touch and pulsations are strong Imperceptible- if pulsation cannot be felt Feeble or thread- if pulsation can be easily obliterated Bounding- if pulsations reach a higher level than normal then disappears Big tension- obliterated only by relatively great pressure Low tension- easily obliterated even under slight pressure

3.

Volume- size or amplitude of blood pushes against the wall of the artery during ventricular contraction a. b. c. d.

4.

Tension- the compressibility of the arterial wall a. b.

PULSE SITES 1. 2. 3. 4. 5. 6. 7. 8. Radial artery- inner aspect of the wrist on the thumb side Temporal artery- superior and lateral to the eye Carotid artery- side of the neck and near the angle of the jaw Brachial artery- inner aspect of the biceps muscle, few cm below the axilla or the inner aspect of the arm Femoral artery- middle of the grain Popliteal artery- behind the knee, along the center of the popliteal space Posterior artery Dorsalis pedis artery

PULSE RHYTHMS 1. 2. Regular rhythms the pulse rhythms and the pauses occur similarly Dyshythmias no pattern or predictability a. b. c. bisferiens pulsus alternans bigeminal

PERIPHERAL PULSE is a recurring wave that courses through the arteries when blood is pumped into an already full aorta during ventricular contraction, flaring its walls.

FACTORS AFFECTING PULSE 1. 2. 3. 4. 5. 6. 7. 8. 9. age gender after puberty females pulses slightly higher than males exercise fever higher related to vasodilation medication hypovolemia [decreased volume of blood] stress position changes lower BP, higher PR pathology heart conditions or those that impairs oxygenation

REASONS FOR USING PULSE SITES 1. 2. 3. Radial artery- readily accessible Temporal artery- used when radial is not accessible Carotid- used in cases of cardiac arrest -used to determine circulation to the brain APICAL PULSE Second sound heard during ventricular contraction Done on children below 3 yrs. old and on people with irregular puls

*Apical and radial pulse are taken by simultaneously PULSE DEFICIT the difference between apical pulse and radial pulse

VARIATION IN PULSE RATE 1. Age 2. 3. 4. 5. 6. 7. 8. 9. New born (120-160 per min) Children (90-140 per min) Adult (60-80 per min) Older Adults (70-80 per min)

Exercise Emotions Heat / Temperature Circadian Rhythm or Diurnal Variation [high at 8pm 12nn] Position horizontal position increases RR Presence of Illness Drugs Sex female 7-8beats faster than men Time of day High at 8am - 12nn

10. Body build tall, slender (low) small, chubby (high) 11. Blood volume and components TYPES OF PULSE 1. Bigeminal Pulse 2 regular beats are followed by a longer pause than normal 2. Collapsing Pulse strikes feebly against the finger then subsides abruptly 3. Corrigan or Water Hammer a jerky pulse with a full extension (sudden) 4. Dierotic has 2 marked expansions in 1 beat of the artery 5. Labile (moving) 6. Wiry small, tense and upon palpation, feels like a cord / wire.

RESPIRATION the act of breathing NORMAL RR Ordinary people: 15-20 cpm Yoga [art of meditation] : 12 cpm Athletes 40 cpm Children 30 cpm

External exchange of O2 and CO2 between the lungs and pulmonary blood. Internal interchange of gases between the blood of the cells of the body tissue PHASES OF RESPIRATION A. Inhalation intake of air into the lungs B. Exhalation breathing out KINDS OF BREATHING A. Costal or Thoracic intercostals muscle and accessory muscles Ex. Sternocleidomastoid B. Diaphragmatic or Abdominal breathing - abdomen Ex. Newborns Eupnea normal breathing Dyspnea difficult in breathing Apnea absence of breathing (sleep apnea loud snore ) Bradypnea lower respiration Tachypnea higher respiration Hyperventilation rapid respiration Hypoventilation shallow respiration BLOOD PRESSURE measure of the pressure exerted by the blood as it flows through the arteries. Systolic pressure of the blood Diastolic pressure when the ventricles are at rest 120 / 80mmhg (120 = working period of the blood, 80 = at rest) 120 80 = 30 (30 = pulse pressure) DETERMINANCE 1.Pumping action of the heart 2.Peripheral Vascular Resistance (arteriosclerosis arteries) 3.Blood Volume 4.Blood Viscosity (hematocrit ratio of RBC) MYOCARDIAL INFARCTION heart attack FACTORS AFFECTING BLOOD PRESSURE 1. Age 2. Exercise 3. Stress 4. Race 5. Sex 6. Medications 7. Obesity 8. Diurnal Variation 9. Disease Process METHOD OF TAKING BLOOD 1. Direct

2. Non-invasive a. Auscultatory Methods b. Palpatory Methods SPHYGMOMANOMETER 1. Aneroid 2. Mercurial Cuff Air bladder Tubing Gauge Air Valve STETHOSCOPE Ear piece Binaural Tension Tubing bar Bell Diaphragm