1. 2 Definition: There are four objective assessment data that indicate how well body is functioning and very sensitive to alteration in physiology.

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DefinitionDefinition: : There are four objective assessment data There are four objective assessment data that indicate how well body is functioning that indicate how well body is functioning and very sensitive to alteration in and very sensitive to alteration in physiology.physiology.

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TimesTimes to assess vital sign: to assess vital sign:

1) On admission to health care agency to 1) On admission to health care agency to obtain base line data.obtain base line data.

2) When client has change in health 2) When client has change in health status.status.

3) Before and after surgery.3) Before and after surgery. 4) Before and after administrat6ion of 4) Before and after administrat6ion of

medication.medication. 5) Before and after any nursing 5) Before and after any nursing

interventionintervention

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1)Body temperature:1)Body temperature:

DefinitionDefinition: the balance between the : the balance between the heat production and heat lost from heat production and heat lost from the body, measured in heat unit the body, measured in heat unit called degree.called degree.

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* * FahrenheitFahrenheit scale uses 32F as the scale uses 32F as the water freeze point and 212F as boil water freeze point and 212F as boil point. point.

**centigradecentigrade scale uses 0 as the scale uses 0 as the water freeze and 100C as boil point.water freeze and 100C as boil point.

Normal body temperature:Normal body temperature:98 – 98.6 F98 – 98.6 F36.4 – 37.4 C36.4 – 37.4 C

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Two type of body temperature:Two type of body temperature:

Core temperature:Core temperature: is the is the temperature of deep tissue of the temperature of deep tissue of the body such as thorax, abdominal body such as thorax, abdominal cavity. it relatively constant. cavity. it relatively constant.

Surface temperatureSurface temperature:: is the temperature of skin, is the temperature of skin,

subcutaneous tissue rise and fall in subcutaneous tissue rise and fall in response to environment. response to environment.

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Factor effect on body heat Factor effect on body heat production:production:

Basal metabolic rateBasal metabolic rate: is rate of energy : is rate of energy utilization in the body required to utilization in the body required to maintain essential activity (metabolism).maintain essential activity (metabolism).Metabolism: the primary source of energy is Metabolism: the primary source of energy is

the sum of all the chemical process that the sum of all the chemical process that occurs in the body.occurs in the body.

Muscle activity.Muscle activity.Thyroxin out put.Thyroxin out put.Epinephrine.Epinephrine.FeverFever..

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Way of heat loss:Way of heat loss:

Radiation:Radiation: is transfer of heat from one is transfer of heat from one object to another object with out object to another object with out contact.contact.

Conduction:Conduction: is transfer of heat from is transfer of heat from one molecules to another of lower one molecules to another of lower temperature.temperature.

Convection:Convection: dispersion of heat by air dispersion of heat by air current.current.

Evaporations:Evaporations: continuous evaporation continuous evaporation of the moisture from the respiratory of the moisture from the respiratory tract.tract.

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Temperature regulation:Temperature regulation:

HypothalamusHypothalamus: a structure within : a structure within the brain that helps controls various the brain that helps controls various metabolic activities.metabolic activities.

It acts as the center of temperature It acts as the center of temperature regulation.regulation.

When sensor of hypothalamus detect When sensor of hypothalamus detect heat, they send signals intend to heat, they send signals intend to reduce temperature reduce temperature

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Factor effect on body Factor effect on body temperature: temperature:

AgeAgeCircadian rhythmCircadian rhythmExercise Exercise HormonesHormonesStressStressEnvironment.Environment.

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Terms:Terms:

PyrexiaPyrexia: body temperature above the usual : body temperature above the usual range (fever). (38 – 40).range (fever). (38 – 40).

HyperpyrexiaHyperpyrexia: very high temperature more : very high temperature more than 40 C.than 40 C.

HypothermiaHypothermia : body temperature less than : body temperature less than 35.35.

My be induced or accidental.My be induced or accidental. Note: the client who has a fever is referred to Note: the client who has a fever is referred to

as febrile, the one who has not called A as febrile, the one who has not called A febrile.febrile.

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Clinical sign of fever:Clinical sign of fever: Increase heart rateIncrease heart rate Increase respiratory rate Increase respiratory rate Shivering Shivering PalledPalledCyanotic nail bedsCyanotic nail beds Increase thirst.Increase thirst.Loss of appetite. Loss of appetite.

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Assessment siteAssessment site:: Oral siteOral site: mouth, convenient, it is contraindicated : mouth, convenient, it is contraindicated

for: uncooperative client, children, unconscious, for: uncooperative client, children, unconscious, shivering and prone to seizers.shivering and prone to seizers.

Delay taking oral temperature at least 10min if client Delay taking oral temperature at least 10min if client been smoking, eating hot or cold food or drinks.been smoking, eating hot or cold food or drinks.

Rectal siteRectal site: can be embarrassing for alert client, : can be embarrassing for alert client,

inconvenient, improper placement, stool in rectum. inconvenient, improper placement, stool in rectum. AuxiliaryAuxiliary: are preferred site for infant, unconscious : are preferred site for infant, unconscious

patient but it takes long time about 5 min.patient but it takes long time about 5 min. TympanicTympanic: tympanic membrane suitable for : tympanic membrane suitable for

children, more reliable for core temperature. children, more reliable for core temperature.

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Type of thermometer:Type of thermometer:

Mercury glass thermometer.Mercury glass thermometer.Electronic thermometer.Electronic thermometer.Skin tape.Skin tape.Tympanic thermometer. Tympanic thermometer.

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Four common types of feversFour common types of fevers

Intermittent:Intermittent: the temperature the temperature alternate regular interavel between alternate regular interavel between period of fever.period of fever.

Remittent:Remittent: it is wide range of of it is wide range of of temperature fluctuation, all of which temperature fluctuation, all of which are above normal.are above normal.

Relapsing feverRelapsing fever: is short febrile period : is short febrile period of a few days with period 1-2 days.of a few days with period 1-2 days.

Constant feverConstant fever always remain above always remain above normal.normal.

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2) Pulse:2) Pulse: Is the wave of blood created by Is the wave of blood created by

contraction of the ventricles of the contraction of the ventricles of the heart.heart.

Cardiac out put = Stroke volume * Cardiac out put = Stroke volume * heart rate.heart rate.

Two type of pulse:Two type of pulse:Peripheral pulsePeripheral pulse is pulse located in is pulse located in

peripheral of the body, foot, hand.peripheral of the body, foot, hand.Apical pulseApical pulse is centered pulse is centered pulse

located above the apex of the heart. located above the apex of the heart.

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Factor effect the pulse:Factor effect the pulse:Age.Age.Exercise.Exercise.feverfevermedicationmedicationHemorrhage.Hemorrhage.Stress.Stress.

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Pulse site:Pulse site: temporaltemporal radialradial carotidcarotid apicalapical brachialbrachial posterior tibial posterior tibial Dorsal spedis pulse.Dorsal spedis pulse. Popliteal Popliteal Femoral Femoral

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Pulse sites Pulse sites

TemporalTemporal: where the temporal artery : where the temporal artery pass over the temporal bone.pass over the temporal bone.

Carotid:Carotid: at the side of the neck where at the side of the neck where carotid artery runs between the trachea carotid artery runs between the trachea and sternoclidomastiod muscle.and sternoclidomastiod muscle.

Apical:Apical: at the apex of the heart. at the apex of the heart.Brachial:Brachial: at the inner aspect of the at the inner aspect of the

biceps tendon or medial antecubital biceps tendon or medial antecubital fossa. fossa.

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Pulse sitesPulse sites

Femoral:Femoral: where the femoral artery passes where the femoral artery passes along side of inguinal ligaments.along side of inguinal ligaments.

Radial:Radial: on the long radial bone, on thumb on the long radial bone, on thumb side of the inner aspect of the wrist.side of the inner aspect of the wrist.

Popliteal:Popliteal: behind the knee. behind the knee. Positerior tebial:Positerior tebial: behind the medial behind the medial

malleolus.malleolus. Dorsalis pedisDorsalis pedis: on the dorsum of the : on the dorsum of the

foot, upper surface. foot, upper surface.

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Terms:Terms:

Tachycardia:Tachycardia: when pulse increase when pulse increase more than 100 bm.more than 100 bm.

Bradycardia:Bradycardia: when pulse decrease when pulse decrease less than 60 bm.less than 60 bm.

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Respiration:Respiration:DefinitionDefinition: is act of breathing, the : is act of breathing, the

normal respiratory rate is 16 – 20 normal respiratory rate is 16 – 20 bpm.bpm.

Two types of respiration:Two types of respiration:External:External: the exchange of oxygen the exchange of oxygen

and carbon dioxide between the and carbon dioxide between the alveoli of the lung and blood.alveoli of the lung and blood.

InternalInternal: is the exchange of the same : is the exchange of the same gas between blood and cell of the gas between blood and cell of the body tissue body tissue

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The muscle that contribute in the The muscle that contribute in the respiration:respiration:

Diaphragm muscle ( main muscle).Diaphragm muscle ( main muscle). Intercostals muscle.Intercostals muscle.Sternoclidomastiod muscle.Sternoclidomastiod muscle.

NoteNote:: In female, observe chest movement.In female, observe chest movement. In male, observe abdominal In male, observe abdominal

movement. movement.

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Terms:Terms:

Inhalation (inspirationInhalation (inspiration):): intake of air into lung. intake of air into lung. Exhalation (expiration):Exhalation (expiration): breathing out or the breathing out or the

movement of gases from the lung in to movement of gases from the lung in to atmosphere.atmosphere.

Breathing patternBreathing pattern::1) Volume:1) Volume: HyperventilationHyperventilation:: refer very deep and rapid refer very deep and rapid

respiration.respiration. HypoventilationHypoventilation:: refer to shallow respiration. refer to shallow respiration. Eupnea:Eupnea: normal respiratory rate and depth. normal respiratory rate and depth. Bradypnea:Bradypnea: slow breathing. slow breathing. TachypneaTachypnea:: fast respiratory rate. fast respiratory rate.

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Mechanism of respiration:Mechanism of respiration:During inhalation: the diaphragm During inhalation: the diaphragm

contracts( flatten) and the ribs move contracts( flatten) and the ribs move up wards and out ward and the up wards and out ward and the sternum move out ward.sternum move out ward.

Exhalation: the diaphragm relaxes, Exhalation: the diaphragm relaxes, ribs moves down ward and inwards ribs moves down ward and inwards the sternum move in ward and the sternum move in ward and decrease the size of thorax.decrease the size of thorax.

Inspiration time 1 – 1.5 sec.Inspiration time 1 – 1.5 sec.Expiration time 2 – 3 sec.Expiration time 2 – 3 sec.

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Regulation of Regulation of respiration:respiration:

Controlled by Controlled by respiratory center in respiratory center in the medulla oblingata.the medulla oblingata.

Chemoreceptor located Chemoreceptor located centrally in medulla centrally in medulla and peripheral in and peripheral in carotid and aortic body. carotid and aortic body.

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Factor influence of respiratory Factor influence of respiratory rate:rate:

Exercise.Exercise.stressstressEnvironmental factor.Environmental factor. Increase altitude.Increase altitude.Certain medication (narcotic)Certain medication (narcotic) Increased intracranial pressure. Increased intracranial pressure.

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4) Blood pressure:4) Blood pressure:

DefinitionDefinition: is measure of pressure : is measure of pressure exerted by the blood as it flows exerted by the blood as it flows through the arteries.through the arteries.

Systolic blood pressure:Systolic blood pressure: the the pressure of the blood as result of pressure of the blood as result of contraction of the ventricles.contraction of the ventricles.

Diastolic blood pressureDiastolic blood pressure: the : the pressure when the ventricles are at pressure when the ventricles are at rest rest

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The differences between the diastolic The differences between the diastolic and systolic pressure called pulse and systolic pressure called pulse pressure.pressure.

The normal blood pressure reading: The normal blood pressure reading: systolic 100 – 140 mmhg and systolic 100 – 140 mmhg and diastolicdiastolic

60 – 90mmhg.60 – 90mmhg.ExampleExample: (130/80), 130= systolic, : (130/80), 130= systolic,

80 = diastolic, 50 = pulse pressure.80 = diastolic, 50 = pulse pressure.

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Determinant of blood pressure:Determinant of blood pressure:a) Cardiac out put (COP).a) Cardiac out put (COP).b) Peripheral resistance (PR).b) Peripheral resistance (PR).Some factor effect on peripheral Some factor effect on peripheral

resistance:resistance: 1) Size of artery.1) Size of artery. 2) Compliance of arteries.2) Compliance of arteries. 3) Viscosity.3) Viscosity. cc) Blood volume.) Blood volume. d) Blood viscosityd) Blood viscosity

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Factor effect on the blood Factor effect on the blood pressure:pressure:

1)1) Age. Age.

2)2) Exercise.Exercise.

3)3) Stress.Stress.

4)4) Obesity. Obesity.

5)5) Sex. Sex.

6)6) Medication.Medication.

7) disease process.7) disease process.

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HypertensionHypertension: blood pressure that : blood pressure that is persistent above the normal.is persistent above the normal.

hypotension:hypotension: the blood pressure is the blood pressure is blow normal range.blow normal range.

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Part of sphygmomanometer:Part of sphygmomanometer:

a)a) Cuff. b) Mercury meter. c) Tubes. Cuff. b) Mercury meter. c) Tubes.

d) Bulp.d) Bulp.

The recommended bladder size for The recommended bladder size for

blood pressure measurement for blood pressure measurement for adult: adult:

13cm width, 24cm length, for 13cm width, 24cm length, for children 8cm width, 13cm length.children 8cm width, 13cm length.

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The correct way to measure your blood The correct way to measure your blood pressure is:pressure is:

Do not use caffeine, tobacco, or alcohol for 30 Do not use caffeine, tobacco, or alcohol for 30 minutes before you measure. minutes before you measure.

Measure your blood pressure when you first wake Measure your blood pressure when you first wake up and before dinner. (Unless your doctor tells up and before dinner. (Unless your doctor tells you other times.) you other times.)

Before you measure your blood pressure, sit in a Before you measure your blood pressure, sit in a chair with a back on it for 3-5 minutes, and do not chair with a back on it for 3-5 minutes, and do not talk. Use the correct sized cuff for your arm talk. Use the correct sized cuff for your arm

Put the cuff in the proper place on your arm by Put the cuff in the proper place on your arm by placing the arrow or tubing on the inside of the placing the arrow or tubing on the inside of the elbow elbow

Keep your arm at heart level while doing a blood Keep your arm at heart level while doing a blood pressure measure pressure measure

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