UNIT #5

NURSING SKILLS (VITAL SIGNS)

FUNDAMENTAL OF NURSING
BSCN (GENERIC)1ST YEAR

BY SARA JOHN
 Contents
 Vital signs
 Terms related to vital sign
 Physiological concept of temperature, respiration and blood
pressure.
 Principles and mechanisms for normal thermoregulation in
the body
 Ways that affect heat production and heat loss in the body.
 Types of body temperature according to its characteristics.
 Sign and symptoms of fever
 Contents
 Normal ranges for temperature, pulse, respiration and
blood pressure.
 Factors affecting temperature, pulse, respiration.
 Characteristics of pulse and respiration.
 Factors responsible for maintaining normal blood
pressure.
 Various methods and sites used to measure T.P and B.P.
 Recognize the signs of alert while taking TPR and B.P.
 Vital signs
 Vital Signs (VS) are the most important measurements you will
obtain when you evaluate or assess a client’s condition. Its
include:
 Temperature, pulse, respiration, blood pressure (B/P) ,
oxygen saturation and pain.
 They are the most frequent measurements taken by HCP.
(health care practitioner)

 Because of the importance of these measurements they are

referred to as Vital Signs. They are important indicators of
the body’s response to physical, environmental, and
psychological stressors.
 When to take vital signs
1. On a client’s admission
2. According to the physician’s order or the institution’s policy or standard of
practice
3. When assessing the client during home health visit
4. Before & after a surgical or invasive diagnostic procedure
5. Before & after the administration of medicines or therapy that affect
cardiovascular, respiratory & temperature control functions.
6. When the client’s general physical condition changes
LOC, (loss of consciousness)and pain
7. Before, after & during nursing interventions influencing vital signs
8. When client reports symptoms of physical distress
 Terms used in vital signs
 Temperature :
It is the hotness or coldness of the body. or it is the balance
between heat production and heat loss of the body. the
body temperature is measure in degreed on two scales :
Celsius (centigrade) and Fahrenheit. normal body
temperature using oral 37 Celsius or 98.6 F.
 Pulse

The pulse is a wave of contraction created by contraction

of left ventricle of heart on each heart beat.
Terms used in vital signs
 Respiration : is the act of breathing.
 Observe the client’s chest movement upward and
outward for a complete minute.
 Blood pressure (BP) is the pressure or tension
exerted on the arterial walls as blood pulsates
through them.
Terms used in vital signs
 Oxygen saturation :
Oxygen saturation is the fraction of hemoglobin that
is saturated with oxygen relative to total
hemoglobin in the blood.
 Pain

Highly unpleasant physical sensation caused by

illness or injury.
It could be acute or chronic pain.
Physiological concept of Temperature

There are two kinds of body temperature according to

its location .
 Core body temperature:

Temperature of deep tissues of the body e.g. cranium,

thorax etc. it remains relatively constant. Core body
temp. of human body is about 36.7c or 98.6F.
 Surface body temperature :

Temperature of skin, subcutaneous tissue, and fat. It

rises and fall according to external environment.
Physiological concept of Temperature

The body continually produces heat as a by-product of

metabolism. This metabolism occur when we absorb
our food and consume calories. When amount of heat
produced by the body exactly equal to the heat loss
from the body, then the person is called in a heat
balanced condition.
This process is done by thermoregulation .
 Principles and mechanisms for normal thermoregulation in the body

Thermoregulation system of the body has three main parts

A. Sensors in skin and in core
B. Hypothalamic integrator
C. Effectors system
There are more sensors in skin for cold than warmth.
When the skin becomes chilled then three processes arise in body to
increase the temperature of body.

Shivering increases Sweating is inhibited to Vasoconstriction to

heat production decrease heat loss prevent heat loss
Principles and mechanisms for normal thermoregulation in the body

 The hypothalamic integrator :

The center that control core temperature, is located in
hypothalamus. When cold sensors are stimulated and send
message to hypothalamic integrator which reduces heat
loss and increase heat production, and vice versa.
The signals from the cold-sensitive receptors of
hypothalamus initiate effectors such as vasoconstriction
to prevent heat loss release epinephrine to produce heat
and opposite action when heat sensors are initiated.
Ways that affect heat production and heat loss in the body. (heat balance)

Heat production Heat loss

Basal metabolism Radiation

Shivering Conduction

Thyroxin and epinephrine Convection

Fever Evaporation
 Heat production
 Basal metabolic rate (BMR)
Is the rate of energy utilization in the body required to
maintain activities of daily living such as breathing.
Metabolic rate of the body decrease with age, so
generally the younger the person the higher the BMR.
 Muscle activity :

Muscle activity including shivering increases the

metabolic rate.
Heat production
 Thyroxin output :
Increased the thyroxin output increases the rate of cellular
metabolism throughout the body.
 Epinephrine , nor epinephrine and sympathetic

stimulation:
These hormones also increase cellular metabolism hence
increase temperature.
 Fever:

Also increases metabolic rate and increase body temperature.

Heat loss

 Radiation :
It is the transfer of heat from the surface of one object to
the surface of another object without contact between
two objects. Mostly in the form of infrared rays .e.g.
heat from the body of a semi-dressed person in a
room is almost 50% in the form of radiation.
 Conduction :

It is the transfer of heat from one molecule to another

molecule having lower temperature. It cannot take
place without contact.
Heat loss

 Convection
It is the dispersion of heat by air currents. The body usually
has small amounts of warm air adjacent to it this warm air
rises and it is replaced by cooler air and that’s why people
always lose a small amount of heat through convection.
 Evaporation

It is continuous vaporization of moisture from respiratory

tract and from the mucosa of mouth, and from the skin ,
this continuous and unnoticed water loss is called
insensible water loss, that causes heat loss also that is
called insensible heat loss.
Different types of body temp according to its
characteristics

 Normothermia /Euthermia
 Hyperthermia /pyrexia

 Hypothermia
 Temperature Sites

Thermometer : is an instrument used to measure

body temperature.
 Normal adult temperature is 98.6ºF, or 37ºC.
 Oral – within the mouth or under the tongue.
(98.6ºF/37.0ºC)
 Axillary – in the armpit. (97.6ºF/36.6ºC)

 Tympanic – in the ear canal. (99.6ºF/37.6ºC)

 Rectal – through the anus, in the rectum.

(99.6ºF/37.6ºC)
 Other sites include on the skin or in the blood.
Types of Thermometers

 Electronic Thermometers
 Measure temperature through a probe at the end of the device.
 Hold as close as possible to the area where you wish to measure
the temperature. (2mint-30seconds)
 Glass Thermometers
 Mercury rises in a glass tube until its level matches the
temperature. (2-8mint)
 Bulb shapes
 Long tip – for oral use.

Security tip – for oral and rectal use.

 Rounded tip – for rectal.
Types of Thermometers

 Disposable thermometer
It is a chemical thermometer. Color of chemical unit
changes to specific temperature. It takes about 60
seconds for accurate reading.
 Tympanic thermometer

It is used to measure ear temperature/tympanic

temperature. It takes about 2-3seconds for accurate
reading.
ADVANTAGES AND DISADVANTAGES OF
SITES FOR BODY TEMP. MEASUREMENT
SITE ADVANTAGE DISADVANTAGES
S

Oral Most accessible Mercury-in-glass thermometers can break if bitten, so they

and convenient are contraindicated in children younger than 6 years and in
clients having convulsive disorders.

rectal Most reliable Unpleasant for clients, presence of stool may interfere with
measurement thermometer placement.

axillary Safest and most Thermometer must be left for a long period for accurate
Non –invasive measurement.
Tympanic Readily Can be uncomfortable , involves risk of injuring
membrane accessible and membranes .
reflects core
temp.very fast
Temporal Very fast Expensive
measurement
Clinical signs of Fever

Onset Course Defervescence

Increase heart Absence of chill. Skin that Flushed , warm skin

rate ,increase respiration feels warm.
rate shivering

Pallid , cold skin. Photosensitivity Sweating

Cyanotic nail beds Glassy eyed appearance
Gooseflesh Increased pulse and Decrease shivering
respiration rate.
Increase thirst

Cessation of sweating Herpetic lesion in mouth Possible dehydration

Factors affecting body temperature
 Stress : sympathetic system stimulation initiate the production
of epinephrine and nor epinephrine thereby increasing
metabolism of the body hence increasing temperature of the
body.
 Hormones :

Certain hormones in female e.g. progesterone keep the body

temperature slightly elevated at the time of ovulation.
 Age :

The body temperature of children is more labile than that of adults .

People more than 75 years of age are at risk of hypothermia.
They are usually sensitive to extremes of environmental
variations.
Factors affecting body temperature
 Diurnal variations : body temperature usually vary
throughout the day but the point of highest body temp. is
(8.00pm to midnight) and the point of lowest body
temperature is (4:00am to 6:00am)
 Exercise : exercise increases the metabolism of the body
hence increasing the body temperature up to 38.3c to 40c if
measured rectally.
 Environment : if the temperature is assessed in a warm room
and the body temperature cannot be modified by conduction,
convection, or radiation, then the temperature of the body will
be high.
 How to convert Celsius to Fahrenheit and
Fahrenheit to Celsius

C TO F F TO C
Formula
Put the formula
c/5=F-32/9
For example the body temperature is 37C For example body
37C=?F temperature is
37/5=F-32/9 100F
37X9/5=F-32
333/5=F-32 You can find the
66.6=F-32 C?
F-32=66.6
F=66.6+32
F=98.6
37C=98.6
.
 Pain
Pain is highly unpleasant and very personal sensation
that cannot be shared with others. It can occupy all the
persons thinking, direct all the activities and change a
persons life.
It has been defined in another way as “an unpleasant
sensory and emotional experience associated with actual
and potential damage or described in terms of such
damage.
Process of pain
 Physiology of pain
 Transduction : pain stimuli is converted to electrical
energy . This electrical energy is known as transduction.
This stimulus sends an impulse across a peripheral
nerve fiber (nociception).
 Transmission : A delta fibers send sharp, localized and
distinct sensations. C fibers relay impulses that are
poorly localized, burning and persistent pain. Pain
stimuli travel- spino thalamic tracts.
 Physiology of pain
 Perception : person is aware of pain – somatosensory
cortex identifies the location and intensity of pain
person unfolds a complex reaction –physiological and
behavioral responses is perceived.
 Modulation : inhibitory neurotransmitters like
endogenous opioids work to hinder the pain
transmission. This inhibition of the pain impulse is
known as modulation .
 Different theories of pain
 Intensive theory
 Specificity theory
 Strong's theory of pain
 Pattern theory
 Central summation theory of pain
 Sensory interaction theory
 Gate control theory
 Intensive theory
Intensive theory : This theory is based on Aristotle's
concept that pain resulted from excessive stimulation of
the sense of touch.
 Specificity theory
Specificity theory is one of the first modern theories for
pain. It holds that specific pain receptors transmit signals
to a “pain center” in the brain that produces the
perception of pain.
Von Frey (1895) argues that the body has a separate
sensory system for perceiving pain- just as it does for
hearing and vision . This theory considers pain as an
independent sensation with specialized peripheral sensory
receptors (noci ceptors) which respond to damage and
send signals through pathways (along nerve fibers) in the
nervous system to target centers in the brain.
 Strong's theory of pain
Strong investigated physical pain, particularly that felt
through the skin. He isolated pain from displeasure by
focusing on cutaneous pain, where the infliction of pain
carried no immediate threat, and therefore the emotional
response was removed. He proposed that pain was an
experience based on both the noxious stimulus and the
psychic reaction or displeasure provoked by the
sensation. Strong concluded that pain is the sensation :
the first sensation was the experience of heat and then
came the sensation of pain.
 Pattern theory

This theory considers that peripheral sensory receptors,

responding to touch , warmth and other non- damaging
as well as to damaging stimuli, give rise to non-painful
or painful experiences as a result of differences in the
patterns (in time) of the signals sent through the nervous
system. Thus, according to this view, people feel pain
when certain patterns of neural activity occur, such as
when appropriate types of activity reach excessively
high levels in the brain. These patterns occur only with
intense stimulation.
 Central summation theory of pain

It proposed that the intense stimulation resulting from

the nerve and tissue damage activates fibers that project
to internuncial neuron pools within the spinal cord
creating abnormal reverberating circuits with self-
activating neurons.
 Sensory interaction theory
The theory is used to explain the relationship between
the brain and behavior and explains why individuals
respond in a certain way to sensory input and how it
affects behavior.
 Gate control theory
Following an injury, pain signals are transmitted to the
spinal cord and then up to the brain. Melzack and wall
suggest that before the information is transmitted to the
brain, the pain messages encounter “nerve gates” that
control whether these signals are allowed to pass
through to the brain.
For example, large fibers can prohibit the impulses from
the small fibers from ever communicating with the
brain. In this way, the large fibers create a hypothetical
“gate” that can open or close the systems to pain
stimulation.
 Gate control theory
According to the theory, the gate can sometimes be
overwhelmed by a large number of small activated
fibers. In other words, the greater the level of pain
stimulation, the less adequate the gate in blocking the
communication of this information.
 COLDERRA pain Assessment Method

 Characteristics : dull, sharp, stabbing , pressure

 Onset: when did the pain start?
 Location: where does it actually hurt?
 Duration: how long does it last?
 Exacerbation :what makes the pain worse?
 Radiation :does it travel? To where?
 Relief: what provides relief? To what degree?
 Associated symptoms: nausea, anxiety, autonomic
responses
Pharmacological interventions for pain
management

Types of pain Medication used

 Mild pain a. Acetylsalicylic acid
b. Ibuprofen
c. Naproxen
d. Meloxicam
 Moderate pain
i. Tramadol
ii. Codeine
iii. Hydrocodone

 Severe pain I. Morphine sulphate

II. Methadone
III. Oxymorphone

 Co analgesics 1. Topical local anesthetics

 Non- pharmacological therapies
 Proper sleep
 Hygiene maintenance
 Proper positioning/immobilization
 Exercise
 Proper diet
 Reduce fear, anxiety stress
 Reducing sadness, helplessness
 Spiritual healing
 Family therapy
 Vocational training