2. 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

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

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

5. Assessing a Client’s Health Status

6. Body Temperature

7. 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

8. 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

9. 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

10. 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)

11. 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

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

13. 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

14. Taking axillary Temperature

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

16. closed the arm and wait for timer to bustle

17. 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.

18. The Oral Cavity

19. Parts: Oral Vestibule and Oral Cavity Proper

20. Floor of the mouth

21. Insert the tip at the sublingual fossa

22. Positioned the thermometer

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

24. Clinical Thermometers  Instruments used to measure body temperature  Electronic  Infrared  Chemical  Digital  Glass

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

26. Electronic Thermometers

27. Infrared Tympanic Thermometer

28. Chemical Thermometer

29. Digital Thermometer

30. Glass thermometer (Glass)

31. 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

32. 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

33. 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)

34. 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

35. 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

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

37. Phases of Fever and Physiologic Changes

38. Question Is the following statement true or false? Fever is a condition where the body temperature exceeds 105.8˚F.

39. Answer False. Fever is a condition where the body temperature exceeds 99.3˚F.

40. 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)

41. 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

42. Pulse Rate

43. 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

44. 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

45. AgeAverageRange Newborn to 1 month 13080-180 1 year12080-140 2 years11080- 130 6 years10075- 120 10 years7050-90 Adult8060- 100 Pulse rate/ Minute Variations in Pulse Rate Kozier Barbara, et.al. Fundamentals of Nursing, 5 th ed. (US Addison-Wesley Publishing Company, Inc. 1995) p. 438

46. Peripheral Pulse Sites

47. 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.

48. Pulse siteReasons for Use RadialReadily accessible & routinely used TemporalUsed when radial pulse is not accessible CarotidUsed for infants, in cases of cardiac arrest and to determine the circulation to the brain ApicalRoutinely 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 BrachialUsed to measure blood pressure, used for cardiac arrest for infants FemoralUsed in cases of cardiac arrest, for infants and children, determine circulation in the leg PoplitealUsed to determine the circulation in the lower leg and leg blood pressure Posterior tibialUsed to determine the circulation in the foot PedalUsed to determine circulation in the foot

49. Respiration

50. 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 Respiratory Rate

51. Hyperventilation Hypoventilation Dyspnea Orthopnea Apnea Stertorous breathing Stridor Abnormal Breathing Characteristics

52. 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 Respiration

53. AgeAverageRange Newborn3530-80 1 year3020-40 2 years2520-30 8 years2015-25 16 years1815-20 Adult1612-20 Respiratory rate/ Minute Variations in Respiratory rate Kozier Barbara, et.al. Fundamentals of Nursing, 5 th ed. (US Addison-Wesley Publishing Company, Inc. 1995) p. 448

54. BLOOD PRESSURE

55. 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

56. 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

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

58. 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

59. 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

60. 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

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

62. Aneroid and Electronic Oscillometric Manometer

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

64. 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

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

66. 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

67. 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

68. 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

69. 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

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

71. Aneroid manometer with stethoscope

72. Part of the sphygmomanometer

73. Mercury manometer and cuffAneroid manometer and cuff

74. Variations in BP by Age AgeMean BP (mm Hg) Newborn73/55 1 year90/55 6 years95/57 10 years102/62 14 years120/80 Adult120/80 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

75. The End My best wishes educator : Ekhlas abu hasna