Vital Signs

Terminology

1. Apical pulse: An apical pulse is a central pulse that is located at the apex of the heart called as point of
maximal impulse.

2. Brachial: Pulse felt at inner aspects of the biceps muscle of the arm or medially in the antecubital
space.

3. Bradycardia: Heart rate in adult less than 60 beats per minute.

4. Carotid pulse: At the side of the neck where the carotid artery runs between the trachea and
sternocleidomastoid muscle.

5. Cardiac output: Cardiac output is the volume of blood pumped into the arteries by the heart that
equals the result of stroke volume times the heart rate (HR) per minute, for example, 65 mL x 70 beats
per minute = 4.55L per minute.

6. Dysrhythmia: A pulse with irregular rhythm is referred as arrhythmia or dysrhythmia.

7. Doppler ultrasound stethoscope: The electronic device helps to detect pulse rate, volume, rhythm,
helps to distinguish arterial sound from venous.

8. Femoral: Where the femoral artery passes alongside of the inguinal ligament.

9. Pulse: Pulse felt where the femoral artery passes alongside of the inguinal ligament.

10. Pulse deficit: An apical pulse greater than radial pulse rate indicate that thrust of blood from heart is
too weak to be felt at the peripheral site, any difference in apical and radial pulse rate is called pulse
deficit.

11. Pulse rhythm: It is the pattern of the beats and interval between the beats.

12. Pulse volume: It is also called as the pulse strength or amplitude, refers to force of blood with each
beat, it is same with each beat, range from absent to bounding.

13. Pulse pressure:vThe difference between diastolic and systolic pressure.

14. Pulse oximeter: It is a noninvasive device that estimate clients arterial blood oxygen saturation
(SaO2) by means of the sensors attached to clients fingers, toe, nose and earlobe.

15.Point of maximum pulse: The apical pulse in contrast, is a central pulse that is it is located at the apex
of the heart, referred as point of maximum pulse.

16.Posterior tibial: Pulse felt on the medial surface of the ankle where the posterior tibial artery passes
behind the medial malleolus.
17. Posterior dorsal pedalis: Pulse felt on the dorsalis pedes.

18. Radia: Felt where the radial artery runs along the radial bone, on the thumb of the inner aspect of
the wrist.

site is superior and lateral away from the midline of the eye.

20. Tachycardia: An excessively fast heart rate over 100 beats per minute.

INTRODUCTION

The importance of vital sign in health sciences. Vital signs include the physiological measurement of
temperature, pulse, BP and respiration. Vital signs are a quick and efficient way of monitoring a patient's
condition or identifying problems and evaluating the patient's response to intervening changes. One
vital sign can influence characteristics of other vital signs.

The basic techniques of inspection, palpation and auscultation are used to determine vital signs.
Assessment of vital signs allows the nurse to identify nursing diagnoses, to implement planned
intervention and to evaluate success. When the nurse learns the physiological variables influencing vital
signs and recognizes the relationship of vital sign changes to other physiological assessment findings,
precise determination of the client's health problems can be made.

GUIDELINES FOR ASSESSING VITAL SIGNS

1.The nurse caring for the patient is responsible for assessing vital signs. The nurse should obtain the
vital signs, interpret their significance and make decisions about interventions.

2. Equipment used to measure vital signs must work properly to ensure accurate findings.

3. Equipment should be selected based on the client's condition and characteristics.

4.The nurse controls or minimizes environmental factors that may affect vital signs.

5.The nurse uses an organized, systematic approach when taking vital signs. Each procedure requires a
step-by-step approach to ensure accuracy.

6. The manner of approach to the patient can alter the vital signs.The nurse should approach the patient
in a calm caring manner while taking vital signs.

7. Based on patient's condition, the nurse collaborates with the physician to decide the frequency of
vital signs assessment.

8.The nurse analyzes the results of vital signs measurement. The nurse is often in the best position to
assess all clinical finding about a patient.

9.The nurse verifies and communicates significant changes in vital signs. The nurse informs the physician
of abnormal vital signs.
10. Vital signs are documented and communicated to the nurse assuming care of the patient.

VITAL SIGNS MEASUREMENT

The vital or cardinal signs are body temperature, pulse respiration and blood pressure. These signs
should be looked at in total, to monitor the vital functions of the body. The signs reflect changes in
functions that otherwise it might not be observed. Vital signs are the measurements, provided data can
be used to determine the patient's usual state of health.

Purpose

1. To assess the health-status of an individual.

2. To plan and implement the nursing care.

3. To understand the effectiveness of the treatment.

4. To modify or change the mode of treatment.

5. Routine part of complete physical assessment.

6. It helps to understand the present problem.

Timings of Taking Vital Signs

1. On patient's admission to a health care facility.

2. In hospital, on routine schedule according to physician's order or hospital policy.

3. During patient's visit to clinic or physician's office.

4. Before and after any surgical procedure.

5. Before and after any invasive diagnostic procedure.

6. Before and after administration of medication that affect cardiovascular, respiratory and temperature
control function.

7. When the patient's general physical condition changes, e.g. loss of consciousness or increase in
intensity of pain.

8. Before and after nursing intervention influencing any one of the vital signs, e.g. before ambulating a
patient previously on bed rest or before patient performs range of motion exercises.

9. Whenever patient reports to nurse any non-specific symptoms of physical distress, e.g.'feeling funny
or different'

Principles of Vital Signs

1. Vital signs are governed by vital organs and often reveal even the slightest deviation fromthe normal
body functions.

2. The changes in the condition of the patient improvement or regression may be detected bythe
observation of these signs.

3. Significant variations in these findings may indicate problems regarding to insufficientconsumption.

4. Through vital signs, specific information may be obtained that will help in the diagnosistreatment
medications and nursing care.

5. Patients emotional state may also cause a significant variation in these symptoms.

Methods of Measurement

1. Inspection: Inspection means observing with the eye and is associated with light and seeing.

2. Percussion: Percussion is tapping an area to elicit sounds.

3. Auscultation: Auscultation is listenig to sounds within the body with a stethoscope.

4. Palpation:Palpation is the art of feeling with the hand.

BODY TEMPERATURE: PHYSIOLOGY, REGULATION AND

FACTORS AFFECTING BODY TEMPERATURE

Temperature is a degree of heat maintained by the body. It is the balance between the heat produced
and heat lost.

Physiology

Body temperature is of two types: Core temperature and the surface temperature.Core temperature is
the most important, including deep tissues such as temperature of cranial, thoracic and abdominal
cavities. Normal body temperature depends on when, where and in whom it is measured. The body has
a regulatory system that keeps the core temperature normal and may vary depending upon the heat
produced and the blood flow.

Heat Production

Heat is generated in the body's cells through food metabolism. The body converts energy supplied by
metabolized nutrients to energy form which can be consumed by body directly. One form of this energy
is the thermal energy for regulating body temperature. It is measured in terms of heat. These types of
heat liberation is expressed as metabolic rate and measured as BMR. Mostly the heat is produced by
deep tissue organ (brain, liver, heart) and skeletal muscles. Skin, subcutaneous tissues and fat of
subcutaneous tissues serves as heat insulators for body. When the body heat rises, hypothalamus
transmits impulses to reduce the body heat by triggering perspiring, dilating blood vessels and
inhabitation of heat production. In case of decreased body heat, hypothalamus spread impulses to
stimulate heat production through vasoconstriction (narrowing of blood vessels) muscle shivering and
piloerection.

Regulation of the Body Temperature

Care of the patients in fevers focuses on reducing the elevated body temperature.When the patient's
temperature is moderately elevated, various methods of reducing the temperature should be
commenced. The room temperature should be maintained at a comfortable temperature.The room
should be well ventilated. The blankets and excess clothing should be removed but prevent the patient
from getting draughts. The various methods used for cooling the body are:

1. Exposure to cool air an electric fan.

2. Administration of cool drinks

3. Application of cold compress and ice bags

4. Tepid sponging

5. Warm bath

5. Ice cold lavages and enemas

6.Use of hypothermic blankets of mattresses.

NOTE: When surface cooling is used treatment is directed at not only cooling the body but also
preventing shivering. Shivering must be prevented because it increases metabolic activity, produces
heat, increases the oxygen usage markedly, increases circulation, may cause hyperventilation and
respiratory alkalosis. It takes longer time to reduce body temperature in a shivering patient.

Factors Influences Heat Production

1. Metabolism:oxidation of food.

2. Muscle activity: exercise.

3. Strong emotional: excitement, anxiety and nervousness.

4. Change in atmospheric temperature.

5. Disease condition: bacterial invasion.

6. Sympathetic stimulation: epinephrine and norepinephrine.

Factors Influences Heat Loss

1. Sleep: Body temperature is low.

2.Fasting: Leads to decreased heat production.

3. Illness and lower vitality: Due to depressed nervous system, the heat production is lowered.

4. Prolonged exposure to cold.

5.Use of narcotic drugs.

Body Heat is Lost Through

1. Conduction:Transfer of heat from body to substance (air,water and cloths) directly in contact.

2. Radiation: Transfer of heat from body to heat waves which travel through the space.

3. Evaporation: Transfer of heat from body in form of vapors (liquid is converted into vapors)

4. Convection: It is transfer of heat from the surface of one subject to the surface, such as skin by
movements of heated air or fluid particles.

Preparation of the Equipment

1. If a thermometer is included in the admission pack, keep it at the patient's bed side and, on discharge,
allow him to take home.

2. Otherwise, obtain a thermometer from the nurse's station or central supply department.

3. If use an electronic thermometer, make sure it's been recharged.

ASSESSMENT OF BODY TEMPERATURE: SITE, EQUIPMENT, TECHNIQUES AND SPECIAL CONSIDERATIONS

Temperature is a measurement of heat expressed in degrees. Body temperature may be defined as the
degree of heat maintained by the body. Temperature means the degree of warmth or balance
maintained between the heat produced (thermogenesis) and heat lost (thermolysis) in the body.
Temperature can also be defined as the level of coldness or hotness of the body

Purpose

1. To determine body temperature.

2. To assist in diagnosis.

3.To evaluate the patients recovery from illness.

4. To plan immediate nursing interventions.

5. To evaluate the patients response.

6. To recognize any variation from the normal and its significant.

Equipment

1. Mercury or electronic thermometer, chemical dot thermometer, or tympanic thermometer.

2. Water soluble lubricant or petroleum jelly (for rectal temperature).

3. Facial tissue.

4.Disposable thermometer sheath or probe cover.

5. Alcohol sponge.

Common Sites for Taking Body Temperature

1. Mouth,

2. Axilla,

3. Groin,

4.Vagina,

5.Rectum.

TYPES OF THERMOMETER

1. The clinical thermometer: It is an instrument used for measuring temperature of bodily heat or cold in
which the mercury remains stationary at registration point until shaken down.

2. Electronic thermometer: It consists of a battery powered display unit, a thin wire cord and a
temperature sensitive probe covered by a disposable plastic sheath to prevent transmission of infection
separate probes are available for oral and rectal insertion.

3.Disposable thermometer: It is a single use thermometer, made of thin plastic strips with chemically
impregnated paper, they are used for children to take oral and auxiliary temperature only 45 seconds
are needed to record the temperature it is less accurate.

4.Infrared/Tympanic membrane thermometer: These are small held devices similar to hodoscopes with
disposable speculum. Infrared-sensing electronic and liquid crystal displays. Results are displayed 1 to 2
seconds after placing their speculum in the outer third of the ear canal. It is accurate.

5. Wall thermometer

6. Lotion thermometer

7. Bath thermometer

8. Digital
Scales of Thermometer

1. Centigrade/Celsius - boiling point 100 degree and freezing 0 degree.

2. Fahrenheit- boiling point 212 degree and freezing point 32 degree.

Parts of Thermometer

1. A bulb contains mercury and in a stem, mercury rises. There is graduated scale on the stem, which
represents the degree of temperature.

2.The bulbs are of different size and shapes. The oral thermometers are with along and slender bulbs.
The rectal thermometers are with short and fat bulbs.

3. The stem has a curved surface which magnifies the lines and figures on the scale. The stem has a
flattened back with a sharp ridge that makes it easier to read the scale. The flat surface prevents rolling.

Reason for Mercury Used in the Thermometer

1. Very sensitive to small changes in temperature.

2.Silver appearance helps in easy visible.

3. Its boiling point is 357°C and freezing point is 39°F.

4. The expansion of mercury is uniform.

5. Mercury is 13.5 times heavier than water, so small glass tube can be used.

CARE OF THERMOMETER

1. Grasp the thermometer securely by the upper end of the stem, never hold it by bulb.

2. Shake it down by quick movement of the wrist.

3. Move away from articles before shaking the thermometer.

4. Be careful that the thermometer will not fall or strike against anything.

5. Thermometer is never washed with hot water because heat expands the mercury.

6. The used thermometer should be washed with soap and water and should be disinfected with a
disinfectant.

7. Advantages of using mercury are low price, wide availability reliable accuracy.

8. Disadvantages are delay for recording and easy breakability.

ORAL TEMPERATURE
Temperature check by the oral cavity.

Purpose

1. To determine the body temperature of the patient.

2. To aid in making diagnosis.

General Instructions

1. Position the tip of the thermometer under the patient's tongue, as far back as possible on either side
of the frenulum linguae.

2. Placing the tip in this area, promotes contact with superficial blood vessels and contributes to an
accurate reading.

3. Instruct the patient to close his lips but to avoid biting down with his teeth.

4. Biting can break the thermometer, cutting the mouth or lips or causing ingestion of broken glass or
mercury.

5. Leave a mercury thermometer in place for at least two minutes or a chemical dot thermometer in
place for 45 seconds to register temperature, for an electronic thermometer, wait until the maximum
temperature is displayed.

6. For a mercury thermometer, remove and discard the disposable sheath then read the temperature at
eye level, noting it before shaking down the thermometer, note the temperature, then remove and
discard the probe cover.

7. For the chemical dot thermometer, read the temperature as the last dye dot that has changed color,
or fired, then discard the thermometer and its dispenser case.

8. Wait 20 to 30 minutes before measuring oral temperature if client has ingested hot or cold liquid or
foods.

Equipment

1. Kidney dish for used swabs

2. Sterile spirit swab in a container.

3. Thermometer in a container of disinfectant.

4. Blue and red pen.

5. Watch with second hand.

6. TPR chart
Method:

1.Take the prepared tray to the bedside.

2.Explain to the patient what you are going to do

3.Take thermometer from the solution and wipe it with dry swabs moving downwards.

4.Check reading and be sure it is below 35.0° (94 F) hold it firmly and shake with a quick moment of the
wrist.

5. Place he bulb of the thermometer under the patients' tongue.

6.Instruct the patient to keep his lips closed.

7. After three minute remove the thermometer from the patients' mouth.

8. Wipe it with dry swabs away from the bulb.

9. Read the thermometer and record temperature accurately.

10. Report any abnormality/sub normality.

After Care

1. Wipe secretions from thermometer with a sterile spirit swab. Wipe in rotating fashion from fingers
towards bulb. Dispose of tissue.

2. Wash thermometer in lukewarm water, rinse in cool water, dry and replace in container.

3. Record the temperature on the chart.

4.Wash hands.

5. Report any unusual variation to the charge nurse.

Contraindications

1. Injuries, inflammation and surgeries of oral cavity.

2. Infants, children below 6 years, and patients who cannot retain thermometer in mouth.

3. Unconscious, delirious, non cooperative and mentally disturbed patients.

4.Patients with mouth breathing, convulsions, oxygen masks, frequent and severe cough.

AXILIARY TEMPERATURE

The temperature is sometimes taken by axilla when it cannot be taken by mouth or contraindicated to
check oral temperature.
Purpose

1. To determine the body temperature of the patient.

2. To aid in making diagnosis.

General Instructions

1. Position the patient with the axilla exposed.

2. Gently pat the axilla dry with a facial tissue because moisture conducts heat. Avoid harsh rubbing,
which generates heat.

3. Ask the patient to reach across his chest and grasp his opposite shoulder and to lower his elbow and
hold it against his chest. This promotes skin contact with the thermometer.

4. Remove a mercury thermometer after 3 minutes; remove an electronic thermometer when it displays
the maximum temperature. Axiliary temperature takes longer to register than oral or rectal temperature
because the thermometer is not closed in a body cavity.

5. Grasp the end of the thermometer and remove it from the axilla.

Preliminary Assessment

1. Determine the need to measure client's body temperature.

2. Assemble equipment.

3. Identify the patient, greet the patient and explain the procedure.

4. Place the client in comfortable position, assess site most appropriate for temperature measurement.

Equipment

1. Clinical thermometer.

2. Swab in a container.

3. Kidney basin or thermometer container.

4. Blue pen.

5. Watch with second hand.

6. Graphic TPR chart.

7. Paper bag.

Procedure
1. Dry the axilla.

2. Insert thermometer into center of axilla, low arm over thermometer, and place arm across client's
chest.

3. Leave the thermometer in place for three minutes.

4. Remove the thermometer from the axilla.

5. Wipe the thermometer using a spirit swab from stem to bulb use a firm twisting motion.

After Care

1. Discard the used swab into the paper bag.

2. Read the thermometer holding it horizontally at the eye level, rotates it until the mercury column is
seen.

3. Place thermometer in the kidney basin.

4. Record the temperature on the chart using blue pen and mention axillary.

5.Wash hands.

6. Report any unusual variations to the charge nurse.

7. Recording and reporting. Record temperature on vital sign flow sheet's or nurse's notes. Also record
any signs or symptoms of temperature alterations.

RECTAL TEMPERATURE

Rectal temperature measurement is a technique used to measure body temperature by placing a

thermometer in the rectum.

Purpose

1. To determine body temperature mainly for infants, young children, adult unconscious patient and
postoperative patient.

2. To aid in making diagnosis.

Indication

1. Unconscious patient.

2. Neonates.

3. Malignant-hyperthermia.
General Instructions

1. Position the patient on his side with his top leg flexed, and drape him to provide privacy.

2. Squeeze the lubricant onto a galipot to prevent contamination of the lubricant supply.

3. Lubricate the thermometer tip. Lubrication reduces friction and thus eases insertion. This step may
be unnecessary when using disposable rectal sheaths because they are pre lubricated.

4. Path the patient's upper buttock, and insert the thermometer about 1.3 cm for an infant 3.8cm for an
adult. Gently direct the thermometer along the rectal wall towards the umbilicus. This will avoid
perforating the anus or rectum or breaking the thermometer. It also will help ensure an accurate
reading.

5. Hold the mercury thermometer in place for 2 to 3 minutes or the electronic thermometer until the
maximum temperature is displayed. Holding the thermometer prevents damage to rectal tissues caused
by displacement or loss of the thermometer. Carefully remove the thermometer, wiping it as necessary.
Then wipe the patient's anal area to remove any lubricant or feces.

Equipment

1. Clinical thermometer.

2. Swab in a container.

3. Kidney dish or thermometer container.

4. Blue pen.

5.Watch with second hand.

6. Graphic TPR chart.

7. Paper bag.

8. Lubricant

9. Galipot

10. Dry swabs in a galipot

Procedure

1.Determine the need to measure client's body temperature.

2. Assemble equipment.

3. Identify the patient, greet the patient and explain the procedure.
4. Place the client in comfortable position, assess site most appropriate for temperaturemeasurement.

5. Provide privacy with a screen. Assist client to sims position with upper leg flexed. Move aside bed
linen to expose only anal area.

6. Squeeze liberal portion of lubricant into the galipot. Dip thermometer's bulb end into lubricant,
covering 2.5 to 3.5 cm (1 to 1.5 inches) for adult or 1.2 to 2.5 cm (0.5 to 1.5 inch) for infant.

7. With non-dominant hand, separate client's buttocks to expose anus. Ask client to breathe slowly and
relax.

8. Gently insert thermometer into anus in direction of umbilicus insert 1.2cm (0.5inch) for infant and 3.5
cm (1.5 inches) for adult do not force thermometer.

9. If resistance is felt during insertion withdraw thermometer immediately.

10. Hold thermometer in place for 2 - 3 minutes.

11. Carefully remove thermometer and wipe off secretions with swab. Wipe in rotating fashion from
stem towards bulb. Dispose of swabs.

12. Read thermometer at eye level rotate until scale appears.

13. Wipe client's anal area to remove lubricant or feces and discard swabs.

14. Help client return to comfortable position.

After Care

1. Wipe secretions from thermometer with swab. Wipe in rotating fashion from stem towards bulb.
Dispose of swab.

2. Wash thermometer in lukewarm water, rinse in cool water, dry and replace in container.

3. Record the temperature on the chart.

4. Wash hands.

5. Report any unusual variation to the charge nurse.

Contraindication

1. Injury, inflammation and surgeries of rectum.

2. Fecal impaction.

3. Chronic diarrhea.

4. Patients requiring bowel wash/enema.

PULSE

Pulse is the wave of expansion and recoil occurring in an artery as response to the pumping action of the
heart.

Pulse is the heart beat, conveniently felt at the wrist and at any point where an artery passes
superficially over the bone.

Pulse is defined as checking rate, rhythm and volume of throbbing of an artery against a bony
prominence.

Purpose

1. To determine number of heart beats acquiring per minutes.

2. To evaluate amplitude (strength) of pulse.

3. To assess the vascular status of limbs.

4. To assess response of heart to cardiac medications, activity, blood volume and gas exchange.

5. To assess hearts ability to deliver blood to distant area of the body.

6. To obtain information about heart rhythm and patterns of beats.

Normal Rate

1. Newborn: 140 beats/minute.

2. Infant:120 beats/minute.

3. 2-3 year: 100 beats/minute.

4. 5-10 years:90 beats/minute.

5. Adults: 60 to 100 beats/minute (average is 72 per minute).

6. Old age:May be slower.

7. Extremely old age:May be more rapid.

Sites of Taking Pulse

1.Radical artery: In front of the wrist

2. Brachial artery: Above the elbow

3.Carotid artery: Sides of the neck

4. Temporal artery:Over the temporal bone

5. Facial artery:Above the lower jaw

6. Femoral artery: In the groin

7. Tibial artery: Behind the medical Milhous

8. Dorsalis pedis artery: On the foot.

Factors Affect the Pulse

1. Age: Very old have slow pulse rate and children will have faster beat.

2. Sex: It is slower in men than in women.

3. Stature: It is slower in tall people than in short people.

4. Position: The pulse rate is slower than at rest or asleep than in standing position.

5. Emotions: Anger or excitement increases the pulse rate temporarily.

6. Exercise: It is much faster during exercise.

Characteristics of Pulse

1. Rate: Number of beats/minute, corresponds with age (above 100 tachycardia, below 60 bradycardia).

2. Rhythm: It is the regularity of beats. The distance between beats (regular).

3. Volume: It is the fullness of artery. It is the force of blood felt at each beat (full/large/small).

4. Tension: It is the degree of compressibility (high/low).

Abnormal Pulse

1. Rate tachycardia: The pulse rate more than 100 beats/minute. It commonly found in patients with
fevers.Thyrotoxicosis, organic heart diseases, nervous disorders and intake of drugs like belladorma and
alcoholism cause tachycardia.

2. Bradycardia: Pulse rate less than 60 beats per minute. Caused by opium poisoning, heart muscle
disorder, cerebral tumors and myxoedema.

3. Abnormal rhythms: Are intermittent pulse, extra-systoles, atrial fibrillation, ventricular fibrillation,
sinus arrhythmia.

General Instruction for Taking Pulse

1. Count the pulse for one full minute. Especially when there is irregularity.

2. Observe rate, rhythm, volume and tension of pulse.

3. Pulse should not be taken immediately after exercise in emotional stress or after a painful treatment.

4. Record pulse immediately.

5. Choose suitable site for taking pulse.

6. Nurse to be aware if patient is on any medication that can interfere with heart rate.

7. To check pulse after 10 to 15 minutes, after strenuous physical exercise.

8. Notify physician if pulse rate is below < 60/minute or above > 100/minute. Normal and abnormal
patterns (missing beats). Record in TPR record.

Equipment

1. Watch with second hand.

2. Red pen.

3. TPR sheet.

Procedure

1.Wash hands

2. If supine, place client's forearm across lower chest with wrist extended straight. If sitting, bend client's
elbow 90 degrees and support lower arm on a chair.

3. Place tips of the first two or middle three fingers of dominant hand over groove along radial or thumb
side of client's.

4. Lightly compress against radius obliterates pulse initially, and then releases pressure so pulse
becomes easily palpable.

5. When pulse is easily palpable, look at watch's second hand and begin to count rate.

6. If pulse is irregular count for full minute.

7. Assess regularity and frequency of any dysrhythmia.

8. Determine strength of pulse. Note whether thrust of vessel against fingertips is bounding,strong weak
or thread.

9. Assist client in returning to comfortable position.

After Care

1.Wash hands.

2. If pulse is assessed for first time establish as baseline.

3. Assess pulse again by having another nurse conduct measurement, if pulse character is abnormal or
irregular.

4. Record characteristic of pulse in nursing progress sheet or vital sign flow sheet. Also record any
accompanying signs and symptoms of pulse alterations.

5. Report abnormal findings to the nurse in charge or physician.

RESPIRATION

Respiration monitoring is an involuntary process of inspiration (inhalation) expiration(exhalation) in a

patient.

Respiration is the act of breathing in ad breathing out. It includes inspiration and expiration.The
exchange of gases between the blood and lungs is called external or pulmonary respiration.The
exchange of gases between the blood and cell is called internal respiration.

Respiration is the act of breathing.It includes the intake of oxygen and the output of carbondioxide, i.e.
respiration consists of inspiration and expiration.

Purpose

1. To determine the respiratory status of the patient.

2. To determine number of respiration occurring per minute

3. To gather information about rhythm and depth.

4. To assess response of patient to any related therapy/medication.

Times of Respiration

1. External respiration: The exchange of gases between the blood and the air in the lungs is called as
external or pulmonary respiration.

2. Internal respiration: The exchange of gases between the blood and the tissue cells is called as internal
or tissue respiration.

3. Regulation of respiration: It is a rhythmical movement's respiration are regulated by respiratory

center in the brain called medulla oblongata, nerve fibers of the autonomic nervous system and the
chemical composition of the blood.
Normal Rates

1. At birth 30 to 40 breaths/minute

2. One year 26 to 30 breaths/minute

3.2 to 5 years 20 to 26 breaths/minute

4. Adolescence 20 breaths/minute

5. Adults 16 to 20 breaths/minute

6. Old age 10 to 24 breaths/minute.

Factors Influences Respiration

1. Sex:Female have slightly rapid respiration than the male.

2. Exercise: Exertion of any type increases the metabolic rate and stimulates respiration.

3. Rest and sleep: During rest and sleep metabolism is decreased so respiration rate is normal or
decreased.

4. Emotions: Sudden stressful condition such as fear and anxiety influences the respiratory rate.

5. Changes in atmospheric pressure: In high altitudes the content of oxygen in the atmosphere is very
low. So rate of respiration is increased and the increased demand of oxygen is fulfilled.

Characteristics of Respiration

1. Normal breathing is effortless.

2. It is painless, quiet and automatic.

3. Normal respiration consists of rhythmical rising and falling of the chest wall.

4. Respiratory rate in resting adult is 16 to 18 breaths/minute.

5. Eupnea: It is regular, even and produces no noise.

Abnormal Respirations

1. Strider respiration: It is noisy shrill and vibrating respiration. It is due to obstruction in the upper air
way. It is commonly seen in laryngitis and foreign body in the respiratory tract.

2. Wheezing: Expiration is difficult and louder. It is due to partial obstruction of the smaller bronchi and
bronchioles. It is seen in asthma or emphysema.

3. Apnea: This is a temporary cessation of breathing due to excessive oxygen and lack of carbon dioxide.
4. Dyspnea: This is forced, difficult or labored breathing. It may be accompanied by pain and cyanosis; it
is seen in heart diseases, respiratory diseases, convulsions, etc.

5. Orthopnea: The patient can breathe only in upright position. Commonly found in congestive cardiac
failure.

6. Cyene- stokes-respiration: This is respiration which gradually increases in rate and volume until it
reaches a climax. Then slowly pause occurs and breathing stops for 5 to 30 seconds and then cycle
begins again. It is a periodic breathing usually found in the patients who are near death.

7. Asphyxia: It is a state of suffocation when the lungs do not get a sufficient supply of fresh air to the
vital organs and they are deprived of oxygen.

8. Cyanosis:It is the blueness or discoloration of the skin and mucous membrane due to lack of oxygen in
the tissues.

9. Rale: An abnormal rattling or bubbling sound caused by the mucus in the air passages ass een in the
bronchitis of pneumonia.

10. Kussumauls-respiration: Respiration is abnormally deep but regular, rate is increased.It is seen in
diabetic ketoacidosis.

11. Biots respiration: It is shallow breathing interrupted by irregular periods of apnea, seen in central
nervous system disorders.

General Instruction

1. Patient to be unaware of the nurse counting respiration.

2. Inform to physician in case of bradypnea, tachypnea or other abnormal respiratory patterns noticed.

Preliminary Assessment

1.Determine the need to assess client's respiration.

2. If client has been active, wait 5 or 10 minutes before assessing respiration.

3. Assess respirations as first vital sign in infant or child.

4. Assess respiration after pulse measurement in adult.

5. Be sure client is in a comfortable position, preferably sitting.

6. Be sure client's chest movement is visible. If necessary, remove bed lines or gown.

Equipment

1. Wrist watch with second hand or digital display.

2. Pen and flow sheet or record form.

3. TPR chart.

Procedure

1. Place client's arm in relaxed a position across the abdomen or lower chest.

2. Observe complete respiratory cycle (one inspiration and one expiration).

3. After cycle is observed, look at watch's second hand and begin to count rate.

wall movement while counting rate.

4. Note depth of respirations.

5. Note rhythm of ventilatory cycle. Normal breathing is regular and uninterrupted.

After Care

1.Wash hands.

2. Compare client's respiration with previous baseline and normal respiratory rate for age group.

3. Record any accompanying signs and symptoms of respiratory alterations in nurse's notes or flow
sheet.

ALTERATIONS IN RESPIRATION

1. Bradypnea: The respiratory is abnormally slow (less than 12 breaths per minute).Occurs In coma due
to cerebral hemorrhage or large doses of sedatives.

2. Tachypnea: The respiratory rate is abnormally rapid (greater than 20 breaths per minute).

3. Apnea: Respirations cease for several seconds.

4. Respiratory arrest: Persistent cessation of respiration.

5. Hyper ventilation: Rate and depth of respirations increase.

6. Hypoventilation:Rate is abnormally low and depth is shallow. Shallow respiration occurs in diseases of
the lung such as pneumonia and pleurisy.

7. Sighing or air hunger: Indicates a need for more oxygen. Occurs in severe hemorrhage diabetic coma
or due to stimulation of respiratory center by excess of acid.

8. Wheezing: Sound made during expiration may be due to obstruction in the lower respiratory tract as
in the case of asthma.
9. Stertorous breathing: Noisy snoring inspiration occurs in unconscious patients which maybe due to
the tongue slipping back. Peculiar hissing respiration occurs in uremic coma.

10. Stridor: It is noisy inspiration due to the obstruction of upper respiratory tract.This noise may be
harsh, grating or whistling sound.

11. Orthopnea: Inability to breath easily unless in an upright position.

12. Dyspnea: Difficult breathing. If it is during inspiration it is due to laryngeal obstruction; if it is during
expiration it is due to asthma.

BLOOD PRESSURE

Blood pressure is the pressure blood exerts against the walIs of the vessels in which it is contained.
Blood pressure may be defined as the force exerted by blood against the walls of the vessels in which it
is contained. Differences in blood pressure between different areas of the circulation provide the driving
force that keeps the blood moving through the body.

Purpose

1. To obtain data for diagnosis and treatment

2. To compare with subsequent changes that may occur during care of patient.

3. To assist in evaluating status of patients blood volume. Cardiac output and vascular system.

4. To evaluate patients response to change in physical condition as a result of treatment with

fluids or medications.

Indication

1. To determine baseline, blood pressure recording and monitor fluctuation.

2. To aid in the diagnostic disease.

3. To aid in the assessment of cardiovascular system.

Types of Pressure

1. Systolic pressure: is the highest degree of pressure exerted by the blood against the arterial wall as
the left ventricle contracts and forces the blood from it into the aorta.

2. Diastolic pressure: is the lowest degree of pressure when the heart is in its resting period just before
contraction of the left ventricle.
3. Pulse pressure: is the difference between systolic and diastolic-pressure for the health, adult is usually
about 120/180 (systolic pressure 12 mm Hg and diastolic pressure 80 mm Hg with pulse pressure of 40
mm Hg).

4. Normal venous pressure:on an average person in a recumbent position is 40 to 110 mm of water.

Venous pressure is a valuable index in determining the efficiency of heart muscles.

Scientific Principles

1. Exercise,emotion,anxiety,fear,tension and worry cause a temporary rise in blood pressure.

2. The brachial artery in superficial in the antecubital area which is convenient place for taking blood
pressure

3. A noisy environment and parallax error interfere with correct reading on manometer.

4. A twisted cuff may produce unequal pressure and can cause inaccurate reading.

5. Accurate reading is possible only when the stethoscope is directly over the artery.

6. Airtight system of cuff and tubing facilitates accurate reading.

7. Sufficient pressure in the cuff obliterates the flow of blood through the brachial artery.

Factors Influencing Blood Pressure

1. Age:Adult's blood pressure tends to increase with advancing age.The older adult's blood pressure is
140-160/80-90 mm Hg.

2. Stress:Anxiety,fear, pain emotional stress increases blood pressure.

3. Medication: Narcotic and analgesics lower blood pressure.

4. Diurnal variation: It is lowest in early morning and higher in late evening.

5. Sex: In men, it is higher than in female.

6. Exercise: It will increase blood pressure.

7. Bleeding:It causes low blood pressure.

Blood Pressure Systolic Diastolic

·Newborn 30-50 mm, Hg 10 mm Hg

·Infant 70-90 mm Hg, 50 mm Hg.

Preliminary Assessment
1. Identify the patient.

2. Check the diagnosis, reason for taking BP schedule frequency of obtaining blood pressure.

3. Previous measurement and range of blood pressure.

4. Physical and mental state of the patient.Post phone blood pressure taking, on a patient whois
angry,anxious or in pain or a crying child.

5.Assess the arm on which the blood pressure can be taken. Do not take blood pressure reading a
patient's arm if:

The arm has an intravenous infusion on it.

The arm is injured or diseased.

The arm has a shunt or fistula for the renal dialysis.

- On the same side of the body where a female patient had a radical mastectomy.

Preparation of the Article

1. Sphygmomanometer.

2. Stethoscope.

3. Piece of paper.

Preparation of the Patient

1. Explain the procedure to the patient to gain the confidence and cooperation of the patient.

2. Place the patient in a comfortable position either lying down with the arm resting on the bed or sitting
with the arm supported on the table at heart level to ensure accurate reading.

3. Patient should be resting at least 5 to 10 minutes prior to taking blood pressure.

Procedure

1. Wash hands.

2. Take the equipment to the bedside.

3. Apply deflated cuff evenly with rubber bladder over the brachial artery, the lower edge being 2 inch
above the antecubital fossa. The two tubes turning towards the palm.

4. Palpate the brachial artery with the finger tips. Place the bell of the stethoscope on the brachial pulse.
The stethoscope must hang freely from the ears.
5. Close the valve on the pump by turning the knob clockwise. Pump up air in the cuff until the
sphygmomanometer registers about 20 mm above the point at which the radial pulsation disappears.

6. Open the valve slowly by turning the knob anti-clockwise. Permit the air to escape veryslowly.Note
the number on the manometer where sound first begins. This is the systolic pressure.

7.Continue to release the pressure slowly. The sound become louder and clearer. Note the point on the
manometer where the sound ceases. This is the diastolic pressure.

8. Allow the air to escape and the mercury to fall zero. Wait for one minute with the caffeinated.

9. Repeat the procedure if there is any doubts about the reading.

10. Do not take blood pressure more than three times in succession on reading the same arm.

After Care

1. Remove the cuff by rolling it and replace it in the box.

2. Assist the patient to cover the arm which was exposed.

3. Take the apparatus to the duty room and keep it safely in the cupboard.

4. Wash hands.

5. Record the readings immediately,with the date and time.