FUNDAMENTALS OF NURSING
TOPIC: VITAL SIGNS




BODY TEMPERATURE
PULSE
RESPIRATIONS
BLOOD PRESSURE
BODY TEMPERATURE
 Reflects the balance between the heat produced and the lost from the
body; DEGREES
 BRAIN (HYPOTHALAMUS) – THERMOREGULATORY CENTER OF THE BODY
 CELCIUS = (F – 32) X 5/9
 FAHRENHEIT = (C x 9/5) + 32
 NORMAL: 36.4 C – 37.2 C or 97.5 F – 98.9 F
HEAT PRODUCTION:
 METABOLISM – the rate of energy utilization in the body required to
maintain essential activities such as breathing. (BASAL METABOLIC RATE)
 HORMONES – increase in THYROXINE output increases the rate of cellular
metabolism of many body tissues; EPINEPHRINE, NOREPHINEPHRINE,
SYMPHATIC STIMULATION RESPONSE, immediately increases rate of
cellular metabolism
 MUSCLE MOVEMENT- Muscle Activity; shivering
 EXERCISE
 FEVER – fever increases cellular metabolic rate thus increasing body temp.
further
HEAT LOSS:
 SKIN
 MECHANISM OF HEAT
o TRANSFER
 RADIATION - the transfer of heat from the surface of one
object to the surface of another without contact between the
two objects, mostly in the form of infrared rays
 CONDUCTION - transfer of heat from one molecule to a
molecule of lower temperature. Conductive transfer cannot
take place without contact between the molecules and
normally accounts for minimal heat loss; example: electric fan
and aircon
 CONVECTION - the dispersion of heat by air currents. The body
usually has a small amount of warm air adjacent to it. This
warm air rises and is replaced by cooler air, so people always
lose a small amount of heat through convection’ example: WET
TOWEL or TOUCHING ICE CUBES (direct contact)
 EVAPORATION- continuous vaporization of moisture from the
respiratory tract and from the mucosa of the mouth and from
the skin. This continuous and unnoticed water loss is called
insensible water loss, and the accompanying heat loss is called
insensible heat loss. Insensible heat loss accounts for about
10% of basal heat loss. When the body temperature increases,
vaporization accounts for greater heat loss; example: when
sweat evaporates, we become cooler in body temp.
FACTORS
 AGE
 CIRCADIAN RHYTHM – behavioral changes that follow a 24-hour cycle
(highest at 6 PM, lowest 4 AM)
 ENVIRONMENT
TERMINOLOGY




PYREXIA – fever; body temp. above the usual range
FEBRILE - fever
AFEBRILE
HYPOTHERMIA - core body temp. is below the lower limit of normal.
o Excessive heat loss
o Inadequate head production to counteract heat loss
o Impaired hypothalamic thermoregulation
 HYPERTHERMIA/HYPERPYREXIA - a very high fever such as 41 C
 NEUROGENIC FEVER – brain injury (hypothalamus)
 FEVER OF UNKNOWN ORIGIN – unidentified cause of fever
TYPES OF FEVER
 INTERMITTENT - the body temperature alternates at regular intervals
between periods of fever and periods of normal or subnormal
temperatures; goes back to normal; example: MALARIA
 REMITTENT – wide range of temp. fluctuations occurs over a 24-hour
period which all are above normal; does not go back to normal; example:
COLD, IMFLUENZA, TYPHOID FEVER
 RELAPSING- short febrile periods of a FEW DAYS are interspersed and 1-2
DAYS are normal; DAYS IS ITS INTERVAL; example: tick-borne diseases
 CONSTANT- fluctuates minimally but always remain above normal
 FEVER SPIKE- rises rapidly and returns to normal within few hours
ASSESING
*NOTE
ORAL- MOUTH; WAIT 30 MINUTES AFTER HOT OR COLD FOOD OR FLUIDS OR
SMOKING
RECTAL – ANAL; MOST RELIABLE
AXILLA – UNDERARM; USED IN NEWBORNS BECAUSE ACCESSIBLE AND SAFE
TYMPHANIC MEMBRANE – NEARBY TISSUE IN THE EAR CANAL; IMPRECISE
TEMPORAL ARTERY – FOREHEAD; INFANTS AND CHILDREN; INCONSISTENT
TYPES OF THERMOMETERS





ELECTRONIC AND DIGITAL – 2 to 60 seconds reading
GLASS (MERCURY IN GLASS THERMOMETERS)
DISPOSABLE – SINGLE USE (CHEMICAL DISPOSABLE THERMOMETERS)
AUTOMATED MONITORY DEVICE
INFRARED THERMOMETERS – sense body heat in the form of infrared
energy
 TEMPORAL ARTERY THERMOMETERS
 TYPHANIC MEMBRANE THERMOMETERS
PULSE
 Wave of blood created by contraction of the left ventricle of the heart
 Represents the stroke volume output or the amount of blood the enters
arteries with each ventricular contraction
 NORMAL – 60-100 in adults
 Tachycardia (above) 100 beats/min
 Bradycardia (below) 60 beats/min
 Dysrhythmia (abnormal) does not beat in a typical rhythm
Normal Sinus Rhythm





If same, distance (regular)
Far distant (slow)
Near distant (fast)
PATTERN: P Q R S T
Q R S: if same, then regular
 ATRIAL FIBRILLATION - irregular and often faster heartbeat
 ATRIAL FLUTTER – irregular (somehow regular); has a saw tooth
 ASYSTOLE – FLATLINE
o CPR;100-120 beats per minutes; 2 cycles
o BABIES – 2 fingers; if two rescuers - two-thumb technique
 Coarse VF
 Fine VF
 Defibrillation max of 10 minutes (after you do CPR) still has high chance of
living (360 joules)
 *DEFIBRILLATION if VF is coarse or fine; with doctor’s consent
 Heart beats- lub dub; if stroke - heart forms spasm
 *BRAIN DAMAGE – IRREVERSIBLE
 PULSELESS VTACH – require immediate defibrillation, CPR
 VTACH – medication to lessen irregular electrical signals
 R-R interval usually regular, not always
 QRS not preceded by p wave
 Wide and bizarre QRS
 Difficult to find separation between QRS and T wave
 Rate= 100-250 bpm
PULSE QUALITY
 ABSENT – 0 beats; cannot detect any pulse at all
 WEAK/THREACY – there is pulse beat, but is not appreciated or heard (do
not press hard)
 NORMAL – 60-100 (+2)
 BOUNDING – feels as through your heart is racing; after exercising (+3)
ASSESSING
 STETHOSCOPE
 DOPPLER ULTRASOUND STETHOSCOPE
*NOTE
RADIAL – line with thumb
BRACHIAL – line with little fingers
FEMORAL – thighs
CAROTID – neck




FATAL MANUEVER/ CAROTID MASSAGE
DURING EMERGENCY
BEFORE CAROTID MASSAGE; ASSESS BREWERY (auscultate)
If there is presence of assess brewery, if smooshing sound, should not
proceed because there might be clot formation that could lead to death
POPLITEAL - back of the knee
POSTERIOR TIBIAL – ankles
*press only once to avoid problems
* while doing this, place the 3 middle fingers to assess
APICAL PULSE- between 5th and 6th ribs, about 8cm to the left of the medial line
and slightly below the nipple
RESPIRATION











INHALATION – diaphragm contracts
EXHALATION – diaphragm relaxes
EXTERNAL RESPIRATION
INTERNAL RESPIRATION
*we release 16% O2; when we CPR, it goes to patient
NORMAL RATE – 12-20 EUPNEA
INCREASE RR – tachypnea
DECREASE RR- bradypnea
APNEA- absence of breathing
DYSPNEA – difficulty of breathing
ORTHOPNEA – a condition wherein a person can breathe easily in an
upright position
*CHRONIC OBSTRUCTIVE PULMONARY DISEASE
1. CHRONIC BRONCHITIS (BLUE BLOATER) – long-term inflammation of the
bronchi
2. EMPYEMA – pocket of pus; pneumonia; trapping of CO2
* HYPOXIC DRIVE – respiratory drive which uses oxygen to regulate
respiratory cycle; helps breathe
PATTERNS OF RESPIRATION




NORMAL
TACHYPNEA - > 24 BREATHE PER MINUTE; shallow
BRADYPNEA - < 10 BREATHE PER MINUTE; regular
HYPERVENTILATION – increased rate and depth
*anxiety attack, hands become stiff, has full 99% to a 100% oxygen,
imbalance of CO2
 HYPOVENTILATION – decreased rate and depth
 CHEYNE-STROKES – alternate; deep, rapid, then apnea; regular
 BIOT’S- varying depths and rate then apnea; irregular
RESPIRATORY CENTER – Medulla oblongata and pons
BLOOD PRESSURE






120/80 mmHg (NORMAL)
SYSTOLIC – as a result of contraction (EJECT)
DIASTOLIC – at rest
PULSE PRESSURE – difference of diastolic and systolic pressure; force that
the heart generates each time it contracts
PERIPHERAL RESISTANCE - resistance in the circulatory system that is used
to create blood pressure
CARDIAC OUTPUT – volume of blood being pumped by the heart; STROKE
VOLUME x HEART RATE = Q
STROKE VOLUME - volume of blood pumped out of the left ventricle of the
heart during systolic cardiac contraction
 HYPERTENSION – blood pressure is above normal (130 is not hyper
tension); (140/90 is hypertension)
 HYPOTENSION – BP is below normal
 ORTHOSTATIC HYPOTENSION – BP decreases when client sits or stands;
FAINT OR VERTIGO
ASSESSING




SPHYGMOMANOMETER - aneroid and digital
NONINVASIVE NP MONITOR
DOPPLER UTZ
STHETHOSCOPE
SITE AND METHODS
 KOROTKOFF’S SOUNDS – nurses identify phases in the series of sounds; 5
phases
 BRACHIA ARTERY – major blood vessel; upper arm
 POPLITEAL ARTERY - Systolic pressure is usually 10-40 mmHg higher than
bronchia artery
 PALPITATING THE BLOOD PRESSURE – sensory detection method
MAP
 MEAN ARTERIAL PRESSURE
 Represents the pressure actually delivered to the body’s organs
 Average pressure in a patient’s arteries during one cardiac cycle. It is
considered as the better indicator of perfusion to vital organs
 MAP = SBP+2 (DBP) / 3
PAIN
1-3 – MINOR PAIN (does not interfere with regular activities)
4-6 - MODERATE PAIN (may interfere)
7-10 – SEVERE PAIN (7-9 - pains keep you from going; 10 – unbearable)
OVERVIEW
NORMAL:
1. INSPECTION – using the 5 senses
2. PALPATION – examination by applying pressure
3. PERCUSSION - striking object from one another to form percussion sounds
(fingers to hands)
4. AUSCULATION – listening to sounds
ABDOMEN:
1.
2.
3.
4.
INSPECTION
ASUCULATION
PALPATION
PERCUSSION
*WHY? To have accurate sound from bowl movement if we auscultate first
*do not give pain relievers to identify accurate of pain
*NOTE
CHEST PAIN – MORPHINE, OXYGEN, NITROGLYCERIN (BASODILATER), ASPIRIN
ASTHMA - take antihistamine, nebulize, puffers if light to moderate, but
epinephrine or epipen if asthma is severe