Quiz

• Vital signs


  Measurements of the body's most basic functions
• Main vital signs routinely monitored


  • Temperature
  • Pulse
  • Respiration
  • Blood pressure (BP)
  • Oxygen saturation
• Temperature


  The balance between heat produced and heat lost by the body, measured using a thermometer
• Normal temperature is 98.6°F (37 °C), with anything between 97.6 °F (36.4 C) to 99,6 °F (37.5° C) acceptable
• A temperature over 100.4 °F (38 °C) indicates a fever caused by illness or injury
• Hypothermia (low temperature) occurs when the body temperature dips below 95 degrees F (35 degrees C)
• Equipment needed for temperature measurement

  • Tray with thermometer
  • Jar of cotton balls soaked in water
  • Jar of cotton balls in soap suds solution
  • Jar with cut tissue paper
  • Waste receptacle
  • Wristwatch with second-hand
  • Jot down notebook and pen
• Oral method


  For taking temperature orally
• Contraindications for oral temperature measurement

  • Infants
  • Unconscious or irrational patients or those with history of seizures
  • Patients who breathe though the mouth
  • Those with disease of the oral cavity or surgery of the nose or mouth
  • Patients who have bad taken cold or hot foods/fluids
• Indications for oral temperature measurement

  • With oral inflammation or recovering from oral surgery
  • Those who cannot breathe through the nose
  • Irrational patients
  • For whom other temperature sites are contraindicated
• Axillary method


  For taking temperature in the armpit
• Tympanic method


  For taking temperature in the ear
• Contraindications for tympanic temperature measurement

  • Infant or child who has significant ear pathology
  • A foreign body in the ear or has moisture in the ear, such as cerebrospinal fluid or blood
• Tympanic temperature measurement


  • More accurate reflection of core temperature
  • Non-invasive
  • Relatively easy to use and is comfortable for children
  • More hygienic, less invasive, and safer than other forms of thermometry
• Rectal method


  For taking temperature rectally
• Indications for rectal temperature measurement

  • To obtain the first temperature in newborns to check anal patency
  • When oral or other routes cannot be used
• Contraindications for rectal temperature measurement

  • Patients with diarrhea, rectal disorder or injury, hemorrhoids
  • Patients with heart disease or any cardiovascular alteration as the thermometer may stimulate the vagus nerve causing bradycardia or rhythm disorder
  • Patients who just had rectal surgery
  • Patients with leukemia-may traumatize the rectal mucosa causing bleeding
  • Patient who is confused or agitated
• Rectal temperature measurement is slightly uncomfortable
• Other types of thermometers

  • Strip Type Thermometers
  • These are held against the forehead and are not an accurate way of taking a temperature
  • They show the temperature of the skin, rather than the body
• Action


  1. Explain to the patient or 50 that vital signs will be taken

  2. Gather equipment

  3. Perform hand hygiene/wash hands and apply gloves when appropriate

  4. Clean the thermometer, from the bulbs downward to the stem in a firm twisting motion, with cotton balls in soap suds solution, then rinse it with cotton balls soaked in water

  5. Turn the thermometer on

  6. ORAL METHOD:

  a. Encourage the patient to refrain from drinking, eating, and smoking

  b. Put the tip under the patient's tongue in the posterior sublingual pocket

  c. Instruct the patient to close mouth with the lips and not the teeth around the thermometer

  7. AXILLARY METHOD:

  a. Cleanse the patient's armpit and by gently wiping or parting it with tissue (you may ask the patient to do it, if able)

  b. Place the thermometer well into the patient's axilla, bring the patient's arm down close to his body and place his forearm over his chest

  For children under 5 years old:

  a. Hold the child comfortably on your knee and put the thermometer in their armpit and gently, but firmly, hold the child's arm against their body

  8. TYMPANIC METHOD:

  a. Place a probe cover on the thermometer tip without touching the probe cover with your hands

  b. Gently pull the patient's ear before putting the thermometer in the ear

  c. Slowly insert the tip of the probe just inside the opening of the ear until it perfectly snugs in place

  d. Never force the thermometer into the ear and do not occlude the ear canal

  e. Activate the device

  Discard the probe cover (without touching the cover) and place the device back into the holder
• Rectal temperature measurement


  1. Close the door or screen the patient

  2. Position the patient in lateral position and drape to expose only the rectum

  3. Lubricate the thermometer

  4. Fold back the bed linen and separate the buttocks

  5. Insert the thermometer 0.5-1 inch into the rectum

  6. Press the patient's buttocks together to hold the thermometer in place

  7. Remove the thermometer when it beeps and wipe it dry

  8. Clean and sterilize the thermometer

  9. Discard used materials and return equipment

  10. Remove gloves and wash hands

  11. Record the temperature
• Pulse


  Rhythmical throbbing that results from a wave of blood passing through an artery as the heart contracts
• Heart rate/pulse


  The number of times a heart beats per minute (bpm)
• Pulse assessment


  • Rate: Count the pulse rate for 1 full minute
  • Strength/Tension: Grade the strength of the pulse and compare bilaterally
  • Rhythm or Regularity: Assess if the pulse is regular or irregular
  • Volume
• Common pulse points


  • Temporal
  • Carotid
  • Apical
  • Brachial
  • Radial
  • Femoral
  • Popliteal
  • Posterior Tibial
  • Dorsalis Pedis
• Normal pulse rate range by age
• Pulse assessment procedure


  1. Wash hands

  2. Explain the procedure to the patient

  3. Ask if the patient has exerted themselves recently

  4. Ensure the patient is relaxed and comfortable

  5. Palpate the radial artery and count the pulse for 1 full minute

  6. Assess the apical pulse if the radial pulse is irregular, weak or rapid

  7. Assess the carotid pulse if the radial pulse is not present or difficult to palpate

  8. Repeat the assessment if the pulse is abnormal

  9. Record the pulse rate, strength and rhythm

  10. Wash and dry hands
• Respiration


  The exchange of oxygen and carbon dioxide between the atmosphere and the body
• Respiration rate


  The number of breaths a person takes per minute
• Normal respiration rates
• Respiration assessment procedure


  1. Observe the rise and fall of the patient's chest

  2. Count the number of respirations for 1 full minute

  3. Repeat the count if respirations are abnormal

  4. Record the respiration rate and any abnormalities
• Observe the patient's respiration


  1. Note the rise and fall of the patient's chest with each inspiration and expiration

  2. Using a watch with second hand, count the number of respiration unobtrusively for ONE (1) FULL MINUTE

  3. If respirations are abnormal, repeat to determine the rate and the characteristics of the breathing accurately

  4. Record respiration rate in the jot down notebook including the abnormalities in rhythm and depth, if any
• Rationale for observing respiration


  • Observe respiration while presumably still counting the pulse keeps the patient from becoming conscious of his breathing which can possibly alter his usual awareness
  • A complete cycle of inspiration and expiration constitutes an act of respiration
  • Sufficient time is necessary to observe the rate, depth and other characteristics (irregularities and other defects)
  • Longer counting and palpation are necessary to identify most accurately the vascular characteristics of the pulse rate
• Blood pressure


  The lateral force exerted by the blood on the arterial walls during contraction and relaxation of the heart
• Purposes of blood pressure measurement

  • To aid in diagnosis
  • To monitor changes in the patient's condition
• Contraindications for brachial artery BP measurement


  • Surgery including the breasts, axilla, shoulder arm or hands
  • Venous access device such as AV shunt and IVF
  • Injury or disease to the shoulder, arm or hand such as trauma, burn, application of cast or bandage
• Sites for BP taking

  • Either arm on the antecubital space
  • Either leg on the popliteal space
  • Dorsalis pedis
• Factors that can cause variation in blood pressure

  • Emotional state
  • Temperature
  • Respiration
  • Bladder distension
  • Pain
  • Exercise
  • Age
  • Food consumption
  • Race/ethnicity
  • Tobacco use
  • Diurnal variation (blood pressure is at its lowest during sleep)
  • Alcohol use
  • White coat' hypertension (raised blood pressure when measured in clinical settings)
  • Sudden change in posture
  • Underlying medical conditions, such as renal failure, diabetes, anaphylaxis, hypovolemia
• Equipment needed for manual BP taking

  • Jot down notebook and pen
  • Sphygmomanometer and stethoscope
• Equipment needed for digital BP taking

  • Jot down notebook and pen
  • Digital BP apparatus