Fifth is the pain
Time to Assess Vital Signs
On admission to a health care agency to obtain baseline data
When a client has a change in health status or reports symptoms
Before and after surgery/invasive procedure
Before and after the admin. Of medications
Before and after any intervention that could affect the vital signs.
Body Temperature – reflects the balance between the heat produced and the heat lost from the body, measured in heat units called degrees.
Factors Affecting Body Temperature
Age - the infant is greatly influenced by the temperature of the environment and must be protected from extreme changes.Children’s temperatures continue to be more variable than those of adults until puberty.Elderly people are at risk of hypothermia
Diurnal Variations (Circadian Rhythms) - body temperatures normally change throughout the day, varying as much as 1.0C(1.8F) between the early ,morning and the late afternoon. The point of highest body temp. is usually reached bet. 8pm -12mn.,and the lowest point is reached between 4am-6am.
Exercise - hard work or strenuous exercise can increase body temp. to as high as 38.3 to 40C measured rectally.
Hormones - women usually experience more hormone fluctuations than men. In women, progesterone secretion at the time of ovulation raises body temp. by about 0.3-0.6C.
Stress - Highly stressed or anxious client could have an elevated body temperature.
Environment - extremes in environmental temperatures can affect a person’s temperature regulatory systems.
Alterations in Body Temperature
Pyrexia/Hyperthermia/Fever - a body temperature above the usual range.
Hyperpyrexia - a very high fever
Febrile - client who has a fever.
Afebrile - client who has no fever
Hypothermia - is a body temperature below the lower limit of normal.
Advantages and Disadvantages of Four Sites for Body Temperature
Oral - accessible and convenient; glass thermometers can break if bitten; inaccurate if pt. has just ingested hot or cold or fluid or smoked.; could injure the mouth ff. oral surgery
Rectal - reliable measurement; inconvenient and more pleasant for clients; difficult for client who cannot turn to the side; could injure the rectum ff. rectal surgery; presence of stool may interfere with thermometer placement.
Axillary - safe and noninvasive; thermometer must be left in place a long time to obtain an accurate measurement.
Tympanic Membrane - readily accessible; reflects the core temp, very fast
can be uncomfortable and involves risk of injuring the membrane if the probe is inserted too far. Repeated measurements may vary. Presence of cerumen can affect the reading.
Pulse is a wave of blood created by contraction of the left ventricle of the heart.
Peripheral Pulse - a pulse located away from the heart
Factors Affecting the Pulse
Age - as age increases, the pulse rate gradually decreases.
Gender - after puberty, the average male’s pulse rate is slightly lower than the female’s.
Exercise - pulse rate increases with activity.
Fever - pulse rate increases a) in response to the lowered blood pressure that results from peripheral vasodilatation associated with elevated body temperature and b) because of the increased metabolic rate
Medications - some medications decrease the pulse rate and some increase the pulse rate.
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. Increases heart rate and the force of the heartbeat.
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 a 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.
Pulse Sites
Temporal Pulse - where the temporal artery passes over the temporal bone of the head. The site is superior and lateral to the eye.
Carotid - at the side of the neck where the carotid artery runs between the trachea and the sternocleidomastoid muscle.
Apical - apex of the heart; adult (located on the left side of the chest, about 8 cm./3 in. to the left of the sternum and at the 4th,5th, or 6th intercostal space); for a child 7-9 yrs. old (located at the 4th or 5th intercostal spaces); 4 yrs. old ( left of the midclavicular line)
Brachial Pulse - inner aspect of the biceps muscle of the arm or medially in the antecubital space.
Radial Pulse - where the radial artery runs along the radial bone, on the thumb side of the inner aspect of the wrist.
Femoral Pulse - where the femoral artery passes alongside the inguinal ligament.
Popliteal Pulse - where the popliteal artery passes behind the knee.
Posterior Tibial - on the medial surface of the ankle where the posterior tibial artery passes behind the medial malleolus.
Pedal (Dorsalis Pedis) - where the dorsalis pedis artery passes over the bones of the foot.
Reasons for Using Specific Pulse Site
Radial - readily accessible
Temporal - used when radial pulse is not accessible
Carotid - used in cases of cardiac arrest; used to determine circulation of the brain
Apical - routinely used for infants and children up to 3 yrs. of age; used to determine discrepancies with radial pulse; used in conjunction with some medication
Brachial - used to measure blood pressure; used during cardiac arrest for infants
Femoral - used in cases of cardiac arrest; used for infants and children; used to determine circulation to a leg.
Popliteal - used to determine circulation to the lower leg
Posterior Tibial - used to determine the circulation to the foot
Pedal - used to determine the circulation to the foot
Medical Terminologies
Tachycardia - an excessively fast heart rate
Bradycardia - abnormally slow pulse rate
Pulse Rhythm - is the pattern of the beats and the intervals between the beats.
Dysrhythmia/Arrhythmia - pulse with an irregular rhythm
Pulse Volume - also called the pulse strength or amplitude, refers to the force of
blood with each beat.
Respiration - act of breathing
Medical Terminologies
1. External Respiration - refers to the interchange of oxygen and carbon dioxide between the alveoli of the lungs and the pulmonary blood.
2. Internal Respiration - interchange of O2 and CO2 between the circulating blood and the cells of the body tissues.
3. Inhalation/Inspiration - refers to the intake of air into the lungs.
4. Exhalation/Expiration - refers to the breathing out or the movement of gases from the lungs to the atmosphere.
5. Ventilation - refer to the movt. of air in and out of the lungs.
6. Eupnea - breathing that is normal in rate and depth.
7. Tachypnea/Polypnea - abnormally fast respirations
8. Bradypnea - abnormally slow respirations
9. Apnea - absence of breathing
10. Hyperventilation - overexpansion of the lungs characterized by rapid and deep breaths
11. Hypoventilation - underexpansion of the lungs, characterized by shallow respirations
12. Cheyne-Strokes Breathing - rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea
13. Dyspnea - difficult and labored breathing during which the individual has a persistent, unsatisfied need of air and feels distressed.
14. Orthopnea - ability to breathe only in upright sitting or standing positions
15. Stridor - shrill,harsh sound heard during inspiration with laryngeal obstruction.
16. Stertor - snoring/sonorous respiration, usually due to a partial obstruction of
the upper airway
17. Wheeze - continuous, high-pitched musical squeak or whistling sound occuring on expiration.
18. Intercostal Retraction - indrawing between the ribs
19. Substernal Retraction - indrawing beneath the breastbone
20. Suprasternal Retraction - indrawing above the clavicles
2 Types of Breathing
1. Costal/Thoracic Breathing - observed by the movt. Of the chest upward and outward.
2. Diaphragmatic/Abdominal Breathing - involves the contraction and relaxation of the diaphragm
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