11-Vital Signs Unit 12 to 17

7/30/2019 11-Vital Signs Unit 12 to 17

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Vital Signs

Rashid Hussain

Nursing Instructor RMISON


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Objectives

Define Vital Signs. Identify the reasons/situations necessary to

take vital signs.

Enlist the components of vital signs.

Explain each component in detail. Temperature Pulse Respiration Blood pressure

Discuss the normal & abnormal values of vitalsigns

Describe the factors affecting vital signs.


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History of nurses taking vital signs

No reference to any form of

vital sign monitoring by nurses

pre 1893

Concept ofnurses taking vitalsigns evolved - 1893 to 1950

Codified into nursing text of the

1950s

Zeitz & McCutcheon (2003)


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Vital Signs

Vital from Latin word vita, which meansLife

Sign means indicator.

So vital signs are the indicators of Life. Vital signs are physical signs that indicate an

individual is alive, such as Heart beat (Pulse),Breathing rate (Respiration), Temperature,

Blood pressure and recently oxygensaturation.


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Vital Signs

These signs may be

observed, measured,

and monitored to

assess an individual'slevel of physical

functioning.

Used to determine

response to treatment

Normal vital signs

change with age, sex,

weight, exercise

tolerance, andcondition.


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Vital Signs

Prior to measuring

vital signs, the patient

should have had the

opportunity to sit for

approximately five

minutes.


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When to take vital signs

On a clients admission

According to the physicians order or the institutionspolicy or standard of practice

When assessing the client during home health visit

Before & after a surgical or invasive diagnostic

procedure Before & after the administration of meds or therapy

that affect cardiovascular, respiratory & temperature

control functions. E.g. Blood Transfusion

When the clients general physical condition changesLOC, pain

Before, after & during nursing interventions

influencing vital signs

When client reports symptoms of physical distress


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Observation Before diving in, take a

minute or so to look atthe patient in their

entirety.

Does the patient seem

anxious, in pain,upset?

What about their dress

and hygiene? Remember, the exam

begins as soon as you

lay eyes on the patient.


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Health Assessment

A nursing assessment consist of collection of

subjective and objective data, which includes

health history, measurement of vital signs and

physical examination:

A bodily assessment from head to toe or

systemic examination by using the techniques

of Inspection, Auscultation, Palpation andPercussion.


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Methods of Physical Examination

Inspection The visual examination of thebody using the eyes and a lighted instrument

if needed. The sense of smell may also be

used.

Auscultation The process of listening tosounds that are produced in the body.

Direct auscultation uses the ear alone,

Indirect auscultation involves the use of a

stethoscope to amplify the sounds from within

the body, like a heartbeat.


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Methods of P.E conti

Palpation The examination of the bodyusing the sense of touch. There are two types:

light and deep.

Percussion An assessment method inwhich the surface of the body is struck with

the fingertips to obtain sounds that can be

heard or vibrations that can be felt. It can

determine the position, size, and consistencyof an internal organ.


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Vital Signs

The vital signs are body temperature, pulse,respirations blood pressure and recently the

pulse oximetry and the pain are also included

in the list of vital signs.

Temperature

Pulse

Respiration

Blood pressure

Oxygen saturation

Pain


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Temperature

Is a state of hotness and coldness of the body.

BODY TEMPERATURE is the balancebetween the heat produced by the body and

the heat lost from the body. The temperature of the body is measured by

thermometer in units called degrees.

Centigrade (C) or Fahrenheit (F)


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Neural control Hypothalamus acts as thermostat

Vascular control

Vasoconstriction ---hypothalamus directsthe body to decrease heat loss and

increase heat production

If cold, vasoconstriction will conserveheatshivering will occur

Regulation of Temperature


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Vasodilatation If body temp is above normal, the

hypothalamus will direct the body to

decrease heat production;Perspiration and increased respiratory rate

Body heat production

Bodys cells produce heat from foodreleasing energy.

Kilocalorie= energy value;

BMR= rate of energy used in the body to

maintain essential activities

Regulation of temperature


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Conduction

Transfer of heat from a warm to cool surface

by direct contact

Convection

Transfer of heat through currents of air orwater

Radiation

Loss of heat through electromagnetic wavesfrom surfaces that are warmer than the

surrounding air

Evaporation

Water to vapor lost from skin or breathing

Heat lost from the body through


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Types of Thermometers

Glass Thermometer

Oral Thermometer

Rectal Thermometer Electronic Thermometer

Digital Thermometer

Disposable Thermometer

Tympanic Thermometer


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A small hollow glass tube that contains

mercury in a bulb at one end. When heated

the mercury rises in the tube.


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Reading a Glass-Thermometer

The scale is marked from 94

to 108

The long lines represent one degree

The short lines represent two tenths of a

degree Only every other degree is marked with a

number


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o Battery operated

o Have an oral probe and a rectal probe

o Disposable probe cover is placed on the probe

o The temperature is recorded in about 30

seconds


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Use a disposable sheath


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o Measures the temperature in the tympanic membrane (eardrum)

o Fast and accurate - 1 to 3 seconds

INFANTS PULLTHE EAR

STRAIGHT BACK

ADULTS ANDCHILDREN OVER

ONE YEAR

PULL THE EAR UPAND BACK


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Sites of taking Temperature


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Sites of taking TemperatureSites Things to consider Duration of Placement

Oral

Posterior sublingual pocket

under tongue (close to carotidartery)

No hot or cold drinks or smoking 20

min prior to temp. Must be awake

& alert.Not for small children (bite down)

Leave in place 3 min

Axillary

Bulb in center of axilla

Lower arm position across

chest

Non invasive good for children.

Less accurate (no major bld vessels

nearby)

Leave in place 5-10 min.

Measures 0.5 C lower than

oral temp.

Rectal

Side lying with upper leg flexed,

insert lubricated bulb (1-11/2

inch adult) (1/2 inch infant)

When unsafe or inaccurate by

mouth (unconscious, disoriented or

irrational)

Side lying position leg flexed

Leave in place 2-3 min.

Measures 0.5 C higher

than oral

Ear

Close to hypothalamus

sensitive to core temp. changes

Adult - Pull pinna up & back

Child pull pinna down & back

Rapid measurement

Easy accessibility

Cerumen impaction distorts reading

Otitis media can distort reading

2-3 seconds


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Factors Affecting Temperature

Exercise Illness

Age

Time of day Medications

Infection Emotions

Hydration

Clothing Environmental

temperature/air

movement


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Alterations in body temperature:

o Pyrexia/Hyperthermia/Fever a bodytemperature above the normal range. >100 F

o Hyperpyrexia a very high fever. 104 F and

above.o Hypothermia Body temp below 95 F

o Febrile referred to a client who has a fever

o Afebrile referred to a client who has nofever


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4 Common types of fever:

o Constant Fever When the fever dose not

fluctuate more than about two degree Fahrenheitduring 24 hours, but at no time touches the normal.

o Intermittent When the temperature is onlypresent for several hours in 24 hours and touches

the normal for few hours. E.g. Malaria.o Remittent When the daily fluctuation of temp is

more than two F and never touches the normal. In

this fever the evening temp is usually higher than

morning one. E.g. Typhoid fever

o Rigor Feversever attack of shivering. 3 stages.

o Shivering stage

o Hot stage

o Cold stage


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Clinical signs of fever

o Onset (cold or chill stage)

o Increased heart rate

o Increased respiratory rate and depth

o Shivering due to increased skeletal muscle

tension and contractionso Pallid, cold skin due to vasoconstriction

o Complaints of feeling cold

o Cyanotic nail beds due to vasoconstriction

o Gooseflesh appearance of the skin due to

contraction of the arrectores pilorum muscles

o Cessation of sweating

o Rise in body temperature


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Clinical signs of hypothermia

o

Decreased body temperatureo Severe shivering (initially), feelings of cold

and chills

o Pale, cool, waxy skin

o Hypotension

o Decreased urinary output

o Lack of muscle coordination

o Disorientation

o Drowsiness progressing to coma

C ti d d F h h it C i


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Centigrade and Fahrenheit ConversionFormulas

Centigrade to Fahrenheit conversion:Multiply the centigrade reading by 9/5 and

add 32:

F = (C 9/5) + 32

Fahrenheit to centigrade conversion:

Deduct 32 from the Fahrenheit reading andmultiply by 5/9:

C = (F 32) 5/9


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Contraindications for oral tempsoAn infant or young child ( under age 6)

o An unconscious patient

o A patient that has had oral surgery or an injury

to the face, neck, nose, or mouth

o A person receiving oxygeno A patient with a nasogastric tube in place

o A patient who is confused or restless

o A patient who is paralyzed on one side of thebody

o Has a history of seizures

o A patient who breathes through the mouth


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Assignment:

Sign & Symptoms ofHyperpyrexia and

Hypothermia.

Nursing care of a patientwith high grade fever.


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What is Pulse

Pulse is a wave of expansion felt in thearteries when the heart pumps blood in the

vessels, that though always full or distensible.

It can be felt in any artery near the surface of

the body with the fingers pads. OR The pulse is caused by the stroke volume

ejection and distension of the walls of the

aorta.

The bounding of blood flow in an artery is

palpable at various points in the body (pulse

points).


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Terms related to Pulse

Peripheral pulse located in the periphery of the

body (ex. foot, hand, neck).

Apical pulse central pulse; located at the apexof the heart.

Compliance of the arteries the ability of thearteries to contract and expand.

Stroke volume output the amount of bloodthat enters the arteries with each ventricular

contractions. Cardiac output the volume of blood pumped

into the arteries by the heart. It is the result of the

stroke volume (SV) x the heart rate (HR) per

minute.


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Pulse Assessment

Pulse Points

Temporal: Over the temporal bone, superior and lateral to eye

Carotid: Bilateral, under the lower jaw in neck along medial

edge of sternocleidomastoid muscle

Apical: Left midclavicular line at fourth to fifth intercostal

space Brachial:

Inner aspect between groove of biceps and tricepsmuscles at antecubital fossa.

Radial: Inner aspect of forearm on thumb side of wrist


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Pulse Points conti

Ulnar: Outer aspect of forearm on finger side of wrist

Femoral: In groin, below inguinal ligament (midpoint between

symphysis pubis and antero-superior iliac spine)

Popliteal: Behind knee, at center in popliteal fossa

PosteriorTibial: Inner aspect of ankle between Achilles tendon and

tibia (below medial malleolus) DorsalisPadis:

Over in step, midpoint between extension tendonsof great and second toe


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Factors that increase pulse

Exercise Strong emotions fear, anger, laughter,

excitement

Infection Fever

Pain

Shock

Hemorrhage, Hypovolemia


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Factors that decrease pulse

Sleep/rest Old age

Heart Diseases e.g. Heart block

Depression Drugs digitalis, morphine

Athletes in good physical condition may

have a lower pulse, probably


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Pulse counting

Regular Pulse Rhythm

Count for 30 seconds,

then multiply by 2(a rate of 35 beats in 30

seconds equals a pulse

rate of 70 beats/minute)

Irregular Pulse Rhythm

Count for one full minute

May use stethoscope tolisten for apical pulse and

count for a full minute

Normal pulse rate for adults is 60 to 100

beats/min & is regular in rhythm..


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Assess: rate, rhythm, strength

Rate N 60-100, average 80 bpm

Tachycardia greater than 100 bpm

Bradycardia less than 60 bpm

Rhythm the pattern of the beats (regular or irregular)

Strength or size or amplitude, the volume of bld pushedagainst the wall of an artery during the ventricular contraction

weak or thready (lacks fullness)

Full, bounding (volume higher than normal)

Imperceptible (cannot be felt or heard)

0----------------- 1+ -----------------2+--------------- 3+ ----------------4+

Absent Weak NORMAL Full Bounding


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What is Respiration?

Respiration is the act of breathing; it includesthe intake of oxygen and the output of carbon

dioxide from the body.

Inhalation/Inspiration refers to the intake ofair into the lungs.

Exhalation/Expiration refers to the

breathing out or the movement of gases fromthe lungs to the atmosphere.


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Respiration conti

Ventilation another word that is used torefer to the movement of air in and out of the

lungs.

External respiration refers to the

interchange of oxygen and carbon dioxidebetween the alveoli of the lungs and the

pulmonary blood.

Internal respiration takes place throughoutthe body; the interchange of same gasesbetween the circulating blood and the cells of

the body tissues.


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Assessing Respiration


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Assessing Respiration

Rate # of breathing cycles/minute (inhale/exhale-1cycle)

N 12-20 breaths/min adult - Eupnea normal rate & depth

breathingAbnormal increase tachypnea

Abnormal decrease bradypnea

Absence of breathing apnea

Depth Amt. of air inhaled/exhalednormal (deep & even movements of chest)

shallow (rise & fall of chest is minimal)

SOB shortness of breath (shallow & rapid)

Rhythm Regularity of inhalation/exhalation

Normal (very little variation in length of pauses b/w I&E

Character Digressions from normal effortless breathing

Dyspnea difficult or labored breathing

Cheyne-Stokes alternating periods of apnea and

hyperventilation, gradual increase & decrease in rate & depth of

M j F t I fl i


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Major Factors InfluencingRespiratory Rate

Exercise (increases metabolism) increaseRR

Stress (readies the body for fight or flight) increase RR

Environment (increase temperature)increase RR

Increased altitude (lower oxygen

concentration) increase RR Certain medications (ex. narcotics,

analgesic) decrease RR


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Breathing Patterns:

Rate: Eupnea normal respiration that is quiet,

rhythmic, and effortless

Tachypnea rapid respiration marked byquick, shallow breaths

Bradypnea abnormally slow breathing

Apnea cessation of breathing

B thi P tt ti


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Breathing Patterns: conti

Volume: Hyperventilation an increase in the

amount of air in the lungs, characterized by

prolonged and deep breaths; may be

associated with anxiety.

Hypoventilation a reduction in theamount of air in the lungs; characterized by

shallow respirations



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Rhythm:

Cheyne-stoke breathing rhythmic waxingand waning of respirations, from very deep

to very shallow breathing and temporary

apnea; often with associated with cardiac

failure, increased ICP, or brain damage

Effort

o Dyspnea difficulty in breathing, in which

an individual has a persistent, unsatisfiedneed for air and feel distressed

o Orthopnea ability to breath only in uprightsitting or standing positions

BLOOD PRESSURE


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BLOOD PRESSURE

Blood pressure is the force or pressure of the

blood exerted on the walls of the arteries at

which the blood is pushed out of heart. OR

Arterial blood pressure is a measure of thepressure exerted by the blood as it flows

through the arteries. It is measured in

millimetres of mercury (mmHg).


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Blood Pressure conti

Blood pressure consist of:

Systolic Pressure

Diastolic Pressure

Systolic pressure the pressure of the blood as

a result of contraction of the ventricles, that is thehigh pressure of the blood wave

Diastolic pressure the pressure when theventricles are at rest; it is the lower pressure

Pulse pressure Difference b/w systolic &diastolic pressure. Normal pulse pressure 30 to

40 mm Hg

E i d Bl d P


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Equipments used to assess Blood Pressure

Stethoscope; is used to auscultate andassess body sounds including the apical

pulse and the blood pressure

Sphygmomanometer; is used to assess

blood pressure consist of cuff, good

selection of the cuff in order to obtainaccurate blood pressure.


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F Aff i Bl d P


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Factors Affecting Blood Pressure

Age BP increases as person grows older. BP

continuous to increase with aging. Gender women usually have lower BP than

men. BP rises in women after menopause.

Blood volume Severe bleeding lowers blood

volume, therefore BP lowers. Rapidadministration of IV fluids increases the bloodvolume, therefore the BP rises.

Stress HR and BP increases as part of the

bodys response to stress. Pain generally increases BP. However, severe

pain can cause shock. BP is seriously low in thestate of shock.

F t Aff ti g B P


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Factors Affecting B.P

Exercise increases HR and BP; so BP

should not be measured right after exercise. Weight BP is higher in overweight persons.

BP lowers with weight loss.

Race black persons generally have higherBP than white persons.

Diet a high-sodium diet increases theamount of water in the body. Extra fluid

volume increases BP. Medications drugs can be given to raise or

lower BP. Other drugs have side effects of

high or low BP.

Factors Affecting B P


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Factors Affecting B.P

Position BP is lower when lying down and higher

in standing position. (orthostatic hypotension).

Alcohol excessive alcohol intake can raise BP.

Smoking increases BP. Nicotine in cigarettes

causes blood vessels to narrow. Diurnal variations BP s usually lowest early in

the morning, when the metabolic rate is lowest; then

rises throughout the day and peaks in the late

afternoon or early evening.

Disease process any condition affecting the

cardiac output, blood viscosity, and/or compliance of

the arteries has a direct effect on the BP.

H t i


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HypertensionAn abnormally high blood pressure, over 140

mmHg systolic and 90 mmHg diastolic.

Factors associated with hypertension

Thickening of the arterial walls, which reduces the

size of the arterial lumen

Elasticity of the arteries

Lifestyle as cigarette smoking

Obesity Lack of physical exercise

High blood cholesterol level

Continued exposure to stress

Hypotension


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Hypotension

Blood pressure below normal, when the systolic

reading less than110 mmHg. It occurs as a resultof peripheral vasodilatation in which blood leaves

the central body organs especially the brain and

moves to the periphery.

Factors associated with hypotension

Analgesics

Bleeding Severe burn

Dehydration.


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Oxygen Saturation

Oxygen is carried in the blood attached to

haemoglobin molecules. Oxygen saturation is

a measure of how much oxygen the blood is

carrying as a percentage of the maximum itcould carry.

Oxygen Saturation provide important

information about cardio-pulmonarydysfunction and is considered by many to be

a fifth vital sign.

Pulse Oximetery


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Pulse Oximetery

Pulse Oximeter is a non invasive device thatmeasures a client's arterial blood oxygen

saturation by means of a sensor attached to

the client's finger, toe, nose, earlobe, orforehead.

The pulse oximeter can detect hypoxemia

before clinical signs and symptoms such as

dusky skin color and dusky nail bed color.

Normal SpO2- 92% to 100%


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Measurement of Height and Weight

Height Height is expressed in inches (in), feet (ft),

centimeters (cm), or meters (m).

A scale for measuring height is usuallyattached to a standing weight scale.

Infants length is measured from vertex(top) of head to soles of feet while infant islying with knees extended.

M t f H i ht d W i ht


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Weight Measurement of weight is expressed in

ounces (oz), pounds (lb), grams (g), or

kilograms (kg).

Daily weights should be obtained at the

same time of the day, on the same scale,

with the client wearing the same type of

clothing.


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M f H i h d W i h


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Nursing Considerations

Accurate recordings are necessary for drug

dosage calculations and evaluation of

effectiveness of drug, fluid, and nutritional

therapy.

Intake and output records provideinformation on fluid balance and kidney

function.


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11-Vital Signs Unit 12 to 17

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Transcript of 11-Vital Signs Unit 12 to 17