Finals

• Vital signs


  Reflect the body’s physiologic status and provide information critical to evaluating homeostatic balance. The term “vital” is used because the information gathered is the clearest indicator of overall health status
• Vital signs include

  • Temperature
  • Pulse rate
  • Respiratory rate
  • Blood pressure
• Equipment for assessing vital signs

  • Vital signs tray
  • Stethoscope
  • Sphygmomanometer
  • Thermometer (glasses, electronic and tympanic)
  • Second hand watch
  • Red and blue pen
  • Pencil
  • Vital sign sheet
  • Cotton swab in bowel
  • Disposable gloves if available
  • Dirty receiver kidney dish (emesis basin)
• Times to assess vital signs

  • On admission - to obtain baseline data
  • When a client has a change in health status or reports symptoms such as chest pain or fainting
  • According to a nursing or medical order
  • Before and after the administration of certain medications that could affect RR or BP (Respiratory and CVS (Cardiovascular system))
  • Before and after surgery or an invasive diagnostic procedures
  • Before and after any nursing intervention that could affect the vital signs. E.g. Ambulation
  • According to hospital/other health institution policy
• Temperature


  Body temperature is the measurement of heat inside a person’s body (core temperature); it is the balance between heat produced and heat lost
• Core Temperature


  Is the temperature of the deep tissues of the body, such as the cranium, thorax, abdominal cavity, and pelvic cavity. Remains relatively constant. Is the temperature that we measure with a thermometer
• Surface Temperature


  The temperature of the skin, the subcutaneous tissue and fat
• Alterations in Body Temperature

  • Normal Body Temperature: 37° C or 98.6° F (Average) the range is 36-38° C (96.8-100°F)
  • Pyrexia: a body temperature above the normal ranges 38° C - 41° C (100.4 - 105.8 F)
  • Hyper Pyrexia: a very high fever, such as 41° C, > 42° C - leads to death
  • Hypothermia: body temperature between 34° C - 35° C, <34° C is death
• Common Types of Fevers

  • Intermittent Fever - the body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperature
  • Remittent Fever - a wide range of temperature fluctuation (more than 2° C) occurs over the 24 hr period, all of which are above normal
  • Relapsing Fever - short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature
  • Constant Fever - the body temperature fluctuations minimally but always remains above normal
• Factors Affecting Body Temperature


  • Age
  • Diurnal Variations (Circadian Rhythms)
  • Exercise
  • Hormones
  • Stress
• Strenuous exercise can increase body temperature to as high as 38.3 - 40°C, measured rectally
• In women, progesterone secretion at the time of ovulation raises body temperature by about 0.3 - 0.6°C above basal temperature
• Stimulations of skin can increase the production of epinephrine and norepinephrine, which increases metabolic activity and heat production
• Extremes in temperature can affect a person’s temperature regulatory systems
• Sites to measure temperature

  • Oral
  • Rectal
  • Axillary
  • Tympanic
• Thermometer


  An instrument used to measure body temperature
• Types of thermometer

  • Oral thermometer
  • Rectal thermometer
  • Axillary thermometer
  • Tympanic thermometer
• Rectal temperature readings are considered to be more accurate and most reliable, being > 0.65°C (1°F) higher than oral temperature
• Rectal temperature measurement procedure

  1. Explain the procedure to the patient

  2. Wash hands and assemble necessary equipment and bring to the patient bedside

  3. Position the person laterally

  4. Apply lubricant 2.5cm above the bulb

  5. Insert the thermometer 1.5-4cm into the anus

  6. Measured for 2-3 minutes

  7. Remove the thermometer and read the finding

  8. Clean the thermometer with tissue paper

  9. A rectal thermometer record does not respond to changes in arterial temperature as quickly as an oral thermometer
• Contraindications for rectal temperature measurement
• Oral temperature measurement procedure

  1. Explain the procedure to the patient

  2. Wash hands and assemble necessary equipment and bring to the patient bedside

  3. Position the person comfortably and request the patient to open the mouth

  4. Hold the thermometer firmly with the thumb and forefinger; shake it with strong wrist movements until the mercury line falls to at least 35°C

  5. Place the bulb of the thermometer well under the client’s tongue

  6. Remove the thermometer after 3 to 5 minutes

  7. Remove the thermometer, wipe it using it once a firm twisting motion

  8. Hold the thermometer at eye level

  9. Dispose the tissue

  10. Record temperature on paper or flow sheet

  11. Report an abnormal reading to the appropriate person
• Axillary temperature measurement procedure

  1. Wash hands

  2. Make sure that the client’s axilla is dry

  3. After placing the bulb of the thermometer in the axilla, bring the client’s arm down against the body as tightly as possible

  4. Hold the glass thermometer in place for 8 to 10 minutes

  5. Remove and read the thermometer

  6. Dispose of the equipment properly

  7. Record the reading
• Procedure for Axillary Temperature

  1. Wash hands

  2. Ensure client’s axilla is dry

  3. Place the bulb of the thermometer into the axilla

  4. Bring the client’s arm down against the body tightly

  5. Hold the glass thermometer in place for 8 to 10 minutes

  6. Hold the electronic thermometer in place until the reading registers directly

  7. Remove and read the thermometer

  8. Dispose of the equipment properly

  9. Wash hands

  10. Record the reading
• Procedure for Tympanic Temperature

  1. Wash hands

  2. Explain the procedure to the client

  3. Hold the probe in the dominant hand

  4. Select the desired mode of temperature

  5. Grasp the adult’s external ear

  6. Advance the probe into the client’s ear

  7. Point the probe’s tip in an imaginary line

  8. Press the button to activate the thermometer

  9. Keep the probe in place until the thermometer makes a sound or flashes a light

  10. Read the temperature

  11. Discard the probe cover

  12. Replace the thermometer

  13. Wash hands

  14. Record the temperature on the client’s record
• Pulse


  The pressure of the blood felt against the wall of an artery as the heart alternately contracts (beats) and relaxes (rests)
• Pulse


  • More easily felt in arteries close to the skin
  • The same in all arteries throughout the body
  • An indication of how the cardiovascular system is meeting the body’s needs
• Pulse Sites

  • Temporal
  • Carotid
  • Apical
  • Brachial
  • Radial
  • Femoral
  • Popliteal
  • Posterior Tibial
  • Pedal (Dorsalis Pedis)
• Pulse Points

  • POPLITEAL - behind the knee
  • POSTERIOR TIBIAL - on the medial surface of the ankle
  • PEDAL (DORSALIS PEDIS) - palpated by feeling the dorsum (upper surface) of the foot on an imaginary line drawn from the middle of the ankle to the surface between the big and 2nd toes
• Factors Affecting Pulse Rates

  • AGE - as age increases, the PR gradually decreases. Newborn to 1 month - 130 bpm (range: 80-180 bpm). Adult - 80 bpm (Range: 60-100 bpm)
  • SEX - after puberty, the average males’ PR is slightly lower than female
  • EXERCISE - PR increases with exercise
  • FEVER - increases PR in response to the lowered bpm that results from peripheral vasodilation - increased metabolic rate
  • MEDICATIONS -digitalis preparation decreases PR, Epinephrine - increases PRHEAT: increases PR as a compensatory mechanism
  • STRESS - increases the sympathetic nerve stimulation - increases the rate and force of heartbeat
  • POSITION CHANGES - when a patient assumes a sitting or standing position, blood usually pools in dependent vessels of the venous system. Pooling results in a transient decrease in the venous blood return to heart and subsequent decrease in BP, increases heart rate
• Average Pulse Rates

  • Adult Men - 60-70 bpm
  • Adult Women - 65-80 bpm
  • Children over 7 years - 75-100 bpm
  • Preschoolers - 80-110 bpm
  • Infants - 120-160 bpm
• Pulse Method

  1. Commonly assessed by palpation (feeling) or auscultation (hearing)

  2. The middle 3 fingertips are used with moderate pressure for palpation of all pulses except apical; the most distal parts are more sensitive

  3. Assess the pulse for: Rate, Rhythm, Volume, Elasticity of the arterial wall

  4. Pulse measurement includes determining the: RATE OR SPEED, CHARACTER
• If the pulse is regular, measure (count) for 30 seconds and multiply by 2. If it is irregular, count for 1 full time
• Types of Pulse

  • PERIPHERAL PULSE - Is a pulse located in the periphery of the body, e.g. in the foot, and/or neck
  • RADIAL PULSE - Most commonly measured pulse, measured at the radial artery in the wrist. Conscious patients can be checked at the radial artery. Unconscious patients should be checked at the carotid artery or apically (over the heart)
  • APICAL PULSE (CENTRAL PULSE) - Located at the apex of the heart, measured by counting the heart contractions. The stethoscope is placed over the apex (tip) of the heart. Listen for the heart sounds that indicate closing of the valves. These sounds occur as the heart pumps blood to the arteries. The sounds should occur at the same rate as the pulse that is felt as an expansion of the radial artery
• How the apex of the heart is found: In the Left side of the front of the chest. Between the 5th and 6th ribs. Men, below the Left nipple. Women, under the Left breast. Listen carefully for two sounds: “lub dub”. The louder sound (lub) corresponds to the contraction of the ventricles pushing
• Apex of the heart is found

  1. In the Left side of the front of the chest between the 5th and 6th ribs

  2. Men, below the Left nipple

  3. Women, under the Left breast
• Heart sounds "lub dub"

  1. Louder sound (lub) corresponds to the contraction of the ventricles pushing the blood forward through the arteries and closing the AV valves

  2. Softer sound (dub) corresponds to the relaxation of the ventricles as they fill with blood for the next contraction and the closing of the semilunar valves
• Documenting an apical pulse reading

  Write "AP" after the value
• Apical-radial pulse rate


  1. Comparison of the apical rate and the radial rate

  2. Usually they are the same

  3. Sometimes no pulse is felt if the heart contraction is weak
• Pulse deficit


  1. Difference between the apical pulse and the radial pulse

  2. Two people measure the heart rate and the radial pulse at the same time

  3. Apical pulse rates are checked in various situations
• Procedure in counting the apical-radial pulse

  Steps to follow for counting the apical-radial pulse