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Fundamental Nursing Skills and Concepts


Why? ... maximum impulse, slightly below the left nipple in line with the middle of the clavicle. ... Circulating blood volume averages 4.5 to 5.5 L in adult men ... – PowerPoint PPT presentation

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Title: Fundamental Nursing Skills and Concepts

Fundamental Nursing Skills and Concepts
  • Chapter 11 page 137

Vital Signs
  • Body temperature
  • Pulse rate
  • Respiratory rate
  • Blood pressure
  • Vital signs are objective data that indicate how
    well or how poorly the body is functioning. These
    signs are measureable.

Body Temperature
  • Refers to the warmth of the human body and is
    produced primarily by exercise and the metabolism
    of food.
  • Bodys shell, (skin surface), temperature is
    lower than the core, (at the center of the body),
  • Measured in the Fahrenheit or Centigrade scale.
    Box 11-2, top 139a. Need to know.
  • Normal body temperature 96.6 to 99.3 Fahrenheit
    or 35.8 to 37.4 Centigrade, for shell temps.
  • For core temps 97.5-100.4 F , or 36.4 -37.3 C

Body Temperature
  • The hypothalmus- (structure within the brain)-
    acts as the center for temp. regulation.
  • Temps higher than 105.8 F (41C) or lower than
    93.2F or (34C) show the hypothalmus is
  • 110F or higher or lower than 84F is not
    compatible with life.

Body Temperature
  • Lost from the skin, lungs and body waste products
    through the process of radiation, conduction,
    convection, and evaporation.
  • Table 11-1 page 138

Factors Affecting Body Temperature
  • Food intake-affects thermogenesis,(heat
    production), both the amount and type eaten
    affect body temp. because the body requires
    energy to digest, absorb, transport, metabolize
    and store nutrients. Restrictions on diet can
    help decrease body heat, because of reduced
    processing of nutrients.
  • Age- infants and older adults have limited body
    fat which helps to maintain body temp.
    regulation. Fat provides insulation to prevent
    heat loss. The ability to shiver and perspire may
    also be inadequate, putting them at risk for
    increase body temps. .
  • Climate
  • Gender-may see slight rise when ovulating due to
    hormonal changes.

Factors Affecting Body Temperature
  • Exercise and activity-involves muscle contraction
    which produces body heat. To provide energy,
    metabolic rate goes up leading to combustion of
    calories, and increases heat production.
  • Circadian rhythm
  • Emotions
  • Illness or injury
  • Medications

Assessment Sites
  • Thermistor catheter (heat sensing device at the
    tip of internally placed tube)
  • Oral site- mouth, oral cavity
  • Rectal site-rectum
  • Axillary site-axilla
  • Ear-tympanic
  • Document site temp. was obtained. Page 141a

Oral site
  • Area under the tongue rear sublingual pocket
    most accurate. Picture top page 141
  • Patient needs to be informed, cooperative, keep
    mouth closed, and breathe at a normal rate.
  • Avoid oral route if uncooperative, very young,
    unconscious, seizure risks, oral surgery patient,
    mouth breathers, and those that are talkative.
  • Avoid if patient has been chewing gum, has smoked
    or has had something cold or hot to drink.
    Assessment should take place after 30 minutes,
    for a more accurate temp. reading.

Assessment sites and time
  • Oral site-leave in place, mercury thermometer, 3
    minutes to 5 minutes if feverish.
  • Rectal site-most accurate site. May be
    embarrassing. For glass mercury thermometers
    leave in place 2 minutes.
  • Axillary site-underarm site, generally 1 lower
    than oral measurement. Infants and small children
    can be injured rectally so the axillary is the
    preferred method. It is safe, readily accessible,
    less disturbing, but longest assessment time, 5
    minutes or longer. Make sure contact is made for
    good transference of heat.

Assessment sites and time
  • The ear-also known as tympanic. This measurement
    has the closest correlation to core temperature.
    Considered more reliable, the electronic
    thermometer will beep when ready.

Thermometers used to measure body temps.
  • Glass- slender or rounded bulbs-
  • Slender, for oral use, (Blue tip)
  • Rounded, for rectal placement, (Red tip)
  • For rectal temps 1.5 adult, 1 child, .5
  • Mercury is used in the stem, it heats up and the
    highest point the mercury reaches in the stem is
    the reading of body temp.
  • To clean them is located on page 144, 11-1.

Thermometers used to measure body temps.
  • Electronic thermometers- temperature sensative
    probe covered with a disposable sheath. They are
    portable and rechargeable. Oral and axillary
    probe may be utilized, which is the blue probe,
    rectal probe is the red probe.
  • The probe is connected to an electronic unit that
    senses the temp. . Temp. is reached. A signal is
    emitted to indicate the end. No specific time
    interval, usually 30-60 seconds. Remove probe -
    eject cover read display.

Thermometers used to measure body temps.
  • Infrared (Tympanic) thermometers-hand held
    covered probe- inserted into ear canal, detects
    warmth through sensor from the eardrum converted
    to temp. measurement in 2-5 seconds.
  • Contraindicated for children younger than 2, due
    to small ear canals.

Thermometers used to measure body temps.
  • Chemical thermometers- heat sensitive tapes, or
    patches can be reused before being discarded,
    placed on forehead or abdomen.
  • Changes color according to body temp., easily
    read. Other varieties of strips are held in the
    mouth and dots change color to indicate temp..
    One use and discard.
  • Page 145 bottom has some examples.

Thermometers used to measure body temps.
  • Automated monitoring devices-allows, B/P, temp.,
    and pulse to be taken at same time. Usually
    rolled from room to room.
  • Be careful of ??????????
  • Continuous monitoring device- usually in
    critical care areas. Probes placed within the
    esophagus of anesthetized pts. Or a sensor
    attached to a pulmonary artery catheter.
  • Skill 11-1 assessing body temp. pg 164.

  • Body temp is elevated _at_99.3F or above.
  • Fever pyrexia
  • Febrile, with fever
  • Afebrile, with out fever, no fever
  • Hyperthermia, high core temp. , usually exceeding
    105.8F or 40.6C at risk for brain damage or
    death due to high metabolic demands.
  • Symptoms- restless, flushed, irritable, poor
    appetite, glassy eyes, increased perspiration,
    headache, increased pulse resp. rate.

Fever cont.
  • May be disoriented, confused and have fever
  • A fever of less than 102.F may be a good thing
    to fight off infection, bodys own defenses,
    fighting microbes.
  • Provide lots of fluids and or rest.
  • Fever of 102-104F, antipyretics may need to be
    used. Aspirin(ASA), or acetaminophen.
  • See nursing care plan guidelines for pts. with a
    fever, pg.148

  • Core body temp. less than 95F, or 35C. , best
    taken with a tympanic thermometer. Why????
  • What will you be seeing in a pt. that is
  • What will you do for a hypothermic pt. ?
  • Nursing guidelines 11-2 page 149.

Phases of a Fever
  • Prodromal Phase The client has nonspecific
    symptoms just before the temperature rises.
  • Onset or Invasion Phase Obvious mechanism for
    increasing body temperature, such as shivering
  • Stationary phase The fever is sustained.
  • Resolution or defervescence phase Temperature
    returns to normal
  • Fig 11.11 page 147

Subnormal Temperature
  • Hypothermia-core temperature less than 95 degrees
  • Mild hypothermia-temperature 95 to 93.2 degrees
  • Moderate hypothermia-93 to 86 degrees
  • Severe hypothermia-below 86 degrees

  • A wavelike sensation that can be palpated in a
    peripheral artery, produced by the movement of
    blood during the hearts contraction.
  • Normal heart rate is 60-100 beats per minute at
    rest, table 11.5 page 149
  • Pulse rate (number of peripheral pulsations
    palpated in 1 minute) is counted by compressing a
    superficial artery against an underlying bone
    with the tips of the fingers, never, never the

Factors Affecting Pulse and Heart Rates
  • Age
  • Circadian Rhythm (lower in am)
  • Gender
  • Body build
  • Exercise and activity
  • Stress and emotions

Factors Affecting Pulse and Heart Rates
  • Body temperature--- for 1F temp. elevation the
    heart and pulse rate increases 10 BPM.
  • Blood volume---excessive blood loss causes heart
    rate to increase. Why??? ( task is to deliver O?
    to cells, so speeds up the action, due to lower
    circulating volume).
  • Drugs---some slow, some speed up rate. Very
    important to know what meds do that you are

Alterations in Pulse Rate
  • Tachycardia-100-150 bpm---heart is overworked,
    cells may not get the O? they need. Monitor
    closely, report document according to agency
  • Palpitation-Awareness of ones heart contraction
    without having to feel the pulse.
  • Bradycardia-lt60 bpm---warrants monitoring,
    reporting documenting.
  • Arrhythmia or dysrhythmia-irregular pattern of
    heartbeats, need to report promptly.

Alterations in Pulse Rate
  • Palpitation- awareness of ones own heart
    contraction without having to feel the pulse.
  • Pulse volume- table 11-6 page 150-quality of
    pulsation felt.
  • Peripheral pulse sites-fig. 11-12---know these
  • Assessing radial pulse---skill 11-2 page 172

Alterations in Pulse Rate
  • Fig. 11-13, page 151b. Apical heart rate point
    of maximum impulse. Point of maximum impulse,
    slightly below the left nipple in line with the
    middle of the clavicle.
  • Listening to the apical, lub dub will be heard,
    this is equal to one beat.
  • The lub will be heard louder than the dub if the
    stethoscope has been placed correctly.
  • Taking a radial pulse this lub dub will come
    across as 1 beat.

Pulse Assessment Sites
  • Peripheral pulses-radial artery
  • Apical heart rate-number of ventricular
    contractions per minute that occur.
  • Apical-radial heart rate-number of sounds heard
    at the hearts apex and the rate of the radial
    pulse during the same period. 2 nurses, (1 nurse
    counts the apical beats, the other counts
    radial), 1 clock is used. They start counting at
    the same time. They should get the same total, if
    not the difference between is called the pulse
    deficit. Should be reported to charge nurse and

  • Doppler ultrasound device- conductive jelly is
    used to hear very faint sounds. Document D, for
  • Doppler is used when slight pressure occludes
  • Page 152 shows a doppler being used.

Pulse rate and respiratory rate
  • Factors that influence the pulse rate usually
    affect the respiratory rate such as temp.,
    activity, anxiety, stress and fright.

  • Exchange of oxygen and carbon dioxide
  • External respiration- exchange between alveolar
    capillary membranes
  • Internal or tissue respiration- exchange between
    blood body cells
  • Ventilation-movement of air in and out of the
  • Inhalation-breathing in
  • Exhalation-breathing out
  • Respiratory rate-number of ventilations per minute

  • The medulla is the respiratory center in the
    brain and controls ventilation. It is sensitive
    to the CO?, (carbon dioxide), in the blood.
  • Count the number of ventilations in one minute.
  • Table 11-7 page 152need to know normal
    respiratory rates.
  • Ratio of 4-5 heartbeats to 1 respiration is
    fairly normal.

Breathing Patterns and Abnormal Characteristics
  • Cheyne-Stokes Respiration-Breathing pattern in
    which the depth of the respirations gradually
    increases followed by gradual decrease, and then
    a period when breathing stops before resuming
    again. Usually seen as death approaches.
  • Hyperventilation-Rapid or deep breathing
  • Hypoventilation-Diminished breathing
  • Changes in ventilation may occur in clients with
    airway obstruction, pulmonary or neuromuscular

Breathing Patterns and Abnormal Characteristics
  • Dyspnea-Difficult or labored breathing. May see
    nostrils flare, or widen, pt. appears anxious, or
    worried. Fight for breath. Abdominal, and neck
    muscles used to breathe, seen in anxious pt.
    along with fast heart rate.
  • Orthopnea-Breathing facilitated by sitting or
    standing up, page 412 shows the examples. The
    abdominal organs move away from the diaphram with
    gravity so breathing is easier.

Breathing Patterns and Abnormal Characteristics
  • Apnea-Absence of breathing. Lasts 4-6 minutes,
    life threatening. Prolonged apnea there will be
    brain damage. Skill 11-3, pg 174.
  • Tachypnea-fast respiratory rate
  • Bradypnea-slower than normal resp. rate. Drugs
    such as MS can slow rate so count 1 full minute.

Sounds to be aware of
  • Stertorous breathing- noisy ventilation
  • Stridor- harsh, hi-pitched sound heard on
    inspiration when there is a laryngeal
    obstruction. Children often have stridor with
  • Anterior and posterior lung assessments are well
    demonstrated on page 199, you will need to know
    these well.

Blood Pressure
  • Force that the blood exerts within the arteries
  • Circulating blood volume averages 4.5 to 5.5 L in
    adult men
  • Contractility of the heart is influenced by the
    stretch of cardiac muscle fibers. If the muscle
    tissues are damaged and scar tissue happens, less
    stretch and reduced contractility occurs.
  • Cardiac output-volume of blood ejected from the
    left ventricle per minute is approximately 5 to 6
    liters, average stroke volume in adults is 70 ml
    x heart rate x minute or time.

Blood Pressure
  • Preload volume of blood that fills the heart and
    stretches the heart muscle fibers during its
    resting phase.
  • Afterload-force against which the heart pumps
    when ejecting blood. Resistance increases when
    valves of the heart and arterioles are narrowed
    or calcified. Afterload is decreased when
    arteries dilate.
  • Systolic and diastolic are expressed as a
    fraction in millimeters of mercury, (abbreviated
  • Generally a B/P of 140/90 is considered the
    beginning of high B/P. Optimal B/P for adult
    120/80 mmHg.

Factors Affecting Blood Pressure
  • Age-tends to rise with age
  • Circadian rhythm-lowest _at_ 12 to 4 or 5 a.m.
  • Gender women tend to have lower B/P
  • Exercise and activity
  • Emotions and pain- B/P rises
  • Arteriosclerosis-arteries loose elasticity
  • Athersclerosis-narrowed arteries due to deposits
  • Miscellaneous factors
  • Drugs-heart stimulants-nicotine,caffiene,cocaine

Pressure Measurements
  • Systolic pressure-Pressure within the arterial
    system with the heart contracts. Is higher than
    the Diastolic pressure- Pressure within the
    arterial system when the heart relaxes and fills
    with blood
  • Pulse pressure-Difference between systolic and
    diastolic pressure measurements
  • A pulse pressure between 30-50 mmHg when
    diastolic is subtracted from systolic blood
    pressure is said to be in the normal range.

Assessment of the Blood Pressure
  • Over the brachial artery at the inner aspect of
    the elbow is usually used. When there is a
    problem with taking it at this location, then the
    lower arm can be used, using the radial artery.
  • Popliteal artery- behind the knee. Always
    document site used.
  • Equipment for Measuring Blood Pressure
    Sphygomomanometer- mercury or aneroid
  • Inflatable cuff that encircles at least 2/3 of
    the limb at mid point
  • Stethoscope

Assessment of the Blood Pressure
  • Table 11-9 page 157 B/P assessment errors
  • First time a B/P is measured it needs to be taken
    in each arm. Should not vary 5-10 mmHg. Doctors
    may request a lying, sitting and standing B/P.
  • Too wide cuff will give a false low reading
  • Too narrow cuff will give a false high reading
  • Stethoscope ear tips need to be positioned
    downward and forward in ears. Tips need to be
    cleaned between uses. Best length of tubing for
    sound conduction 20 inches.

Measuring Blood Pressure
  • Korotkoff Sounds-Sounds that result from the
    vibrations of blood within the arterial wall or
    changes in blood flow, fig 11-21, page 158
  • Phase I-begins with the first faint but clear
    tapping sound that follows a period of silence as
    pressure is released from the cuff. This is the
    systolic pressure measurement. Note the placement
    of the gauge mark.
  • Auscultatory gap-Period during which sound
  • Phase II-is characterized by a change form
    tapping sounds to swishing sounds
  • Phase III-is characterized by change to loud and
    distinct sounds, described as crisp knocking

Measuring Blood Pressure
  • Phase IV-sounds are muffled and have a blowing
  • Phase V-Last sound is heard, this is the
    diastolic pressure reading.
  • Palpating the B/P- instead of using a stethoscope
    use fingers over the artery, when the first
    palpation is felt after the release of the cuff
    pressure, this is the systolic B/P. No diastolic
    is perceptible. Document systolic B/P palpated
    and the number.
  • Doppler stethoscope used, please document D.

Abnormal Pressure Measurements
  • Hypertension-High blood pressure-140/90 or above
    for adults 18 or over for sustained amount of
    time is considered HTN. HTN often associated
    with anxiety, obesity, vascular diseases, stroke,
    heart failure, kidney disease.
  • Whitecoat Hypertension-Condition in which the
    blood pressure is elevated when taken by a health
    care worker, but normal other times.
  • A sudden rise or fall of 20-30 mmHg is
    significant- take B/P on both arms and report it
    to your charge nurse.

Abnormal Pressure Measurements
  • Hypotension-Low blood pressure- may indicate
    shock, hemorrhage, drugs, orthostatic hypotension
    or postural hypotension, which is a sudden but
    temporary drop in B/P when rising from a
    reclining position. Commonly seen in patients
    with circulatory problems, dehydration, patients
    on diuretics. Patient will present with
    dizziness, going weak, and fainting. Postural or
    orthostatic hypotension-Sudden temporary drop in
    blood pressure when rising from a reclining
  • Report any abnormal vital signs!!!!
  • Skill 11-4 assessing the B/P page 176
  • Please look over general gerontologic