4. 1. CONSCIOUSNESS
Human ability to be aware of own thoughts,
emotions, surroundings → adequate responses
GLASGOW COMA SCALE (GCS)
Patient’s response to:
- verbal stimulation
- painful stimulation
- movement
Scale 3 – 15
6. 2. BODY TEMPERATURE
Balance between heat produced and heat lost by the body
Heat regulating centre – hypothalamus
Heat production caused by increasing cell metabolism
Heat losses (cool off process):
- perspiration
- respiration
- radiation
Types of thermometers:
- mercury-in-glass
- electronic
- chemical
7. BODY TEMPERATURE
BODY TEMPERATURE SYMPTOMS
Hypothermia
↓ 36 °C
Skin paleness
Tiredness
Normal
36 – 36,9 °C
Lowest 5 – 6am
Highest 4 – 6pm
Pyrexia / slight fever
37,0 – 37,9 °C
Perspiration
Skin redness
Headache
Fever
38 °C
Presence of infection → body defence
General weakness
Tachycardia / hyperpnea
Skin paleness/redness
Shivers
Perspiration
8. BODY TEMPERATURE
ROUTES FOR MEASURING THE BODY TEMPERATURE
- ORAL
best site for measuring in the clinical settings
triangle shaped thermometer
axillo – oral difference 0,3 °C
- AXILLARY
more likely to be affected by the environmental temperature,
used in children/adults
- RECTAL
fast thermometer, used in infants/confused patients/receiving O2 th.
axillo – rectal difference 0,5 °C
- VAGINAL
used in gynecology
9. 3. RESPIRATION
NORMAL RESPIRATIONS
Effortless
Regular
Smooth
AVERAGE RESPIRATIONS
Infant to 2 years 24–34/min
To puberty 20-26/min
Adults 12-18/min
RESPIRATORY RATE
Normal 12 – 20 / min
Bradypnea ↓ 10 / min
Tachypnea 25 / min
Apnea
RESPIRATORY RHYTHM
Normal
Dyspnea (exertion/rest)
Cheynes-Stokes respiration
(irregular deep/slow/shallow )
Kussmaul’s breathing (deep)
10. 4. BLOOD PRESSURE (BP)
The pressure of blood in the arterial wall
Factors affecting BP:
- blood volume
- strength of contraction
- elasticity of artery wall
Assessment:
- Normal 120-140/60-80 mmHg
- Hypertension 150/90 mmHg
- Hypotension ↓100 mmHg
Measurements stated in terms of millimetres of mercury (mmHg)
11. BLOOD PRESSURE (BP)
BP reading:
- systolic pressure (ventricle contraction)
- diastolic pressure (ventricle at rest)
BP readings record: BP 120/80
Equipment:
- sphygmomanometer
- stethoscope
13. 5. PULSE
Expansion of an artery with each hart beat
Measuring techniques / places of assessing:
- PALPATION
a. carotis
a. brachialis, radialis
a. femoralis, poplitea etc.
- AUSCULTATION
stethoscope
15. REPETITION
1. What do you evaluate in Glasgow Coma Scale?
2. What is the normal body temperature?
3. Name 3 symptoms of fever.
4. What is the most commonly used route for measuring the
body temperature in infant?
5. Could you define the term for the high respiratory rate?
6. What is the limit for hypertension?
7. Name 2 methods of BP measurement?
8. Name 2 arteries where the pulse is most commonly felt?
9. Could you specify the normal pulse rate?
10. What is the point at which the beat stops during the BP
measurement called?