Taking Vital Signs Student Guide PDF

TAKING VITAL (CARDINAL) SIGNS  Objectives  At the end of this chapter, the students will able to:  Explain the vital sign  Describe the four primary vital sign within its purposes.  Explain factors affect vital signs  Identify normal range of child and adult v/s a...

TAKING VITAL (CARDINAL) SIGNS  Objectives  At the end of this chapter, the students will able to:  Explain the vital sign  Describe the four primary vital sign within its purposes.  Explain factors affect vital signs  Identify normal range of child and adult v/s at rest  Describe the instruments used to measure vital sign  Explain the procedure used to measure vital sign. 9/13/2024 2 Vital signs (cardinal signs) reflect the body’s physiologic status and provide information critical to evaluating homeostatic balance.  They are indicators of whether the individual is alive.  They indicate the overall health status of a person.  These signs reflect changes in the function of the body.  It is the fundamental to physical assessment (the first step in the physical examination) to establish baseline values of the clients  It is imperative that nurses measure vital signs correctly and accurately, understand the data, and communicate appropriately 9/13/2024 3  There are four primary vital/cardinal signs. These are:  Body temperature (To)  Pulse rate (PR)  Respiratory rate (RR)  Blood pressure (BP) 9/13/2024 4  Purposes of taking V/S  To obtain baseline data about patients’ condition  To aid in diagnosing patients’ problem  For therapeutic purpose so that to intervene accordingly.  To monitor a patient’s condition  Monitor risks for alterations in health. 9/13/2024 5  Time to assess V/S  On admission  When client has a change in health status  Before & after surgery or invasive diagnostic procedures  Before & after any nursing intervention that could affect V/S such as ambulation  According to nursing or medical order  According to hospital or other health institution policy.  Before, during & after administrating of certain medication that will affect V/S (respiratory and cardiovascular system) 9/13/2024 6  Factors affecting VS Age :- in new born the thermoregulation and respiration centers are immature. The newborn’s temperature fluctuates with the environment. As age increased the thermoregulation is reduced that affected by the physiologic change like loss of subcutaneous fat, reduced in metabolism, reduced the sweat gland activity and loss of vasomotor control Gender:- women usually experience temp fluctuation than men due to hormonal change. This occur in menstrual cycle with the change of progesterone level. ---During the ovulation period the progesterone level increased so that of temp. during the menopause period also there is a temp increase. Men in general have higher BP than women in the same age group 9/13/2024 7  cont Medications:- can directly or indirectly alter the RR, PR,BP eg Digitalis preparations decrease the pulse rate and narcotic analgesic for pain also decrease the depth and rate of respiration and BP Environment:- heat and noise env’t can increase the PR and industrialized env’t can affect the RR due to increased respiratory infections Pain:-with acute pain there is a sympathetic stimulation which causes increased cardiac output, vaso-contriction caused peripheral vascular resistance. This changes the PR, RR, BP. chronic pain causes parasympathetic stimulation and decreased the PR 9/13/2024 8  cont Anxiety and stress :- increase the sympathetic stimulation which Increase the production of epinephrine and nor-epinephrine, with a resultant increase in metabolic activity and heat production Postural change- BP decrease when the person change the position from the lying to sitting or standing, PR increase when the person is in sitting or standing position Others factors (exercise, daily variation, lifestyle) 9/13/2024 9  Body temperature (T)  It is the hotness or coldness of the body.  It is the balance b/n heat production & heat loss of the body. 9/13/2024 10  CONT There are 2 types of body temperature 1. Core body temperature:- it is the temperature of internal organ.  It reflects the temperature of viscera and muscles.  It remains constant most of the time (37.5oc); with range of 37-38oc.  It is maintained within a fairly constant range by thermoregulatory center in the hypothalamus.  The core temperature is warmer than the surface or outer temperature 9/13/2024 11 Surface body temperature: - is the temperature of the skin, subcutaneous tissue & fat cells.  It doesn’t indicate internal physiology.  Affected by environmental temperature, and it rises & falls in response to the environment (ranges b/n 20-40oc). 9/13/2024 12  Body temperature regulation  Body temperature is regulated by balancing heat production & heat loss to maintain homeostasis.  Heat production: The primary source of heat in the body is metabolism. Most heat production comes from the deep tissue organs (brain, liver, and heart) and the skeletal muscles Various mechanism increases the body metabolism (hormones, muscle movement, exercise) When additional heat is required to maintain balance epinephrine and nor-epinephrine (sympathetic neurotransmitters) are released and alter metabolism so that energy production increased and heat production increase 9/13/2024 13  HEAT LOSS  The skin is the primary sites of heat loss. The circulation brings heat to the skin’s surface where small connection between the arterioles & the venues lie directly below the surface. The arterio-venous shunts is controlled by sympathetic nervous system. This shunt opens when heat is loss & close to retains heat.  Heat loss also occurs through evaporation of sweat, humidifying of inspired air, eliminating urine & faces. 9/13/2024 14  Heat is transferred to the external environment through the physical process of  Radiation:- loss of heat in the form of infrared wave.  Convection:- the dissemination of heat by motion between areas of unequal density  Evaporation:- the conversion of liquid to vapor) perspiration & insensible loss  Conduction:- the transfer of heat to another object during direct contact 9/13/2024 15  Factors affecting body temperature 1. Circadian rhythms:-A predictable fluctuation in measurement of body temperature is usually about 0.6oc lower in the early morning than in the late afternoon & early evening. 2. Age( reduced : metabolism, body mass , blood flow to skin, thermoregulation change) 3. Gender:- The increase in progestin secretion at ovulation increases body temperature as much as 0.5oc 4. Stress:- activate the sympathetic nervous system which in turn increase the production of epinephrine and norepinephrine which cause The metabolic rate increases, raising the body temperature. 5. Illness :- infection and WBC increase temp 9/13/2024 16 1. Medication :- may change the metabolic rate 2. Environmental temperature:- exposure to excessive warm or cold 3. Food and fluid consumption: malnourished have low temps 4. Time of day(diurnal) lower in early morning and higher in the afternoon 9/13/2024 17  Body temperature variations Normal body temperature  Normal body temperature varies among individuals with a range of 0.3-0.6oc from the average normal temperature considered to be within normal limits.  Normal body adult temperature can range from 36.5oc- 37.2oc or 97.8-99 degrees F for a healthy adult. 9/13/2024 18  Average normal temperature for healthy adults at various sites.  ORAL-37oc  RECTAL-37.5oc  TYMPANIC-37.5oc AXILLARY-36.5oc 9/13/2024 19 Increased body temperature  Febrile; a person with increased body temperature.  A febrile; a person with normal temperature.  Pyrexia (fever); is body temperature above normal  Hyperpyrexia; (high fever) usually above 41oc. Survival is rare when temperature reaches 44oc.  Heat exhaustion –increase temp (38-40) which cause diaphoresis, sign loss of Na and water, nausea, vomiting, weakness, thirst  Heat stroke- critical increase in body temp (41-44) signs dry skin, confusion, thirst, abd distress, muscle pain and loss of consciousness 9/13/2024 20 Types of fever 1. Intermittent; the body temperature alternates regularly between a period of fever & a period of normal or sub-normal. 2. Remittent; the body temperature fluctuates several degrees( more than 2oc) above normal but doesn’t reach normal between fluctuations. 3. Constant; the body temperature remains constantly elevated & fluctuates less than 2oc. 4. Relapsing; the body temperature returns to normal for at least a day but then the fever recurs. 5. Crisis; the fever returns normal suddenly ( dramatic drop) 6. Lyses; the fever returns normal gradually. 9/13/2024 21 Decreased body temperature  Hypothermia; is a body temperature below the lower limit of normal (below 35.0oc)  Death occurs when the temperature falls below about 34oc. This is because of rate of chemical reaction in the body are slowed and decreases metabolic demands for oxygen Decrease in metabolism leads to impaired mental functioning and depressed pulse, respirations, and can result in cardiac arrest if untreated.  Frostbite – freezing in earlobe, toe and finger and circulatory impairment will occur if untreated, gangrene will occur 9/13/2024 22  Sites for measuring body temperature  Body temperature is measured by using an instrument called thermometer.  There are four most commonly used sites for measuring body temperature.  These are: oral, tympanic, rectal and axillary temperature 9/13/2024 23  1. Oral:- obtained by putting the thermometer under the tongue Contraindications:  Most accessible & convenient site.  Children under age of 6  Its measurement is 0.5 less than rectal To. and 0.5 greater than  Epileptic, mentally ill axillary temp. patients  It can lead to a false reading if a  Unconscious patients person has taken hot or cold food/  Patients with ulcer or drink by mouth, & has smoked so sore of the mouth we have to wait for at least 10-  Clients with persistent 15min, after meal or smoking. cough 9/13/2024  Clients receiving O2 24 Equipment 1. Thermometer: glass or electronic 2. Two pairs of non sterile gloves 3. Watch 4. Dry Cotton 5. Receiver/receptacle 6. Soapy water 7. tray 8. Pen or pencil 9. Vital following sheet or record form 9/13/2024 25 Procedure 1. Explain the procedure 2. Wash hands 3. Assemble the necessary equipment 4. Remove thermometer from storage container and cleanse under cool water. 5. Wipe thermometer dry with a tissue from bulb’s end toward fingertips. 6. Read thermometer by locating mercury level. It should read 35.5°C (96°F). 9/13/2024 26 7. If thermometer is not below a normal body temperature reading, grasp thermometer with thumb and forefinger and shake vigorously by snapping the wrist in a downward motion to move mercury to a level below normal. 8. Assist the client to assume semi fowlers position 9. Place thermometer in mouth under the tongue and along the gum line to the posterior sublingual pocket. Instruct client to hold lips closed. 9/13/2024 27 10. Leave in place as specified by agency policy, usually 3–5 minutes. 11. Remove thermometer and wipe with a tissue away from fingers toward the bulb’s end. 12. Read at eye level and rotate slowly until mercury level is visualized. 13. Shake thermometer down, and cleanse glass thermometer with soapy water, rinse under cold water, and return to storage container. 14. Remove and dispose of gloves in receptacle. 15. Comfort the patient 16. Return used equipment and wash your hand 17. Record reading and indicate site as “OT.”(oral temperature) 9/13/2024 28 9/13/2024 29 Rectal temperature Definition: It is method of measuring body temperature by inserting thermometer through the anus into the rectum Contraindication Patient with diarrhea Rectal surgery, leukemia (hematologic disorder) Disease of the rectum (anal fissure, hemorrhoid etc) Client with cardiovascular alteration Precaution:  Never use oral thermometer for rectal and vise verse 9/13/2024 30 Equipment 1. Thermometer: glass (client’s bedside); electronic 2. Lubricant (rectal, glass thermometer) and disposable protective sheath 3. tray 4. Two pairs of disposable gloves 5. Pen or pencil 6. Receiver /receptacle 7. Vital following sheet or record form 8. Tissue paper 9. Screen 9/13/2024 31 Procedure 1. Explain the procedure 2. Wash hands 3. Assemble the necessary equipment 4. Keep privacy 5. Place client in the Sims’ position with upper knee flexed. Adjust sheet to expose only anal area. 6. Instruct client to take a deep breath. 7. Clean the anal area as necessary 8. Lubricate the tip of rectal thermometer or probe 9. Insert thermometer or probe gently into anus: infant, 1.2 cm (0.5 in.); adult, 3.5 cm (1.5 in.) 10. If resistance is felt, do not force insertion. 11. Length of time (as specified by agency policy, usually 3–5 minutes). 9/13/2024 32 12. Wipe secretions of glass thermometer with a tissue for reading without touching the bulb. Dispose of tissue in a receptacle. 13. Read measurement and inform client of temperature reading. 14. While holding glass thermometer in one hand, wipe anal area with tissue to remove lubricant or feces with other hand and dispose of soiled tissue. 15. Comfort of the patient 16. Cleanse thermometer (Remove thermometer and wipe with a tissue away from fingers toward the bulb’s end) 17. Hand washing and return in the place 18. Record reading and indicate site as “RT.”(Rectal temperature) 9/13/2024 33 9/13/2024 34 3. Axillary: - it is safe and non-invasive  It is the least accurate and the least reliable measurement. Disadvantage The thermometer must be left in place for a long time (> 3-5min.) to obtain an accurate measurement It is less accurate as it is not close to major vessels. 9/13/2024 35  Equipment Thermometer: glass or electronic Two pairs of non sterile gloves Dry Cotton tray Face towel Receiver/receptacle Soapy water Watch with second hand Pen or pencil Vital following sheet or record form 9/13/2024 36  Procedure 1) Explain the procedure 2) Wash hands 3) Assemble the necessary equipment 4) Maintain privacy if necessary 5) Remove client’s arm and shoulder from one sleeve of gown. Avoid exposing chest. 6) Assist the client assume supine or semi sitting position 7) Make sure axillary skin is dry; if necessary, pat dry 9/13/2024 37 8) Prepare thermometer (If thermometer is not below a normal body temperature reading, grasp thermometer with thumb and forefinger and shake vigorously by snapping the wrist in a downward motion to move mercury to a level below normal). 9) Place thermometer or probe into center of axilla. 10) Fold client’s upper arm straight down and place arm across client’s chest. 11) Leave glass thermometer in place as specified by agency policy (usually 6–8 minutes). Leave an electronic thermometer in place until signal is heard. 9/13/2024 38  12) Remove and read thermometer. 13) Inform client of temperature reading. 14) Cleanse glass thermometer (Remove thermometer and wipe with a tissue away from fingers toward the bulb’s end) and return to storage container. 15) Assist client with replacing gown. 16) Comfort the patient 17) Return used equipment and wash your hand 18) Record reading and indicate site as “AT.”(Axillary temperature) 9/13/2024 39 9/13/2024 40 9/13/2024 41  4. Tympanic membrane  It reflects the core body temperature  It is very fast method  It is readily accessible.  Not as reliable as oral or rectal, are far from the core temp, careful when inserting these  Disadvantages:  It may be uncomfortable; involves risk of injuring the membrane  Presence of cerumen (wax) can affect the reading.  Right & left measurements may differ. 9/13/2024 42 Contraindication  Perforated ear drum  Ear infection (Otitis media) Precaution: Take tympanic and oral temperature for children above 6 year Never use tympanic temperature in any ear surgery 9/13/2024 43 Equipment 1. Thermometer: glass (client’s bedside); electronic 2. Two pairs of disposable gloves 3. Probe cover 4. tray 5. Pen or pencil 6. Receiver /receptacle 7. Vital following sheet or record form 8. Dry cotton 9. Cotton tipped applicator 9/13/2024 44 Procedure 1. Explain the procedure 2. Wash hands 3. Assemble the necessary equipment 4. Assist clients for assuming comfortable position with hand toward one side away from nurse for Right handed nurse take from right ear and for Left handed nurse take from left ear 5. Note if any excess ear wax 6. Position client in Sims’ position 7. Remove probe from container and attach probe cover to tympanic thermometer unit. 8. Turn client’s head to one side. For an adult, pull pinna upward and back; for a child, pull down and back. 9/13/2024 45 9. Gently insert probe with firm pressure into ear canal. 10. Remove probe after the reading is displayed on digital unit (usually 2 seconds). 11. Remove probe cover and replace in storage container. 12. Comfort the client 13. Return tympanic thermometer to storage unit and wash hand 14. Record reading and indicate site as “ET.”(Ear temperature) 9/13/2024 46 9/13/2024 47  Pulse rate (PR)  Pulse is a wave of distention blood in artery created by the contraction of left ventricle.  Stroke volume and the compliance of arterial wall are the two important factors influencing pulse rate.  Pulse rate is regulated by autonomic nervous system.  The pulse is commonly assessed by palpation (feeling) and auscultation (hearing using a stethoscope). 9/13/2024 48  Purpose  To determine number of heart beats occurring per minute( rate)  To gather information about heart rhythm and pattern of beats  To evaluate strength of pulse  To assess heart's ability to deliver blood to distant areas of the body  To assess response of heart to cardiac medications, activity, blood volume and gas exchange  To assess vascular status of limbs 9/13/2024 49  Factors affecting pulse rate 1. Age:- in infants heart is not well muscular to eject sufficient amount of blood. As age increases PR decreases depend up on life style of an individual. b/c heart loses its elasticity as age increases 2. Autonomic nervous system: stimulation of SNS increased pulse rate  Activation of nerves system occurs in response to stimuli including pain, anxiety, stress, fever, ingestion of caffeine, beverage, in response to change in intravascular volume. 3. Medication:- certain drugs slow down or speed up the rate such as caffeine, nicotine, cocaine and adrenaline like epinephrine speed up the heart. Sedatives like valium, slow down the heart rate. Digitalis toxicity causes bradycardia 9/13/2024 50 4. Exercise :- Hard work and exercise increase the heart rate of a healthy heart. To meet the body's demand for more oxygen, the heart beats faster and harder 5. Blood volume – excessive blood loss causes HR to increase to move the smaller volume around 6. Stress and emotions- stimulation of the sympathetic nervous system such as fear, anger, and excitement increase the HR. 9/13/2024 51 7. Body temperature – for every degree of F elevation, your HR increases 10 beats per minute. 8. Gender:- women are usually smaller than men and require a faster heart beat to facilitate metabolism. Much of the size difference between men and women is due to women having a less total muscle mass. the higher heart rates experienced by women may be a natural compensatory mechanism to turn up the metabolic rate. 9/13/2024 52  Characteristics of pulse  A Normal pulse has defined characteristics: rate, rhythm, volume and quality.  Pulse rate – refers to the number of pulsations per minute. In adults (60-100) times per minute. Bradycardia; refers to pulse rate below 60BPM. Tachycardia; “ “ “ “ above 100BPM 9/13/2024 53  Pulse Rhythm- It describes how evenly the heart is beating: regular (the beats are evenly spaced) or irregular (the beats are not evenly spaced).  Dysrhythmia (arrhythmia) is an irregular rhythm  Pulse Volume -Measurement of the strength or amplitude of the force exerted by the ejected blood against the arterial wall with each contraction  Normal(full)- easy palpable, moderate pressure may cause disappear the pulse  Thread/weak/feeble- diminished pulse, slight pressure cause disappear  Strong (Bounding)- strong pulse, does not disappear with the pressure 9/13/2024 54  It is expressed in numerical classification on a 0-3+ Grading pulse scale 0 - absent pulse 1+ -weak and thready pulse 2+-Normal pulse 3+ -bounding pulse  Pulse quality-Refers to the “feel” of the pulse, its rhythm and forcefulness. 9/13/2024 55  Sites for taking pulse rate  There are peripheral and apical pulses.  A pulse may be measured in nine sites in our body. This is by using the following arteries: Peripheral pulse 1. Radial artery-The most commonly assessed in the clinical settings. 2. Temporal artery- used for infants when the radial pulse is not accessible. 3. Carotid artery-lies benth of sternomastoid muscle. It is used to assess circulation to the brain, shock, cardiac arrest. 9/13/2024 56 4. Brachial artery- near to the center of anti-cubital space. It used to measure BP. To know cardiac arrest in child 5. Femoral artery- half way b/n anterior superior iliac spine & the symphysis pubis just below the inguinal ligament. It is used to asses circulation to the leg 6. Popliteal artery-behind the knee in the popliteal fossa. It is used to asses’ circulation to the lower leg & to measure BP. 7. Posterior tibial:- located behind the medial malleolus/bony prominence on each side of ankel 8. Pedal artery (dorsalis pedis)- dorsal aspect of the foot to the tendon that runs the great toe towards the ankle. 9/13/2024 57  Pulse Points 9/13/2024 58  Apical pulse  Is measured by listening over the apex of the heart using stethoscope.  It can be palpated at the level of the 5th intercostal space, at the left side of mid-clavicular line.  Is more accurate than the radial pulse because the sound of a heart beat is obvious and distinct  Take an apical heart rate if  the heart contraction may not be strong enough to be felt at a peripheral site,  peripheral pulses are irregular or difficult to feel  Pulse deficit- condition in which the apical pulse rate is greater than the radial pulse rate. 9/13/2024 59  What To Listen For?  You hear a “lub-dub” sound  This lub-dub sound equals one pulsation at a the apical site, that is 1 beat. But, on a peripheral site, you feel one wave and you count each throb separately as 1 hrt beat  Lub-dub, lub-dub, lub-dub = 3 beats 9/13/2024 60  Equipment  Watch with a second hand  Stethoscope  Swab  tray  waste receiver  Vital sign flow sheet  pencil and pen 9/13/2024 61 Procedure 1. Explain the procedure 2. Wash hands 3. Assemble the necessary equipment 4. Inform client of the site(s) at which you will measure pulse 5. If supine, place client’s forearm straight alongside body or Flex client’s elbow and place lower part of arm across chest. 6. Support client’s wrist by grasping outer aspect with thumb. 7. Place your index and middle finger on inner aspect of client’s wrist over the radial artery or thumb side and apply light but firm pressure until pulse is palpated 9/13/2024 62 8. Identify pulse rhythm and then determine pulse volume. 9. Count pulse rate by using second hand on a watch:  For a regular rhythm, count number of beats for 30 seconds and multiply by 2.  For an irregular rhythm, count number of beats for a full minute, noting number of irregular beats. 10. Comfort the client 11. Return equipment and wash hand 12. Record reading and indicate site as “PR.”(pulse rate) 9/13/2024 63 Obtaining Radial Pulse 9/13/2024 64 9/13/2024 65 9/13/2024 66  Apical pulse 1. Explain the procedure 2. Wash hands 3. Assemble the necessary equipment 4. Raise client’s gown to expose sternum and left side of chest. 5. Cleanse earpiece and diaphragm of stethoscope with an alcohol swab. 6. Put stethoscope around your neck. 9/13/2024 67 7. Apex of heart: With client lying on left side, locate suprasternal notch. Palpate second intercostal space to left of sternum. Place index finger in intercostal space, counting downward until fifth intercostals space is located. Move index finger along fourth intercostals space left of the sternal border and to the fifth intercostal space, left of the midclavicular line to palpate the point of maximal impulse (PMI) Keep index figure of non dominant hand on PMI 9/13/2024 68 8. Inform client that you are going to listen to his/her heart. 9. Instruct client to remain silent 10. With dominant hand put ear piece of the stethoscope in your ear and grasp diaphragm of the stethoscope in palm of your hand for 5 to 10 second 11. Comfort the client 13. Return equipment and wash hand 14. Record reading and indicate site as “PR.”(pulse rate) 9/13/2024 69 9/13/2024 70 9/13/2024 71  Respiration rate (RR)  Respiration is the act of breathing.  Includes intake of oxygen and removal of carbon-dioxide. Purpose To evaluate breathing for rate, depth and rhythm To evaluate the progress of patient condition For diagnostic purpose To evaluate the effect of administered drugs 9/13/2024 72  Respiration involves several physiologic events.  Pulmonary ventilation (breathing):- is the movement of air in & out of the lungs. Inspiration (inhalation):- is the act of breathing in Expiration (exhalation):- is the act of breathing out One respiration is one inhalation & one exhalation.  External respiration: - is the exchange of oxygen and carbon dioxide between the alveoli of the lungs & circulating blood.  Internal respiration: - is the exchange of o2 &co2 between the circulating blood & tissue or cells  Transport:- transport of oxygen and carbon dioxide between the lungs and tissues 9/13/2024 73 9/13/2024 74  There are two types of breathing: 1. Costal(thoracic) breathing:- occurs when the external inter- costal muscles and the other accessory muscles are used to move the chest upward and outward.  observed by the movement of the chest upward and downward.  It is commonly used for adults. 2. Diaphragmatic (abdominal):- occurs when the diaphragm contraction and relaxation, observed by the movement of the abdomen.  Commonly used for children 9/13/2024 75  Regulation of respiration The rate & depth of breathing change in response to  body demands by the inhalation or  stimulation of the respiratory muscles.  This is controlled by the respiratory centers in medulla & pones. 9/13/2024 76  The respiratory centers are activated by impulses from: Chemo receptors located in the aortic arch & carotid arteries Stretch & irritant receptors in the lungs Receptors in the muscles & joints 9/13/2024 77  Hypercarbia (an increase in co2)  is the most powerful respiratory stimulant causing an increase respiratory rate & depth.  A decrease in o2 level is also has the effect of increasing respiratory rate & depth.  Normally breathing is an autonomic & involuntary, but cerebral cortex of the brain allows voluntary control of breathing (singing or playing). 9/13/2024 78  Factors affecting Respiration 1. Age  Normal growth (from infancy to adulthood) results in larger lung capacity.  When the lung capacity is larger, slower rate of respiration is sufficient to exchange air. 2. Sex  Men normally have a larger lung capacity than women. Thus men have a lower respiratory rate than women. 9/13/2024 79 3. Altitude  The o2 content of air decreases as altitude increases  To compensate for the decreased o2 content, the rate & depth of respirations at the higher altitudes increase 4. Medication  Narcotics can impair the ability to involuntarily inspire  respiratory rate & depth may decrease.  Drugs depending on their action may alter rate, rhythm & depth of respiration. 5. Stress :- strong emotions change respiratory pattern through stimulation of SNS 9/13/2024 80 6. Exercise:- during exercise tissues need more oxygen  Extra co2 & heat are produced & must be eliminated. The body responds to these needs by increasing rate & depth of respiration. 7. Body position:-When a body is slumped or stooped, gas exchange can be impaired. The rate & depth may increase. 8. Fever: - when a person has fever, the respiratory system provides the release of the extra heat  As metabolic rate increases with the temperature; respiratory rate is affected.  Respiratory rate can increase as much as 4 breaths/minute with every 0.6oc increase temperature above the normal. 9/13/2024 81  Assessing respiration  Assessing pt breathing for rate, depth and rhythm  Rate:- refers to the number of times the person breathes in & out in one minute.  Under normal condition adult respiratory rate is 12-24 br/min (Eupnoea).  Depth of respiration  It is estimated by observing the movement of chest during inspiration.  The depth of respiration normally varies from shallow to deep. 9/13/2024 82  Rhythm:- the frequency of the respiration follows an even tempo with equal intervals between each respiration.  Quality:- respirations are usually automatic, quite, & effortless.  Methods:- client must be unaware that the nurse is doing a respiratory assessment.  Respiration is taken after taking the radial pulse, while still holding the client’s wrist. 9/13/2024 83 Characteristics of normal and abnormal breath sound  Eupnea:- easy respirations with a normal rate of breaths per minute that are age-specific.  Apnea:-a period during which there is no breathing.  Dyspnea:-is difficult of breathing. observed by labored or forced respirations through the use of accessory muscles in the chest and neck to breath. Mostly pt complain about shortness of breath If apnea lasts longer than 4-6 minutes, brain damage & death may occur.  Orthopnea:-inability to breath easily except in an upright position. 9/13/2024 84  Patterns of respiration TERMS DESCRIPTION ASSOCIATED FEATURES Normal 12-24br/min, Normal condition Regular Tachy- >24 br/min Fever, anxiety, pnea shallow respiratory disorder, exercise Brady-