Session 4Vital Signs –Temperature, Pulse and Respiration

Session 4Vital Signs –Temperature, Pulse and Respiration

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Learning Objectives

Learning Objectives

By the end of this session, students are expected to be able to:

Define: vital or cardinal signs, temperature, respiration and pulse, and other related terms to specific vital sign(s)

List five components regarded as vital or cardinal signs

Identify normal ranges of vital signs by age

Identify appropriate times for assessing vital signs

Describe factors that affect the respective vital sign

Identify sites used to assess temperature and pulse

Describe procedure of assessing and interpret each individual vital sign

Describe appropriate interventions for alterations in body temperature

Describe common altered breathing pattern and sounds

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Definition of Terms

Definition of Terms

Vital or cardinal signs: Are body temperature, pulse, respiration, blood pressure and pain that indicate how effectively the body is carrying out the essential activities of life.

Vital signs are governed by the body’s vital organs such as the brain, heart and lungs.

Any serious illness or any failure of body organ to function adequately will be evident through changes in the vital signs.

Vital signs should be looked at in total and are checked to monitor the function of the body.

Monitoring a client’s vital signs should not be an automatic or routine procedure; it should be thoughtful, scientific assessment.

Vital signs which should be evaluated with reference to the client presence and prior health status are compared to the clients usual (if known) and accepted normal standards in order to identify the underline cause/problem.

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Temperature: A state of hotness or coldness of a substance as measured by a thermometer.

Temperature: A state of hotness or coldness of a substance as measured by a thermometer.

Body temperature: The measure of warmth or coldness of the body resulting from body metabolism.

It is the balance between heat production and heat loss and is measured in heat units called degrees.

Core temperature: A temperature of the deep tissues of the body such as abdominal cavity and pelvic cavity and remains relatively constant (37 oC).

Surface temperature: The temperature of the skin, the subcutaneous tissue and fat. It falls in response to the environment.

Respiration: The process of breathing in (inhaling) air into the lungs and breathing out (exhaling air) from the lungs.

This process enables the body to obtain oxygen and get rid of carbon dioxide.

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External respiration: The interchange of gases between blood flowing through the lungs and atmosphere.

External respiration: The interchange of gases between blood flowing through the lungs and atmosphere.

Internal respiration: This is interchange of gases between the blood stream and the tissues all over the body.

In normal breathing the main muscle of respiration used are the ‘intercostals muscles’ and the diaphragm.

Although these are voluntary muscles, respiration is normally an automatic process which does not require a conscious effort.

Deep respiration: Are those in which a large amount of air is inhaled and exhaled, inflating most of the lungs.

Shallow respirations: Are those in which they involve the exchange of a small amount of air and often minimal use of the lung tissue.

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Characteristics of Respiration: In normal respiration a person breathes quietly, regularly and without effort.

Characteristics of Respiration: In normal respiration a person breathes quietly, regularly and without effort.

The observation made include

The rate

The rhythm

The character of respiration

Respiration Rate: The average normal ranges of respiration at rest are

Newborn infant – 60 breath per minute

Children 2-5 yrs- 40 breath per minute

Adults 14-20 – breath per minute

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The Rhythm of respiration: Normal respiration should be rhythmic and evenly spaced.

The Rhythm of respiration: Normal respiration should be rhythmic and evenly spaced.

Assessing respirations: Resting respirations should be assessed when a client is relaxed because exercises affect respirations and increase their rate and depth.

Respirations may also be assessed after exercises to identify the client’s tolerance to activity.

Before assessing the client’s respirations the health care provider should be aware of the following:

The client’s normal breathing pattern

The influence of the client’s health problems on respirations

The relationship of the client’s respiration to the cardiovascular function

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Pulse: A wave of blood created by contraction of the left ventricle of the heart.

Pulse: A wave of blood created by contraction of the left ventricle of the heart.

Generally the pulse wave represents the stroke volume output and the amount of blood that enters the arteries with each ventricular contraction.

The average normal pulse of an adult person is 72 beats per minute.

Peripheral pulse: A pulse located away from the heart for example in foot, wrist or neck.

Apical pulse: The central pulse that is located at the apex of the heart.

Bradycardia: This is a term used to describe unusual slow pulse rate.

The heart beats under 60 times per minutes.

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Conditions associated with bradycardia include:

Conditions associated with bradycardia include

Decreased metabolic rate, as in myxoedema

Heart block

Digitalis poisoning

Head injury affecting the brain

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Tachycardia: A term used to describe fast heart beat over 100 times per minute in adult.

Tachycardia: A term used to describe fast heart beat over 100 times per minute in adult.

Tachycardia can be observed in the following conditions

Patient with pyrexia

Increased metabolism as in thyrotoxicosis

Haemorrhage, anaemia, shock

Failing heart muscle

Nervousness

Certain drugs e.g. atropine

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Components of Vital or Cardinal Signs

Components of Vital or Cardinal Signs

Vital or Cardinal Signs are characterized by the following components

Body temperature

Pulse

Respiration

Blood pressure

Pain (recently added as a component of cardinal sign.

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The Normal Ranges of Vital Signs by Age

The Normal Ranges of Vital Signs by Age

Age

Oral Temperature in Degrees Celsius

Pulse (Average and Ranges)

Respiration (Average and Ranges)

Blood Pressure (mm Hg)

Newborn

36.8 (axillary)

130 (80-180)

35 (30-80)

73/55

1 year

36.8 (axillary)

120 (80-140)

30 (20-40)

90/55

5-8 years

37

100 (75-120)

20 (15-25)

95/57

10 years

37

70 (50-90)

19 (15-25)

102/62

Adolescents

37

75 (50-90)

18 (15-20)

120/80

Adults

37

80 (60-100)

16 (12-20)

120/80

Older Adults (>70 years)

37

70 (60-100)

16 (15-20)

Possible increased diastolic

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Times for Assessing Vital Signs

Times for Assessing Vital Signs

On admission in order to obtain baseline data.

When a client has a change in health status or report symptoms such as chest pain, feeling hot or faint.

Before and after surgery or invasive procedure.

Before and or after the administration of a medication that could affect the respiratory or cardiovascular system for example, before giving a digitalis preparation.

Before and after ambulating a patient who has been on bed rest.

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Factors that Affect the Respective Vital Signs

Factors that Affect the Respective Vital Signs

Health care providers should be aware of the factors that can affect a client’s body temperature, respiration, blood pressure and pulse, so that they can recognize normal temperature, pulse and respiration variations and understand the significance of measurements that deviate from normal.

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These factors include:

These factors include

Age: Infants and older people are at risk of hypothermia (temperatures below 36 oC) for a variety of reasons such as:

Inadequate diet

Loss of subcutaneous fat

Lack of activity

Reduced thermoregulatory efficiency

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Diurnal Variations

Diurnal Variations

Body Temperatures normally change throughout the day varying as much as one degree centigrade (1oC) between early morning and late afternoon

The point of highest body temperature is usually reached between 8.00 p.m. and midnight, and the lowest point is reached during sleep between 4.00 a.m. and 6.00 a.m.

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Exercise

Exercise

Hard work or strenuous exercise can increase body temperature as high as 38.3oC to 40oC measured rectally.

Hormones

Women experience more hormone fluctuations than men.

Progesterone secretion during ovulation raises body temperature by about 0.3 to 0.6oC.

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Stress

Stress

Stimulation of sympathetic nervous system increases the production of epinephrine and norepinephrine, thereby increasing metabolic activity and heat production.

A highly stressed or anxious client could have an elevated body temperature for that reason.

Environment

Extremes in environmental temperatures can affect a person’s temperature regulatory systems.

If the temperature is assessed in a very warm room and the body temperature cannot be modified by convention, conduction or radiation, the temperature will be elevated.

If the client has been in an extremely cold weather without suitable clothing, the body temperature can be low.

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Factors which Increase Respiration Rate

Factors which Increase Respiration Rate

Exercises

States of excitement

Fear, worry and anger

Disease state

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Factors which Decrease Respiration Rate

Factors which Decrease Respiration Rate

Sleeping

Resting

In a state of fatigue

Having calm emotional state

Pulse

Factors that affect pulse rate are the same as those that increase the respiration rate.

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Sites for Checking Body Temperature and Pulse Sites for Checking Temperature

Sites for Checking Body Temperature and Pulse Sites for Checking Temperature

ORAL

Place the bulb on either side of the frenulum.

AXILLA

Pat the axilla dry if very moist

Place the bulb in the centre of the axilla

RECTAL

Apply clean gloves

Instruct the client to take a slow deep breath during insertion

Lubricate the thermometer

Never force the thermometer if resistance is felt.

Inset ½ of thermometer

EAR

Pull the pinna slightly upward and backward while inserting the tympanic thermometer.

Point the probe slightly anteriorly toward the eardrum.

Insert the probe slowly using a circular motion until snug.

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Sites to Check Pulse Rate

Sites to Check Pulse Rate

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Appropriate Interventions for Alterations in Body Temperature

Appropriate Interventions for Alterations in Body Temperature

There are two primary alterations in body temperature namely

Pyrexia

Hypothermia

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Pyrexia

Pyrexia

This is body temperature above the usual range.

There are various terms used to describe pyrexia depending on the degree of temperature.

These include

Hyperpyrexia: This is very high fever (41°C)

Febrile: This indicates the person has fever

Afebrile: This indicates the person has no fever

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Clinical Signs of Fever

Clinical Signs of Fever

Malaise, headache, general aches and pains

Hot and dry skin, dry mouth and tongue and thirst

Loss of appetite

Nausea and sometimes vomiting

Decreased urine output

Mild to severe dehydration

Occasionally delirium and insomnia

Convulsions (in children)

Increased pulse and respiration rate

Herpetic lesions of the mouth

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Interventions for Patients with Fever

Interventions for Patients with Fever

The following are important interventions in managing a patient with fever.

These include

Monitoring vital signs

Assessing skin colour and temperature

Monitor white blood cell count, haematocrit level and other laboratory reports for indication of infection and dehydration

Removing extra clothing when the patient feels warm, but provide extra warmth when the patient feels chilled

Opening windows to increase ventilation

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Hypothermia

Hypothermia

This is a condition when the temperature of the body is below 36 oC.

There are 3 physiologic mechanisms of hypothermia namely

Excessive heat loss

Inadequate heat production

Impaired hypothalamic thermoregulation

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Clinical Signs of Hypothermia

Clinical Signs of Hypothermia

Decreased body temperature, pulse, and respirations

Severe shivering (initially)

Feelings of cold and chills

Pale cool waxy skin

Hypotension

Decrease urinary output

Lack of muscle coordination

Disorientation

Drowsiness progressing to coma

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Interventions for a Patient with Hypothermia

Interventions for a Patient with Hypothermia

Provide warm environment and dry clothing

Apply warm blankets

Keep limbs close to body

Cover the client’ head with a cap or turban

Give warm oral fluids

Monitor vital signs

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Altered Breathing Patterns and Sounds

Altered Breathing Patterns and Sounds

Breathing Patterns

Rate

Tachypnoea- quick shallow breath

Bradypnoea- abnormally shallow breathing

Apnoea: Cessation of breathing

Volume

Hyperventilation- Overexpansion of the lungs characterized by rapid and deep breaths

Hypoventilation- under expansion of the lungs characterized by shallow respirations

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Rhythm

Rhythm

Cheyne – stokes breathing: Respiration is characterized by slow and shallow respiration which increases in rate and depth to a maxim.

Then respirations get slower and shallower until they cease completely (apnoea) for about 5-10 seconds then the whole cycle begins again.

This type of breathing is commonly seen in advanced stage of uremia, some heart disease and cerebral diseases.

The sign indicates that death is in door.

Ease or Effort

Dyspnoea: Difficult and laboured breathing during which the individual has a persistent, unsatisfied need for air and feels distressed.

Orthopnoea: Ability to breath only in upright sitting or standing positions.

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Breath Sounds

Breath Sounds

Stridor: A thrill, harsh sound heard during inspiration with laryngeal obstruction

Wheezing: Continuous, high-pitched whistling sound occurring on expiration and sometimes on inspiration when air moves through a narrowed or partially obstructed airway

Bubbling: Gurgling sounds heard when air passes through moist secretions in the respiratory tract

Chest movements

Intercostals retraction- in drawing between the ribs

Secretion and coughing

Haemoptysis- the presence of blood in the sputum

Productive cough- a cough accompanied by expectorated secretion

Non productive cough- a dry harsh cough without secretion

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Key Points

Key Points

Vital signs reflect chances in the body function that otherwise might not be observed.

Monitoring a client’s vital signs should not be an automatic or routine procedure, should be thoughtful scientific assessment.

Respirations are normally quiet, effortless, and automatic and are assessed by observing respiratory rate, depth, rhythm, quality and effectiveness

Many factors may affect a person’s pulse rate i.e. age, gender, exercise, presence of fever, certain medications, hypovolemia, stress and disease.

Hypothermia involves three mechanisms excessive heat loss, inadequate heat production and impairments of hypothalamic thermo regulation.

Body temperature can be measured orally, tympanically, rectally or by axilla.

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Evaluation

Evaluation

What are the characteristics of normal respiration?

What are the factors that affect respiration, pulse, and temperature?

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References

References

Kozie, B. et al. (2004). Fundamentals of Nursing: Concepts Process and Practice, (7th ed.), Pearson Education Inc. New Jersey 07458

Magret, F. and Alexander, (2008). Nursing Practice Hospital and Home. (3rd ed.). London: Chechil

MOHSW. (2008). Basic Nursing Procedures: A Manual for Nursing Practice in Tanzania, (3rd ed ). Dar es Salaam, Tanzania: Ministry of Health and Social Welfare.

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As a man Thinks,so IS he

As a man Thinks,so IS he

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