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there are four objective assessment there are four objective assessment data that indicate how well body is data that indicate how well body is functioning .functioning .And And provide information about the patients basic body condition

Body TemperatureBody TemperaturePulsePulseRespirationsRespirationsBlood PressureBlood Pressure

Other Vital SignsOther Vital Signs

Pain assessmentPain assessmentSkin colorSkin colorPupil size and reactionPupil size and reactionLevel of consciousnessLevel of consciousnessResponse to stimuliResponse to stimuli

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TimesTimes to assess vital sign: to assess vital sign:

1) On admission to health care agency to 1) On admission to health care agency to obtain base line data.obtain base line data.

2) When client has change in health 2) When client has change in health status.status.

3) Before and after surgery.3) Before and after surgery. 4) Before and after administration of 4) Before and after administration of

medication.medication. 5) Before and after any nursing 5) Before and after any nursing

interventionintervention

Vital SignsVital Signs

Accuracy is essentialAccuracy is essentialAbnormal vital signs are often the first Abnormal vital signs are often the first

indication of a disease of abnormalityindication of a disease of abnormalityNever guess or report an inaccurate Never guess or report an inaccurate

readingreading If you note any abnormality or change If you note any abnormality or change

in a vital sign, report it immediately to in a vital sign, report it immediately to your supervisoryour supervisor

If you have difficulty obtaining a correct If you have difficulty obtaining a correct reading for any vital sign, ask for helpreading for any vital sign, ask for help

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1)Body temperature:1)Body temperature:

DefinitionDefinition: the balance between the : the balance between the heat production and heat lost from heat production and heat lost from the body, measured in heat unit the body, measured in heat unit called degree.called degree.

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* * FahrenheitFahrenheit scale uses 32F as the scale uses 32F as the water freeze point and 212F as boil water freeze point and 212F as boil point. point.

**centigradecentigrade scale uses 0 as the scale uses 0 as the water freeze and 100C as boil point.water freeze and 100C as boil point.

Normal body temperature:Normal body temperature:36.4 – 37.4 C36.4 – 37.4 C

Converting Fahrenheit (F) Converting Fahrenheit (F) to Celsius (C)to Celsius (C)

C = (F – 32) x 0.5556C = (F – 32) x 0.5556Subtract 32 from the Fahrenheit and Subtract 32 from the Fahrenheit and

multiply the result by 5/9 or 0.5556multiply the result by 5/9 or 0.5556

ExampleExampleConvert 212Convert 212°F to C°F to CC = (212 – 32) x 0.5556C = (212 – 32) x 0.5556C = 100C = 100°°

Converting Celsius (C)Converting Celsius (C)to Fahrenheit (F)to Fahrenheit (F)

F = (C x 1.8) - 32F = (C x 1.8) - 32Multiply the Celsius by 9/5 or 1.8 and Multiply the Celsius by 9/5 or 1.8 and

then add 32 to the totalthen add 32 to the total

ExampleExampleConvert 37Convert 37°C to F°C to FF = (37 x 1.8) + 32F = (37 x 1.8) + 32F = 98.6F = 98.6°°

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Two type of body temperature:Two type of body temperature:

Core temperature:Core temperature: is the is the temperature of deep tissue of the temperature of deep tissue of the body such as thorax, abdominal body such as thorax, abdominal cavity. it relatively constant. cavity. it relatively constant.

Surface temperatureSurface temperature:: is the temperature of skin, is the temperature of skin,

subcutaneous tissue rise and fall in subcutaneous tissue rise and fall in response to environment. response to environment.

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Factor effect on body heat production:Factor effect on body heat production:Basal metabolic rateBasal metabolic rate: is rate of energy : is rate of energy

utilization in the body required to utilization in the body required to maintain essential activity (metabolism).maintain essential activity (metabolism).Metabolism: the primary source of energy is Metabolism: the primary source of energy is

the sum of all the chemical process that the sum of all the chemical process that occurs in the body.occurs in the body.

Muscle activity.Muscle activity.Thyroxin output.Thyroxin output.Epinephrine.Epinephrine.FeverFever..

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Way of heat loss:Way of heat loss:

Radiation:Radiation: is transfer of heat from one is transfer of heat from one object to another object with out object to another object with out contact.contact.

Conduction:Conduction: is transfer of heat from is transfer of heat from one molecules to another of lower one molecules to another of lower temperature.temperature.

Convection:Convection: dispersion of heat by air dispersion of heat by air current.current.

Evaporations:Evaporations: continuous evaporation continuous evaporation of the moisture from the respiratory of the moisture from the respiratory tract.tract.

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Temperature regulation:Temperature regulation:

HypothalamusHypothalamus: a structure within : a structure within the brain that helps controls various the brain that helps controls various metabolic activities.metabolic activities.

It acts as the center of temperature It acts as the center of temperature regulation.regulation.

When sensor of hypothalamus detect When sensor of hypothalamus detect heat, they send signals intend to heat, they send signals intend to reduce temperature reduce temperature

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Factor effect on body Factor effect on body temperature: temperature:

AgeAgeCircadian rhythmCircadian rhythmExercise Exercise HormonesHormonesStressStressEnvironment.Environment.

Variations in Body TempVariations in Body Temp

Normal range for body temp is 97Normal range for body temp is 97°F °F to 100°F or 36.1°C to 37.8°Cto 100°F or 36.1°C to 37.8°C

Variations are caused by individual Variations are caused by individual differences, time of day, part of body differences, time of day, part of body and other factorsand other factorsPeople with accelerated body processes People with accelerated body processes

usually have high tempsusually have high tempsPeople with slower body processes People with slower body processes

usually have lower tempsusually have lower temps

Variations in Body TempVariations in Body Temp

Time of day affects body tempTime of day affects body tempUsually lower in morning after body has Usually lower in morning after body has

restedrestedHigher in evening after muscular activity Higher in evening after muscular activity

and food intake with metabolismand food intake with metabolismParts of the body where temp is Parts of the body where temp is

measured can also lead to variationsmeasured can also lead to variations

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Terms:Terms:

PyrexiaPyrexia: body temperature above the usual : body temperature above the usual range (fever or hyperthermia). (38 – 40).range (fever or hyperthermia). (38 – 40).

HyperpyrexiaHyperpyrexia: very high temperature more : very high temperature more than 40 C.than 40 C.

HypothermiaHypothermia : body temperature less than : body temperature less than 35.35.

My be induced or accidental.My be induced or accidental. Note: the client who has a fever is referred to Note: the client who has a fever is referred to

as febrile, the one who has not called Afebrile.as febrile, the one who has not called Afebrile.

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Clinical sign of fever:Clinical sign of fever: Increase heart rateIncrease heart rate Increase respiratory rate Increase respiratory rate Shivering Shivering PalledPalledCyanotic nail bedsCyanotic nail beds Increase thirst.Increase thirst.Loss of appetite. Loss of appetite.

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Four common types of feversFour common types of fevers

Intermittent:Intermittent: the temperature the temperature alternate regular intervals between alternate regular intervals between period of fever.period of fever.

Remittent:Remittent: it is wide range of it is wide range of temperature fluctuation, all of which temperature fluctuation, all of which are above normal.are above normal.

Relapsing feverRelapsing fever: is short febrile period : is short febrile period of a few days with period 1-2 days.of a few days with period 1-2 days.

Constant feverConstant fever always remain above always remain above normal.normal.

Recording TemperatureRecording Temperature

Write 98Write 9866 instead of 98.6 instead of 98.6 Reduces the possibility of making an error Reduces the possibility of making an error

while readingwhile reading If temp is taken orally, not necessary to If temp is taken orally, not necessary to

indicate an oral reading indicate an oral reading Rectal – place a (R) by the readingRectal – place a (R) by the reading Axillary – place an (Ax) by the readingAxillary – place an (Ax) by the reading Groin – place a (Gr) by the readingGroin – place a (Gr) by the reading Aural – place a (T) for tympanic by the Aural – place a (T) for tympanic by the

readingreading

Recording TemperatureRecording Temperature

ExamplesExamples989866 indicates an oral temp indicates an oral temp999966 (R) indicates a rectal temp (R) indicates a rectal temp979766 (Ax) indicates an axillary temp (Ax) indicates an axillary temp979766 (Gr) indicates a groin temp (Gr) indicates a groin temp989866 (T) indicates an aural temp (T) indicates an aural temp

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Assessment siteAssessment site:: Oral siteOral site: Taken in the mouth: Taken in the mouth Advantage: Advantage: Most common, Most common, convenient convenient

and accessible, and accessible, comfortable way to take comfortable way to take temperaturetemperature

Disadvantage:Disadvantage: can break in bitten, so its can break in bitten, so its contraindicatedcontraindicated for: uncooperative for: uncooperative client, children, unconscious, shivering and client, children, unconscious, shivering and prone to seizers.prone to seizers.

Thermometer left in for 3-5 minutesThermometer left in for 3-5 minutes

Inaccurate if the patient been Inaccurate if the patient been smoking, eating hot or cold food or smoking, eating hot or cold food or drinks. drinks.

So you should Delay taking oral So you should Delay taking oral temperature at least 10-15mintemperature at least 10-15min

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Assessment SiteAssessment Site

Rectal siteRectal site: Taken in the rectum: Taken in the rectumThermometer left in for 3-5 minutesThermometer left in for 3-5 minutesAdvantageAdvantage: Most reliable : Most reliable DisadvantageDisadvantage: can be : can be

embarrassing for alert client, embarrassing for alert client, (inconvenient), and can injury the (inconvenient), and can injury the rectum.rectum.

Its above than the oral site by 0.5 cIts above than the oral site by 0.5 c

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Assessment SiteAssessment Site

AuxiliaryAuxiliary: Taken under the armpit or : Taken under the armpit or in the groin foldin the groin fold

Thermometer left in for 8-10 minutesThermometer left in for 8-10 minutes AdvantageAdvantage: safe, and most : safe, and most

noninvasive, its preferred site for noninvasive, its preferred site for infant, unconscious patient.infant, unconscious patient.

Disadvantage: it takes long time to Disadvantage: it takes long time to obtain an accurate reading.obtain an accurate reading.

Least Accurate Least Accurate Its less than the oral site by 0.5 cIts less than the oral site by 0.5 c

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Aural/Tympanic TemperatureAural/Tympanic Temperature

Taken in the earTaken in the ear

Measures the thermal infrared energy Measures the thermal infrared energy radiating from the blood vessels in the radiating from the blood vessels in the eardrumeardrum

Position and ear wax can affect readingsPosition and ear wax can affect readings Left in until it beepsLeft in until it beeps

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Advantage: Very fast, accessible, and Advantage: Very fast, accessible, and reflect the core temperature. Its reflect the core temperature. Its suitable for childrensuitable for children

Disadvantage: right and left Disadvantage: right and left measurement can differ, and there is measurement can differ, and there is risk of membrane injury in inserted risk of membrane injury in inserted too far.too far.

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Type of thermometer:Type of thermometer:

Mercury glass thermometer.Mercury glass thermometer.Electronic thermometer.Electronic thermometer.Skin tape.Skin tape.Tympanic thermometer. Tympanic thermometer.

Types of Types of ThermometersThermometers

ElectronicElectronic Can be used for Can be used for

oral, rectal, or oral, rectal, or axillaryaxillary

Blue probe for oralBlue probe for oral Red probe for rectalRed probe for rectal

Disposable probe Disposable probe covers prevent covers prevent cross-contaminationcross-contamination

TympanicTympanic

- used to record - used to record temperature in the temperature in the earear

- Records - Records temperature in 1-3 temperature in 1-3 secondsseconds

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2) Pulse:2) Pulse: Is the wave of blood created by Is the wave of blood created by

contraction of the ventricles of the contraction of the ventricles of the heart.heart.

Cardiac out put = Stroke volume * Cardiac out put = Stroke volume * heart rate.heart rate.

Two type of pulse:Two type of pulse:Peripheral pulsePeripheral pulse is pulse located in is pulse located in

peripheral of the body, foot, hand.peripheral of the body, foot, hand.Apical pulseApical pulse is centered pulse is centered pulse

located above the apex of the heart. located above the apex of the heart.

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Factor effect the pulse:Factor effect the pulse:Age.Age.Exercise.Exercise.feverfevermedicationmedicationHemorrhage.Hemorrhage.Stress.Stress.

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Pulse site:Pulse site: temporaltemporal radialradial carotidcarotid apicalapical brachialbrachial posterior tibial posterior tibial Dorsals pedis pulse.Dorsals pedis pulse. Popliteal Popliteal Femoral Femoral

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Pulse sites Pulse sites

TemporalTemporal: where the temporal artery : where the temporal artery pass over the temporal bone.pass over the temporal bone.

Carotid:Carotid: at the side of the neck where at the side of the neck where carotid artery runs between the trachea carotid artery runs between the trachea and sternoclidomastiod muscle.and sternoclidomastiod muscle.

Apical:Apical: at the apex of the heart. at the apex of the heart.Brachial:Brachial: at the inner aspect of the at the inner aspect of the

biceps tendon or medial antecubital biceps tendon or medial antecubital fossa. fossa.

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Pulse sitesPulse sites

Femoral:Femoral: where the femoral artery passes where the femoral artery passes along side of inguinal ligaments.along side of inguinal ligaments.

Radial:Radial: on the long radial bone, on thumb on the long radial bone, on thumb side of the inner aspect of the wrist.side of the inner aspect of the wrist.

Popliteal:Popliteal: behind the knee. behind the knee. Positerior tebial:Positerior tebial: behind the medial behind the medial

malleolus.malleolus. Dorsalis pedisDorsalis pedis: on the dorsum of the : on the dorsum of the

foot, upper surface. foot, upper surface.

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Terms:Terms:

Tachycardia:Tachycardia: when pulse increase when pulse increase more than 100 bm.more than 100 bm.

Bradycardia:Bradycardia: when pulse decrease when pulse decrease less than 60 bm.less than 60 bm.

Normal heart rate: 60- 100 bm.Normal heart rate: 60- 100 bm. Infants more than 100 bmInfants more than 100 bmAthletes less than 60 bm Athletes less than 60 bm

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TermsTerms

Pulse rhythm:Pulse rhythm: is the pattern of the is the pattern of the beats and the intervals between the beats and the intervals between the beats.beats.

Dysrhythmia or arrhythmia:Dysrhythmia or arrhythmia: pulse pulse with an irregular rhythm.with an irregular rhythm.

Pulse volume (pulse strength):Pulse volume (pulse strength): the force of blood with each beat. the force of blood with each beat.

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Respiration:Respiration:DefinitionDefinition: is act of breathing, the : is act of breathing, the

normal respiratory rate is 12 – 20 normal respiratory rate is 12 – 20 bpm.bpm.

Two types of respiration:Two types of respiration:External:External: the exchange of oxygen the exchange of oxygen

and carbon dioxide between the and carbon dioxide between the alveoli of the lung and blood.alveoli of the lung and blood.

InternalInternal: is the exchange of the : is the exchange of the same gas between blood and cell of same gas between blood and cell of the body tissue the body tissue

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The muscle that contribute in the The muscle that contribute in the respiration:respiration:

Diaphragm muscle ( main muscle).Diaphragm muscle ( main muscle). Intercostals muscle.Intercostals muscle.Sternoclidomastiod muscle.Sternoclidomastiod muscle.

NoteNote:: In female, observe chest movement.In female, observe chest movement. In male, observe abdominal In male, observe abdominal

movement. movement.

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Terms:Terms:

Inhalation (inspirationInhalation (inspiration):): intake of intake of air into lung.air into lung.

Exhalation (expiration):Exhalation (expiration): breathing breathing out or the movement of gases from out or the movement of gases from the lung in to atmosphere.the lung in to atmosphere.

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Breathing patternBreathing pattern

1) Volume:1) Volume:HyperventilationHyperventilation:: refer very deep refer very deep

respiration.respiration.HypoventilationHypoventilation:: refer to shallow refer to shallow

respiration.respiration.

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Breathing patternBreathing pattern

2) Rate: 2) Rate: Eupnea:Eupnea: normal respiratory rate and normal respiratory rate and

depth.depth.Bradypnea:Bradypnea: slow breathing. slow breathing.TachypneaTachypnea:: fast respiratory rate. fast respiratory rate.

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Breathing patternBreathing pattern

3) Easy or Effort:3) Easy or Effort:

Dyspnea: difficult and labored Dyspnea: difficult and labored breathing.breathing.

Orthopnea: ability to breath only in Orthopnea: ability to breath only in upright sitting or standing positions. upright sitting or standing positions.

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Breathing patternBreathing pattern

4) Secretions and Coughing:4) Secretions and Coughing:Hemoptysis:Hemoptysis: the presence of blood the presence of blood

in the sputum.in the sputum.Productive cough:Productive cough: a cough a cough

accompanied by secretions.accompanied by secretions.Nonproductive cough:Nonproductive cough: a dry, harsh a dry, harsh

cough without secretions. cough without secretions.

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Mechanism of respiration:Mechanism of respiration:During inhalation: the diaphragm During inhalation: the diaphragm

contracts( flatten) and the ribs move contracts( flatten) and the ribs move up wards and out ward and the up wards and out ward and the sternum move out ward.sternum move out ward.

Exhalation: the diaphragm relaxes, Exhalation: the diaphragm relaxes, ribs moves down ward and inwards ribs moves down ward and inwards the sternum move in ward and the sternum move in ward and decrease the size of thorax.decrease the size of thorax.

Inspiration time 1 – 1.5 sec.Inspiration time 1 – 1.5 sec.Expiration time 2 – 3 sec.Expiration time 2 – 3 sec.

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Regulation of Regulation of respiration:respiration:

Controlled by Controlled by respiratory center in respiratory center in the medulla oblongata.the medulla oblongata.

Chemoreceptor located Chemoreceptor located centrally in medulla centrally in medulla and peripheral in and peripheral in carotid and aortic body. carotid and aortic body.

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Factor influence of respiratory rate:Factor influence of respiratory rate:

Exercise. (increase RR)Exercise. (increase RR) Stress (increase RR) Stress (increase RR) Environmental factor ( increase Temp, Environmental factor ( increase Temp,

increase RR, decrease Temp, Decrease increase RR, decrease Temp, Decrease RR) RR)

Increase altitude (Increase RR)Increase altitude (Increase RR) Certain medication (narcotic) decrease RR.Certain medication (narcotic) decrease RR. Increased intracranial pressure (Decrease Increased intracranial pressure (Decrease

RR)RR)

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4) Blood pressure:4) Blood pressure:

DefinitionDefinition: is measure of pressure : is measure of pressure exerted by the blood as it flows exerted by the blood as it flows through the arteries.through the arteries.

Systolic blood pressure:Systolic blood pressure: the the pressure of the blood as result of pressure of the blood as result of contraction of the ventricles.contraction of the ventricles.

Diastolic blood pressureDiastolic blood pressure: the : the pressure when the ventricles are at pressure when the ventricles are at rest rest

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The differences between the diastolic The differences between the diastolic and systolic pressure called and systolic pressure called pulse pulse pressure.pressure.

E.g. BP: 130/ 80E.g. BP: 130/ 80

Pulse Pressure = 50Pulse Pressure = 50Mean Arterial Pressure (MAP):Mean Arterial Pressure (MAP):

MAP= 1/3 systolic + 2/3 diastolicMAP= 1/3 systolic + 2/3 diastolic

e.g. BP: 120/90e.g. BP: 120/90

MAP= 40 + 60 = 100MAP= 40 + 60 = 100

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BP Normal RangeBP Normal Range

The normal blood pressure readingThe normal blood pressure readingsystolicsystolic 100 – 140 mmhg 100 – 140 mmhgDiastolicDiastolic 60 – 90mmhg. 60 – 90mmhg.ExampleExamples: s: BP: 150/80 AbnormalBP: 150/80 AbnormalBP: 105/85 NormalBP: 105/85 NormalBP: 130/ 95 AbnormalBP: 130/ 95 Abnormal

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Determinant of blood pressure:Determinant of blood pressure:

a) Cardiac out put (COP).a) Cardiac out put (COP).

b) Peripheral resistance (PR).b) Peripheral resistance (PR).

Some factor effect on peripheral Some factor effect on peripheral resistance:resistance:

1) Size of artery.1) Size of artery.

2) Compliance of arteries.2) Compliance of arteries.

cc) Blood volume.) Blood volume.

d) Blood viscosityd) Blood viscosity

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Factor effect on the blood Factor effect on the blood pressure:pressure:

1)1) Age. Age.

2)2) Exercise.Exercise.

3)3) Stress.Stress.

4)4) Obesity. Obesity.

5)5) Sex. Sex.

6)6) Medication.Medication.

7)7) Diurnal variationsDiurnal variations

8)8) disease preprocess. disease preprocess.

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HypertensionHypertension:: blood pressure that blood pressure that is persistent above the normal.is persistent above the normal.

Hypotension:Hypotension: the blood pressure is the blood pressure is blow normal range.blow normal range.

Orthostatic hypotensionOrthostatic hypotension: blood : blood pressure falls when the clients sits or pressure falls when the clients sits or stands.stands.

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Equipment: Equipment: 1) Stethoscope1) Stethoscope 2)sphygmomanometer:2)sphygmomanometer:

a)a) Cuff (included the bladder). b) Cuff (included the bladder). b) Mercury meter. c) Tubes. d) Bulb.Mercury meter. c) Tubes. d) Bulb.

The bladder of BP cuff should be The bladder of BP cuff should be 40% of the arm circumference. 40% of the arm circumference.

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Sites of BPSites of BP

1) the arm ( brachial artery)1) the arm ( brachial artery)

2) the thigh (popliteal artery) 2) the thigh (popliteal artery)

3) the forearm (Radial artery) 3) the forearm (Radial artery)

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When you want measure blood When you want measure blood pressure :pressure :

Do not use caffeine, tobacco, or alcohol for Do not use caffeine, tobacco, or alcohol for 30 minutes before you measure. 30 minutes before you measure.

Before you measure your blood pressure, sit Before you measure your blood pressure, sit in a chair with a back on it for 3-5 minutes.in a chair with a back on it for 3-5 minutes.

Use the correct sized cuff for your arm. Use the correct sized cuff for your arm. Put the cuff in the proper place on your arm Put the cuff in the proper place on your arm

by placing the arrow or tubing on the inside by placing the arrow or tubing on the inside of the elbow of the elbow

Keep your arm at heart level while doing a Keep your arm at heart level while doing a blood pressure measure. blood pressure measure.

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