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1 The vital or cardinal signs are body temperature, pulse, respirations, and blood pressure.

Recently, many agencies such as the Veterans Administration have designated pain as a fifth vital sign, to be assessed at the same time as each of the other four. Body temperature reflects the balance between the heat produced and the heat lost from the body, measured in heat units called degrees. There are two kinds of body temperature: core temperature and surface temperature. Core temperature Is the temperature of the deep tissues of the body, such as the abdominal cavity and pelvic cavity. It remains relatively constant. The normal core body temperature is a range of temperature 37C. Core temperature Is the temperature of the skin, the subcutaneous tissue, and fat. It, by constant, rises and falls in response to the environment. The body continually produces heat as a by-product of metabolism. When the amount of heat produced by the body equal the amount of heat lost, the person is in heat balance. Factors affect the body's heat production. The most important are these five: 1. Basal metabolic rate (BMR). Is the rate of energy utilization in the body required to maintain essential activities such as breathing, BMR decrease with age. In general, the younger the person, the higher the BMR. 2. Muscle activity. Including shivering increases the MR. 3. Thyroxine output. Increased thyroxine output increases the rate of cellular metabolism throughout the body. This effect is called chemical thermogenesis, the stimulation of heat production in the body through increased cellular metabolism. 4.Epinephrine, norepinephrine, and sympathetic stimulation. These hormones immediately increase the rate of cellular metabolism in many body tissues. Fever. Fever increases the cellular metabolic rate and thus increases the body's temperature further. Factors affect the body's heat loss. The most important are: 1. Radiation is the transfer of heat from the surface of one object to the surface of another without contact between the two objects. 2. Conduction is the transfer of heat from one molecule to a molecule of lower temperature. For example, when a body is immersed in cold water the amount of heat transferred depends on the temperature difference and the amount and duration of the contact. 3. Convection Is the dispersion of heat by air currents. The body usually has a small amount of warm air adjacent to it. This warm air rises and is replaced by cooler air, and so people always lose a small amount of heat through convection. Is continuous evaporation of moisture from the respiratory tract and from the mucosa of the mouth and from the skin. Regulation of body temperature The system that regulates body temperature has three main parts: sensors in the shell and in the core, an integrator in the hypothalamus, and an effectors system that adjusts the production and loss of heat. Most sensors or sensory receptors are in the skin. The skin has more receptors for cold than warmth. Therefore, skin sensors detect cold more efficiently than warmth.

2 When the skin becomes chilled over the entire body. Three physiologic processes to increase the body temperature take place Shivering increases heat production. Sweating is inhibited to decrease heat loss. Vasoconstriction decreases heat loss. The hypothalamic integrator, the center that controls the core temperature, is located in the preoptic area of the hypothalamus. When the sensors in the hypothalamus detect heat, they send out signals intended to reduce the temperature that is to decrease heat production, and increase heat loss. When the cold sensors are stimulated, signals are sent out to increase heat production and decrease heat loss. Factors affecting body temperature

1. Age The infant is greatly influenced by the temperature of the environment and must be protected from extreme changes. Older people are also particularly sensitive to extremes in the environmental temperature due to decreased thermoregulatory controls.

3 Diurnal variations- Body temperatures normally change throughout the day, varying as much as 1.0C between the early morning and the late afternoon. The point of highest body temperature is usually reached between 8:00 PM and midnight, and the lowest point is reached during sleep between 4:00 and 6:00 AM. Exercise. Hard work or strenuous exercise can increase body temperature to as high 38.3 to 40C measured rectally. Stress. Stimulation of the sympathetic nervous system can increase the production of epinephrine and norepinephrine, thereby increasing metabolic activity and heat production. Hormones. The women usually experience more hormone fluctuations than men. In women, progesterone secretion at the time of ovulation raises body temperature by about 0.3 to 0.6C above basal temperature. Environment. Extremes in environmental temperatures can affect a person's temperature regulatory systems. Alterations in body temperature Temperature Normal range /Average 36 37.5 C Hypothermia below 36 C 34 death Pyrexia 37.6 to 41C Hyperthermia above 41C 42 and above Death Pyrexia-A body temperature above the usual range is called pyrexia 38 to 40C, hyperthermia, or fever. A very high fever, such as 41C is called hyperpyrexia. Febrile with fever Afebrile absence of fever Four common types of fevers are Intermittent fever, the body temperature alternate at regular intervals between periods of fever and periods of normal or subnormal temperatures. Relapsing fever, short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature. Constant fever, the body temperature fluctuates minimally but always remains above normal. A temperature that rises to fever level rapidly following a normal temperature and then return to normal within a few hours is called a fever spike. (Bacterial blood infections) Remittent fever, a wide range of temperature fluctuations more than 2C occurs over the 24hour period, all of which above normal. Heat Exhaustion due to excessive heat & dehydration Signs: Paleness dizziness N/V Fainting moderately increased temp Exercising in hot weather, flushed skin do not sweat Delirious, unconscious / seizures

Clinical Signs of Fever

4 The clinical signs of fever vary with the onset, course, and abatement stages of the fever. These signs occur as a result of changes in the set point of the temperature control mechanism regulated by the hypothalamus. Onset (cold or Chill Stage) Increased heart rate. Increased respiratory rate and depth. Pallid, cold skin and shivering. Complaints of feeling cold. Cyanotic nail beds. Gooseflesh appearance of the skin. Cessation of sweating. Course Stage Absence of chills. Skin that feels warm. Glassy eyed appearance. Increased pulse and respiration rates. Increased thirst. Mild to sever dehydration Drowsiness, restlessness, delirium, or convulsions. Herpetic lesions of the mouth. Loss of appetite. Malaise, weakness, and aching muscles. Abatement stage of fever flushed phase/defervescence Skin that appears flushed and feels warm. Sweating. Decreased shivering and possible dehydration. Nursing Interventions for clients with Fever Monitor vital signs. Assess skin color and temperature. Monitor white blood cell count, hematocrit value. Remove excess blankets when the client feels warm, but provide extra warmth when the client feels chilled. Provide adequate nutrition and fluids. Measure intake and output. Reduce physical activity to limit heat production, especially during the flush stage. Administer antipyretics as ordered. Provide oral hygiene to keep the mucous membranes moist. Provide a tepid sponge bath to increase that loss through conduction. Provide dry clothing and bed linens. Hypothermia: is a core body temperature below the lower limit of normal 35C. The three physiologic mechanisms of hypothermia are: Excessive heat loss.

5 Inadequate heat production to counteract heat loss. Impaired hypothalamic thermoregulation. The Clinical Signs of Hypothermia Decreased body temperature, pulse, and respirations. Severe shivering (initially) Feelings of cold and chills. Pale, cool, waxy skin. Frostbite(nose, fingers, toes) Hypotension and disorientation. Decreased urinary output. Lack of muscle coordination. Drowsiness progressing to coma.

Nursing Interventions for Clients with hypothermia Provide a warm environment. Provide dry clothing. Apply warm blankets. Keep limbs close to body. Cover the client's scalp with a cap or turban. Supply warm oral or intravenous fluids. Apply warming pads. Assessing Body temperature Most common site of measuring temperature: Oral Rectal Axillary Tympanic membrane Temporal artery Sites for Measuring Body Temperature 1. Oral body temperature is measured orally Nx intervention: wait for 30 minutes before taking temperature when clients takes foods/ fluids Disadvantage: Can break when bitten Inaccurate if client has just ingested hot/cold/food Could injure the mouth following oral sx 2. Rectal temperature is considered the most accurate Inconvenient & unpleasant Contraindication: MI, rectal sx, diarrhrea, clotting disorders, hemorrhoids 3. Axilla preferred site for measuring temperature in NB, accessible and safe Takes to be left in place for a longer time to obtain accurate measurement 4. Tympanic membrane nearby tissue ear canal is a frequent site for estimating core body temperature. Non invasive infrared thermometers are used

6 Readily accessible reflects core temperature, very fast direct application to tympanic membrane result to membrane injury Presence of cerumen can affect readings 5. Temporal artery safe & non invasive very fast Types of Thermometers 1.Temperature sensitive tape used to obtain a general indication of body surface temperature. The tape contains liquid crystals that change in color according to temperature Applied on forehead/abdomen 2. Infrared thermometer sense body heat in the form of infrared energy given off by a heat source w/c is the ear canal (tympanic membrane) 3.Temporal artery thermometer Determine thermometer using scanning infrared that compares arterial temperature in the temporal of the forehead to room temperature & calculate heat balance to approximate the core temp of the blood in the pulmonary Probe is placed in the middle of the forehead & drawn laterally to the hairline C = (Fahrenheit temperature 32) X 5/9 Temperature is 100F C= (100 32) X 5/9 =(68) x 5/9 = 37.8C F = (C X 9/5) + 32 F = ( 40 X 9/5) + 32 = (72 + 32) = 104F

The Pulse is a wave of blood created by contraction of the left ventricle of the heart. Generally the pulse wave represents the stroke volume output and the amount of blood that enters the arteries with each ventricular contraction Compliance of the arteries is their ability to contract and expand. When a person's arteries loss their distensibility as can happen in old age, greater pressure is required to pump the blood into the arteries Cardiac output is the volume of blood pumped into the arteries by the heart and equals the result of the stroke volume (SV) times the heart rate (HR) per minute. SV: The amount of blood ejected with each cardiac contraction For example, 65mL x70 beats per minute = 4.55 L per minute. When an adult is resting, the heart pumps about 5 liters of blood each minute. In a healthy person, the pulse reflects the heartbeat that is the pulse rate is the same as the rate of the ventricular contractions of the heart. However, in some types of cardiovascular disease, the heartbeat and pulse rate can differ. For example, a client's heart may produce very weak or small pulse waves that are not detectable in a peripheral pulse far from the heart. In these instances, the nurse should assess the heartbeat and the peripheral pulse. A Peripheral pulse is a pulse located away from the heart, for example, in the foot, wrist, or neck.

7 Apical pulse, in contrast, is a central pulse, that it is located at the apex of the heart. Also referred as point of maximal impulse (PMI) Pulse Sites Radial Readily accessible


When radial pulse is not accessible


During cardiac arrest/shock in adults Determine circulation to the brain


Infants and children up to 3 years of age Discrepancies with radial pulse Monitor some medications

Pulse Sites
Brachial Blood pressure Cardiac arrest in infants


Cardiac arrest/shock Circulation to a leg;


Circulation to lower leg

Posterior tibial

Circulation to the foot

Dorsalis pedis

Circulation to the foot

Factors Affecting the Pulse Age. Specific variations in pulse rates from birth to adulthood.

Gender. After puberty, the average male's pulse rate is slightly lower than the female's. Exercise. The pulse rate normally increases with activity. Fever The pulse rate increases: a. in response to the lowered blood pressure that results from peripheral vasodilatation associated with elevated body temperature. b. because of the increased metabolic rate. Medications Some medications decrease the pulse rate, and others increase it. For example, cardiotonics (digitalis) decrease the heart rate, whereas epinephrine increase it. Hypovolemia. Loss of blood from the vascular system normally increases pulse rate. Stress. In response to stress, sympathetic nervous stimulation increases the overall activity of the heart. Stress increases the rate as well as the force of the heartbeat.

9 Position changes. When a person is sitting or standing, blood usually pools in dependent vessels of the venous system. Pooling results in a transient decrease in the venous blood return to the heart and subsequent reduction in blood pressure and increase in heart rate. Pathology. Certain diseases such as some heart conditions or those that impair oxygenation can alter the resting pulse rate. When assessing the pulse, the nurse collects the following data: Tachycardia. An excessively fast heart rate over 100 BPM in adult is referred to as tachycardia. Bradycardia. A heart rate in an adult of 60 BPM or less is called. The pulse rhythm. Is the pattern of the beats and the intervals between the beats. Equal time elapses between beats of a normal pulse. A pulse with an irregular rhythm is referred to as a dysrhythmia or arrhythmia. Pulse volume Also called the pulse strength or amplitude, refers to the force of blood with each beat. The elasticity of the arterial wall reflects its expansibility or its deformities. A healthy, normal artery feels straight, smooth, soft, pliable. Pulse deficit The difference between the apical and radial pulse Pulse pressure The difference between systolic and diastolic blood pressure. Cardiac Glycosides/ Digitalis Glycoside (Digoxin(Lanoxin) Increase cardiac contractility, w/c increases cardiac output. As a result perfusion to the kidneys is increased w/c increases the production of urine. Cardiac glycosides also decrease HR by prolonging cardiac conduction, esp AV node. Used for the mngt of Heart Failure & Fibrillation, Atrial Flutter & Paroxysmal atrial tachycardia Nursing responsibilities Take apical pulse 1 minute before giving the meds If AP <60 beats/min retake pulse after 1 hour if remain <60 notify the physician Monitor electrolyte levels: Low K & low Mg & high Ca indicates risk for digitalis toxicity Check the latest electrolyte lab result before giving of medications Give w/out meals Assess signs of toxicity: Anorexia N/V diarrhea Blurred or yellow vision unusual tiredness weakness

Respiration is the act of breathing. External respiration refers to the interchange of oxygen and carbon dioxide between the alveoli of the lungs and pulmonary blood. Internal respiration, by contrast, takes place throughout the body; it is the interchange of these same gases between the circulating blood and the cells of the body tissues. Inhalation or inspiration refers to the intake of air into the lungs. Exhalation or expiration refers to breathing out or the movement of gases from the lungs to the atmosphere. Ventilation is also used to refer to the movement of air in and out of the lungs.

10 There are basically two types of breathing: Costal (thoracic) breathing involves the external intercostals muscles and other accessory muscles, such as sternocleidomastoid muscles. It can be observed by the movement of the chest upward and outward. Diaphragmatic (abdominal) breathing involves the contraction and relaxation of the diaphragm, and it is observed by the movement of the abdomen, which occurs as a result of the diaphragm's contraction and downward movement. Mechanics and Regulation of breathing During inhalation, the diaphragm contracts (flattens), the ribs move upward and outward, and the sternum moves outward, thus enlarging the thorax and permitting the lungs to expand. During exhalation, the diaphragm relaxes, the ribs move downward and inward, and the sternum moves inward, thus decreasing the size of the thorax as the lungs are compressed. Normally breathing is carried out automatically and effortlessly. Respiration is controlled Respiratory centers in medulla oblongata and the pons of the brain. by chemoreceptors located centrally in the medulla and peripherally in the carotid and aortic bodies. These centers and receptors respond to changes in the concentrations of oxygen (O2), carbon dioxide (CO2) and hydrogen (H) in the arterial blood. Factors Affecting Respiration Several factors influence respiratory rate. Those that increase the rate include exercise (increase metabolism), stress (readies the body for fight or flight), increased environmental temperature, and lowered oxygen concentration at increased altitudes. Factors that may decrease the respiratory rate include decreased environmental temperature, certain medications e.g. narcotics and increased intracranial pressure. Altered Breathing Patterns and Sounds 1. Breathing Patterns Rate Tachypnea -----quick, shallow breaths. Usually more than 24R/M Bradypnea------abnormally slow breathing. Usually less than 10R/M Apnea---------cessation of breathing. Volume Hyperventilation------overexpansion of the lungs characterized by rapid and deep breath. Hypoventilation-------under-expansion of the lungs, characterized by shallow respirations. Respiratory quality/character Refers to aspects of breathing that are different from normal: effortless breathing Breathe with effort- Labored breathing Rhythm refers to the regularity of expirations & inspirations Cheyne-stokes breathing------Rhythmic waxing and waning of respiration, from very deep to very shallow breathing and temporary apnea. Ease or Effort

11 Dyspnea -----difficult and labored breathing during which the individual has a persistent, unsatisfied need for air and feels distressed. Orthopnea-------ability to breathe only in upright sitting or standing positions Breath sounds Audible without amplification Stridor ------a shrill (high-pitch), harsh sound heard during inspiration with laryngeal obstruction. Stertor-------snoring or sonorous (loud) respiration, usually due to a partial obstruction of the upper airway. Wheeze------continuous, high-pitched musical squeak or whistling sound occurring on expiration and sometimes on inspiration when air moves through a narrowed or partially obstructed airway. Bubbling-------gurgling sounds heard as air passes through moist secretions in the respiratory tract. Chest movements Intercostal retraction---indrawing between the ribs Substernal retraction---indrawing beneath(under) the breastbone Suprasternal retraction-----indrawing above the clavicles Secretions and coughing Hemoptysis -------the presence of blood in the sputum. Productive cough-------a cough accompanied by expectorated secretions. Nonproductive cough------a dry, harsh cough without secretions.

Blood pressure Arterial blood pressure is a measure of the pressure exerted by the blood as it flows through the arteries. Because the blood move in waves. There are two blood pressure: Systolic pressure, which is the pressure of the blood as a result of contraction of the ventricles, that is, the pressure of the height of the blood wave. Diastolic pressure, which is the pressure when the ventricles are at rest. Diastolic pressure is the lower pressure, present at all times within the arteries. Pulse pressure, the difference between the diastolic and the systolic pressures. Blood pressure is measured in millimeters of mercury (mmHg) and recorded as a fraction. The systolic pressure is written over the diastolic pressure. The average blood pressure of a healthy adult is 120/80 mm Hg. First the nurse pumps the cuff 30 mm Hg above the point where the pulse is no longer felt , that is the point when the blood flow in the artery is stopped. Korotkoffs Sounds Phase 1 First faint, clear tapping or thumping sounds Systolic pressure Phase 2 Muffled (muted), whooshing, or swishing sound Phase 3

12 Blood flows freely Crisper and more intense sound Thumping quality but softer than in phase 1 Phase 4 Muffled and have a soft, blowing sound Phase 5 Pressure level when the last sound is heard Period of silence Diastolic pressure Measuring Blood Pressure Direct (Invasive Monitoring) Indirect Auscultatory Palpatory Sites Upper arm (brachial artery) Thigh (popliteal artery Factors Affecting Blood Pressure Age : Newborns have a mean systolic pressure of about 75 mm Hg. The pressure rises with age, reaching a peak at the onset of puberty, and then tends to decline somewhat. Exercise: Physical activity increases the cardiac output and hence the blood pressure, thus 20 to 30 minutes of rest following exercise is indicated before the resting blood pressure can be reliably assessed. Stress: Stimulation of the sympathetic nervous system increases cardiac output and vasoconstriction of the arterioles, thus increasing the blood pressure reading. However, severe pain can decrease blood pressure greatly by inhibiting the vasomotor center and producing vasodilatation. Race: African American males over 35 years have higher blood pressure than European American males of the same age. Gender: After puberty, females usually have lower blood pressure than males of the same age this difference is thought to be due to hormonal variations. After menopause women generally have higher blood pressure than before. Medication: Many medications may increase or decrease the blood pressure. Obesity: Both childhood and adult obesity predispose to hypertension. Diurnal variations: Pressure is usually lowest early in the morning, when the metabolic rate is lowest, then rises throughout the day and peaks in the late afternoon or early evening. Disease process: Any condition affecting the cardiac output blood volume, blood viscosity and/or compliance of the arteries has a direct effect on the blood pressure. Hypertension: A blood pressure that is persistently above normal. Primary hypertension an elevated blood pressure of unknown cause Secondary hypertension an elevated blood pressure of known cause. Hypotension is a blood pressure that is below normal. Orthostatic hypotension is a blood pressure that falls when the client sits or stands.

Common Errors in Assessing Blood Pressure Bladder cuff too narrow

13 Bladder cuff too wide Arm unsupported Insufficient rest before the assessment. Repeating assessment too quickly. Deflating cuff too quickly. Deflating cuff too slowly. Failure to use the same arm consistently. Arm above level of the heart. Assessing immediately after a meal or smoker or has pain. Variations in Normal Vital Signs by AgeAgeOral temperature in degree Pulse Average and Ranges RespirationsAverage and RangesBlood pressure (mm Hg)Newborns36.8130 (80180)35(30-80)73/551 year36.8120 (80-140)30 (20-40)90/555-8 years37100 (75-120)20 (1525)95/5710 years3770 (50-90)19 (15-25)102/62Teen3775 (50-90)18 15-20)120/80Adult3780 (60-100)16 (12-20)120/80Older adult (>70 years)3770 (60-100)16 (15-20)Possible increased diastolic

Pulse Oximetry Noninvasive Estimates arterial blood oxygen saturation (SpO2) Normal SpO2 85-100%; < 70% life threatening Detects hypoxemia before clinical signs and symptoms Sensor, photodetector, pulse oximeter unit Factors that affect accuracy include: Hemoglobin level Circulation Activity Carbon monoxide poisoning Pulse Oximetry Prepare site Align LED and photodetector Connect and set alarms Ensure client safety Ensure accuracy