Assessing Vital Signs Notes

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    ASSESSING VITAL SIGNSRLE 1aVITAL SIGNSAlso known as Cardinal SignsIncludes TEMPERATURE, PULSE, RESPIRATION, and BLOOD PRESSUREA persons physiologic status is reflected by these indicators of body function

    Vital Signs are commonly assessed:1. Screenings at health fairs and clinics2. In the home3. Upon admission to a healthcare setting4. When certain medications are given

    Vital Signs are commonly assessed:5. Before and after diagnostic and surgical procedures6. Before and after certain

    nursing interventions7. In emergency

    situationsPurposes of assessing Vital Signs

    1. To obtain baseline measurement of the patients vital signs2. To assess patients response to treatment or medication3. To monitor patients condition after invasive procedures

    ASSESSING TEMPERATURE

    TEMPERATUREheat of the body measured in

    degreesDifference between production of heat and loss of heatPROCESS OF HEAT PRODUCTION DONE THROUGH:

    1. Food Metabolism and Activity2. Increased thyroxin production3. Chemical thermogenesis

    PROCESS OF HEAT LOSS IS DONE THROUGH:1. Radiation surface to surface by waves2. Conduction contact between 2 surfaces3. Convection movt by air currents or fluid4. Evaporation water to steam5. Elimination urination, defecation

    TYPES of TEMPERATURECore Temperature

    measured thru tympanic and rectal routesSurface Temperature

    measured thru oral and axillary routes

    FACTORS AFFECTING BODY TEMPERATURE1. Age2. Sex3. Exercise4. Time of day5. Emotions6. Environment7. Others; food, drugs

    COMMON SITES FOR ASSESSING BODY TEMPERATURE

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    1. Oral most frequently used, least disruptive, most convenient, done for 3minutes

    COMMON SITES FOR ASSESSING BODY TEMPERATURE2. Rectal most accurate route, but invasive and uncomfortable to

    patientCONTRAINDICATIONS:

    Rectal abnormalities Diarrhea

    Certain heart conditions

    Immunosuppressed

    COMMON SITES FOR ASSESSING BODY TEMPERATURE3. Axillary safer than the oral method, non-invasive, least accurate

    Done for 10 minutesCOMMON SITES FOR ASSESSING BODY TEMPERATURE4. Tympanic accessible, less invasiveASSESSING TEMPERATURE (axillary route)

    Unexpected Situations in assessing TEMPERATURETemperature higher/lower than expected based on how skin feels(re-assess with new thermometer)

    Feeling lightheaded or passes out during rectal temp assessment(remove thermometer immediately, assess BP & HR, notify doctor,

    dont take another rectal temp)Types of ThermometerTympanic ThermometerElectronic or Digital ThermometerGlass ThermometerGlass Thermometer

    Temperature sensitive Tape

    Chemical ThermometerASSESSING PULSEPULSEA wave of blood being pumped into the arterial circulation by the contraction of theleft ventricle

    Throbbing sensation palpated over a peripheral arteryASSESSMENT PARAMETERS / CHARACTERISTICS OF PULSE

    1. Rate number of beats per minuteASSESSMENT PARAMETERS / CHARACTERISTICS OF PULSE

    2. Rhythm pattern or regularity of beats and interval between each beat

    3. Volume/amplitude amount of blood pumped with each heartbeat

    Cardiac Output 5-6 Liters of blood is forced out of the leftventricle per minutePulse Deficit difference

    between the apical andradial counts takensimultaneously

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    LOCATION OFPERIPHERALPULSESReasons for Using Specific Pulse SiteRadial PulseApical Pulse

    1. Age2. Sex3. Exercise4. Emotions5. Prolonged heat application6. Body positions7. Pain8. Decreased BP9. Increased temperature10.Any conditions resulting to poor

    oxygenation of blood ex. CHF

    Respiration

    Pulmonary ventilation (breathing) movement of air in and out of thelungs

    Inspiration (inhalation) act or breathing in

    Expiration (exhalation) act of breathing out

    External respiration exchange of O2 and CO2 between alveoliand blood

    Internal respiration exchange of O2 and CO2 between blood andtissue cells

    1. Rate number of breaths per minuteASSESSMENT PARAMETERS /

    CHARACTERISTICS OF RESPIRATION2. Rhythm regularity of respiration, inhalation and exhalation

    are evenly spacedASSESSMENT PARAMETERS /

    CHARACTERISTICS OF RESPIRATION3. Depth assessed by watching the movement of the chest

    2 TYPES OF BREATHING1. Costal/thoracic breathing involves external intercostal muscles and other

    accessory muscles

    Observed thru upward and outward movement of the chestFACTORS AFFECTING RESPIRATION

    1. Exercise2. Certain infections3. Age4. Emotions5. Cardiac illness6. stress

    TERMINOLOGIES REGARDING RESPIRATION

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    TERMINOLOGIES REGARDING RESPIRATIONKussmauls Faster and deeper respiration without pauses in between pantingApneustic Prolonged grasping followed by extremely short insufficient exhalationDyspnea difficulty of breathingOrthopnea DOB unless sittingWheezing narrowing of airways, causingwhistling or sighing sounds

    Stridor high-pitched sounds heard oninspirationTERMINOLOGIES REGARDING RESPIRATIONRales - sound caused by air passing thru fluid or mucus in the airways usually heardon inhalationRhonchi sound caused by air passing thruairways narrowed by fluids,edema, musclespasm usually heard during exhalationASSESSING RESPIRATIONBLOOD PRESSUREFactors affecting Blood pressure

    1. Age2. Emotions3. Exercise

    4. Drugs5. Environment

    Korotkoffs soundThe End