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Ray Andrew S. del Rosario, RN College of Nursing and Health Sciences Aquinas University of Legazpi.

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Presentation on theme: "Ray Andrew S. del Rosario, RN College of Nursing and Health Sciences Aquinas University of Legazpi."— Presentation transcript:

1 Ray Andrew S. del Rosario, RN College of Nursing and Health Sciences Aquinas University of Legazpi

2 reflects changes in body functions that otherwise might not be observed Temperature Pulse Respiration Blood pressure Pain

3 When to Assess Vital Signs Upon admission to any healthcare agency Based on agency institutional policy and procedures Any time there is a change in the patient’s condition Before and after surgical or invasive diagnostic procedures Before and after activity that may increase risk Before administering medications that affect cardiovascular or respiratory functioning

4 Special Nursing Interventions: Wash hands before and after a procedure to maintain asepsis Gather equipment needed including watch with a second hand to maximize time and reduce effort Greet client and introduce oneself to promote client’s sense of well-being

5 Special Nursing Interventions: Inform client what you will do to elicit cooperation and allay anxiety Check for proper lighting and diminish noise when necessary to obtain accurate baseline data Assist to a comfortable resting position, for a child, have the parent remain close by and position the child comfortably in the parent’s arm to ensure comfort Record/document appropriately and transfer readings to TPR sheet

6 Ray Andrew S. del Rosario, RN College of Nursing and Health Sciences Aquinas University of Legazpi BODY TEMPERATURE

7 Body Temperature the balance between the heat produced by the body and the heat lost from the body Types: Core Temperature – temperature of the deep tissues of the body measured by taking oral and rectal temperature Surface Temperature – temperature of the skin, subcutaneous tissue and fat measured by taking axillary temperature

8 Maintenance of Body Temperature Thermoregulatory center in the hypothalamus regulates temperature Center receives messages from cold and warm thermal receptors in the body Center initiates responses to produce or conserve body heat or increase heat loss

9 Heat Production Primary source is metabolism Hormones, muscle movements, and exercise increase metabolism Epinephrine and norepinephrine are released and alter metabolism Energy production decreases and heat production increases

10 Factors affecting Heat Production Basal metabolic rate (BMR) Muscle activity Thyroxine output Epinephrine, norepinephrine and sympathetic stimulation Increased temperature of the body cells (fever)

11 Sources of Heat Loss Skin (primary source) Evaporation of sweat Warming and humidifying inspired air Eliminating urine and feces

12 Processes involved in Heat Loss Radiation transfer of heat loss from the surface of one object to the surface of another without contact between two objects Convection dissipation of heat by air currents Evaporation continuous vaporization of moisture from the skin, oral mucous, respiratory tract; insensible heat loss Conduction Transfer of heat from one surface to another transfer of heat from one surface to another, which requires temperature difference between two surfaces

13 Factors affecting TEMPERATURE Age Diurnal variations Exercise Hormones Stress

14 TYPES of FEVER (pyrexia): Intermittent temperature fluctuates between periods of fever and periods of normal/subnormal temperature Remittent temperature fluctuates within a wide range over the 24 hour period but remains above normal range Relapsing temperature is elevated for few days, alternated with 1 or 2 days of normal temperature Constant body temperature is consistently high

15 Decline of FEVER (pyrexia): Crisis/flush/defervescent stage sudden decline of fever which indicates impairment of function of the hypothalamus Lysis gradual decline of fever which indicates that the body is able to maintain homeostasis

16 Clinical Signs of FEVER (pyrexia): Onset (cold or chill stage) of fever Course of fever Defervescence (fever abatement)

17 TEMPERATURE CONVERSION To change from Fahrenheit to Celsius: subtract 32 degrees from the Fahrenheit reading Multiply by 5/9 or divide by 9/5 (1.8) o C = ( o F – 32) x 5/9 To change from Celsius to Fahrenheit Multiply the Celsius reading by 9/5 or 1.8 Add 32 o F = (9/5 x o C) + 32 or ( o C x 1.8) + 32

18 Special Nursing Interventions: Remove thermometer from its container and check the temperature reading. Shake down the mercury as necessary (until mercury is below 35 C) by holding the thermometer between the thumb and forefinger at the end farthest from the bulb. Snap the wrist downward. Wash/wipe the thermometer in a rotating manner before use, from the bulb to the stem, after use, from the stem to the bulb. This practice ensures medical asepsis.

19 Special Nursing Interventions: Hold the thermometer at eye level, and rotate it until the mercury column is visible Rinse the thermometer in tap water, dry it, shake it down and return to its container

20 METHODS of Temperature Taking: ORAL: most accessible and convenient method Nursing Considerations: Allow 15 minutes to elapse between client’s intake of hot or cold food or smoking and the measurement of oral temperature

21 METHODS of Temperature Taking: ORAL: most accessible and convenient method Nursing Consideration: Place the thermometer under the tongue, directed towards the side and instruct client to gently close the lips not the teeth around the thermometer

22 METHODS of Temperature Taking: ORAL: most accessible and convenient method Nursing Consideration: Wash the thermometer before use, from the bulb to the stem, after use, from the stem to the bulb. This practice ensures medical asepsis.

23 METHODS of Temperature Taking: ORAL: most accessible and convenient method Nursing Consideration: Take oral temperature for 2 – 3 minutes. This ensures adequate time for recording of the temperature Normal value: 97.6 o – 99.6 o F (36.5 o – o C)

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25 METHODS of Temperature Taking: Contraindications to Oral Temperature Taking: oral lesions or oral surgery dyspnea cough nausea and vomiting presence of oro-nasal pack, nasogastric tube seizure prone very young children unconscious restless, disoriented, confused

26 METHODS of Temperature Taking: Oral Thermometers

27 METHODS of Temperature Taking: RECTAL: most accurate measurement of temperature Indications: When there is respiratory obstruction which prevents closure of the mouth When the mouth is dry, parched and inflamed When there is oral/nasal surgery or disease For very young, restless and irrational children For mentally disturbed, unconscious, dyspneic, irrational, restless and convulsive patients When a patient is mouth breather and with oxygen

28 METHODS of Temperature Taking: RECTAL: most accurate measurement of temperature Nursing Considerations: Assist client to assume lateral position/sims position. To expose anal area Lubricate thermometer about 1 inch above the bulb with water soluble jelly before insertion. To reduce friction and prevent trauma to the mucous membrane in the anus

29 METHODS of Temperature Taking: RECTAL: most accurate measurement of temperature Nursing Considerations: Insert thermometer by 0.5 – 1.5 inches (1.5 – 4 cm) for adults, 0.9 inch (2.5 cm) for a child and 0.5 inch (1.5 cm) for an infant or insert beyond the internal anal sphincter Instruct the client to take a deep breath during the insertion of the thermometer. To relax the internal anal sphincter

30 METHODS of Temperature Taking: RECTAL: most accurate measurement of temperature Nursing Considerations: Hold the thermometer in place for 2 minutes (for neonates, 5 minutes). To ensure recording of temperature Do not force the insertion of thermometer. To prevent trauma in the area Normal value: 98.6 o – o F (37.0 o – 38.1 o C)

31 METHODS of Temperature Taking: Contraindications to Rectal Temperature Taking Anal/rectal conditions or surgeries, e.g. anal fissure, hemorrhoids, hemorrhoidectomy Diarrhea Quadriplegic clients. Vagal stimulation may occur, causing bradycardia and syncope

32 METHODS of Temperature Taking: Rectal Thermometers

33 METHODS of Temperature Taking: AXILLARY: safest and most non-invasive method Nursing Considerations: Pat dry the axilla. Rubbing causes friction and will increase temperature in the area Place the thermometer in the client’s axilla Place the arm tightly across the chest to keep the thermometer in place for 9 minutes (for infants and children, 5 minutes Normal value: 96.6 o – 98.6 o F (35.8 o – 37.0 o C)

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35 METHODS of Temperature Taking: Axillary Thermometers

36 METHODS of Temperature Taking: Tympanic: readily accessible, reflects the core temperature, very fast Nursing Considerations: Can be very uncomfortable and involve risks of injuring the membrane if the probe is inserted too far Repeated measurements may vary (right and left ears may differ) Presence of cerumen can affect the reading Normal value: 98.2 o – o F (36.8 o – 37.9 o C)

37 METHODS of Temperature Taking: Tympanic Thermometers

38 METHODS of Temperature Taking: Other Thermometers

39 Ray Andrew S. del Rosario, RN College of Nursing and Health Sciences Aquinas University of Legazpi PULSE

40 wave of blood created by contraction of left ventricle of the heart Regulated by the autonomic nervous system through cardiac sinoatrial node Parasympathetic stimulation — decrease heart rate Sympathetic stimulation — increases heart rate Pulse rate = number of contractions over a peripheral artery in 1 minute

41 Factors affecting the PULSE rate Age Sex/Gender Exercise Fever Medication Hemorrhage Stress Position changes

42 PULSE sites: Temporal Carotid Apical Brachial Radial Femoral Popliteal Dorsalis Pedis Pedal

43 PULSE site: TEMPORAL

44 PULSE site: CAROTID

45 PULSE site: APICAL

46 PULSE site: RADIAL/BRACHIAL

47 PULSE site: RADIAL

48 PULSE site: FEMORAL

49 PULSE site: POPLITEAL

50 PULSE site: POSTERIOR TIBIAL

51 PULSE sites: PEDAL/DORSALIS PEDIS

52 ASSESSMENT of the Pulse: If pulse is regular, count for 30 seconds and multiply by 2. If irregular, count for 1 minute. When obtaining baseline date, count for the pulse for a full minute Assess pulse rhythm by noting the pattern and intervals of beat. Dysrhytmia is irregular rhythm

53 ASSESSMENT of the Pulse: Asses the pulse volume (amplitude) – strength of the pulse Normal pulse ca be felt with moderate pressure Full or bounding pulse can be obliterated only by great pressure Thready pulse can easily be obliterated (weak or feeble)

54 ASSESSMENT of the Pulse: Arterial wall elasticity: the artery feels straight, smooth, soft and pliable Presence/absence of bilateral equality: absence of bilateral equality indicates cardiovascular disorder

55 ASSESSMENT of the Pulse: Pulse pressure: Systolic pressure MINUS diastolic pressure Pulse deficit Apical pulse MINUS peripheral pulse Pulsus paradoxus Systolic pressure falls by more than 15 mmHg during inhalation Pulsus alternans Alternating strong and weak pulses

56 ASSESSMENT of the Pulse: AgeNormal Pulse Rate Newborn to 1 month80 – 180 beats/min 1 year80 – 140 beats/min 2 years80 – 130 beats/min 6 years75 – 120 beats/min 10 years60 – 90 beats/min Adult60 – 100 beats/min Tachycardia – pulse rate above 100 beats/min Bradycardia – pulse rate below 60 beats/min

57 Ray Andrew S. del Rosario, RN College of Nursing and Health Sciences Aquinas University of Legazpi RESPIRATION

58 Respiration the act of breathing carbon dioxide is the primary chemical stimulus of breathing; when carbon dioxide level in the blood is high, there is stimulation for breathing Pulmonary ventilation — movement of air in and out of lungs Inhalation: breathing in Exhalation: breathing out

59 Respiration Three processes Ventilation: movement of gases in and out of the lungs Diffusion: exchange of gases from an area of higher pressure to an area of lower pressure and occurs in the alveolo-capillary membrane Perfusion: the availability and movement of blood for transport of gases, nutrients and metabolic waste products

60 Respiration Two Types of Breathing: Costal (thoracic) Diagphragmatic (abdominal)

61 Respiratory Centers: Medulla Oblongata – primary center for respiration Pons – (1) Pneumotaxic center; responsible for rhythmic quality of breathing (2) Apneustic center; responsible for deep, prolonged inspiration Carotid and aortic bodies – contain peripheral chemoreceptors, which take up the work of breathing when central chemoreceptors in the medulla are damaged, oxygen level concentration is low and respond to pressure. Muscle and joints contain proprioreceptors, e.g. exercise

62 Factors Affecting Respiratory Rate: Exercise Pain/Stress/Anxiety Environment Increased altitude Medication Respiratory and cardiovascular disease Alterations in fluid, electrolyte, and acid balances Trauma Infection

63 Assessment of Respiration: With fingers still in place, after taking pulse rate, note the rise and fall of patient’s chest with respiration. You may place the client’s arm across the chest and observe chest movement and for infants, observe the movement of the abdomen, these observes for depth of respiration Observe rate. Count for 30 seconds if respirations are regular and multiply by 2. If irregular, count for 60 seconds.

64 Assessment of Respiration: Observe the respiration (inhalations and exhalations) for regular or irregular rhythm Observe the character or quality of respiration – the sound of breathing and respiratory effort

65 Assessment of Respiration: Normal rate in adult 12 – 20 breaths/minute Normal rate in infant 20 – 40 breaths/minute Normal rate in preschool 20 – 30 breaths/minute

66 Assessment of Respiration: Types of BreathingDescription Eupnea Tachypnea Bradypnea Hyperventilation Hypoventilation Dyspnea Orthopnea Apnea Biot’s respiration Kussmaul respiration Apneustic respiration Normal respiration that is quiet, rhythmic and effortless Rapid respiration, above 20 breaths/min in an adult Slow breathing, less than 12 breaths/minute in an adult Deep rapid respiration, carbon dioxide is excessively exhaled (resp. alkalosis) Slow, shallow respiration, carbon dioxide is excessively retained (resp. acidosis) Difficult and labored breathing Ability to breathe only in an upright position Absence/cessation of breathing Quick, shallow inspiration followed by regular or irregular periods of apnea Very deep and labored breathing; acetone breath (metabolic acidosis) Deep, gasping inspiration with a pause at full inspiration followed by insufficient release

67 Ray Andrew S. del Rosario, RN College of Nursing and Health Sciences Aquinas University of Legazpi BLOOD PRESSURE

68 Physiology of Blood Pressure Force of the blood against arterial walls Controlled by a variety of mechanism to maintain adequate tissue perfusion Sound of Korotkoff Pressure rises as ventricle contracts and falls as heart relaxes Highest pressure is systolic Lowest pressure is diastolic

69 Physiology of Blood Pressure:..\Pictures\3DScience_Human_Heart.jpg..\Pictures\3DScience_Human_Heart.jpg systolic pressure – pressure of blood as a result of contractions of the ventricles (100 – 140 mmHg); systole (contraction of the heart); numerator in BP reading diastolic pressure – pressure exerted when the ventricles are at rest (60 – 90 mmHg); diastole (relaxation of the heart); denominator in BP reading

70 Physiology of Blood Pressure pulse pressure – difference between the systolic and diastolic pressures, normal is 30 – 40 mmHg hypertension is an abnormally high blood pressure for at least two consecutive readings hypotension is an abnormally low blood pressure, systolic pressure below 100/60 mmHg

71 Determinants of Blood Pressure Blood volume Peripheral resistance Cardiac output Elasticity or compliance of blood vessels Blood viscosity

72 Factors Affecting Blood Pressure: Age, gender, race Circadian rhythm Food intake Exercise Weight Emotional state Body position Drugs/medications Disease process

73 Sphygmomanometers

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75 Parts of the Stethoscope: stethoscopebasics.pdf stethoscopebasics.pdf 30 – 35 cm (12-14 inches) long 0.3 cm (1/8 inch) internal diameter

76 Stethoscope

77 ASSESSING Blood Pressure: Ensure that the client is rested Allow 30 minutes to pass if the client had engaged in exercise or had smoked or ingested caffeine before taking the BP (might tend to increase BP) Use appropriate size of the BP cuff. Too narrow cuff causes high false reading and too wide cuff causes false low reading. Position the client in sitting or supine position

78 ASSESSING Blood Pressure: Position the arm at the level of the heart, with the palm of the hand facing up. The left arm is preferably used because it is nearer the heart Apply/warp the deflated cuff snugly in upper arm, the center of the bladder directly over the medial aspect or 1 inch above the antecubital space or at least 2 – 3 fingers above the elbow

79 ASSESSING Blood Pressure: Determine palpatory BP before auscultatory BP to prevent auscultatory gap Use the bell of the stethoscope since the BP is a low frequency sound Inflate and deflate BP cuff slowly, 2 -3 mmHg at a time Wait 1 -2 minutes before making further determinations

80 ASSESSING Blood Pressure: Palpate the brachial artery with your fingertips Close the valve on hand pump by turning the knob clockwise Insert the ear attachment of the stethoscope in your ears so they tilt slightly forward an ensure it hangs freely from the ear to the diaphragm

81 ASSESSING Blood Pressure: Place the diaphragm of stethoscope over brachial pulse and hold with the thumb and index finger Pump out the cuff until the sphygmomanometer registers about 30 mmHg above the point where the brachial pulse disappeared Release the valve on the cuff carefully so that the pressure decreases at the rate of 2 – 3 mmHg per second

82 ASSESSING Blood Pressure: As the pressure falls, note the first sound, muffling, and last sound heard Deflate the cuff rapidly and completely after noting the last sound

83 ASSESSING Blood Pressure: Read lower meniscus of the mercury level of the sphygmomanometer at eye level to prevent error of parallax Error of parallax happens if the eye level is higher than the lever of the lower meniscus of the mercury, this causes false low reading, if the eye level is lower, this causes false high reading

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85 Ray Andrew S. del Rosario, RN College of Nursing and Health Sciences Aquinas University of Legazpi END References: Fundamentals of Nursing, Kozier, Erb et al Lippincott William and Wilkins Fundamental of Nursing, Udan World wide web


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