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• 5 Cardinal Signs

  • Body Temperature
  • Pulse
  • Respiration
  • Blood Pressure
  • Pain

  
• Cardinal Signs


  • Reflect the body's physiological status & ability to regulate temperature, maintain local and systemic blood flow, & oxygenate tissues
• Normal Range of Vital Signs

  • Body Temperature: 36°C to 37.5°C
  • Pulse: 70-80 bpm (Adult M), 80-90 bpm (Adult F)
  • Respiration: 30 to 40 per min (Infant), 20 to 25 per min (Child), 16 to 20 per min (Adult)
  • Blood Pressure: 120/80
• Times to Assess Vital Signs

  • On admission
  • Institution policy
  • Before & after invasive procedure
  • Before & after administration of medications
  • Change in client's condition
  • Before & after a nursing intervention
• Take the patient's vital sign every 4 hours
• If your schedule is 7AM-3PM, VS taking is 8AM & 12NN
• If your schedule is 3PM-11PM, VS taking is 4PM & 8PM
• If your schedule is 11PM-7AM, VS taking is 12MN & 4AM
• 4AM can be delayed, however, if the doctor instructed to closely monitor the PT, wake the patient up
• Body Temperature


  Reflects the balance between the heat produce and heat loss
• Core Temperature


  Temperature of the deep tissues in the body (abdominal pain, pelvic cavity)
• Surface Temperature


  Temperature of the skin, subcutaneous tissue, & fats
• Factors Affecting Body Temperature

  • Age
  • Diurnal Variations (Circadian Rhythms)
  • Exercise
  • Hormones
  • Stress
  • Environment
• Methods in Taking Body Temperature

  • Oral
  • Rectal
  • Tympanic
  • Axillary
  • Forehead
  • Temporal Arterial
• Oral


  Easy, fast, and accurate. Not for the unconscious, confused, prone to seizures, and patients recovering from oral surgery. Not for under 6 yrs. Need to wait 15-20 mins after eating.
• Rectal


  More reflective of core temperature. Not for patients with rectal bleeding, hemorrhoids, diarrhea & recovering from rectal surgery. Contraindicated for cardiac patients as it may stimulate vagus nerve and decrease heart rate.
• Tympanic


  Fast, more reflective of core temperature, safe and good for children.
• Axillary


  Safe, good for children and newborn. Reports of accuracy are conflicting, baby/kids are too small, and kids would cry or get scared.
• Forehead


  Safe and easy. Measures skin surface, which can be variable.
• Temporal Arterial


  Safe for children. Measures skin surface temp, least accurate method.
• Heat Gain


  • Environmental (Conductive, Convective, Radiant)
  • Metabolic (BMR/RMR, Thermogenesis, Muscular Activity)
• Heat Loss


  • Evaporative
  • Radiant
  • Conductive
  • Convective
• Contributing Factors for Heat Production

  • Basal metabolic rate (BMR)
  • Muscle Activity
  • Thyroxine Output
  • Stress
  • Fever
• Factors Affecting Heat Loss

  • Radiation
  • Conduction
  • Convection
  • Evaporization
• Body Temperature Alterations


  • Pyrexia (Febrile, Hyperpyrexia)
  • Hypothermia (Accidental, Induced)
• Types of Fever

  • Intermittent
  • Remittent
  • Relapsing
  • Constant
  • Fever Spike
• Fever Resolution

  • By Crisis
  • By Lysis
• Types of Thermometers

  • Mercury in glass
  • Electronic
  • Chemical Disposable
  • Temperature sensitive tape
  • Infrared
  • Temporal Artery
• Pulse


  Waves of blood created by contraction of the left ventricle of the heart. Represents the stroke volume output and the amount of blood that enters the arteries with each ventricular contraction.

  
• Compliance


  Ability to contract and expand
• Cardiac Output


  The volume of blood pumped into the arteries by the heart. CO = SV x HR

  
• Peripheral Pulse


  Pulse located away from the heart
• Apical Pulse


  A central pulse located at the apex of the heart

  
• Pulse Sites

  • Temporal
  • Carotid
  • Brachial
  • Radial
  • Femoral
  • Popliteal
  • Posterior Tibial
  • Dorsalis Pedis
  • Apical
• Reasons for Using Pulse Sites

  • Radial: Readily accessible
  • Temporal: Used when Radial is not accessible
  • Carotid: Cardiac arrest/Shock Determine Circulation to the brain
  • Apical: Children below 3 years of age
  • Brachial: Used to measure BP Cardiac Arrest for infants
  • Femoral: Cardiac arrest/shock Determine circulation of the leg
  • Popliteal: Determine circulation of the LL
  • P. Tibialis & D. Pedis: Determine Circulation of the foot

  
• Assessing the Pulse

  • Palpation
  • Auscultation
  • Doppler Ultrasound Stethoscope (DUS)
• Things to Note in Pulse Assessment

  • Rate (Tachycardia, Bradycardia)
  • Pulse Rhythm (Dysrhythmia or Arrhythmia)
  • Pulse Volume (Normal, Full or Bounding, Weak, feeble, or thready)
  • Arterial Wall Elasticity
  • Presence or Absence of Bilateral Equality

  
• Apical Pulse Assessment


  Indication: Peripheral pulse is irregular, Unavailable p. Pulses, Clients with known cardiovascular, pulmonary, and renal diseases, Commonly assess prior to administering cardiotonics, Newborns, infants and children up to 2 to 3 years old

  
• Apical Radial Pulse


  Normal: apical and radial rates are identical. Abnormal: apical pulse rate greater than a radial pulse rate. Pulse Deficit: any discrepancy between the two pulse rates (more than 2 ang difference)
• An APICAL RATE never be lower to Radial pulse