What is Vital sign?

measures of various physiological status, in order to assess the most basic body function

indicates that the person is alive

Measurements for body’s basic function

a. Body temperature (Temp)

b. Pulse/heart Rate (PR/HR)

c. Respiration Rate (RR)

d. Blood Pressure (BP)

When to assess Vital Signs?

Upon admission to any healthcare agency

Based on agency institutional policy and procedures

Any time there is changes in the patient’s condition

Before and after surgical or invasive diagnostic procedure

Before and after activity that may increase risk

Before and after administering medications that affect cardiovascular ore respiratory
functioning

BODY TEMPERATURE - the balance between the heat production due to chemical activities by the body

Types of Body Temperature

1. CORE TEMPERATURE

• the temperature of deep tissues of the body (ex: cranium, thorax, abdominal cavity)

remain relatively constant (37c or 98.6F)

true core temperature can only be measured by invasive means

non-invasive sites (rectum, oral cavity, axilla, temporal artery, external auditory canal) are
accessible and provide best estimation of core temperature

normal body temp : 36.2 to 37.2c

SURFACE TEMPERATURE

the temperature of the skin, the subcutaneous tissue and fat

rises and falls in response to environmental changes

average oral temp: 36.7 – 37c

Factors affecting Body’s Heat Production

Basal Metabolic Rate (BMR)

Muscle Activity

Epinephrine and symphathetic stimulation

Age

Gender

Diurnal variation

exercise

Alterations in Body temperature: PYREXIA

• A body temperature above the usual range

• Hyperthermia or usually referred as fever.

• * Hyperpyrexia: A very high temperature, e.g. 41c (105 f) is called

Common Types of Fever

Intermittent Fever – body temperature alternates at

Remittent Fever - a wide range of temperature fluctuations occurs over the 2 hour period, all of which
are above normal

Relapsing Fever - short febrile periods of a few days are interspersed with periods of 1 or 2 days of
normal temperature.

Constant Fever - body temperature fluctuates minimally but always remains elevated.

Treatment of Increasing Body temperature

Antypyretics

Cold sponge bath

Cold compress

HYPOTHERMIA

Core body temperature below the lower limit of normal

The ability of hypothalamus to regulate temperature is greatly impaired when the body
temperature falls below 34.5c ( 94 F), and death usually occurs when the temperature falls
below 34c (93.2 F)

Sites of Assessing Body temperature

 considered reliable when thermometer is place posteriorly into the sublingual pocket

tracks changes of core temp

Axillary (safe way) n:36c +0.5c (10mins)

measure by placing thermometer in the central position and adducting the arm close to the
chest wall

Rectal (accurate reading) 37c – 0.5c (2-3 mins)

most accurate method for measuring core temperature

should reduce 0,5c to actual reading

. Tympanic membrane

senses reflected infrared emissions from the tympanic membrane through a probe placed in the
external auditory canal

quick (<1min),

Types of Thermometer

Electronic /Digital

Glass/mercury

Tympanic

infrared

Alterations in thermoregulation

Heat exhaustion
Heat stroke
Hypothermia
Frostbite

PULSE - a wave of blood created by contraction of the left ventricle of the heart

Pulse Quality: refers to the feel of the pulse, its rhythm and forcefulness

Pulse Rate: indirect measurement of cardiac output obtained by counting the number of apical or
peripheral pulse waved over a pulse point

Bradycardia: less than normal rate

Tachycardia : more than normal rate

Pulse Rhythm: regularity of the heartbeat

Regular: the beats are evenly spread

 Irregular: the beats are not evenly spread

Dysrhythmia (arrhythmia) : irregular rhythm caused by early or late or missed

heartbeat

. Pulse Volume: measurement of the strength or amplitude of force exerted by the ejected blood against
the arterial wall with each contraction

Normal: full, easily palpable

Weak : thread and usually rapid

Strong : bounding

Factors contributing to increase pulse rate

pain

fever

stress, exercise

bleeding

decrease in blood pressure some medications (Adrenalin, aminophylline

Factors contributing to slow pulse rate

rest

increasing age

people with thin body size

some medications

thyroid gland disturbances

Pulse point Assessment

1. Temporal

Accessible, used routinely and when radial is inaccessible

. Carotid

- Accessible, used routinely for infants and during shock or cardiac arrest when peripheral pulses
are too weak to palpate,

- Used to assess cranial circulation

Carotid

- Accessible, used routinely for infants and during shock or cardiac arrest when peripheral pulses
are too weak to palpate,

- Used to assess cranial circulation

Apical

used to auscultate heart sounds and assess apical field

Brachial

used in cardiac arrest for infants

to assess lower arm circulation

to auscultate the blood pressure

Radial

accessible, used routinely in adults to assess character of peripheral pulse

Ulnar

used to assess circulation to ulnar side of hand and to perform allen’s test

Femoral

- used to assess circulation to legs and during cardiac arrest

Femoral

- used to assess circulation to legs and during cardiac arrest

Popliteal

- used to assess circulation to the legs and blood pressure

Posterior Tibial & Dorsalis

- Use to assess circulation of the feet

Peripheral Pulse Assessment

A peripheral pulse, usually the radial pulse,

is assessed by palpation for all individual except :

newborns and children up to 2 or 3 years.

very obese or elderly clients

Individual with heart disease, who require apical pulse assessment.

Individuals in whom the circulation to a specific body part must be assessed, e.g. following leg surgery
the pedal ( dorsalis pedis) is assessed.

Apical Pulse Assessment - Assessment of the apical pulse is indicator for clients whose
peripheral pulse is irregular as well as for clients with known cardiovascular, pulmonary, and
renal diseases.

Apical-radial Pulse - An apical-radial pulse may need to be assessed for clients with certain
cardiovascular disorders. Normally the apical and radial rates are identical.

Pulse Deficit - difference in the apical pulse and the radial pulse.

RESPIRATION (RR) - Pulmonary Ventilation (breathing) : movement of air in and out of the lungs

Inspiration: the act of breathing in

Expiration: the act of breathing out

Characteristics of Normal and Abnormal Sounds

Eupnea – refers to easy respirations with normal rate of breaths per minute that is age specific

Bradypnea – characterized by rate of 10 or fewer breaths per minute

Hypoventilation – characterized by shallow respiration

Tachypnea – respiratory rate greater thatn 24 breaths per minute

Hyperventilation – characterized by deep, rapid respiration

Costal (thoracic) breathing - occurs when external intercostal muscles and the other accessory
muscles are used to move the chest upward and outward.

Diaphragmatic(abdominal) breathing- occurs when the diaphragm contracts and relaxes as

observed by movement of the abdomen.

Dyspnea - refers to difficulty in breathing as observed by labored or forced respirations through

the use of accessory muscles in the chest and neck to breathe.

Apnea - respirations cease for several seconds. Persistent cessation is called respiratory arrest.

Cheyne–Stockes respiration - respiratory rhythm is irregular, characterized by alternating

periods of apnea and hyperventilation.
 Kussmaul respiration - respirations are abnormally deep but regular, similar to hyperventilation.
Characteristic of clients with diabetic ketoacidosis.

Orthopnea - respiratory condition in which a person must sit or stand in order to breathe deeply
or comfortably.

Assessment of Respiration

Depth- deep or normal

Rhythm – regular or irregular

Rate

normal range: 12-20 breaths/ minute

Site of Breathing Measurement

Normal breathing is slightly observable, effortless, quiet, automatic, and regular.

BLOOD PRESSURE - is the force required by the heart to pump blood from the ventricles of the heart
into the arteries. It is measured in systolic and diastolic pressure. NORMAL BP: 120/80mmHg

Systolic pressure : it is known as the force to pump blood out

Diastolic pressure – it is known as relaxation

Alteration in Blood Pressure

Hypertension - refers to a systolic blood pressure more than 120 mm Hg or 20 to 30 mm Hg

more the client’s normal systolic pressure

Hypotension - refers to a systolic blood pressure less than 90 mm Hg or 20 to 30 mm Hg below

the client’s normal systolic pressure.

Five phases in the series of sound called Korotkoff's sounds.

Phase I: The period initiated by the first faint clear taping sound. These sound gradually become
more intense.

Phase II: The period during which the sounds have a swishing quality.

Phase III: The period during which the sounds are crisper and more intense.

Phase IV: The period , during which the sounds become muffled and have a soft, blowing quality.

Phase V: The period where the muffled, blowing sound disappear.

Pulse Pressure - the numeric difference between the systolic and diastolic blood pressure

A pulse pressure within 40 is the normal and healthy pulse pressure .

A pulse pressure greater than 40 mm Hg is abnormal.

Equipment for assessing blood pressure

Stethoscope and sphygmomanometer.

Electronic or digital devices.

Alcohol cotton swap.

OXYGENATION
Sufficient oxygenation is vital to maintain life

Respiratory Functions

1. Ventilation
- Process of moving gases into and out of the lungs, This requires the coordination of the
muscular and elastic properties of the lung and thorax
- Major Muscle for inspiration: Diaphragm stimulated by phrenic nerve (3rd cervical
vertebrae)

2. Respiration
- The process that brings oxygen into the body and removes carbon dioxide waste
- The exchange occurs in the lungs
* Phases of Respiration
a. Internal Respiration – the process by which oxygen is taken from the bloodstream into
the cell and carbon dioxide is removed from cell to the bloodstream
b. External Respiration – refers to delivery of oxygen to the lungs so that it can be taken
into the bloodstream
> 2 Component:
1. Inspiration – taking in care into the lungs
2. Expiration – expelling air from lungs

3. Perfusion
- The passage of fluid through the circulatory and lymphatic system to an organ or tissue
- Usually referred as delivery of blood to a capillary bed in tissue

Respiratory System: Structure

 Alteration in Respiratory Function

1. HYPERVENTILATION
- state of ventilation in excess of that required to eliminate the normal venous CO2 produced
by cell metabolism
- Anxiety, infection, drugs or acid-base imbalance can produce hyperventilation

* Signs and Symptoms

- Lightheadedness - Chest pain
- Disorientation - Shortness of Breath
- Dizziness - Blurred Vision
- Tachycardia - Extremity Numbness

*Interventions
Breathe through pursed lips
Breath slowly into a paper bag or cupped hands
Attempt to breathe into your belly rather than chest
Hold breath for 10 to 15 seconds
Brown bag

2. HYPOVENTILATION
- Alveolar ventilation is inadequate to meet body’s O2 demand
 - PaCO2 elevates, PaO2 drops
- Severe atelectasis can cause hypoventilation
- COPD (Chronic Obstructive Pulmonary disease)

* Signs and Symptoms

- Disorientation - convulsion
- lethargy - coma
- dizziness - dysrythmias
- headache - cardiac death
- decrease ability to follow instructions

* Interventions
 Oxygen therapy
 Airway management: CPAP/BIPAP
 Surgery
 Weight loss
 Inhaled medications

3. HYPOXIA
- Inadequate tissue oxygenation at the cellular level
- Deficiency of O2 delivery or O2 utilization at cell level
- Causes: Decreased Hgb, diminished concentration of inspired O2, decreased diffusion poor
tissue perfusion, impaired ventilation

Other factors affecting Oxygenation

- Age
- Environment
- Lifestyle
- Medications
- Stress
- Infection

Nursing Process for Oxygenation

1. Nursing History
- Contains respiratory component
- Before starting the interview make sure patient is not in respiratory distress
- If distress, postpone the interview and help patient
- If no emergency intervention are needed, obtain comprehensive history

2. Physical Assessment
a. Inspection
- Inspect chest contour and shape
- Observe respiratory rate and depth for 1 full minute

b. Palpation
 - Palpate trachea (Should be midline) and assess skin temp
- Ensure thoracic excursion is symmetrical
- Assess tactile fremitus (the capacity to feel sound on the chest wall)

c. Auscultation
- Using diaphragm move from apex to base of lungs comparing one side other side
- Normal breath sounds includes vesicular, bronchial and broncho vesicular
- If abnormal breath sounds is heard ask patient to cough then reassess

• Adventitious Breath Sounds

1. Crackles – popping sound heard on inspiration
2. Wheezes – continuous sound produced as air passes through constricted airways,
narrowing, secretions and around obstruction
3. Pleural Friction Rub – continuous dry grating sounds caused by inflammation of
pleural space

Common Diagnostic Test

1. Pulmonary Function
- Group of test that evaluate respiratory status to detect abnormalities
- Evaluate lung dysfunction and respiratory interventions

2. Spirometry – measure the volume of air in liters exhaled or inhaled over time

3. Peak flow Expiratory flow rate - refers to point of highest flow during expiration

Nursing Diagnosis
 Ineffective airway clearance
 Impaired gas exchange
 Ineffective breathing pattern

Promoting Optimal Function

1. STOP smoking

2. Reduce anxiety

3. Maintain good nutrition

4. Maintain adequate fluid intake

5. Provide air humidifier

6. Using Cough Medications

 Expectorant – facilitate removal of respiratory tract secretion by reducing the
viscosity of the secretion
  Cough suppressants – drugs that suppress cough, recommended if patient is
unable to sleep
 Lozenges – use to relieve milk, nonproductive cough

7. Suctioning Airway - If patient is unable to clear the coughing, aspirate secretions

* Nursing Interventions in Suctioning
a. Assess indication for suctioning (audible secretion during respiration adventitious
sounds)
b. Position: Conscious ( semi-fowler’s position) unconscious (lateral position)
c. Appropriate size for suction catheter
 Adult: Fr 12-18
 Child :Fr 8-10
 Infant: Fr 5-8
d. Don sterile technique
e. Length of Catheter : measure from tip of the clients nose to the earlobe or about 13cm
(5in) for adult
f. Apply suction during withdrawal to prevent trauma
g. Apply suction 5-10seconds (maximum 15sec)
h. Hyperventilate client with 100% before suctioning
i. Allow 20-30 seconds interval each
j. Assess effectiveness by auscultating chest for clear breath sounds.

8. Meeting respiratory need with medications

a. Administering Inhaled Medications
 Bronchodilators - Administered to dilate airways
 Mucolytics - loosen thick secretions
 Corticosteroid- reduce inflammation
 Nebulizers - disperse fine particles of medication into the airway

9. Providing supplemental Oxygen

 Source of Oxygen
- wall mount, portable cylinder
 Flow rate
- measured in liters per minute
- determines the amount of O2 delivered
- doctor prescribes flow rate
 Oxygen Delivery System/Devices

Device O2 Concentration Flow rate

Nasal cannula 24-45% 2-6 Lpm
Nasopharyngeal catheter - -
Simple Mask 40-60% 5-8 Lpm
Partial rebreather 60-90% 6-10 Lpm
Non Rebreather 95-100% 6-15 Lpm
Venturi Mask Delivers precise -
concentration
 Oxygen hood/tent - -
Incubator/ isolette - -

CPAP (continuous positive airway pressure)

BIPAP (bi-level positive airway pressure)
- Applies mild airway pressure on continuous basis to keep airways continuously open in people
who are not able to breath spontaneously

Thoracentesis
- Also called pleural tap
- Invasive procedure to remove fluid and air from the pleural space
- A cannula is introduced to the thorax
- Drains fluids from the lungs
- Used for patient with pleural effusion, hemothorax, pneumothorax

Chest Physiotherapy
 Percussion (Clapping) – forceful striking of the skin with cupped hands. Can mechanically
dislodge tenacious secretion from bronchial walls
 Vibration - series of vigorrous quivering produced by hands that are place flat against the
client’s chest wall. It is done to loosen mucous secretions
 Postural Drainage – expulsion of secretion form various lung segment by gravity