FUNDAMENTALS

VITAL SIGNS (CARDINAL SIGNS)

  • Vital signs reflect the body's physiologic status and provide information critical to evaluating homeostatic balance.
  • Considered from the clearest indicators of overall health status.
  • Vital signs include:
    • T (temperature)
    • PR (pulse rate)
    • RR (respiratory rate)
    • BP (blood pressure)

PURPOSES OF ASSESSING VITAL SIGNS

  • Monitor bodily functions: Helps in tracking the functions of the body over time.
  • Detect changes in condition: Signals changes in function that might not be observed otherwise.
  • Baseline data collection: Collects baseline data about the patient's condition for future comparisons.
  • Aid in diagnosis: Assists in diagnosing the patient's condition for better intervention.
  • Therapeutic intervention: Helps in deciding on the therapeutic actions needed for the patient.

TIMES TO ASSESS VITAL SIGNS

  • Upon admission to a healthcare facility to obtain baseline data.
  • When a client's health changes (e.g., reports symptoms like chest pain, feeling faint).
  • Before and after surgery or invasive procedures.
  • Prior to and following medication that may impact the respiratory or cardiovascular systems.
  • Before and after nursing interventions that may affect vital signs.
  • As per nursing or medical orders and institutional policies.

BODY TEMPERATURE

  • Body temperature is a measure of the heat inside a person's body, and reflects the balance between heat produced and lost.

TYPES OF BODY TEMPERATURE

  1. Core Temperature
    • Represents temperature in the deep tissues of the body, measured with a thermometer, and remains constant.
  2. Surface Temperature
    • Temperature of the skin and subcutaneous tissues.

HEAT TRANSFER MECHANISMS

  1. Conduction
    • Direct transfer of heat from one area to another; minimal heat loss except when immersed in cold water.
  2. Convection
    • Heat dispersion through air currents (e.g., use of an electric fan).
  3. Radiation
    • Indirect heat transfer without contact, primarily through infrared rays.
  4. Vaporization
    • Continuous evaporation of moisture from the respiratory tract and skin, impacting temperature regulation.

SITES FOR MEASURING BODY TEMPERATURE AND NORMAL VALUES

  • Oral: 37°C (98.6°F)

    • Wait for 20-30 minutes post hot/cold food/drinks, smoking or strenuous activity.
    • Contraindicated for:
    • Children below 7 years
    • Patients with certain mental or physical conditions

  • Rectal: 37.5°C (99.6°F)

    • Most reliable site. Not to be taken in newborns due to trauma risk.
    • Contraindicated for:
    • Rectal surgery
    • Neonates (risk of perforation)

  • Axillary: 36.4°C (97.6°F)

    • Safest site, but less accurate; requires about 5 minutes for measurement.

  • Tympanic Membrane: Fast measurement, reflects core temperature directly using a tympanic thermometer.

  • Forehead (Temporal Artery): Fast and non-invasive; less affected by perspiration.

TYPES OF THERMOMETERS

  1. Clinical Glass Mercury Thermometers
    • Use thermal expansion of mercury in glass.
  2. Electronic Thermometers
  3. Infrared Thermometers (Tympanic)
  4. Temperature-Sensitive Strips (disposable thermometers)
  5. Liquid Crystal Thermometer

FACTORS AFFECTING BODY TEMPERATURE

  • Age:
    • Infants: Temperature fluctuates with the environment.
    • Elderly: Sensitive to temperature extremes.
  • Exercise: Increases metabolism and temperature due to muscle activity.
  • Circadian Rhythms: Regular variations in temperature within a 24-hour cycle.
  • Stress: Can raise temperature through hormonal and neural stimulation.
  • Environment: Extreme temperatures can affect body temperature regulation.

ALTERATIONS IN BODY TEMPERATURE

  1. Pyrexia/Hyperthermia (Fever): Temp above normal.
  2. Hyperpyrexia: Extreme fever, usually above 41°C; risk of mortality at 42°C.
  3. Intermittent Fever: Alternates between fever and normal temperatures.
  4. Remittent Fever: Temperature fluctuates (more than 2°C) but remains above normal.
  5. Relapsing Fever: Short febrile periods interspersed with normal temperature.
  6. Constant Fever: Minimal fluctuations but always above normal.

SIGNS AND SYMPTOMS ASSOCIATED WITH FEVER

  • CNS disturbances: Cyanotic nail beds, “goose flesh”, cessation of sweating, and skin warmth.
  • Clinical manifestations include nausea, vomiting, rapid pulse, dizziness, body shivers, joint pain, fatigue, and dehydration symptoms.

NURSING INTERVENTIONS FOR CLIENTS WITH FEVER

  • Monitor vital signs and assess skin color.
  • Remove excess clothing as the patient feels warm but provide warmth if chilly.
  • Ensure adequate hydration and nutrition.
  • Utilize tepid sponge baths and maintain a comfortable environment.

PULSE

  • Pulse is the wave of blood from the heart, indicating stroke volume output and correlating to the overall cardiac output, given by the formula: ext{CO} = ext{SV} imes ext{HR}.
  • Different pulse types: Peripheral pulse (away from the heart) and Apical pulse (direct heart area).
  • Terms to remember:
    • Pulse volume: Strength per beat.
    • Pulse deficit: Difference between apical and radial pulse.
    • Rhythm: Pattern and intervals of heartbeats.
    • Dysrhythmia: Irregular pulse rhythm.

FACTORS AFFECTING PULSE RATE

  1. Age: Pulse decreases gradually with age.

  2. Gender: Males generally lower than females post-puberty.

  3. Exercise: Normal increases in activity; athletes have lower rates.

  4. Fever: Usually increases pulse due to metabolic changes.

  5. Medication: Varies the rate.

    • E.g., Digitalis decreases; Epinephrine increases.

  6. Hypovolemia: In blood loss, compensatory heart rate increase.

  7. Stress: Increases heart activity through sympathetic stimulation.

  8. Position Changes: Change from standing/sitting may temporarily raise rates.

  9. Pathology: Diseases affecting heart function can alter resting rates.

BLOOD PRESSURE

  • Blood pressure measures the force exerted by blood against arterial walls.
  • Systolic Pressure: Pressure during ventricular contraction.
  • Diastolic Pressure: Pressure during ventricular relaxation.
  • Pulse Pressure: Difference between systolic and diastolic pressures.

FACTORS AFFECTING BLOOD PRESSURE

  1. Age: BP typically increases with age, especially post-puberty.
  2. Exercise: Physical activity temporarily raises BP.
  3. Stress: Activates sympathetic responses elevating BP.
  4. Race and Gender: Genetic and hormonal influences can raise BP in specific demographics.
  5. Diurnal Variations: BP generally lowest in the early morning and peaks in the late afternoon/evening.
  6. Disease Process: Conditions affecting circulation directly impact blood pressure.

RESPIRATION

  • Respiration is the gas exchange process between the atmosphere and body tissues, encompassing inhalation and exhalation.

TYPES OF RESPIRATION

  1. External Respiration: Exchange of O2 and CO2 between the atmosphere and lungs.
  2. Internal Respiration: Exchange of O2 and CO2 at the cellular level.

FACTORS AFFECTING RESPIRATIONS

  • Exercise: Increases both depth and rate to meet metabolic demands.
  • Stress/Anxiety: Elevates respiratory activity.
  • Body Position: Upright enhances chest expansion.
  • Altitude: Increased elevation requires adaptations in respiratory function.
  • Medications: Various drugs can stimulate or depress respiration rates.

NORMAL RESPIRATORY RATES BY AGE

  • Newborn: 35-45 breaths/min
  • Infant (6 months): 30-50 breaths/min
  • Toddler (2 years): 25-32 breaths/min
  • Child: 20-30 breaths/min
  • Adolescent: 16-19 breaths/min
  • Adult: 12-20 breaths/min

MEDICATION ADMINISTRATION

  • Definition: A substance given for diagnosis, treatment, or relief. Includes:
    • Drug: Often implies illicit substance.
    • Prescription: Directions for drug preparation and administration.

KEY TERMS IN PHARMACOLOGY

  1. Generic Name: Pre-approved non-brand name.
  2. Chemical Name: Describes the actual molecular structure.
  3. Trade Name: Brand name by the manufacturer.
  4. Side Effect: Secondary, often unintended effects of drugs (e.g., nausea from Digitalis).
  5. Adverse Reactions: Severe harmful effects.
  6. Drug Interactions: Altered effectiveness when two or more drugs are taken together.

ROUTES OF ADMINISTRATION

  • Oral: Most common; via the alimentary tract.
  • Sublingual/Buccal: Dissolved under the tongue or against cheek lining.
  • Rectal/Vaginal: Local or systemic effects.
  • Parenteral: Includes injections (Subcutaneous, Intramuscular, Intravenous).
  • Topical: Applied directly to the body surface.

10 RIGHTS OF MEDICATION ADMINISTRATION

  1. Right Medication
  2. Right Dose
  3. Right Time
  4. Right Route
  5. Right Client
  6. Right Documentation
  7. Right Education
  8. Right to Refuse
  9. Right Assessment
  10. Right Evaluation