FHC

• Vital signs


  Includes a person's temperature, pulse, respiration, and blood pressure
• Vital signs


  • They are the signs reflecting the physiologic state which governed the body's vital organs such as the heart, lungs & brain necessary to sustain life
  • They are called "vital" because of the importance of these indicators in predicting the effectiveness of body functions
  • Health status is reflected in these indicators of body functions and regulated through homeostatic mechanisms and falling within the normal range
  • A change in vital signs indicates a change in physiological functioning or a change in comfort signaling the need for medical or nursing interventions
• When to measure vital signs

  1. Upon admission to a health care facility

  2. When assessing the patient during home visits

  3. Before and after a surgical procedure or invasive diagnostic procedure

  4. Before, during, and after a transfusion of blood products

  5. Before, during, and after the administration of medications or applications of therapies that affect cardiovascular, respiratory, or temperature- control functions

  6. When the patient's general condition changes (loss of consciousness or increased intensity of pain)

  7. Before and after nursing interventions that influence a vital sign (ROM exercises, and ambulating a client who has been on bed rest)

  8. When the patient reports nonspecific symptoms of physical distress
• Body temperature


  • It reflects the balance between the heat produced and the heat lost from the body
  • The heat of the body is measured in degrees
  • The difference between the amount of heat produced by the body processes & the amount of heat lost to the external environment
• Types of body temperature


  • Core temperature
  • Surface temperature
• Core temperature


  • Temperature of the deep tissues of the body such as abdominal and pelvic cavity
  • Remains relatively constant within a range of 36 C – 37 .4 C
  • Higher than surface temperature
  • Measured at tympanic or rectal sites, but they may also be measured in the esophagus, pulmonary artery or bladder by invasive monitoring devices
• Surface temperature


  • Temperature of the skin, subcutaneous tissue and fat
  • Measured at oral and axillary sites
  • Rises and falls in response to the environment
• Body temperature assessment sites


  • Oral
  • Rectal
  • Axillary
  • Tympanic membrane
• Oral temperature


  • Accessible and convenient
  • Generally measures 0.5 – 0.6 C below core temperature
  • The area under the tongue is in direct proximity to the sublingual artery
  • The most practical clinically preferred method because oral temperature fluctuates more accurately in response to alteration in body heat balance than does rectal temperature
  • Reflects changing body temperature more quickly than the rectal method
  • Contraindications: uncooperative, very young, unconscious, shivering, prone to seizures, or mouth breathers or oral surgery
• Rectal temperature


  • Most accurate and reliable measurement
  • Rectal temp. differs about 0.1 C from core temperature
  • Can be embarrassing and emotionally traumatic for alert clients and difficult for client who cannot turn to side
  • Used to check for imperforate anus in newborns
  • Contraindications: rectal surgery, diarrhea or hemorrhoids and other diseases of the rectum
• Axillary temperature


  • Safe and noninvasive
  • Preferred site for the newborns because it is safe and accessible
  • Less potential for spreading microorganisms than oral and rectal sites
  • Some research indicates that this method is inaccurate when assessing fever
  • The thermometer must be left in place longer to obtain an accurate measurement
  • Make sure that the area is dry and not wet with perspiration, deodorants, cream, or the like; do not rub the area dry vigorously as friction will increase the temperature
• Tympanic/infrared thermometer


  • Use infrared sensors to detect heat given off by the tympanic membrane
  • The probe is covered with a probe cover and inserted into the ear canal tightly enough to seal the opening
  • The reading takes from 1-3 seconds, depending on the product
  • The probe contains an infrared sensor that detects the warmth radiating from the tympanic membrane and converts the heat into a temperature measurement
• Normal range of body temperature by site

  • Oral: 97.6 - 99.6 F (36.5 – 37.4 C)
  • Rectal: 98.6 – 100.6 F (37.0 – 38.1 C)
  • Axilla: 96.6 – 98.6 F (36.0 – 37.0 C)
• Digital thermometer


  • Works by using heat sensors that determine body temperature
  • Looks similar to a glass thermometer & can be used at oral, axillary, and rectal sites
  • It has an on/off button, and a display that lights up during use
  • The battery used to operate the thermometer requires occasional replacement
  • It takes 1-60 seconds to measure body temperature, depending on the site and product used
  • Requires cleansing similar to glass thermometer except that it is wiped rather than soaked with alcohol
• Fever/pyrexia/hyperthermia


  • Body temperature above the usual range
  • Occurs because heat loss mechanisms are unable to keep pace with excess heat production
  • Not harmful if it stays below 39 C in adults or 40 C in children
  • Results from a response to bacterial or viral infection and in response to tissue injury
• Hyperpyrexia


  A very high fever with body temperature of 41 ºC
• Types of fever


  • Intermittent fever
  • Remittent fever
  • Relapsing fever
  • Constant fever
• In some conditions, an elevated temperature is not a true fever: heat exhaustion (results of excessive heat & dehydration) and heat stroke (due to exercising in hot weather)
• How to measure body temperature: axillary


  1. Turn on the thermometer according to package directions

  2. Place the thermometer on a dry armpit. You may remove the child's shirt and undershirt to ensure that the bulb of the thermometer is touching the skin only

  3. Fold your child's arm across the chest to hold the thermometer in place

  4. Wait until you hear the appropriate number of beeps or other signal that the temperature is ready to be read. Write down the number on the screen, noting the time of day that you took the reading
• Pulse


  • A wave of blood created by contraction of the left ventricle of the heart
  • A throbbing sensation that can be palpated over a peripheral artery or auscultated over the apex of the heart
  • Produced by the movement of blood during heart's contraction
  • The distention or pulsation of arteries produced by the wave of blood forced into them by the heart's left ventricular contraction or by the pumping action of the heart
  • A wave can be felt when direct pressure is applied at certain points /pulse sites of the body
• Pulse sites


  • Temporal
  • Carotid
  • Apical
  • Brachial
  • Radial
  • Femoral
  • Popliteal
  • Posterior Tibial
  • Dorsalis Pedis/Pedal
• Assessing a peripheral pulse

  1. Wash hands

  2. Introduce self

  3. Explain the purpose and procedure to the client

  4. Prepare the client

  5. Provide privacy

  6. Select the pulse site. Normally, the radial pulse is taken, unless it cannot be exposed or circulation to another body area is to be assessed

  7. Assist client to a comfortable resting position, either in a lying or sitting position

  8. Palpate and count the pulse. Place 2 or 3 middle fingertips (index, middle & ring fingers) lightly and squarely over the pulse site i.e. radial pulse. NEVER used the thumb, because it has a pulse of its own. Count the pulse for one full minute especially when obtaining baseline data, with the aid of a wristwatch or stopwatch

  9. Assess the pulse quality (rhythm) and volume

  10. Document and report pertinent data
• Pulse rate


  • The number of pulse beats in one full minute
  • The number of pulsations felt over a peripheral artery or normally heard over the apex of the heart per min
  • This rate normally corresponds to the same rate at which the heart is beating
  • Normal range = 60-100 beats/min (adult & adolescence at rest)
  • Increases and decreases in response to a variety of physiologic mechanisms
• Tachycardia


  • Rapid pulse rate
  • A pulse rate of an adult that exceeds 100 beats/min. at rest
  • Can exceed 150 beats/min during exercise
  • Rapid contraction, if sustained, tends to overwork the heart and may not oxygenate cells adequately because the heart has little time between contractions to fill with blood
  • Clients with rapid pulse rate are monitored closely, and the results are reported and recorded
• Palpitation


  Awareness of one's own heart contraction and can accompany tachycardia
• Bradycardia

  • Slow pulse rate
  • Pulse rate of an adult less than 60 beats/min
  • Less common than tachycardia
  • Needs prompt reporting and continued monitoring
• Pulse rhythm/regularity


  • The pattern by which the heart beats are spaced, normally regular with each beat
  • Rhythm is regular, beats are felt by the finger at a regular interval and are of equal force
• Dysrhythmia/arrhythmia


  An irregular pattern/rhythm of heartbeats
• Tachycardia


  Rapid pulse rate, pulse rate of an adult that exceeds 100 beats/min at rest, can exceed 150 beats/min during exercise
• Tachycardia


  • Rapid contraction, if sustained, tends to overwork the heart and may not oxygenate cells adequately because the heart has little time between contractions to fill with blood
  • Clients with rapid pulse rate are monitored closely, and the results are reported and recorded
• Bradycardia


  Slow pulse rate, pulse rate of an adult less than 60 beats/min, less common than tachycardia
• Bradycardia


  • Needs prompt reporting and continued monitoring
• Pulse Rhythm/Regularity


  The pattern by which the heart beats are spaced, normally regular with each beat, rhythm is regular, beats are felt by the finger at a regular interval and are of equal force
• Dysrhythmia/arrhythmia


  • Apical pulse should be assessed, should be reported promptly
• Bigeminal


  Pulse has occasional premature beats, resulting in a shorter interval between beats followed by a longer interval
• Pulse Volume/Amplitude


  Reflects the strength of left ventricular contraction, quality of pulsation felt usually is related to the amount of blood pumped with each heartbeat, or the force of heart contraction
• Types of Pulse Volume

  • Absent pulse - no pulsation is felt despite of extreme pressure
  • Thready pulse - pulsation is not easily felt; slight pressure causes it to disappear
  • Weak pulse - pulse is stronger than thready; light pressure causes it to disappear
  • Normal pulse - pulsation is felt easily; moderate pressure causes it to disappear
  • Bounding pulse - pulsation is strong and does not disappear with moderate pressure
• Pulse Oximeter


  Non-invasive device that measures a client's arterial blood oxygen saturation by means of sensor attached to the client's finger, toe, nose or forehead, indicates oxygen saturation measurement and pulse rate
• Respiration


  The act of breathing, transport of oxygen from the atmosphere to the body cells and transport of carbon dioxide from the cells to the atmosphere, the process of gas exchange between the atmosphere, blood, and body cells consisting of pulmonary ventilation, external respiration, and internal respiration
• Inspiration (inhalation)


  Intake of air into the lungs, "Breathing-in" process, active process, contractions of the diaphragm and external intercostal muscles enlarge the chest cavity & create partial vacuum