Introduction Assessing vital signs or cardinal sign is

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Introduction � Assessing vital signs or cardinal sign is a routine medical procedure. And

Introduction � Assessing vital signs or cardinal sign is a routine medical procedure. And somehow determines the internal functions of the body � Vital signs composes of the following: � Body temperature � Pulse � Respiration and � Blood pressure � pain

Vital Signs (continued) �Abbreviations: �Temperature – T �Pulse – P �Respirations – R �Blood

Vital Signs (continued) �Abbreviations: �Temperature – T �Pulse – P �Respirations – R �Blood Pressure – BP �Vital signs - TPR and 3 BP

Vital Signs (continued) �Purpose �Measured to detect any changes in normal body function �Used

Vital Signs (continued) �Purpose �Measured to detect any changes in normal body function �Used to determine response to treatment 4

Assessing a Client’s Health Status

Assessing a Client’s Health Status

Body Temperature

Body Temperature

�Body temperature ◦ It is a balance between the internal and external environment of

�Body temperature ◦ It is a balance between the internal and external environment of the body, or ◦ It is the balance between the heat produced by the body and the heat lost from the body. ◦ It is measured in heat units, called degrees

Body Temperature Shell temperature: the warmth at the skin surface Core temperature: the warmth

Body Temperature Shell temperature: the warmth at the skin surface Core temperature: the warmth in deeper sites within the body like the brain and heart

Temperature Measurement Fahrenheit scale: uses 32˚F as the temperature at which water freezes and

Temperature Measurement Fahrenheit scale: uses 32˚F as the temperature at which water freezes and 212˚F as the point at which it boils Centigrade scale: uses 0˚C as the temperature at which water freezes and 100˚C as the point at which it boils

Normal Body Temperature In normal, healthy adults, shell temperature generally ranges from 96. 6˚F

Normal Body Temperature In normal, healthy adults, shell temperature generally ranges from 96. 6˚F to 99. 3˚F or 35. 8˚C to 37. 4˚C Chances of survival diminish if body temperatures exceed 110˚F (43. 3˚C) or fall below 84˚F (28. 8˚C)

Normal Body Temperature (cont’d) Based on temperature, animals are either: ◦ Poikilothermic: temperature fluctuates

Normal Body Temperature (cont’d) Based on temperature, animals are either: ◦ Poikilothermic: temperature fluctuates depending on environmental temperature ◦ Homeothermic: structural and physiologic adaptations keep body temperature within a narrow stable range

Factors Affecting Body Temperature Food intake, age, gender Climate, exercise Circadian rhythm Emotions Illness

Factors Affecting Body Temperature Food intake, age, gender Climate, exercise Circadian rhythm Emotions Illness Medications

Assessment Sites Accurate assessment site: ◦ Brain, heart, lower third of the esophagus, and

Assessment Sites Accurate assessment site: ◦ Brain, heart, lower third of the esophagus, and urinary bladder Practical and convenient assessment sites: ◦ Ear, mouth, rectum, and axilla ◦ Ear provides the temperature closest to the core temperature

lary l i x ga n i re k u t Ta a per

lary l i x ga n i re k u t Ta a per m e T

Digital thermometer is commonly used in infants and children, insert it at the axillary

Digital thermometer is commonly used in infants and children, insert it at the axillary region

closed the arm and wait for timer to bustle

closed the arm and wait for timer to bustle

Remember when taking BT in infants and children make sure that the patient is

Remember when taking BT in infants and children make sure that the patient is not in distress mood because any change in the activity will directly affect the BT reading.

The Oral Cavity

The Oral Cavity

Parts: Oral Vestibule and Oral Cavity Proper

Parts: Oral Vestibule and Oral Cavity Proper

Floor of the mouth

Floor of the mouth

Insert the tip at the sublingual fossa

Insert the tip at the sublingual fossa

Positioned thermometer

Positioned thermometer

Let stay for 1 to 2 minutes, tell the patient to close the mouth

Let stay for 1 to 2 minutes, tell the patient to close the mouth

Clinical Thermometers � Instruments used to measure body temperature � � � Electronic Infrared

Clinical Thermometers � Instruments used to measure body temperature � � � Electronic Infrared Chemical Digital Glass

Types of Clinical Thermometers (Refer to Table 12 -3 in the textbook. )

Types of Clinical Thermometers (Refer to Table 12 -3 in the textbook. )

Electronic Thermometers

Electronic Thermometers

Infrared Tympanic Thermometer

Infrared Tympanic Thermometer

Chemical Thermometer

Chemical Thermometer

Digital Thermometer

Digital Thermometer

Glass thermometer (Glass)

Glass thermometer (Glass)

Automated Monitoring Devices Equipment that allows for the simultaneous collection of multiple data Measure

Automated Monitoring Devices Equipment that allows for the simultaneous collection of multiple data Measure the temperature, blood pressure, pulse, heart rhythm, and pulse oximetry Portable to save time and money

Continuous Monitoring Devices Used primarily in critical care areas Measure body temperature using internal

Continuous Monitoring Devices Used primarily in critical care areas Measure body temperature using internal thermistor probes within the esophagus of anesthetized clients, inside the bladder, or attached to a pulmonary artery catheter

Elevated Body Temperature Fever is a condition in which the body temperature exceeds 99.

Elevated Body Temperature Fever is a condition in which the body temperature exceeds 99. 3˚F (37. 4˚C) Pyrexia is a condition in which the temperature is warmer than the normal set point Hyperthermia is a condition in which core temperature is excessively high and the temperature exceeds 105. 8˚F (40. 6˚C)

Symptoms of Fever Pinkish, red (flushed) skin that is warm to the touch Restlessness

Symptoms of Fever Pinkish, red (flushed) skin that is warm to the touch Restlessness in some; excessive sleepiness in others Irritability; poor appetite Glassy eyes and sensitivity to light Increased perspiration Headache

Symptoms of Fever (cont’d) Above-normal pulse and respiratory rates Disorientation and confusion (when the

Symptoms of Fever (cont’d) Above-normal pulse and respiratory rates Disorientation and confusion (when the temperature is high) Convulsions in infants and children (when the temperature is high) Fever blisters about the nose or lips in clients who harbor the herpes simplex virus

Phases of Fever Prodromal phase Onset or invasion phase Stationary phase Resolution or defervescence

Phases of Fever Prodromal phase Onset or invasion phase Stationary phase Resolution or defervescence phase

Phases of Fever and Physiologic Changes

Phases of Fever and Physiologic Changes

Question Is the following statement true or false? Fever is a condition where the

Question Is the following statement true or false? Fever is a condition where the body temperature exceeds 105. 8˚F.

Answer False. Fever is a condition where the body temperature exceeds 99. 3˚F.

Answer False. Fever is a condition where the body temperature exceeds 99. 3˚F.

Hypothermia Core body temperature less than 95˚F (35˚C) Mildly hypothermic: 95˚F to 93. 2˚F

Hypothermia Core body temperature less than 95˚F (35˚C) Mildly hypothermic: 95˚F to 93. 2˚F (35˚C to 34˚C) Moderately hypothermic: 93˚F to 86˚F (33. 8˚C to 30˚C) Severely hypothermic: below 86˚F (30˚C)

Symptoms of Hypothermia Shivering until body temperature is extremely low Pale, cool, and puffy

Symptoms of Hypothermia Shivering until body temperature is extremely low Pale, cool, and puffy skin Impaired muscle coordination Listlessness and irregular heart rhythm Slow pulse and respiratory rates Incoherent thinking and diminished pain sensation

Pulse Rate

Pulse Rate

Pulse Produced by the movement of blood during the heart’s contraction In most adults,

Pulse Produced by the movement of blood during the heart’s contraction In most adults, the heart contracts 60 to 100 times per minute at rest ◦ Pulse rhythm ◦ Pulse volume ◦ Pulse rate

Pulse Assessment Techniques Primary pulse assessment site: radial artery located at inner (thumb) side

Pulse Assessment Techniques Primary pulse assessment site: radial artery located at inner (thumb) side of the wrist Alternate assessment techniques ◦ Counting the apical heart rate ◦ Obtaining an apical–radial rate ◦ Using a Doppler ultrasound device over a peripheral artery

Variations in Pulse Rate Age Average Range Newborn to 1 month 130 80 -180

Variations in Pulse Rate Age Average Range Newborn to 1 month 130 80 -180 1 year 120 80 -140 2 years 110 80 - 130 6 years 100 75 - 120 10 years 70 50 -90 Adult 80 60 - 100 Pulse rate/ Minute Kozier Barbara, et. al. Fundamentals of Nursing , 5 th ed. (US Addison-Wesley Publishing Company, Inc. 1995) p. 438

Peripheral Pulse Sites

Peripheral Pulse Sites

5. The pulse is normally palpated by applying are moderate pressure with the three

5. The pulse is normally palpated by applying are moderate pressure with the three fingers of the hand. 6. The pads of the most distal aspect of the fingers are the most sensitive areas of detecting the pulse.

Pulse site Reasons for Use Radial Readily accessible & routinely used Temporal Used when

Pulse site Reasons for Use Radial Readily accessible & routinely used Temporal Used when radial pulse is not accessible Carotid Used for infants, in cases of cardiac arrest and to determine the circulation to the brain Apical Routinely used in infants and children up to 3 years of age, Used to determine the discrepancies with radial pulse, and Used in conjunction with some medication Brachial Used to measure blood pressure, used for cardiac arrest for infants Femoral Used in cases of cardiac arrest, for infants and children, determine circulation in the leg Popliteal Used to determine the circulation in the lower leg and leg blood pressure Posterior tibial Used to determine the circulation in the foot Pedal Used to determine circulation in the foot

Respiration

Respiration

Respiratory Rate • Rapid respiratory rate – Tachypnea accompanies elevated temperature or diseases affecting

Respiratory Rate • Rapid respiratory rate – Tachypnea accompanies elevated temperature or diseases affecting cardiac and respiratory systems • Slow respiratory rate – Bradypnea can result from medications; observed in clients with neurologic disorders or hypothermia

Abnormal Breathing Characteristics • Hyperventilation • Hypoventilation • Dyspnea • Orthopnea • Apnea •

Abnormal Breathing Characteristics • Hyperventilation • Hypoventilation • Dyspnea • Orthopnea • Apnea • Stertorous breathing • Stridor

Respiration • Exchange of oxygen and carbon dioxide • Respiratory rate is the number

Respiration • Exchange of oxygen and carbon dioxide • Respiratory rate is the number of ventilations per minute • Cheyne-Stokes respiration: a breathing pattern in which the depth of respirations gradually increases, followed by a gradual decrease, and then a period when breathing stops briefly before resuming again

Variations in Respiratory rate Age Average Range Newborn 35 30 -80 1 year 30

Variations in Respiratory rate Age Average Range Newborn 35 30 -80 1 year 30 20 -40 2 years 25 20 -30 8 years 20 15 -25 16 years 18 15 -20 Adult 16 12 -20 Respiratory rate/ Minute Kozier Barbara, et. al. Fundamentals of Nursing , 5 th ed. (US Addison-Wesley Publishing Company, Inc. 1995) p. 448

BLOOD PRESSURE

BLOOD PRESSURE

Blood Pressure Force that the blood exerts within the arteries Lower-than-normal volumes of circulating

Blood Pressure Force that the blood exerts within the arteries Lower-than-normal volumes of circulating blood cause a decrease in blood pressure Excess volumes cause an increase in blood pressure Regular aerobic exercise increases tone of heart muscle and increases efficiency Cardiac output

Blood Pressure (cont’d) Cardiac output is approximately 5 to 6 L in adults at

Blood Pressure (cont’d) Cardiac output is approximately 5 to 6 L in adults at rest Blood pressure measurements provide physiologic data about: ◦ Ability of arteries to stretch ◦ Volume of circulating blood ◦ Amount of resistance heart must overcome when it pumps blood

Factors Affecting Blood Pressure Age Circadian rhythm Gender Exercise and activity Emotions and pain

Factors Affecting Blood Pressure Age Circadian rhythm Gender Exercise and activity Emotions and pain

Factors Affecting Blood Pressure (cont’d) Lower blood pressure ◦ Lower when lying down than

Factors Affecting Blood Pressure (cont’d) Lower blood pressure ◦ Lower when lying down than when sitting or standing Higher blood pressure ◦ When urinary bladder is full, when the legs are crossed, when the person is cold ◦ When drugs that stimulate the heart are taken

Pressure Measurements Systolic pressure Diastolic pressure Blood pressure is expressed in millimeters of mercury

Pressure Measurements Systolic pressure Diastolic pressure Blood pressure is expressed in millimeters of mercury (mm Hg) as a fraction; systolic pressure/diastolic pressure Pulse pressure: difference between systolic and diastolic blood pressure measurements

Assessment Sites Usually assessed over the brachial artery Lower arm and radial artery Measured

Assessment Sites Usually assessed over the brachial artery Lower arm and radial artery Measured over the popliteal artery behind the knee in case: ◦ Client’s arms are missing ◦ Both of a client’s breasts have been removed ◦ Client has had vascular surgery

Equipments for Measuring Blood Pressure Sphygmomanometer Aneroid manometer Electronic oscillometric manometer Inflatable cuff Stethoscope

Equipments for Measuring Blood Pressure Sphygmomanometer Aneroid manometer Electronic oscillometric manometer Inflatable cuff Stethoscope

Aneroid and Electronic Oscillometric Manometer

Aneroid and Electronic Oscillometric Manometer

Alternate Techniques for Assessing Blood Pressure Palpation Using a Doppler stethoscope Automatic blood pressure

Alternate Techniques for Assessing Blood Pressure Palpation Using a Doppler stethoscope Automatic blood pressure monitoring Measuring thigh blood pressure

Abnormal Blood Pressure Measurements Blood pressures above or below normal ranges indicate significant health

Abnormal Blood Pressure Measurements Blood pressures above or below normal ranges indicate significant health problems Hypertension: high blood pressure Hypotension: low blood pressure Postural or orthostatic hypotension: sudden but temporary drop in blood pressure when rising from a reclining position

Abnormal Blood Pressure Measurements (cont’d) Hypertension or high blood pressure is associated with: ◦

Abnormal Blood Pressure Measurements (cont’d) Hypertension or high blood pressure is associated with: ◦ Anxiety ◦ Obesity ◦ Vascular diseases ◦ Stroke, heart failure ◦ Kidney diseases

Documenting Vital Signs Once vital sign measurements are obtained: ◦ Document the data in

Documenting Vital Signs Once vital sign measurements are obtained: ◦ Document the data in medical record for analysis of patterns and trends ◦ Enter the data, along with any other subjective or objective information in narrative nursing notes

Nursing Implications Vital sign assessment is the basis for identifying problems Nurses identify from

Nursing Implications Vital sign assessment is the basis for identifying problems Nurses identify from the nursing diagnoses: ◦ Hyperthermia, hypothermia, ineffective thermoregulation, decreased cardiac output, risk for injury, or ineffective breathing pattern

Gerontologic Considerations Lower “normal” or baseline temperature Changes in thermoregulation system Delayed or diminished

Gerontologic Considerations Lower “normal” or baseline temperature Changes in thermoregulation system Delayed or diminished febrile response to illnesses Change in cognitive function, restlessness, or anxiety may be initial sign of illness

Gerontologic Considerations (cont’d) Susceptible to hypothermia and heat-related conditions; elevated blood pressure readings in

Gerontologic Considerations (cont’d) Susceptible to hypothermia and heat-related conditions; elevated blood pressure readings in clinical settings Blood pressure assessment in bilateral arms; document subsequent trends Older adults are more susceptible to arrhythmias and postural and postprandial hypotension

Gerontologic Considerations (cont’d) If older client is hypotensive, plan for limited activities during the

Gerontologic Considerations (cont’d) If older client is hypotensive, plan for limited activities during the hour following eating or frequent smaller food consumption throughout the day More profound responses to cardiovascular medications than younger adults

Aneroid manometer with stethoscope

Aneroid manometer with stethoscope

Part of the sphygmomanometer

Part of the sphygmomanometer

Mercury manometer and cuff Aneroid manometer and cuff

Mercury manometer and cuff Aneroid manometer and cuff

Variations in BP by Age Mean BP (mm Hg) Newborn 73/55 1 year 90/55

Variations in BP by Age Mean BP (mm Hg) Newborn 73/55 1 year 90/55 6 years 95/57 10 years 102/62 14 years 120/80 Adult 120/80 Elderly (over 70 years) Diastolic pressure may increase Kozier Barbara, et. al. Fundamentals of Nursing , 5 th ed. (US Addison-Wesley Publishing Company, Inc. 1995) p. 452

The End My best wishes educator : Ekhlas abu hasna

The End My best wishes educator : Ekhlas abu hasna