Vital Signs Taking

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Assessing Assessing Vital Signs Vital Signs Dr. Lorena C. Balacanao

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AssessingAssessing Vital SignsVital SignsDr. Lorena C. Balacanao

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IntroductionIntroductionAssessing vital signs or cardinal sign is a

routine medical procedure. And somehow determines the internal functions of the body

Vital signs composes of the following:◦Body temperature◦Pulse◦Respiration and ◦Blood pressure

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Body Body TemperatureTemperature

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Body temperature◦It is a balance between the internal and

external environment of the body, or◦It is the balance between the heat produced by

the body and the heat lost from the body.◦It is measured in heat units, called degrees

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Two types of Body Two types of Body temperaturetemperatureCORE Temperature- it is the temperature

of the deep tissues of the body, such as the cranium, thorax, abdominal cavity and pelvic cavity.

It remains relatively constant (37 °C/ 98 °F)

An accurate measurement is usually done using a pulmonary catheter.

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SURFACE temperature- is the temperature of the skin, the subcutaneous tissues and fat

It constantly rises and falls in relation to the environment

It varies from 20 °C (68 °F) to 40 °C (104 °F)

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Sites commonly used in taking Sites commonly used in taking BTBT

Oral- most commonAxilla –mostly used in infants and

childrenRectal- second choice Tympanic membrane- most favorable site

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Factors that affect heat Factors that affect heat productionproduction

1. BMR- is the rate of energy utilization in the body required to maintain essential activities such as breathing, walking, speaking and others.

Metabolic rate decreases with age2. Muscle Activity- such as shivering

increases metabolic rateExample: walking, jogging etc

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3. Thyroxine output- increase in thyroxine hormone, increases the rate of cellular metabolism throughout the body.

This is called Chemical thermogenesis, the stimulation of heat production in the body through increase cellular metabolism.

4. Sympathetic stimulation- the release of epinephrine and nor epinephrine thus increase the rate of cellular metabolism

5. Fever- it increases metabolic rate and thus increases the body temperature

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Heat lossHeat loss

1. Radiation is the transfer of heat from the surface of one object to the surface of another without contact between the two objects

2. Conduction is the transfer of heat from one molecule to another. E.g. the body is immersed in ice water

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3. Convection is the dispersion of heat by air currents

4. Evaporation is the continuous evaporation of moisture from the respiratory tract and from the mucosa of the mouth as well as from the skin.

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Regulation of body Regulation of body temperaturetemperature

System that regulates body temperature1. Sensors in the skin and in the core2. An integrator in the hypothalamus and3. A system that adjusts the production

and loss of heat.NOTE: the skin has a more receptor for

colds than warmth, it therefore detect cold more efficiently that warmth

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Factors affecting Body Factors affecting Body temperaturetemperature1. Age – infants greatly influenced by the

temperature, children more labile than adult and elderly are extremely sensitive to environmental change due to decreased thermoregulatory control

2. Diurnal variations (circadian rhythms) – Body temperature normally change throughout the day, varying as much as 1.0 °C between early morning and late afternoon

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The point of highest body temperature is usually reached between 8pm and 12 midnight and the lowest point is reached during sleep between 4 a.m. and 6 a.m.

3. Exercise4. Hormones –women usually experience more

hormone fluctuations than men, progesterone secretion in women raises body temperature.

5. Stress- epinephrine and nor epinephrine increases metabolic activity and heat production

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Alteration in Body Alteration in Body temperaturetemperaturePyrexia, hyperpyrexia or fever- increase

body temperature◦ febrile with fever◦Afebrile without fever

Types of fever Intermittent-alternate body temperature (time) Remittent- wide range of temperature fluctuation Relapsing- short febrile periods few days then normal Constant- continuous

Hypothermia- decrease in core temperature below the low limit of normal

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Types of ThermometerTypes of Thermometer1. Mercury in glass◦Oral thermometer have a long, slender tips ◦Rectal thermometer have a short, rounded tips

2. Electronic thermometer◦Digital thermometer

3. Chemical thermometer4. Temperature sensitive strip5. Infrared thermometer◦Tympanic thermometer

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Oral thermometer (Glass)Oral thermometer (Glass)

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Digital ThermometerDigital Thermometer

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Taking axillary

Temperature

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Digital thermometer is commonly Digital thermometer is commonly used in infants and children, used in infants and children, insert it at the axillary regioninsert it at the axillary region

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closed the arm and wait for timer closed the arm and wait for timer to bustle to bustle

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Remember when taking BT in infants and children Remember when taking BT in infants and children make sure that the patient is not in distress mood make sure that the patient is not in distress mood because any change in the activity will directly affect because any change in the activity will directly affect the BT reading.the BT reading.

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Taking Oral

temperatur

e

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The Oral CavityThe Oral Cavity

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Parts: Oral Vestibule and Oral Parts: Oral Vestibule and Oral Cavity ProperCavity Proper

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Floor of the mouthFloor of the mouth

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Insert the tip at the sublingual Insert the tip at the sublingual fossafossa

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Positioned the thermometerPositioned the thermometer

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Let stay for 1 to 2 minutes, tell the Let stay for 1 to 2 minutes, tell the patient to close the mouthpatient to close the mouth

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Temperature conversion Temperature conversion °C = (Fahrenheit – 32 ) x 5/9 ◦Convert 100 °F

°F = (Celsius x 9/5) + 32◦Convert 40 °C

◦Normal/ Average temperature is between 36-37.9 °C or 96.8 – 100.3 °F

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Pulse Rate

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PulsePulseIs a wave of blood created by contraction of

left ventricle of the heartGenerally, the pulse wave represents the

stroke volume output and the compliance of arteries.

Stroke volume output is the amount of blood that enters the arteries with each ventricular contraction.

Compliance its the ability of the arteries to contract andexpand.

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When adult is resting, the heart pumps 4 to 6 liters of blood per minute. This volume is called cardiac output,

The cardiac output (CO) is the result of the stroke volume (SV) times the heart rate (HR) per minute

CO= SV x HRNote: in healthy person the pulse reflects

the heartbeat

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Peripheral pulse- is a pulse located in the periphery of the body.

Apical pulse- is a central pulse located at the apex of the heart.

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Pulse sitePulse site1. Temporal- it is where the temporal artery

located, between the upper, lateral part of the eye and upper medial part of the ear

2. Carotid- at the side of the neck, at the carotid triangle. Located between the Anterior/front of SCM and below the angle of the mandible

3. Apical- at the apex of the heart. ◦In adult this is located on the left side of the chest,

no more than 8 cm (3 in) to the left sternum under the

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Carotid pulseCarotid pulse

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◦4th, 5th or 6th intercostal space. ◦In Children 7 to 9 years old, the apical pulse

is located between the 4th and 5th intercostal space.

◦In Young Children below 4 years old , it is located at the left side of midclavicular line and

◦In Children between 4 and 6 years old it is at the midclavicular line.

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4. Brachial- at the anterior part of the arm in children and at the ante-cubital space (elbow crease) in adult.

5. Radial – located at the wrist (anterior part), along with the thumb. It is where the radial artery is located

6. Femoral – at the inguinal ligament, the femoral artery is located.

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Radial and Brachial pulseRadial and Brachial pulse

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7. Popliteal- at the popliteal region, located at the back of the knee

8. Posterior Tibial- at the medial aspect of the ankle, it is where the posterior tibial artery is located

9. Dorsalis pedis- where the dorsalis pedis artery passes over the bones of the foot, at the space between the big toe and the 2nd toe.

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Posterior tibial & Dorsalis pedis Posterior tibial & Dorsalis pedis PulsePulse

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Pulse site Reasons for Use

Radial Readily accessible & routinely used

Temporal Used when radial pulse is not accessible

Carotid Used for infants, in cases of cardiac arrest and to determine the circulation to the brain

Apical Routinely used in infants and children up to 3 years of age, Used to determine the discrepancies with radial pulse, and

Used in conjunction with some medicationBrachial Used to measure blood pressure, used for cardiac arrest for

infantsFemoral Used in cases of cardiac arrest, for infants and children,

determine circulation in the legPopliteal Used to determine the circulation in the lower leg and leg

blood pressurePosterior

tibialUsed to determine the circulation in the foot

Pedal Used to determine circulation in the foot

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Assessing the PulseAssessing the Pulse1. A pulse is commonly assessed by

palpation or auscultation.2. 3 middle fingers are used for palpating

all pulse site, except for apical pulse.3. Stethoscope is used in assessing apical

pulse and fetal heart tones.4. Doppler ultrasound is used for pulses

that is to difficult to assess.

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5. The pulse is normally palpated by applying are moderate pressure with the three fingers of the hand.

6. The pads of the most distal aspect of the fingers are the most sensitive areas of detecting the pulse.

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7. When assessing the pulse, there is a need to take note of the following

1. rate2. rhythm3. volume4. arterial wall elasticity5. presence or absence of bilateral

equality.

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Age Average RangeNewborn to 1

month130 80-180

1 year 120 80-1402 years 110 80- 1306 years 100 75- 12010 years 70 50-90

Adult 80 60- 100Pulse rate/

Minute

Variations in Pulse Rate

Kozier Barbara, et.al. Fundamentals of Nursing , 5th ed. (US Addison-Wesley Publishing Company, Inc. 1995) p. 438

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Rate- referred to tachycardia- (over 100 beats/ minute) bradycardia –(60 beats/minute or less)

Rhythm- is the patterns of beat and the interval between the beats.

Dysrhythmia or arrhythmia is an example of irregular rhythm.

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Volume- is the pulse strength or the amplitude, refers to the force of blood with each beat. E.g. bounding/full; weak/feeble/thready pulse

Scale Description of pulse0 Absent1 Thready or weak; difficult to feel

2 Normal, detected readily, obliterated by strong pressure

3 Bounding; difficult to obliterateKozier Barbara, et.al. Fundamentals of Nursing , 5th ed. (US Addison-Wesley Publishing Company, Inc. 1995) p. 440

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Elasticity of the arterial wallElasticity of the arterial wallIt reflects the expansibility of the arterial

wall.A healthy, normal artery feel straight,

smooth, soft and pliableWhile, elderly people often have inelastic

arteries that feels twisted or tortuous and irregular upon palpation

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Factors affecting pulse rateFactors affecting pulse rate1. Age2. Sex- after puberty the man’s pulse rate

is slightly lower than the female3. Exercise4. Fever- pulse rate increases when

metabolic rate increases5. Medications6. Hemorrhage- loss of blood increase

pulse rate7. Stress

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Respiration

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Is the act of breathing; it includes the intake of oxygen and the output of carbon dioxide

Types1. External respiration- the interchange of

O2 and CO2 between the alveoli and the pulmonary blood

2. Internal respiration- takes place throughout the body; it is the interchange of gases between the circulating blood and the cells of the body tissues

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TerminologiesTerminologiesInhalation or inspiration- the act of intake of

air into the lungsExhalation or expiration- the act of breathing

out of gases from the lungs to the environment

Ventilation- movement of air in and out the lungs

Hyperventilation- refers to very deep and rapid ventilation

Hypoventilation- refers to very shallow respiration

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Types of breathingTypes of breathing1. Costal or thoracic breathing2. Diaphragmatic or abdominal breathing

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Costal breathingCostal breathingIt involves the external intercostal muscle

and other intercostal muscle. It can be observed by the movement of the chest upward and outward or downward

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Diaphragmatic breathing Diaphragmatic breathing It involves the contraction and relaxation

of the diaphragm, it is observed by the movement of the abdomen

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Control Centers for Control Centers for RespirationRespiration1. Medulla oblongata and Pons 2. Chemoreceptors located centrally in the

medulla and peripherally in the carotid and aortic bodies

NOTE: These centers and receptors respond to changes in the concentration of O2, CO2 and Hydrogen in arterial blood.

Increased CO2 concentration in the blood triggers chemoreceptors thus stimulates respiration

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Assessing RespirationAssessing Respiration1. The client normal breathing pattern is

assessed therefore the client should be at resting mode.

2. Identify behavior/ activities of the patient as well as medication or therapies because these will affect the respiration taking.

3. Identify if there are any health problems such as heart problems and others

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Age Average RangeNewborn 35 30-80

1 year 30 20-402 years 25 20-308 years 20 15-2516 years 18 15-20

Adult 16 12-20Respiratory rate/ Minute

Variations in Respiratory rate

Kozier Barbara, et.al. Fundamentals of Nursing , 5th ed. (US Addison-Wesley Publishing Company, Inc. 1995) p. 448

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Respiratory rate Respiratory rate is normally described in breaths per

minuteTypes:Eupnea- Normal BreathingBradypnea- Abnormally slowTachypnea or polypnea- Abnormally fastApnea- cessation of breathing

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Respiratory depths Respiratory depths is established by watching the movement

of the chest. It is generally describe as normal, deep or

shallow, deep respiration are those in which a large volume of air is inhaled and exhaled. Shallow respiration involve the exchange of small volume of air

NOTE: in normal inspiration and expiration, an adult takes in about 500ml of air. This volume is called Tidal volume

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Respiratory rhythm/ patternRespiratory rhythm/ patternIt refers to regularity of expiration and

inspiration Types RegularIrregular◦Dsypnea- difficulty in breathing◦Orthopnea- ability to breath in an upright

position

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BLOOD PRESSURE

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Heart SoundHeart Sound1. First Sound-occurs at the beginning of

ventricular systole. It is caused by the closure of the tricuspid and mitral valves

2. Second Sound- marks the beginning of ventricular diastole and is caused by the closure of aortic and pulmonary valves.

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Arterial blood Pressure Arterial blood Pressure is a measure of the pressure exerted by the

blood as it flows through the arteries. Two blood pressure measurements1. Systolic pressure- is the maximum

pressure developed on the ejection of blood from the left ventricle into the arteries

2. Diastolic Pressure-is the lowest pressure and is a measure of the peripheral resistance.

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In measuring the BPIn measuring the BPBy means of auscultation- the systolic

pressure is taken at the point when beats becomes audible. As the mercury continues to fall, the sound of the beats becomes louder, then gradually diminishes until a point is reached at which there is a sudden, marked diminution in intensity.

The average BP is about 120/80 at 20 yrs old and at the age of 60 is 160/90

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Aneroid manometer with Aneroid manometer with stethoscopestethoscope

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Part of the Part of the sphygmomanometersphygmomanometer

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Taking BPTaking BPIt is measured with a blood pressure cuff, a

sphygmomanometer and a stethoscopeThe BP cuff has a bladder than can be

inflated with air, it is covered with cloth and has two tubes attached to it (sometimes it’s three), one tube is connected to the rubber bulb.

To introduce air turn the valve clockwise and to release air turn it counterclockwise, the second tube to the sphygmomanometer and the third to stethoscope

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Auscultatory method of obtaining Auscultatory method of obtaining BPBPFirst the health care provider must

determine the Korotkoff’s sound- this is a series of sounds heard during BP assessment.

Phases of Korotkoff’s soundPhase 1- The first faint clear tapping sound is

heard. This sound gradually becomes strong and deep

Phase 2- This is the period during deflation when the sounds have a swishing quality.

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Phase 3- The period during which the sounds are forceful and powerful

Phase 4- The time when the sounds begins to decrease in intensity, and has a less bounding force

Phase 5- The pressure level wherein the sound disappear.

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Reading Blood PressureReading Blood PressureThe first sound heard is the systolic

pressure and the last sound heard is the diastolic pressure

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Mercury manometer and cuff

Aneroid manometer and cuff

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2 types of sphygmomanometer2 types of sphygmomanometerAneroid and mercury manometerAneroid is a calibrated dial with a needle

that points to the calibrations while the other is a calibrated cylinder filled with mercury.

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Other typesOther typesElectric sphygmomanometerDoppler stethoscope

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Variations in BP cuffVariations in BP cuffIf the bladder is too narrow, the obtained BP

reading is erroneously elevated; if it is too wide the reading will be erroneously low

The width should be 40% of the circumference or 20% wider than the diameter of the midpoint of the limb on which it is used

The length of the bladder should be sufficiently long almost to encircle the limb and to cover at least 2/3 of its circumference

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Variations in BP by AgeVariations in BP by AgeAge Mean BP (mm Hg)

Newborn 73/551 year 90/556 years 95/5710 years 102/6214 years 120/80

Adult 120/80Elderly (over 70 years) Diastolic pressure may increase

Kozier Barbara, et.al. Fundamentals of Nursing , 5th ed. (US Addison-Wesley Publishing Company, Inc. 1995) p. 452

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