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RLE 10
@VITAL SIGNS
• Also known as Cardinal Signs
• Includes (1) TEMPERATURE, (2) PULSE, (3) RESPIRATION, and (4) BLOOD PRESSURE &
recently PAIN as the 5th V/S in some facilities
• A person’s physiologic status is reflected by these indicators of body function
• Checked to monitor the functions of the body, functions that might not be observed
• Should be evaluated with reference to the client’s present and prior health status, are compared to the
client’s usual (if known) and accepted normal standars
• When and where? Chiefly a nursing judgement or depending on facility or physician’s order
BODY TEMPERATURE
• heat of the body measured in degrees
• Difference between production of heat and loss of heat from the body
@FACTORS AFFECTING BODY TEMPERATURE – nurses should be aware so that they can recognize
normal temperature variations & understand the significance of the body temperature measurements that deviate
from normal
• Age – infant is greatly influenced by the temperature of environment and must be protected from
extreme changes; people 75 y.o & up are at risk for hypothermia (T < 36C or 96.8F) for a variety of reasons
such as inadequeate diet, loss of subcutaneous tissue, lack of activity & decreased thermo-regulatory efficiency
• Sex – d/t hormones; women > men hormone fluctuations; progesterone during ovulation rises body
temperature
• Exercise – can inc temp to as high as 38.3C to 40C (101-104F) rectally
• Time of day – also “diurnal variations” or “circadian rhythms”; @ 1C between early am and late pm;
highest @ 8pm and midnight; lowest @ sleep between 4-6 am
• Emotions/stress – stimulation of SNS
• Environment – extremes in environmental temp
• Others; food, drugs
BODY TEMPERATURE
1. Oral – most frequently used, least disruptive, most convenient, done for 3 minutes ; wait 30 mins if
client ate or drank cold or hot food/fluids
CONTRAINDICATIONS:
• Infants and very young children
• Patients with oral surgery
• Unconscious or irrational patients
• Seizure-prone patients
• Mouth breathers and pts. with oxygen
2. @ Rectal – most accurate route, but invasive and uncomfortable to patient; done for 2-3 mins
CONTRAINDICATIONS:
Rectal abnormalities – ex. Significant hemorroids
Diarrhea
Certain heart conditions – ex. CHF; may result to vagal stimulation = bradycardia
Immunosuppressed - may inc risk of infection
Clotting disorder
3. @Axillary – safer than the oral method, non-invasive, least accurate; Done for 10 minutes; for clients
with oral problem( oral inflammation, wired jaws, oral surgery)
4. @Tympanic membrane – accessible, less invasive; has abundant arterial blood supply; Within two
seconds
Up/back for adult
Down/back for pedia
CONTRAINDICATIONS:
• Presence of ear ache
• Significant ear drainage
• Scarred tympanic membrane
@ASSESSING TEMPERATURE
(axillary route) Taylor’s p. 14
@ Assessment Findings
Pyrexia Elevated BT
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
• Assessed by palpation (feeling) or auscultation (hearing)
• Middle three fingertips are used for palpating all pulse sites except the apex of the heart; a stethoscope is
used for assessing apical pulses & FHT
• @Volume/amplitude – also pulse strength; amount of blood pumped with each heartbeat
Normal pulse – can be felt w/ moderate pressure of the fingers & can be obliterated w/ greater pressure
Full or bounding pulse – forceful or full blood volume that is obliterated only with difficulty
Weak, feeble, thready – pulse that is readily obliterated w/ pressure from the fingers
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
Newborn 30 – 60 bpm
Irregular Abnormal
@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
2. diaphragmatic (abdominal) breathing – involves contraction & relaxation of the diaphragm
@AF:
• Hypertension – above 140/90 mmHg
• Hypotension – below 90/60 mmHg
• Orthostatic Hypotension –
decrease in Bp when changing
position
@Korotkoff’s sound –schematic diagram
@Factors that control Blood Pressure
1.Cardiac Output – amount of blood ejected from the heart per contraction
2. Blood Volume – adult has about 5-6 liters of circulating blood
3. Elasticity of arterial walls – yields upon systole and retracts upon diastole
Assessment Findings:
1. hypertension – dx made when the ave of 2 or more diastolic readings on 2 visits subsequent to initial
assessment is 90 mmHg or higher or ave of multiple systolic BP readings is higher than 140mmHg
2. hypotension = systolic pressure is consistently between 85-110 mmHg
Parts of BP apparatus
Assessing BP Taylor’s p. 23
The End