Professional Documents
Culture Documents
Prepared by:
Hayden S. Ganta
Nurse Educator
5 Vital Signs
vPulse vTemperature vRespiration vBlood Pressure vPain
Body Temperature
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
Age Variations
Age
Newborn 1 year old 2 4 years old 6 years old to adult Elderly (over 70 years old)
Average Temperature
36.1C to 37.7C (97.0F to 100.0F) 37.2C (98.9F) 37.0C ( 98.6F) 36.0C ( 96.8F)
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.
Fever it increases the cellular metabolic rate and thus increases the bodys temperature further.
v Vaporization it is the continuous evaporation of moisture from the respiratory tract and from the mucosa of the mouth and from the skin.
Alterations in Thermoregulation
v Pyrexia/Febrile A temperature that is above the normal range
v
v Hypothermia a temperature that is below the normal range
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
Mercury Electronic Disposable Tympanic
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
Site Axillary
Disadvantages The thermometer must be left in place a long time to obtain an accurate measurement.
Tympanic
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.
Rectal
Can cause trauma to the area especially for newborns and infants.
Temperature Conversion
C = (F 32) x 5/9
Ex:Convert 98.6F (Normal Body Temperature!) to Celsius First: 98.6 - 32 = 66.6 Then: 66.6 5/9 = 333/9 = 37 C
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
Pulse
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.
Pulse Sites
Apical
Age Variations
Age
Newborn 1 3 years old 6 8 years old Adult/Elderly (Healthy)
Range
80 - 180 bpm 80 140 bpm 75 120 bpm 60 100 bpm
Respiration
It is the act of breathing. It involves the intake of oxygen through inhalation and expels carbon dioxide through exhalation.
It involves the contraction and relaxation of the diaphragm. It is observed by the rise and fall movement of the abdomen.
Breathing Patterns
Rate
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.
Volume
qHyperventilation an increase amount of air in the lungs. q qHypoventilation a reduction of air in the lungs.
Rhythm
Age Variation
Age
Newborn 1 3 years old 8 16 years old Adult
Range
30 80 cpm 20 30 cpm 15 25 cpm 12 20 cpm
Blood Pressure
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
Korotkoff Phases
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
Age Gender Blood Volume Stress Pain Exercise Weight Race Diet M e d i ti n s ca o Po si o n ti A l h o l co S m o ki g n D i rn a lV a ri ti n s u a o D i a se Pro ce ss se
BP Equipment
Age Variation
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
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 aperson 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 overclothing. 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 cuffanother 30mmHg . This prevents cuff inflation to an unnecessarily high pressure which is painful to the person. (You can deflate the cuff at thistime 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 sounddisappears is the diastolic pressure. Take the BP again if you are not sure of an accurate measurement. Wait 30-
Pain
Whatever the patient says it is, existing whenever when the patient says it exists
Pain Assessment
PQRST
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 youve 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)?
R (Radiation/Relief)
S(Severity/S&Sx)
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 youve eaten? Frequency?