Vital Signs Definition Vital Signs or cardinal sign is a routine medical procedure and it determines the internal functions

of the body. Vital signs, or signs of life, include the following objective measures for a person: Temperature, Respiratory Rate, Heart Rate (Pulse), and Blood Pressure. All of these vital signs can be observed, measured, and monitored. This will enable the assessment of the level at which an individual is functioning. Purpose To establish a baseline on admission to a hospital or clinic, the nurse should take the patient's vital signs. It is his or her responsibility to detect any abnormalities from the patient's normal state, and to establish if current medication(s) is having the desired effect. Vital Signs compose of the following: Body Temperature Respiratory Rate Heart Rate (Pulse) Blood Pressure

1.

Body Temperature It is a balance of the external and internal environment of the body. It is the balance between the heat produced by the body and the heat loss from the body. It is measured in heat units called Degrees.

Two Types of Body Temperature: Core Temperature- it is the temperature of deep tissues of the body such as the cranium, thorax, abdominal cavity and pelvic cavity. It remains relatively constant to (37C/ 98F). An accurate measurement is usually done with pulmonary catheter. Surface Temperature- is the temperature of the skin, subcutaneous tissues and fat. It constantly rises and falls in relation to the environments temperature. It varies from 20 C to 40 C.

Sites used in taking Body Temperature: Factors affecting Body Temperature:

Axillary, under the armpit. This method provides the least accurate results.

Orally, under the tongue. This method is never used with infants or very young children because they may accidentally bite or break the thermometer. They also have difficulty holding oral thermometers under their tongues long enough for their temperatures to be accurately measured. Rectally, inserted into the rectum. This method provides the most accurate recording of recording the temperature. It is most often used for infants

Factors that affect Body Temperature: Age- infants are greatly influenced by temperature; children are more labile than adults and elderly due to decreased thermoregulatory control. Environment- the body's ability to regulate its temperature is compromised by extreme environmental conditions. Exercise- Physical activity can compromise the body's normal temperature. The response to physical activity is an increase in metabolic rate, resulting in increased heat production within the body. Diurnal Variations (circadian rhythm)- body temperature normally changes throughout the day, varying as much as 0.1 C between early morning and late afternoon. Hormones- women usually experience hormone fluctuations than men. Increase in Progesterone level increases womens body temperature. Stress- Epinephrine and norepinephrine increases metabolic activity and heat production.

Alterations in Body Temperature: The body's normal temperature, taken orally, is 98.6F (37C), with a range of 97.8 to 99.1F (36.5-37.2C). A pyrexia, hyperpyrexia or fever is a temperature of 101F (38.3C) or higher in an infant younger than three months or above 102F (38.9C) for older children and adults. Hypothermia is recognized as a temperature below 96F (35.5C). Types of Thermometer: Mercury in glass Electronic thermometer- Digital thermometer Infrared thermometer- Tympanic thermometer Chemical thermometer Temperature sensitive strip

Taking Temperature Using Digital Thermometer in Three Methods: Oral Method Insert a digital thermometer inside the mouth, Place carefully under the tongue. Wait for the thermometer to beep. A digital reading will give the body temperature.

Rectal Method Cover the tip of the digital thermometer with Lubricant. Place the child across the lap, stomach down, or on a firm surface. Gently insert the thermometer about 1/2 to 1-inches. Stop if any resistance is felt. Keep the thermometer in place by holding it between the fingers. Meanwhile, keep the hand firmly but gently on the child's bottom to prevent squirming. Once the beep sounds carefully remove the thermometer. This sounds difficult but it is fairly easy to do.

Axillary (Armpit) Method Place the digital thermometer in the armpit. Fold the arm down to cover the digital thermometer. Wait for the beep and read the recorded temperature. This is the easiest method of all.

2. Pulse is a wave of blood created by contractions of left ventricle of the heart. Generally, the pulse wave represents the stroke volume output and the compliance of arteries. Stroke Volume Output- is the amount of blood that enters the arteries with each ventricular contraction. Compliance- is the ability of the arteries to contract and expand. The Cardiac Output (CO) is the result of Stroke Volume(SV) times the Heart Rate (HR) per minute; CO= SVx HR Types of Pulse: Peripheral Pulse-is the pulse located in the periphery of the body. Apical Pulse- is the central pulse located in the apex of the heart.

Site: Radial.The radial pulse (the pulse taken using the radial artery) is taken at a point where the radial artery crosses the bones of the wrist. If the patient's hand is turned so that the palm is up, the radial pulse is taken on the thumb side of top side of the wrist. Carotid. The carotid pulse is taken on either side of the trachea (windpipe). The best location is the grooves located to the right and to the left of the larynx (Adam's apple). Brachial. The brachial pulse is taken in the depression located about one-half inch above the crease on the inside (not the bony side) of the elbow. This site is used when taking the patient's blood pressure. Temporal. The temporal pulse is taken in the temple area on either side of the head. The temple area is located in front of the upper part of the ear. The pulse is felt just above a large, raised bony area called the zygomatic arch. Ulnar. Like the radial pulse, the ulnar pulse is taken at the wrist. The radial pulse is taken over the artery on the thumb side of the wrist while the ulnar pulse is taken on the other side of the wrist. Both pulses are taken on the palm side of the wrist. The radial artery is normally preferred over the ulnar artery for taking the pulse because the radial artery is somewhat larger. Femoral. The femoral pulse is taken in the groin area by pressing the right or left femoral artery against the ischium (the lower part of the pelvic bones located in the front part of the body). Popliteal. The popliteal pulse is taken in the middle of the area located on the inside of the knee (the area opposite the kneecap). Posterior Tibial. The posterior tibial pulse is taken at the top of the ankle or just above the ankle on the back, inside part of the ankle. Dorsalis Pedis. The dorsalis pedis pulse is taken on the top portion of the foot just below the ankle. The pulse is taken in the middle of this area (not to the inside or outside). Apical. Unlike the other sites, the apical pulse is not taken over an artery. Instead, it is taken over the heart itself. The apical pulse (actually, the heartbeat) can be felt over the apex of the heart (the pointed lower end of the heart.) This site is located to the (patient's) left of the breastbone and two to three inches above the bottom of the breastbone. The apical pulse is easily heard when a stethoscope is used.

Pulse rates that are outside the normal range are classified as tachycardia or bradycardia. (a) Tachycardia. If the patient's pulse rate is over 100 beats per minute, the patient is said to have tachycardia. Tachycardia means "swift heart." Constant tachycardia could be a sign of certain diseases and heart problems. Often, however, tachycardia is only temporary. Temporary tachycardia can be caused by exercise, pain, strong emotion, excessive heat, fever, bleeding, or shock. (b) Bradycardia. If the patient's pulse rate is below 50 beats per minute, the patient is said to have bradycardia. Bradycardia means "slow heart." Bradycardia can be sign of certain diseases and heart problems. Certain medicines, such as Digitalis, can result in bradycardia.

Strength. The strength (force) of the pulse is determined by the amount of blood forced into the artery by the heartbeat. A normal pulse has a normal strength. You will be able to identify a normal strength pulse with practice. (1) Bounding. If the heart is pumping a large amount of blood with each heartbeat, the pulse will feel very strong. This strong pulse is called "bounding" pulse (as in "by leaps and bounds"). A bounding pulse can be caused by exercise, anxiety, or alcohol consumption. (2) Weak. If the heart is pumping only a small amount of blood with each heartbeat, the pulse will be harder to detect. This type of pulse is called weak, feeble, or thready. If the pulse is weak, you may have trouble finding (palpating) the pulse at first. (3) Strong. A strong pulse is stronger than normal pulse, but is less than bounding. Shock and hemorrhage (serious bleeding) can cause a strong pulse.

c. Rhythm. Rhythm refers to the evenness of the beats. In a regular pulse, the time between beats is the same (constant) and the beats are of the same strength. (1) Irregular. A pulse is irregular when the rhythm does not have an even pattern. The time between beats may change, or the strength of the beats may change or the pulse may vary in both time between beats and strength. (2) Intermittent. An intermittent pulse is a special type of irregular pulse. A pulse is intermittent when the strength does not vary greatly, but a beat is skipped (missed) either at regular or irregular intervals. If the missing beats in an intermittent pulse were present, then the pulse rhythm would be normal. Measuring Pulse Rate: The pulse can be recorded anywhere that a surface artery runs over a bone. The radial artery in the wrist is the point most commonly used to measure a pulse. To measure a pulse, one should place the index, middle, and ring fingers over the radial artery. It is located above the wrist, on the anterior or front surface of the thumb side of the arm. Gentle pressure should be applied, taking care to avoid obstructing blood flow. The rate, rhythm, strength, and tension of the pulse should be noted. If there are no abnormalities detected, the pulsations can be counted for half a minute, and the result doubled. However, any irregularities discerned indicate that the pulse should be recorded for one minute. This will eliminate the possibility of error. Pulse results should be noted in the patients chart.

3. Respiration is the act of breathing; it includes the intake of Oxygen and the output of Carbon Dioxide. Respiratory Rate- is usually described in breaths per minute. Types: Eupnea- normal breathing Bradypnea- abnornmally slow Tachypnea- abnormally fast Apnea- cessation of breathing

Rhythm: Regular Irregular

Measuring Respiratory Rate: Observe the person's stomach or chest and watch until you see it rise and fall. Count the number of times the stomach or chest rises for 15 seconds and multiply by 4, or for 30 seconds and multiply by 2. This tells you the respiratory rate per minute. Note the rhythm of the breathing. Is it regular or irregular? Note how much effort it takes for the person to breathe. Is the breath labored, or effortless? Note if the breathing is deep or shallow. Smell the breath for any unusual odor, especially noting a fruity odor or a fecal odor. Record your findings in the following manner: rate, rhythm, effort, depth, noise and odors. For example: "Respiratory rate is 30, irregular, labored, shallow, gurgling and with no odor."

4. Blood Pressure Blood pressure is the amount of force (pressure) that blood exerts on the walls of the blood vessels as it passes through them. Two pressures are measured for a blood pressure reading:

heartbeats. Taking Blood Pressure: Blood pressure is taken using a cuff that is the correct size for the patient. This will ensure the most accurate reading possible. With an electronic unit, the cuff is placed level with the heart and, if possible, wrapped around the upper left arm. Following the manufacturers guidelines, the cuff is inflated and then deflated automatically, and the health care provider records the reading. If blood pressure is monitored manually, a cuff is placed level with the heart and wrapped around the upper arm. Placing a stethoscope over the brachial artery in front of the elbow with one hand and listening through the ear-piece, the cuff should be inflated until the artery is occluded, and no sound is heard. The cuff should then be inflated a further 10 mm Hg above the last sound heard. Opening the valve in the pump slowlyo faster than 5mm Hg per secondressure in the cuff is deflated until a sound is detected over the brachial artery. This point is noted as the systolic

pressure. The pressure is further deflated until a soft muffled sound is heard. This allows the diastolic pressure to be taken. As in the case with in children, sounds will continue to be heard as the cuff deflates to zero. The results are charted, with the systolic pressure being recorded first, and then the diastolic pressure. An entry in the patients chart might appear as 120/70 (systolic/diastolic).

Heart sounds: First Sound- occurs at the beginning of a ventricular systole. Second Sound- marks the beginning of a ventricular systole.

Ateneo de Davao University College of Nursing

Vital Signs Output

Submitted by: Edelou A. Jumawan Submitted to: Mr. Ronald Rebollido, Rn., Mn.

July 18,2012

Ateneo de Davao University College of Nursing

Drug Study

Submitted by: Edelou A. Jumawan Submitted to: Mr. Ronald Rebollido, Rn., Mn.

July 18,2012