VITAL SIGNS PAPASA

VITAL SIGNS - Includes body temperature, pulse, respirations and blood pressure - These signs should be checked to monitor the functions of the body BODY TEMPERATURE - Reflects the balance between the heat produced and heat lost from the body - It is measured in degrees (Celsius or Centigrade) CORE TEMPERATURE - Refers to the temperature of the deep tissues of the body (Abdominal/ Pelvic Cavity) SURFACE TEMPERATURE - Temperature of the skin, subcutaneous tissue, and fat FACTORS AFFECTING BODY’S HEAT PRODUCTION 1. BMR - Rate of energy utilization in the body required to maintain life sustaining activities such as breathing NOTE: The younger the person the higher the BMR 2. Muscle Activity - Increases BMR 3. Thyroxine Output - Increased thyroxine output increases the rate of cellular metabolism (chemical thermogenesis) 4. Epinephrine, Norepinephrine, & Sympathetic Stimulation/ Stress Response - These hormones immediately increase the rate of cellular metabolism HEAT LOSS 1. Radiation - Transfer of heat from the surface of one object to the surface of another without contact between the two objects, mostly in the form of infrared rays 2. Conduction - Transfer of heat from one molecule to a molecule of lower temperature 3. Convection - Dispersion of heat by air currents 4. Vaporization - Continuous evaporation of moisture from the respiratory tract, mucosa of the mouth and skin (insensible water loss) REGULATION OF BODY TEMPERATURE Hypothalamus - Responsible for the regulation of body temperature 3 PHYSIOLOGIC PROCESSES TO INCREASE BODY TEMPERATURE ✓ Shivering increase heat production ✓ Sweating is inhibited to decrease heat loss ✓ Vasoconstriction decreases heat loss FACTORS AFFECTING BODY TEMPERATURE 1. Age - Persons over 75 years of age are at high risk of HYPOTHERMIA due to inadequate diet, loss of subcutaneous fat, lack of activity and decreased thermoregulatory efficiency 2. Diurnal Variations (Circadian Rhythms) - Body temp change throughout the day - Highest: 4:00 to 6:00 pm - Lowest: 4:00 to 6: 00 am 3. Exercise - Strenuous activities can increase body temp to as high as 38.3 to 40 degrees centigrade 4. Hormones - Progesterone secretion during ovulation for women increases body temp by about 0.3 to – 0.6 degrees centigrade (0.5-1 F) 5. Stress - Stimulation of the sympathetic nervous system can increase the production of epinephrine and norepinephrine, thereby increasing metabolic activity and heat production 6. Environment - Extremes in environment can affect body temperature ALTERATIONS IN BODY TEMPERATURE PYREXIA/ HYPERTHERMIA ➢ Fever in lay terms ➢ Temperature above the normal range ➢ Normal: 36.5 to 37.5 degrees centigrade or 96.8 to 98.6 degrees Fahrenheit ➢ Febrile or afebrile? 4 TYPES 1. Intermittent (malaria) - Temp is elevated but returns to normal in 24 hrs. Highest in late PM and lowest in early AM 2. Remittent - A wide range of temperature fluctuations above 2 C occurs over the 24hour period, all of which are above normal 3. Relapsing - A short febrile period then 2 to 3 days normal temp 4. Constant - Fluctuates minimally but always remains above normal CLINICAL SIGNS OF HYPERTHERMIA 1. Chills 2. Shivering 3. Pallid Skin 4. Gooseflesh 5. Increased pulse rate due to inc Cardiac rate 6. Headache 7. Flushing of skin warm to touch 8. Restlessness HYPOTHERMIA - A core body temperature below the lower limit of normal 3 PHYSIOLOGIC MECHANISMS OF HYPOTHERMIA ✓ Excessive heat loss ✓ Inadequate heat production to counteract heat loss ✓ Impaired hypothalamic thermoregulation CLINICAL MANIFESTATIONS OF HYPOTHERMIA 1. Decreased body temp 2. Severe shivering 3. Feelings of cold and chills 4. Pale, cool waxy skin 5. Frostbite 6. Hypotension 7. Decreased urinary output 8. Disorientation 9. Drowsiness progressing to coma ASSESSING BODY TEMPERATURE Site Advantage Disadvantag e Oral Accessible and Convenient Rectal Reliable Measurement Axillary Safe and Noninvasive Tympanic Membran e Readily Accessible; Reflects the Core Temperature , Very Fast Temporal Artery Safe and Noninvasive TYPES OF THERMOMETERS 1. Electronic Thermometer - Provides reading in just 2 to 60 seconds 2. Chemical Disposable Thermometers - e.g., heat sensitive tape or patches applied to the forehead that change its color to indicate temp 3. Temperature Sensitive Tape 4. Temporal Artery Thermometers TEMPERATURE SCALES - Measured in degrees on two scales: 1. Centigrade= (Fahrenheit temp – 32) X 5/9 2. Fahrenheit= (Celsius temp X 9/5) + 32 PULSE - It is a wave of blood created by contraction of the left ventricle to the heart - It represents the stroke volume output or the amount of blood that enters the arteries with each ventricular contraction - In a healthy person, the pulse reflects the heartbeat, that is, the pulse rate is the same as the number of ventricular contractions of the heart - CO is the amount of blood pumped into the arteries by the heart - CO = SV X HR e.g., 60 ml X 70 = 4220 ml or 4.22 L FACTORS AFFECTING THE PULSE 1. Age - As age increases pulse rate decreases 2. Gender - After puberty, the average male’s PR is slightly lower than the female’s 3. Exercise - PR normally increases with activity 4. Fever - PR increases due to vasodilation and increased BMR 5. Medications - Some may increase some may decrease PR (e.g., digoxin – decrease, epinephrine – increase) 6. Hypovolemia 7. Stress - Sympathetic nervous stimulation increases the overall activity of the heart 8. Position Changes 9. Pathology - Cardiac and oxygenation problems PULSE SITES ✓ Temporal ✓ Carotid ✓ Apical ✓ Brachial ✓ Radial ✓ Femoral ✓ Popliteal ✓ Posterior Tibial ✓ Pedal (Dorsalis Pedis) VARIATIONS IN PULSE AND RESPIRATIONS BY AGE Age Pulse Respirations Newborn 80-180 30-80 1 year 80-140 20-40 5-8 years 75-120 15-25 10 years 50-90 15-25 Teen 50-90 15-20 Adult 60-100 12-20 Older Adult 60-100 15-20 ASSESSING THE PULSE - It is commonly assessed by palpation or auscultation - Use the 3 middle fingertips except for the apical pulse NOTE: - Check for any medication taken - Ask for current/past activity performed Assess for the following: 1. Rate (tachycardic or bradycardic?) 2. Rhythm (regular or with dysrhythmia/arrhythmia?) 3. Volume (it can range from absent to bounding) 4. Arterial wall elasticity - Normal artery feels straight, smooth, soft and pliable 5. Presence or absence of bilateral equality PULSE DEFICIT - Apical pulse is greater than peripheral pulse - Occurs when some heart contractions are too weak to produce a palpable pulse at the radial site RESPIRATIONS - Is the act of breathing a. Inhalation (lasts 1 to 1.5 seconds) b. Exhalation (lasts 2 to 3 seconds) - Respiratory Center: medulla oblongata and the pons of the brain 2 TYPES OF BREATHING 1. Costal (Thoracic) 2. Diaphragmatic (Abdominal) ASSESSING RESPIRATION - Assess for the rate, rhythm, depth - The RR is normally described as BREATHS PER MINUTE 1. Bradypnea – abnormally slow respiration 2. Tachypnea/Polypnea – abnormally fast respiration 3. Eupnea – breathing that is normal in rate and depth 4. Apnea – absence of breathing FACTORS AFFECTING RESPIRATION ✓ Exercise 8. Position Changes 9. Pathology - Cardiac and oxygenation problems PULSE SITES ✓ Temporal ✓ Carotid ✓ Apical ✓ Brachial ✓ Radial ✓ Femoral ✓ Popliteal ✓ Posterior Tibial ✓ Pedal (Dorsalis Pedis) VARIATIONS IN PULSE AND RESPIRATIONS BY AGE Age Pulse Respirations Newborn 80-180 30-80 1 year 80-140 20-40 5-8 years 75-120 15-25 10 years 50-90 15-25 Teen 50-90 15-20 Adult 60-100 12-20 Older Adult 60-100 15-20 ASSESSING THE PULSE - It is commonly assessed by palpation or auscultation - Use the 3 middle fingertips except for the apical pulse NOTE: - Check for any medication taken - Ask for current/past activity performed Assess for the following: 1. Rate (tachycardic or bradycardic?) 2. Rhythm (regular or with dysrhythmia/arrhythmia?) 3. Volume (it can range from absent to bounding) 4. Arterial wall elasticity - Normal artery feels straight, smooth, soft and pliable 5. Presence or absence of bilateral equality PULSE DEFICIT - Apical pulse is greater than peripheral pulse - Occurs when some heart contractions are too weak to produce a palpable pulse at the radial site RESPIRATIONS - Is the act of breathing a. Inhalation (lasts 1 to 1.5 seconds) b. Exhalation (lasts 2 to 3 seconds) - Respiratory Center: medulla oblongata and the pons of the brain 2 TYPES OF BREATHING 1. Costal (Thoracic) 2. Diaphragmatic (Abdominal) ASSESSING RESPIRATION - Assess for the rate, rhythm, depth - The RR is normally described as BREATHS PER MINUTE 1. Bradypnea – abnormally slow respiration 2. Tachypnea/Polypnea – abnormally fast respiration 3. Eupnea – breathing that is normal in rate and depth 4. Apnea – absence of breathing FACTORS AFFECTING RESPIRATION ✓ Exercise FACTORS AFFECTING BLOOD PRESSURE 1. Age 2. Exercise 3. Stress - Stimulation of the sympathetic nervous system increases CO and vasoconstriction thereby increasing BP 4. Gender 5. Medications 6. Obesity 7. Diurnal Variations - Daily happenings 8. Disease Process - Any condition affecting the CO, blood volume, blood viscosity, compliance of the arteries can directly affect the BP HYPOTENSION - A blood pressure below normal - It may be due to analgesics, bleeding, severe burn, and dehydration ORTHOSTATIC HYPOTENSION - Place client in supine position for 10 min. - Record the clients PR and BP - Assist the client to slowly sit or stand - Immediately recheck the BP and PR ASSESSING BLOOD PRESSURE Materials Needed: - BP cuff - Sphygmomanometer - Stethoscope Bp Sites: - Upper arm - Thigh KOROTKOFF’S SOUND - Sounds heard through either a stethoscope or a doppler that is placed distal to the blood pressure cuff.

IPPA (Inspection, Palpation, Percussion and Auscultation) ‡ Purpose: - To gather baseline data about the FOLHQW¶VKHDOWK - To supplement, confirm or refute data obtained in the nursing history - To confirm and identify nursing diagnoses - To make clinical judgments about a FOLHQW¶VFKDQJLQJKHDOWKVWDWXVDQG management ‡Physical Assessment - $FRPSOHWHDVVHVVPHQWRISDWLHQW¶V physical and mental status ‡ Modes of examination (Head to Toe) - IPPA TECHNIQUE ڹ Inspection (1st technique) ڹ Palpation (2nd technique) ڹ Percussion (3rd technique) ڹ Auscultation (4th technique) ‡ If Assessing the Abdomen (IAPePa Technique) Inspection ڹ Auscultation ڹ Percussion ڹ Palpation ڹ ‡ Where do the Nurse conduct Physical Assessment? - Before the Admission of the Patient - When the Doctor Orders the patient for Discharge - During Follow up-Check-ups - Before and after every diagnostic and therapeutic procedures ‡ Before the Assessment, the Nurse must prepare the following: - Environment - Equipment - Client ‡ INSPECTION - Inspect body parts accurately the nurse observes the following principles: - Make sure good lighting is available - Position and expose body parts so that all surface can be viewed - Inspect each area from size, shape, color, symmetry, position and abnormalities ‡ When INSPECTING the nurse must focus on: - Overall appearance of Health or Illness - Facial Expression or Mood - Signs of Distress - Body size ‡ PALPATION - The nurse uses different parts of the hand to detect characteristics such as texture, temperature and the perception of movement. ‡ Principles: - Short Fingernails - The nurse should warm his/ her KDQGVSULRUWRXFKLQJWKHSDWLHQW¶V body - Encourage the patient to continue to breathe normally throughout the palpation ‡ 2 TYPES OF PALPATION 1. LIGHT PALPATION - It is used to detect tenderness and areas of muscular spasm or rigidity. - The examiner should systematically palpate the entire abdomen by using the flat part of his or her right hand or the pads of the fingers, not the fingertips. 2. DEEP PALPATION - To determine organ size, as well as the presence of abnormal abdominal masses. - In deep palpation, the examiner places the flat portion of his or her right hand on the patient's abdomen, and his or her left hand is placed over the right hand. ‡ PERCUSSION - Examination by striking the ERG\¶V surface with a finger, vibration and sound are produced. - This vibration is transmitted through the body tissues and the character of the sound depends on the density of the underlying tissue ‡ 2 TYPES 1. DIRECT 2. INDIRECT ‡ What do the Nurses hear? - PERCUSSION TONES Sounds Intensity Location Flat Soft Muscle and Bone Dull Medium Liver Resonance Loud Normal Lung Hyper Resonance Very Loud Empysematous Lung Tympany Loud Stomach that is filled with gas (air) ‡ AUSCULTATION - Listening to sound created in body organs to detect variations from normal. Normal Breath Sounds Vesicular Soft-Intensity, Low3LWFKHG³*HQWOH 6LJKLQJ´ (Bronchioles and Alveoli) Broncho-Vesicular Moderate-Intensity and Moderate3LWFKHG³%ORZLQJ´ (Bronchi) Bronchial (Tubular) High Pitched Loud, ³+DUVK´7UDFKHD - The nurse must also know on what will be the Position of the Patient when Assessing ‡326,7,216 1. Dorsal recumbent 2. Supine 3. Sitting - Seated position; back unsupported and leg hanging freely (Head and neck, axillae, anterior and posterior thorax, lungs, breasts, heart, vital signs, upper and lower extremities, reflexes) 4. Lithotomy 5. Sim's 6. Prone ‡ NURSING RESPONSIBILITIES: - GENERAL RESPONSIBILITIES - PREPARATION ENVIRONMENT - PROVIDE PRIVACY - CHECK LIGHTING ‡7KHVHTXHQFHRIPHWKRGVIRUSK\VLFDO examination is as follows: (IPPA) Inspection ڹ Palpation ڹ Percussion ڹ Auscultation ڹ ‡ SPECIAL CONSIDERATION ‡ The sequence for examination of the abdomen is as follows: (IAPePa) Inspection ڹ Auscultation ڹ Percussion ڹ Palpation ڹ - No abdominal palpation among clients with tumor of the liver or kidneys - During abdominal examination, it is important to flex the knees to relax the abdominal muscles - The sequence of examining the abdomen is as follows: 1. Right lower quadrant 2. Right upper quadrant