Vital Signs C.

Factors affecting temperature

 Temperature 1. Season/environment
 Pulse Rate  Vasomotor nerve controls the size of the
 Temperature blood vessels. They constrict during cold
 Blood Pressure season so that less heat is loss from the
body. During summer, blood vessels dilate
Vital Signs in the skin, blood vessels dilate in the skin
 serves as important indicators of the client's dilate so that great volume of blood flows
condition through them. Heat is therefore lost from
the body.
Temperature
 The balance between heat produced and 2. Age
heat loss form the body. It is affected by the  Infant and young children have
centers of the hypothalamus. undeveloped heat-regulation mechanism
causing variation in temperature. In older
2 Types of Temperature persons, body temperature needs to be
1. Core Temperature lower and is great affected by cold weather.
 Internal temperature of the body
2. Surface Temperature 3. Sex
 external temperature of the body  Increase progesterone level in female
during ovulation raises body temperature.
A. Heat Production
1. Chemically 4. Hormonal Activity
A. Food Metabolism  Hormonal action of thyroxine, epinephrine
B. Activity of the hormones by endocrine and norepinephrine elevates during
glands(thyroxin, epinephrine, norepinephrine) extreme emotions (rage, fright, excitement)
which raises body temperature.
2. Physically
 through activity of the skeletal muscle 5. Time of Day
 If there is lowered vitality, fasting, depression  Lowest during early mornings and
of the nervous system, and sleep, there is increased during the day due to food
decrease heat production. metabolism and increased body activity.

B. Heat loss 6. Exercise

1. Radiation  Sedentary people have lower body
 Heat transfer from the surface of the body temperature due to decrease of muscle
to the surface of another without contact activity. Rest and sleep decreases body
between these objects. Waves, air temperature.

2. Conduction 7. Food intake

 Heat transfer by direct contact between
molecule -TSB
3. Convection transfer occurring with air
movement -air from electric fan
 A high caloric, energy giving food increase
temperature. Fasting or starvation
decreases temperature due to minimal
metabolism or less energy and heat
production.

4. Evaporation Deviation on Temperature

 Heat transfer or heat loss occurs 1. Afebrile/ normothermia
continuously through the respiratory tract Normal body temperature
and through insensible perspiration from  36.4 C to 37.4 (97.6 to 99.3)
the skin.
2. Fever/ Pyrexia
 Elevation in the body

3. Hyperpyrexia
 A very high fever
4. Hypothermia NURSING INTERVENTIONS OF CLIENTS WITH
 An extremely low body temperature FEVER.

Stages of Fever 1. Monitor Vital Signs

 Invasion
 Fastigium( stadium of fever)
 Defervescence/ Decline
1. Invasion
 Period when the body temperature is rising
characterized by shivering or strong muscle
contractions resulting to shaking, chills,
increase body metabolism, pallid skin due to
peripheral vasoconstriction, gooseflesh
appearance, due to construction of erector
pili muscle and feeling of coldness.
2. Fastigium (stadium of fever)
 Period when the body temperature is at its
highest peak. Skin is warm to touch,
peripheral vasodilation results in skin
flushing, individual is irritatable, complains of
headache, feels generalized weakness, body
acne. Prolonged fever causes weight loss
and anorexia, nausea, vomiting, dehydration,
convulsions or disorientation maybe present.
3. Defervescence/ Decline
 Period when elevated temperature return to
normal.
2. Assess the skin color and temperature.
3. Monitor WBC or White Blood Cells. HCT and
other pertinent laboratory records
4. Removes excess blankets when the clients
feel warm.
5. Provide adequate food and fluid.
6. Measure I and O.
7. Maintain prescribed IV fluids.
8. Promote rest.
9. Provide good oral hygiene.
10. Provide cool, circulating air by using a fan.
11. Provide dry clothing and bed linens.
12. Provide TSB.
13. Administer antipyretics as ordered.
KINDS OF THERMOMETER
1. Traditional
2. Electronic
3. Infrared
4. Disposable
Electronic Thermometer
Battery powered display unit with a sensitive probe(
blue for oral and red for rectal) covered with a
disposable plastic sheath for individual use.

Tympanic Thermometer
A. Cross Battery powered display unit with disposable
speculums and infrared sensing electronics.
 dressing drip in temperature
B. Lysis
Disposable (Chemical)
 elevation drop in temperature over a period of
Single use
several days
Thin strips of plastic with chemically impregnated
dots that change color to reflect temperature.
Types of Fever
1. Intermittent Fever-
Methods of Temperature Taking
 Temperature fluctuates between periods of
fever and period of normal/subnormal 1. ORAL
temperature.
 most accessible and convenient
 2 to 3 minutes
2. Remittent Fever
 36.7-37.7 C
 Temperature fluctuates within a wide range
over the 24hr periods but remains above
Contradiction
normal range.
 Oral lesion or surgery
3. Relapsing Fever  Dyspnea
 Temperature is elevated for few days,  Cough
alternated with 1 or 2 days of normal  Nausea and vomiting
temperature.  Seizure prone
 Presence of nasal contraptions
4. Constant Fever  Young Children
 Body temperature is consistently high.  Unconscious
 Restless, disoriented, and confused.
2. RECTAL - most accurate Fahrenheit to Centigrade Conversion:
 Assist client to assume lateral position
 Apply lubricant  Deduct 32 from the Fahrenheit reading and
 Insert Thermometer multiply by 5/9
 Deep breathe  °C= ( °F-32) × 5/9
 2 minutes
 Fahrenheit scale is named after a German
CONTRADICTIONS: Physicist, Garbriel Daniel Fahrenheit
 Anal/ Rectal conditions or surgeries - anal
fissure  Centigrade scale is named after a Swedish
 Hemorrhoids scientist, Anders Celsius
 Hemorrhoidectomy
 Diarrhea Pulse
 The wave felt caused by the expansion and
3. AXILLARY distention of the arterial walls as the blood is
 safest and most invasive forced into the aorta and then into the smaller
 Pat dry axilla arteries each time the heart beats.
 Place the thermometer in the client's axilla.
 Place the arm tightly across the chest to keep
the thermometer in place for 9 minutes. Assessment of the Pulse
1. Rate
 ( Infants/ Children for 5 minutes)
 36.4 - 37.4 C  The number of beats per minute (60-80 beats
per minute)
NORMAL AGE-RELATED VARIATIONS IN BODY
TEMPERATURE The normal pulse rates per minute are as
follows:

Newborn to 1 month: 100-180 beats/min

AGE NORMAL CELSIUS FAHRENHEIT
1 year: 80-140 beats/min
RANGE
2 years: 80-130 beats/min
6 years: 75-120 beats/min
NEWBORN Axillary 35.5 96.0
10 years: 60-90 beats/min
-39.5 °C - 99.5 °F
Adult: 60-100 beats/min
1 year old Oral 37.7 °C 99.7 °F •Tachycardia. Pulse rate above 100 beats/min.
(Adult) (Very fast heart beat)
3 years old Oral 37.2 °C 99.0 °F
•Bradycardia. Pulse rate below 60 beats/min(Adult).
5 years old Oral 37.0 °C 98.6 °F (Very slow heart beat)
Adult Oral 37.0 °C 98.6 °F 2. Rhythm
 Pattern of heart beats, Interval between
Axillary 36.4 °C 97.6 °F beats.
Rectal 37.6 °C 99.6 °F A. Regular- time between beats is essentially the
same.
70 years B. Arrhythmia- interval between beats is irregular.
Old+ Oral 36.0 °C 96.8 °F
3. Volume
Centigrade and Fahrenheit Conversion Formulas  Size or amplitude of blood pushed against
the wall of the artery during ventricular
 Centigrade (Celsius) to Fahrenheit contractions.
conversion:
 Multiply the centigrade reading by 9/5 and A. Normal - if compressed artery is full to touch and
add 32: pulsations is strong.
 °F (°C×9/5) + 32
B. Imperceptible - if pulsations cannot be felt.
C. Thready or feeble - pulsations can be easily • > Apical- Radial Pulse
obliterated.  Apical pulse is counted at the Apex of the
heart while another nurse counts the radial
D. Bounding- if pulsations reaches a higher level pulse.
than normal then disappears again.  This is done simultaneously for one full
minute.
Pulse Sites
> Pulse Deficit
1. Radial  The difference between the apical and radial
 On the thumb side of the inner aspect of the pulses.
wrist.
Factors Affecting the Pulse Rate
2. Temporal
 Over the temporal bone of the head; 1. Age
 Superior and lateral to the eye.  Younger persons have higher pulse rate than
older persons.
3. Carotid
 At the lateral aspect of the neck; below the 2. Sex/Gender
ear lobe.  After puberty, females have higher pulse rate
 Side of the neck near the angle of jaw. than the males.

4. Brachial 3. Exercise
 At the inner aspect of the upper arm (Biceps  Increases metabolic rate, thereby increasing
muscles) or medially at the antecubital space. the pulse rate.
 A few meters below the axilla on the inner
aspects of the arm. 4. Fever
 Increases metabolic rate, therefore the pulse
5. Apical rate increases.
 Apical left midclavicular line (MCL) at four to
fifth intercostals space (ICS), Use 5. Medications
stethoscope. Used to auscultate heart  Digitalis, beta blockers decrease pulse rate;
sounds and assess apical- radical sounds. epinephrine, atrophine sulfate increase pulse
rate.
6. Femoral
 Along side the inguinal ligament. 6. Hemorrhage
 Middle of the groin.  Increases pulse rate as compensatory
mechanism for blood loss.
7. Popliteal Artery
 At the back of the knee. 7. Stress
 Behind the knee, along the center of popliteal  Sympathetic nervous stimulation increases
space. the activity of the heart.

8. Posterior Tibial artery 8. Position changes

 At the medial aspect of the ankle, behind the  In sitting or standing position there is
medial malleolus. decreased venous return to the heart,
 The groove between the Achilles tendon and decrease BP, therefore increase in the heart
the tibia just above the medial malleolus then rate.
pressing toward the tibia.
Types of Pulse Rate
9. Pedal (Dorsalis Pedis)
 At the dorsum of the foot 1. Bigeminal Pulse
 Pedal pulse, at the instep of the foot on an  Two regular beats are followed by longer
imaginary line drawn from the middle ankle to pulse than normal
the interdigital space between the big and the
second toes. 2. Collapsing Pulse
 From the dorsum of the foot in a line between  Pulse strikes feebly against the finger then
the big or first and second toes. subsidy abruptly.
 RESPIRATION
3. Corrigan's Pulse or the Water Hammer Pulse • The act of breathing.
 A jerky pulse with a full extension followed by
a sudden collapse THREE PROCESSES

4. Dicrotic pulse Ventilation

 Has two marked expansion in one beat of the  The movement of gases in and out of the
artery. lungs
 Inhalation (Inspiration)
5. Labile Pulse  •Exhalation (Expiration)
 It’s rate and other characteristics are normal
when patient is resting but increases when he Diffusion
sits up, stands or exercise.  The exchange of gases from an area of
higher pressure to an area of lower pressure.
6. Wiry Pulse It occurs at the alveolo-capillary membrane.
 Small, tense and upon palpations, it feels
like a cord or wire. Perfusion
 The availability and movement of blood for
Pulse Site transport of gases, nutrients and metabolic
1. Temporal waste products.
2. Carotid
3. Apical- TWO TYPES OF BREATHING
4. Brachial 1. Costal (thoracic)
5. Radial  Involves movement of the chest
6. Femoral
7. Popliteal 2. Diaphragmatic (abdominal)
8. Dorsalis Pedis  Involves movement of the abdomen
9. Posterior tibialis
RESPIRATORY CENTERS
NORMAL AGE-RELATED TO VARIATIONS IN
RESTING PULSE 1. Medulla Oblongata
• Is the primary respiratory center.

AGE NORMAL AVERAGE 2. Pons contains the following:

RANGE RATE/ • Pneumotaxic center - responsible for the rhythmic
MINUTE quality of breathing.

Newborn 100-170 140 • Apneustic center - responsible for deep,

prolonged inspiration.
1 year old 80 - 170 120
3, Carotid and aortic bodies
3 years old 80 - 130 110 • contain peripheral chemoreceptors. These take up
the work of breathing when central chemoreceptors
6 years old 75 - 120 100 in the medulla oblongata are damaged. Respond to
low oxygen concentration in the blood. Respond to
10 years old 70 - 110 90 pressures. If the BP is elevated the respiratory rate
becomes slow. (Hypertension leads to respiratory
14 years old 60- 110 90 acidosis). If the BP is decreased, the respiratory rate
is rapid.(Hypotension leads to respiratory alkalosis.)
Adult 60 - 100 80 The primary chemical stimulation for breathing is
high carbon dioxide level in the blood.

4. Muscle and joints contain proprioreceptors.

•Proprioreceptors. Exercise increases respiratory
rate.
Factors that Influence Variation in Respiration
1. Age
 Newborn has higher respiratory rate than
older people (30- 60 beats per minute)
2. Strong emotions
 Hormones are secreted in large amount
which tends to stimulate respiratory rate.
3. Sex
 Female have slightly rapid respiratory rate
than males.
4. Exposure to extreme of temperature
 Cold application makes breathing fuller and
deeper while hot application increases
breathing
5. Ingestion of toxins, caffeine and stimulants
 increase respiration
6. Changes in altitude
 The higher the place, the more you gasp for
breath because air does not provide enough
oxygen for the blood to absorb and circulate.
7. Ingestion of food and exercise
 Increase metabolism, therefore increasing
need for oxygen, this respiratory rate is
increased.
Types of Respiration
1. Apnea
 Temporary cessation of breathing
2. Eupnea
 Normal respiration
3. Dyspnea
 Difficult respiration
4. Polypnea
 Abnormal increase in respiratory rate
5. Bradypnea
 Abnormal decrease in respiratory rate.
6. Orthopnea
 Inability to breath in lying or horizontal
position
7. Hyperventilation
 A very deep and rapid ventilation
8. Hypoventilation
 Shallow and slow respiration
9. Hypoxemia
 A decrease oxygen in blood
10. Hypoxia
 A decrease oxygen in tissue
11. Abdominal Breathing
 Breathing involving chiefly the muscles of the
abdomen and diaphragm
12. Diaphragmatic Breathing
 Breathing accomplished chiefly by the
diaphragm
13. Kussmaul's Respiration
 Paroxysmal breathing ( diabetic coma)
14 Stertorous Respiration
 Noisy breathing in snoring
15. Cheynestokes Respiration
 Respiration with alternating periods of
hyperpnea and apnea
Abnormal Sounds of Respiration
Wheezing
 Due to constricted airways as in asthma
Stridor
 A harsh crowing sound heard on inspiration
due to acute constriction of the trachea.
Rales/ Rhonchi
 Bubbling or crackling or fizzing sounds
evident in patient with lung disease
BLOOD PRESSURE
 Is a measure of the pressure exerted by the
blood as it pulsates through the arteries.
 BP = C.O. × Tot. Peripheral Resistance
 Cardiac Output, the amount of blood pumped
by each ventricle in one minute.
 Cardiac Output is equal to the heart rate
multiplied by the stroke volume.
 Stroke volume is the amount of blood
pumped by a ventricle with each beat.
2 PHASES
Systole
 The working period of the heart
 The heart contracts and pumps blood into the
circulation
Diastole
 The resting period of the heart
 The time when the heart is filling with blood,
which will pumped out during the next
systole.
Systolic Pressure
 Is the pressure of blood as the result of
contraction of the ventricle.
Diastolic Pressure
 Is the pressure when ventricles are at rest.
Pulse Pressure
 Is the difference between the systolic and
diastolic pressure.
Factors Affecting Blood Pressure
Age
• Blood pressure rises with age. Arteries loose
their and become more rigid( arteriosclerosis)
resulting in even greater resistance to the
heart's effort to fill the arteries with blood or
arteries maybe filled with fat deposits(
atherosclerosis) interferes with the amount of
blood that can be contained within the
arteries thus blood pressure is Increased.
Time of Day
• Blood Pressure tends to be lowest in the
morning than later during the day.
Sex
• Women have lower blood pressure than men.
Exercise and Activity
 Increases during periods of activity or
exercise though regular exercise helps
maintain blood pressure within normal range.
Emotions and pain
• Strong emotions and pain tends to make
blood pressure to rise.
Miscellaneous Factor
 A person has lower Blood Pressure when
lying down than when sitting or standing.
 Blood Pressure rises when the urinary
bladder is full and when legs are crossed.
 Blood Pressure rises when a person uses
tobacco, drinks a caffeinated beverage or is
cold.
 Arise and fall of 20 to 30 mm Hg in an
person's usual blood pressure is considered
normal
Related Terms
Hypertension
• A abnormally high blood pressure or two
different but subsequent visits
Hypotension
 Abnormally low blood pressure for two
different but subsequent visits
Orthostatic Hypotension or Postural
Hypotension
 Sudden change in position causing decrease
in blood pressure
Pulse pressure
 The difference between systolic and diastolic
blood pressure measurements
 Pulse pressure between 30- 50 normal is
considered within normal range.
Korotkoff sounds
• Sounds heard when obtaining blood pressure
EQUIPMENTS USED TO OBTAIN BP
Sphygmomanometer
 Used to measure the pressure of blood within
the artery, should cover not more than 2/3 of
the arm when in use.
• Mercurial manometer
• Aneroid manometer
Stethoscope
• Instrument that carries sounds from body to the
examiner's ears; it magnifies sounds.
A. Bell - the cupped tip
B. diaphragm -flat disk tip
 The average BP of healthy adult is 120/80
mmHg
 Hypertension is an abnormally high blood
pressure over 140 mmHg systolic and/or 90
mmHg diastolic for at least two consecutive
readings.
 Hypotension is an abnormal blood pressure,
systolic pressure below 100 mmHg
 The diagnosis of HPN is made
  When the average of diastolic is 90 mmHg
and systolic of 140 mmHg is higher on two or
more readings on two visits.

Hypertension
• Blood Pressure is persistently above normal
• Systolic Blood Pressure is above 130
• Diastolic Blood Pressure is below 85

HYPOTENSION
• Blood Pressure below normal
• Systolic reading consistently between 85 and
110 mmHg

ORTHOSTATIC HYPOTENSION
• BP that falls when client sits/stands
• The result of peripheral vasodilation

• CAUSES: analgesic (Demerol). Bleeding

severe burn, dehydration
• NSG. Inteverntion: Prevent fall

CONTRAINDICATIONS
 The shoulder, arm or hand is injured or
diseases
 A cast or bulky bandage is on any part of
the limb
 The client has had a removal of axilla (or
hip) lymph nodes on that side.
 Client has IV infusion in that limb
 Client has AV fistula in that limb

• Korotkoff's sounds -a series of

sounds heard during Blood Pressure (BP) taking.

• Auscultatory gap- temporary

disappearance of sounds normally heard over the
brachial artery when the cuff pressure is high
followed by the reappearance of the sounds at the
lower level.