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1 Definition: There are four objective assessment data that indicate how well body is functioning and very sensitive to alteration in physiology. 2 Times to assess vital sign: 1) On admission to health care agency to obtain base line data. 2) When client has change in health status. 3) Before and after surgery. 4) Before and after administrat6ion of medication. 5) Before and after any nursing intervention 3 1)Body temperature: Definition: the balance between the heat production and heat lost from the body, measured in heat unit called degree. 4 * Fahrenheit scale uses 32F as the water freeze point and 212F as boil point. *centigrade scale uses 0 as the water freeze and 100C as boil point. Normal body temperature: 98 – 98.6 F 36.4 – 37.4 C 5 Two type of body temperature: Core temperature: is the temperature of deep tissue of the body such as thorax, abdominal cavity. it relatively constant. Surface temperature: is the temperature of skin, subcutaneous tissue rise and fall in response to environment. 6 Factor effect on body heat production: Basal metabolic rate: is rate of energy utilization in the body required to maintain essential activity (metabolism). Metabolism: the primary source of energy is the sum of all the chemical process that occurs in the body. Muscle activity. Thyroxin out put. Epinephrine. Fever. 7 Way of heat loss: Radiation: is transfer of heat from one object to another object with out contact. Conduction: is transfer of heat from one molecules to another of lower temperature. Convection: dispersion of heat by air current. Evaporations: continuous evaporation of the moisture from the respiratory tract. 8 Temperature regulation: Hypothalamus: a structure within the brain that helps controls various metabolic activities. It acts as the center of temperature regulation. When sensor of hypothalamus detect heat, they send signals intend to reduce temperature 9 Factor effect on body temperature: Age Circadian rhythm Exercise Hormones Stress Environment. 10 Terms: Pyrexia: body temperature above the usual range (fever). (38 – 40). Hyperpyrexia: very high temperature more than 40 C. Hypothermia : body temperature less than 35. My be induced or accidental. Note: the client who has a fever is referred to as febrile, the one who has not called A febrile. 11 Clinical sign of fever: Increase heart rate Increase respiratory rate Shivering Palled Cyanotic nail beds Increase thirst. Loss of appetite. 12 Assessment site: Oral site: mouth, convenient, it is contraindicated for: uncooperative client, children, unconscious, shivering and prone to seizers. Delay taking oral temperature at least 10min if client been smoking, eating hot or cold food or drinks. Rectal site: can be embarrassing for alert client, inconvenient, improper placement, stool in rectum. Auxiliary: are preferred site for infant, unconscious patient but it takes long time about 5 min. Tympanic: tympanic membrane suitable for children, more reliable for core temperature. 13 Type of thermometer: Mercury glass thermometer. Electronic thermometer. Skin tape. Tympanic thermometer. 14 Four common types of fevers Intermittent: the temperature alternate regular interavel between period of fever. Remittent: it is wide range of of temperature fluctuation, all of which are above normal. Relapsing fever: is short febrile period of a few days with period 1-2 days. Constant fever always remain above normal. 15 2) Pulse: Is the wave of blood created by contraction of the ventricles of the heart. Cardiac out put = Stroke volume * heart rate. Two type of pulse: Peripheral pulse is pulse located in peripheral of the body, foot, hand. Apical pulse is centered pulse located above the apex of the heart. 16 Factor effect the pulse: Age. Exercise. fever medication Hemorrhage. Stress. 17 Pulse site: temporal radial carotid apical brachial posterior tibial Dorsal spedis pulse. Popliteal Femoral 18 Pulse sites Temporal: where the temporal artery pass over the temporal bone. Carotid: at the side of the neck where carotid artery runs between the trachea and sternoclidomastiod muscle. Apical: at the apex of the heart. Brachial: at the inner aspect of the biceps tendon or medial antecubital fossa. 19 Pulse sites Femoral: where the femoral artery passes along side of inguinal ligaments. Radial: on the long radial bone, on thumb side of the inner aspect of the wrist. Popliteal: behind the knee. Positerior tebial: behind the medial malleolus. Dorsalis pedis: on the dorsum of the foot, upper surface. 20 Terms: Tachycardia: when pulse increase more than 100 bm. Bradycardia: when pulse decrease less than 60 bm. 21 Respiration: Definition: is act of breathing, the normal respiratory rate is 16 – 20 bpm. Two types of respiration: External: the exchange of oxygen and carbon dioxide between the alveoli of the lung and blood. Internal: is the exchange of the same gas between blood and cell of the body tissue 22 The muscle that contribute in the respiration: Diaphragm muscle ( main muscle). Intercostals muscle. Sternoclidomastiod muscle. Note: In female, observe chest movement. In male, observe abdominal movement. 23 Terms: Inhalation (inspiration): intake of air into lung. Exhalation (expiration): breathing out or the movement of gases from the lung in to atmosphere. Breathing pattern: 1) Volume: Hyperventilation: refer very deep and rapid respiration. Hypoventilation: refer to shallow respiration. Eupnea: normal respiratory rate and depth. Bradypnea: slow breathing. Tachypnea: fast respiratory rate. 24 Mechanism of respiration: During inhalation: the diaphragm contracts( flatten) and the ribs move up wards and out ward and the sternum move out ward. Exhalation: the diaphragm relaxes, ribs moves down ward and inwards the sternum move in ward and decrease the size of thorax. Inspiration time 1 – 1.5 sec. Expiration time 2 – 3 sec. 25 Regulation of respiration: Controlled by respiratory center in the medulla oblingata. Chemoreceptor located centrally in medulla and peripheral in carotid and aortic body. 26 Factor influence of respiratory rate: Exercise. stress Environmental factor. Increase altitude. Certain medication (narcotic) Increased intracranial pressure. 27 4) Blood pressure: Definition: is measure of pressure exerted by the blood as it flows through the arteries. Systolic blood pressure: the pressure of the blood as result of contraction of the ventricles. Diastolic blood pressure: the pressure when the ventricles are at rest 28 The differences between the diastolic and systolic pressure called pulse pressure. The normal blood pressure reading: systolic 100 – 140 mmhg and diastolic 60 – 90mmhg. Example: (130/80), 130= systolic, 80 = diastolic, 50 = pulse pressure. 29 Determinant of blood pressure: a) Cardiac out put (COP). b) Peripheral resistance (PR). Some factor effect on peripheral resistance: 1) Size of artery. 2) Compliance of arteries. 3) Viscosity. c) Blood volume. d) Blood viscosity 30 Factor effect on the blood pressure: 1) Age. 2) Exercise. 3) Stress. 4) Obesity. 5) Sex. 6) Medication. 7) disease process. 31 Hypertension: blood pressure that is persistent above the normal. hypotension: the blood pressure is blow normal range. 32 Part of sphygmomanometer: a) Cuff. b) Mercury meter. c) Tubes. d) Bulp. The recommended bladder size for blood pressure measurement for adult: 13cm width, 24cm length, for children 8cm width, 13cm length. 33 34 The correct way to measure your blood pressure is: Do not use caffeine, tobacco, or alcohol for 30 minutes before you measure. Measure your blood pressure when you first wake up and before dinner. (Unless your doctor tells you other times.) Before you measure your blood pressure, sit in a chair with a back on it for 3-5 minutes, and do not talk. Use the correct sized cuff for your arm Put the cuff in the proper place on your arm by placing the arrow or tubing on the inside of the elbow Keep your arm at heart level while doing a blood pressure measure 35 36