ASSESSING VITAL SIGNS RLE 1a VITAL SIGNS Also known as Cardinal Signs Includes TEMPERATURE, PULSE, RESPIRATION, and

BLOOD PRESSURE A persons physiologic status is reflected by these indicators of body function Vital Signs are commonly assessed: 1. Screenings at health fairs and clinics 2. In the home 3. Upon admission to a healthcare setting 4. When certain medications are given Vital Signs are commonly assessed: 5. Before and after diagnostic and surgical procedures 6. Before and after certain nursing interventions 7. In emergency situations Purposes of assessing Vital Signs 1. To obtain baseline measurement of the patients vital signs 2. To assess patients response to treatment or medication 3. To monitor patients condition after invasive procedures ASSESSING TEMPERATURE TEMPERATURE heat of the body measured in degrees Difference between production of heat and loss of heat PROCESS OF HEAT PRODUCTION DONE THROUGH: 1. Food Metabolism and Activity 2. Increased thyroxin production 3. Chemical thermogenesis PROCESS OF HEAT LOSS IS DONE THROUGH: 1. Radiation surface to surface by waves 2. Conduction contact between 2 surfaces 3. Convection movt by air currents or fluid 4. Evaporation water to steam 5. Elimination urination, defecation TYPES of TEMPERATURE Core Temperature measured thru tympanic and rectal routes Surface Temperature measured thru oral and axillary routes FACTORS AFFECTING BODY TEMPERATURE 1. Age 2. Sex 3. Exercise 4. Time of day 5. Emotions 6. Environment 7. Others; food, drugs COMMON SITES FOR ASSESSING BODY TEMPERATURE

1. Oral most frequently used, least disruptive, most convenient, done for 3 minutes COMMON SITES FOR ASSESSING BODY TEMPERATURE 2. Rectal most accurate route, but invasive and uncomfortable to patient CONTRAINDICATIONS: Rectal abnormalities Diarrhea Certain heart conditions Immunosuppressed COMMON SITES FOR ASSESSING BODY TEMPERATURE 3. Axillary safer than the oral method, non-invasive, least accurate Done for 10 minutes COMMON SITES FOR ASSESSING BODY TEMPERATURE 4. Tympanic accessible, less invasive ASSESSING TEMPERATURE (axillary route) Unexpected Situations in assessing TEMPERATURE Temperature higher/lower than expected based on how skin feels (re-assess with new thermometer) Feeling lightheaded or passes out during rectal temp assessment (remove thermometer immediately, assess BP & HR, notify doctor, dont take another rectal temp) Types of Thermometer Tympanic Thermometer Electronic or Digital Thermometer Glass Thermometer Glass Thermometer Temperature sensitive Tape Chemical Thermometer ASSESSING PULSE PULSE A wave of blood being pumped into the arterial circulation by the contraction of the left ventricle Throbbing sensation palpated over a peripheral artery ASSESSMENT PARAMETERS / CHARACTERISTICS OF PULSE 1. Rate number of beats per minute ASSESSMENT PARAMETERS / CHARACTERISTICS OF PULSE 2. Rhythm pattern or regularity of beats and interval between each beat 3. Volume/amplitude amount of blood pumped with each heartbeat Cardiac Output 5-6 Liters of blood is forced out of the left ventricle per minute Pulse Deficit difference between the apical and radial counts taken simultaneously

LOCATION OF PERIPHERAL PULSES Reasons for Using Specific Pulse Site Radial Pulse Apical Pulse 1. Age 2. Sex 3. Exercise 4. Emotions 5. Prolonged heat application 6. Body positions 7. Pain 8. Decreased BP 9. Increased temperature 10.Any conditions resulting to poor oxygenation of blood ex. CHF Respiration Pulmonary ventilation (breathing) movement of air in and out of the lungs Inspiration (inhalation) act or breathing in Expiration (exhalation) act of breathing out External respiration exchange of O2 and CO2 between alveoli and blood Internal respiration exchange of O2 and CO2 between blood and tissue cells 1. Rate number of breaths per minute ASSESSMENT PARAMETERS / CHARACTERISTICS OF RESPIRATION 2. Rhythm regularity of respiration, inhalation and exhalation are evenly spaced ASSESSMENT PARAMETERS / CHARACTERISTICS OF RESPIRATION 3. Depth assessed by watching the movement of the chest 2 TYPES OF BREATHING 1. Costal/thoracic breathing involves external intercostal muscles and other accessory muscles Observed thru upward and outward movement of the chest FACTORS AFFECTING RESPIRATION 1. Exercise 2. Certain infections 3. Age 4. Emotions 5. Cardiac illness 6. stress TERMINOLOGIES REGARDING RESPIRATION

TERMINOLOGIES REGARDING RESPIRATION Kussmauls Faster and deeper respiration without pauses in between panting Apneustic Prolonged grasping followed by extremely short insufficient exhalation Dyspnea difficulty of breathing Orthopnea DOB unless sitting Wheezing narrowing of airways, causingwhistling or sighing sounds Stridor high-pitched sounds heard oninspiration TERMINOLOGIES REGARDING RESPIRATION Rales - sound caused by air passing thru fluid or mucus in the airways usually heard on inhalation Rhonchi sound caused by air passing thruairways narrowed by fluids,edema, muscle spasm usually heard during exhalation ASSESSING RESPIRATION BLOOD PRESSURE Factors affecting Blood pressure 1. Age 2. Emotions 3. Exercise 4. Drugs 5. Environment Korotkoffs sound The End