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Unit20II.20Taking-the-Vital-Signs
Page 1: Introduction to Vital Signs
Taking the Vital Signs
Unit II of the MADE4Learners Framework
Page 2: Vital Signs Overview
Key Vital Signs
Vital Signs: Body temperature, pulse, respirations, blood pressure.
Pain: Recently recognized as a fifth vital sign due to its importance in assessing health.
Important indicators of body's response to various stressors.
Page 3: Timing for Assessment
When to Assess Vital Signs
On admission to healthcare facilities for baseline data.
With changes in health status or concerning symptoms (e.g., chest pain).
Before and after surgery/invasive procedures.
Before/after medications affecting respiratory/cardiovascular systems.
Before/after nursing interventions impacting vital signs.
Page 4: Purpose of Assessing Vital Signs
To assess health status of individuals.
To plan and implement nursing care.
To evaluate effectiveness of treatments.
To modify treatment strategies.
A routine part of physical assessments.
To understand present health issues.
Page 5: Body Temperature Regulation
Heat Balance
Body temperature is the balance between heat produced and lost.
Measured in Celsius or Fahrenheit.
Heat produced mainly through metabolism.
Page 6: Types of Body Temperature
Core vs. Surface Temperature
Core Temperature: Deep tissue temperature, stable at around 37°C.
Surface Temperature: Fluctuates with environmental changes.
Page 7: Factors Affecting Heat Production
Basal Metabolic Rate (BMR)
Energy utilization for essential body functions.
Decreases with age.
Higher in younger individuals.
Page 8: Normal Temperature Ranges by Body Part
Forehead: 35.8°C - 37.8°C
Ear canal: 35.8°C - 38.0°C
Mouth: 35.5°C - 37.5°C
Armpit: 34.7°C - 37.3°C
Anus: 36.6°C - 38.0°C
Page 9: Factors Affecting Heat Production (Continued)
Muscle Activity
Increases metabolic rate significantly, thus elevating heat production.
Page 10: Thyroxine's Role
Thyroxine Output
Increases metabolism, promoting heat production known as thermogenesis.
Page 11: Strong Emotions and Body Temperature
Impact of Emotions
Fight/flight response enhances metabolic rate during stress.
Page 12: Illness Influence
Disease Effects
Presence of illness can lead to fever, increasing metabolic rate.
Page 13: Environmental Effects
Atmospheric Temperature Changes
Increased CO2 levels lead to higher earth temperatures.
Page 14: Heat Loss Factors
Through Skin
Radiation: Heat transfer without contact.
Page 15: Heat Loss Methods
Conduction and Convection
Conduction: Heat transfer via direct contact.
Convection: Heat transfer through gas/liquid currents.
Page 16: Evaporation
Evaporative Cooling
Loss of heat via sweat evaporation.
Page 17: Respiratory and Renal Heat Loss
Breathing and Urine
Heat lost through exhaling or urine.
Page 18: Heat Loss Through Other Means
Bowel Movements
Feces can absorb body heat.
Page 19: Physiological Response to Increased Temperature
Hypothalamus Regulation
Detects fever from triggers like infection or climate changes.
Responds with mechanisms to reduce heat loss.
Page 20: Age and Temperature Sensitivity
Age Factors in Thermoregulation
Infants vulnerable to environmental extremes.
Older adults have decreased thermoregulatory function.
Page 21: Diurnal Variations
Daily Temperature Fluctuations
Highest temperatures may occur between 8 PM - midnight; lowest between 4 AM - 6 AM.
Page 22: Other Influences on Body Temperature
Exercise, Stress, and Hormones
Hormones can cause fluctuations, especially during menstrual cycles.
Page 23: Measuring Body Temperature
Measurement Methods
Oral: Placed under the tongue.
Rectal: More accurate, often for infants or unconscious patients.
Axillary: Less accurate, but preferred in certain circumstances.
Page 24: Precautions for Oral Measurements
Requirements Before Taking Oral Temperature
No hot or cold intake 15-30 minutes prior.
Must be able to follow directions.
Page 25: Contraindications for Oral Temp
Patients with recent oral surgery or inability to follow commands should not have oral temp measured.
Page 26: Measuring Rectal Temperature
Guidelines for Rectal Measurement
Insert thermometer about 1 inch.
Page 27: Indications for Rectal Temperature
Used when oral is contraindicated or for more accurate readings.
Page 28: Contraindications for Rectal Measurement
Precautions
Avoid in patients with rectal surgery, diarrhea, or heart conditions.
Page 29: Axillary Temperature Measurement
Technique
Placed in the armpit for at least 5-10 minutes.
Page 30: Indications for Axillary Measurement
Used if both oral and rectal routes are contraindicated.
Page 31: Tympanic Membrane Temperature Measurement
Ear Canal Technique
Use electronic probe; non-invasive.
Page 32: Temporal Artery Measurement
Skin/Temporal Route
Quick and non-invasive.
Page 33: Peripheral Temperature Measurement
Extremities and Skin Temperature
Reflects condition but can vary.
Page 34: Advantages and Disadvantages of Temperature Measurement
Routes Overview
Oral: Convenient but inaccurate post-intake.
Rectal: Accurate but invasive.
Axillary: Safe but less accurate.
Tympanic: Fast but can be uncomfortable.
Temporal: Safe but equipment-dependent.
Page 35: Pyrexia - Definitions
Temperature Definitions
Pyrexia: Fever indicated when above normal.
Hyperthermia: Very high temperature, over 40°C.
Hypothermia: Below 34°C.
Page 36: Types of Fever
Fever Classifications
Intermittent Fever: Fluctuates between normal and high.
Remittent Fever: Sustained slight fluctuation.
Relapsing Fever: Alternates between high ages.
Continuous Fever: Remains elevated.
Page 37: Fever Spikes
Sudden Increase in Fever
Sharp increase, often linked to specific conditions.
Page 38: Resolution of Pyrexia
Types of Temperature Drops
Crisis: Rapid dip in temperature.
Lysis: Slow decline.
Page 39: Temperature Conversion
Celsius to Fahrenheit Formula
F = [(9/5) °C] + 32.
Page 40: Nursing Process for Fever Management
Nursing Steps
Assessment: History, physical exam for signs of infection.
Diagnoses and Goals: Establish care objectives based on assessment.
Nursing Interventions: Adjust environment, encourage fluids, use antipyretics.
Page 41: Vehicle for Evaluation
Evaluation Phase for Patients with Fever
Confirm temperature reduction and other signs of recovery.
Page 42: Understanding Pulse
Definition of Pulse
Represents blood wave from heart's contraction, reflecting heart rate.
Page 43: Peripheral vs Apical Pulse
Types of Pulse Locations
Peripheral pulse: Far from heart; apical pulse: near heart.
Page 44: Sites for Measuring Pulse
Common Pulse Sites
Temporal
Carotid
Apical
Brachial
Radial
Femoral
Popliteal
Posterior tibial
Dorsalis pedis
Page 45: Measuring Radial Pulse
Pulsation Technique
Use index and middle fingers to locate and assess.
Page 46: Factors Influencing Pulse Rate
Influencing Factors
Age - Pulse varies from newborn to adult.
Gender - Men average lower than women.
Exercise - Increases pulse rate.
Fever - Higher temps raise pulse rate.
Medications - Impact pulse rates differently.
Hypovolemia - Blood loss increases pulse.
Stress - Elevates pulse due to sympathetic activation.
Position changes - Sitting/standing can affect blood return.
Pathology - Heart conditions alter pulse rate.
Page 47: Pulse Characteristics
Assessing Pulse Quality
Volume: Weak to bounding.
Rhythm: Regularity of beats.
Page 48: Grading Pulse Strength
Grading Scale for Pulse
0 = none; 1+ = faint; 2+ = weak; 3+ = normal; 4+ = bounding.
Page 49: Terminologies related to Pulse
Important Definitions
Tachycardia: Over 100 bpm.
Bradycardia: Below 60 bpm.
Pulse deficit: Difference between apical and peripheral rates.
Page 50: Understanding Blood Pressure
Blood Pressure Basics
Recorded as a fraction: systolic over diastolic.
Page 51: Korotkoff Sounds
Phases of Blood Pressure Sounds
Five phases representing pressure changes during measurement.
Page 52: Blood Pressure Measurement Technique
Steps for Measurement
Place cuff over brachial artery.
Inflate above systolic estimate.
Listen for sounds with stethoscope.
Page 53: Recommended Measurement Guidelines
Best Practices for Accurate Reading
Ensure patient is relaxed; wait post-exercise.
Page 54: Blood Pressure Factors
Influencing Factors
Age, exercise, stress, gender, medication, obesity, diurnal variations, disease processes.
Page 55: Hypertension Definitions
Types of Hypertension
Primary: Unknown cause.
Secondary: Known cause.
Hypotension: Below normal blood pressure.
Orthostatic Hypotension: BP drops upon standing.
Page 56: Stethoscope Parts
Components of Stethoscope
Bell: Low-pitched sounds; diaphragm: high-pitched sounds.
Page 57: Equipment for Blood Pressure Measurement
Equipment Components
Sphygmomanometer with gauge, cuff, and tubing.
Page 58: Pain as a Vital Sign
Importance of Pain Assessment
Pain assessment should occur alongside vital signs measurements.
Page 59: Types of Pain
Four Major Pain Types
Nociceptive Pain: From tissue injury.
Inflammatory Pain: Response to tissue damage.
Neuropathic Pain: Nervous system injury.
Functional Pain: No identifiable cause.
Page 60: Acute vs. Chronic Pain
Differences in Pain Duration
Acute: Short and reversible; Chronic: Long-lasting and may not have a clear cause.
Page 61: Factors Influencing Pain Reporting
Patient Reluctance Reasons
Desire to be compliant, addiction fears, concern over side effects.
Page 62: Pain Terminologies
Key Definitions
Addiction: Chronic drug-seeking behavior.
Tolerance: Need for larger doses over time.
Physical Dependence: Withdrawal symptoms when not taking the drug.
Page 63: Pain Assessment Methods
Techniques for Nonverbal Patients
Assess facial expressions, vocalizations, movements, and behavioral changes.
Page 64: Pain Characteristics Assessment
"PQRST" Method
P = Palliative, Provocative; Q = Quality; R = Radiation; S = Severity; T = Temporal.
Page 65: Pain Scales for Assessment
Assessment Tools
FLACC Score: Assesses pain in nonverbal patients.
Wong-Baker FACES: Visual pain scale for children.
NoteStudied by 43 peopleNoteStudied by 14 peopleNoteStudied by 14 peopleNoteStudied by 17 peopleNoteStudied by 4 peopleNoteStudied by 230 people