Vital Signs RAMJ Feb. 2012
-
Upload
solideo-gloria -
Category
Documents
-
view
216 -
download
0
Transcript of Vital Signs RAMJ Feb. 2012
-
8/2/2019 Vital Signs RAMJ Feb. 2012
1/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
N203: Vital Signs Assessment (1)Rolando A. Martinez Jr.
Nursing Lecturer
Royal College of Surgeons in Ireland
Medical University of Bahrain
-
8/2/2019 Vital Signs RAMJ Feb. 2012
2/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Learning Outcome
By the end of this lecture you will be able to;
1. Discuss the importance of human Vital Signs (V/S).
2. Determine when to assess the V/S.
3. Describe factors that affect the vital signs andaccurate measurement of them.
4. Identify the variations in normal body temperature,
pulse,respirations, and blood pressure that occurfrom infancy to old age.
5. Compare methods of measuring body temperature.
RAMJ / SONM
-
8/2/2019 Vital Signs RAMJ Feb. 2012
3/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Learning Outcome
6. Describe appropriate nursing care for alterations in
body temperature.
7. Identify nine sites used to assess the pulse and statethe reasons for their use.
8. List the characteristics that should be includedwhen assessing pulses.
9. Explain how to measure the apical pulse10. Describe the mechanics of breathing and the
mechanisms that control respirations.
RAMJ / SONM
-
8/2/2019 Vital Signs RAMJ Feb. 2012
4/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Learning Outcome
11. Identify the components of a respiratory assessment.
12. Differentiate systolic from diastolic blood pressure.
13. Describe five phases ofKorotkoffs sounds.14. Describe methods and sites used to measure blood
pressure.
15. Discuss measurement of blood oxygenation using
pulse oximetry.16. Identify when it is appropriate to delegate
measurement of vital signs measurement.
RAMJ / SONM
-
8/2/2019 Vital Signs RAMJ Feb. 2012
5/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Vital Signs
RAMJ / SONM
1. Temperature
2. Pulse
3. Respirations
4. Blood Pressure
5. Pulse Oximetry = Pulse + SaO2
6. Pain
-
8/2/2019 Vital Signs RAMJ Feb. 2012
6/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Vital Signs Importance
1.Provides data that determine a patients health
status.2. It reflects changes in physiologic function.
3. Objectively monitor a persons response to any
given stimuli.
4. Serves as a basis for intervention.
RAMJ / SONM
-
8/2/2019 Vital Signs RAMJ Feb. 2012
7/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
When to Assess V/S?
On admission
Change in clients health status
Client reports symptoms such as chest pain,feeling hot, or faint
Pre and post surgery/invasive procedure
Pre and post medication administration thatcould affect CV system
Pre and post nursing intervention that couldaffect vital signs
RAMJ / SONM
-
8/2/2019 Vital Signs RAMJ Feb. 2012
8/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Factors Affecting Body Temperature
RAMJ / SONM
Age
Diurnal variations
(circadian rhythm)
Exercise
Hormones
StressEnvironment
-
8/2/2019 Vital Signs RAMJ Feb. 2012
9/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Factors Affecting Pulse
Age
Gender
Exercise Fever
Medications
Hypovolemia
Stress
Position changes
Pathology
RAMJ / SONM
-
8/2/2019 Vital Signs RAMJ Feb. 2012
10/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Factors Affecting Respiration
Exercise
Stress Environmental
temperature
Medications
RAMJ / SONM
-
8/2/2019 Vital Signs RAMJ Feb. 2012
11/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Factors Affecting Blood Pressure
RAMJ / SONM
AgeExercise
StressRaceGenderMedicationsObesityDiurnal variationsDisease process
-
8/2/2019 Vital Signs RAMJ Feb. 2012
12/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
(1) Assessment of Body Temperature
Body Temp: reflects balance between heatproduced & heat lost from body.
Measurement: Heat units: degrees (F/C)
Normal: 37C = 98.6F
C = (Fahrenheit temp 32) x 5/9
e.g.: 100F
C=(100-32) x 5/9 = (68) x 5/9 = 37.8
F = (Celsius temp x 9/5) + 32
-
8/2/2019 Vital Signs RAMJ Feb. 2012
13/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Types of Body Temperature
Core Temperature:
Temp. of deep tissue of
body.
E.g.: abdominal, pelviccavity.
Remains relatively
constant.
Surface Temperature:
Temp. of the skin,
subcutaneous tissue &
fat. Raises & falls in
response to the
environment.
-
8/2/2019 Vital Signs RAMJ Feb. 2012
14/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Estimated Variations in Normal Body Temp.
Kozier (2008.
-
8/2/2019 Vital Signs RAMJ Feb. 2012
15/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Heat Balance Heat Produced by body = Amount of Heat
Lost
Kozier (2008. P.528)
-
8/2/2019 Vital Signs RAMJ Feb. 2012
16/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Factors Affecting Heat Production
1. Basal Metabolic Rate (BMR):Rate of energy utilization.
2. Muscle Activity & shivering: Metabolic Rate (MR).
3. Thyroxin output: Thyroxin= Cellular MR.
4. Epinephrine, norepinephrine, & sympathetic
stimulation/stress response: Hormones Cellular
MR (affect liver & muscles).
5. Fever: CellularMR = Further body Temp.
-
8/2/2019 Vital Signs RAMJ Feb. 2012
17/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Heat Loss
1. Radiation
2. Conduction
3. Convection
4. Vaporization:skin, oral mucosa & Respiratory
tract.
Insensible water & heat loss:continuous &unnoticed (10% of heat loss).
Body Temp. = vaporization.
-
8/2/2019 Vital Signs RAMJ Feb. 2012
18/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Regulation of Body Temperature
Three main parts: sensors in skin & core Hypothalamusan effector system that adjusts production/loss of heat.
Cold sensitive Receptors:
Shivering: increases heat production
Sweating inhibited: reduce heat loss
Vasoconstriction: decreases heat loss
Release of epinephrine: increases Cellular MR
Warmth Sensitive Receptors:
Sweating, peripheral vasodilation, conscious responses
(fanning, taking off clothing).
-
8/2/2019 Vital Signs RAMJ Feb. 2012
19/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Factor Affecting Body Temperature
1. Age2. Diurnal Variations (circadian Rhythms).
3. Exercise
4. Hormones5. Stress
6. Environment
Kozier (2008. P.529)
-
8/2/2019 Vital Signs RAMJ Feb. 2012
20/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Alterations in Body Temperature
1. Hyperthermia:Pyrexia, hyperpyrexia
(Fever): above usual
range.
Febrile / Afebrile
2. Hypothermia: body
temp. below lower
normal limit.
Kozier (2008. P.529)
-
8/2/2019 Vital Signs RAMJ Feb. 2012
21/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Types of Fever
Remittent FeverIntermittent fever
Adopted from: Al-Zayani. N. (2008). Vital signs: Body Temperature, N203-FN (1)-RCSI-Bahrain.
Constant FeverRelapsing Fever Fever Spike
-
8/2/2019 Vital Signs RAMJ Feb. 2012
22/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Clinical Manifestations of Fever
Elevated Temp, But NotTrue Fever:
Heat Exhaustion:due to
excessive heat & dehydration
(38-39C).Pale, dizzy, fainting, N&V.
Heat Stroke: exercising inwarm weather (+41C).
Warm flushed skin,
delirious, unconscious, or
seizures. Kozier (2008. P.530)
-
8/2/2019 Vital Signs RAMJ Feb. 2012
23/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Nursing Care: Fever
Kozier (2008. P.531)
Nursing Diagnosis:
Risk for
imbalanced body
Temp./At risk tomaintain body temp.
within normal range.
Hyperthermia/bodyTem. Elevated above
normal range.
-
8/2/2019 Vital Signs RAMJ Feb. 2012
24/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Hypothermia Core Body Temp. below the lower limit of normal
temperature (
-
8/2/2019 Vital Signs RAMJ Feb. 2012
25/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Nursing Care: Hypothermia
Kozier (2008. P.531)
-
8/2/2019 Vital Signs RAMJ Feb. 2012
26/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Assessing Body Temperature
Oral
Axillary
Rectal
Infrared Tympanic
Temporal Artery
Refer: Kozier (2008). Table 29-1: Advantages &
disadvantages of sites for body temp. measurement (P.532).
-
8/2/2019 Vital Signs RAMJ Feb. 2012
27/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
WhichSite Would You Use to Measure Temperature
In The Following Cases?
1. Mr. Saleh came back from surgery with a nasal pack in both
nostrils after removal of a nasal polyp?
2. Mr. Saad is a 89 year old bedridden emaciated patient?
3. Ms. Jones is a 76 year old, confused patient?
4. After examination you found that Ms. Brown has impacted
stool in the rectum?
5. Mr. Saeed was been smoking 10 minutes ago?
6. Maria is a newborn girl who has just been brought into the
nursery from the labor ward?
Adopted from: Al-Zayani. N. (2008). Vital signs: Body Temperature, N203-FN (1)-RCSI-Bahrain.
-
8/2/2019 Vital Signs RAMJ Feb. 2012
28/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
References
Berman, A, Snyder. S. J, Kozier. B. & Erb. C. (2008)Kozier & Erbs Fundamentals of Nursing (8th ed).
Prentice Hall, New Jersey: USA. (Chapter: 29:
P.527-563).
-
8/2/2019 Vital Signs RAMJ Feb. 2012
29/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
1. Temperature
2. Pulse
3. Respirations
4. Blood Pressure
5. Pulse Oximetry = Pulse + SaO2
6. Pain
-
8/2/2019 Vital Signs RAMJ Feb. 2012
30/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Importance of Vital Signs
1. Provides data that determine a patients
health status.
2. It reflects changes in physiologic function.
3. Objectively monitor a persons response to
any given stimuli.
4. Serves as a basis for intervention.
-
8/2/2019 Vital Signs RAMJ Feb. 2012
31/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
When or How often to Assess V/S?
1. Hospital policy (on admission)
2. Patients health status (stable vs.
unstable)
3. Pre and post
procedure/medication/intervention.
-
8/2/2019 Vital Signs RAMJ Feb. 2012
32/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
When to delegate
V/S Assessment?
-
8/2/2019 Vital Signs RAMJ Feb. 2012
33/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Temperature Assessment
-
8/2/2019 Vital Signs RAMJ Feb. 2012
34/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Learning Outcomes
Upon completion of this module, the student will be able to:
1. Discuss the thermo-regulation concept.
2. Identify the factors that affect body
temperature. 3. Compare methods of measuring body
temperature.
4. Enumerate appropriate nursing measures for
alterations in body temperature.
-
8/2/2019 Vital Signs RAMJ Feb. 2012
35/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Temperature
Regulation Temperature - Hypothalamus unit measurement heat units
Conversion - C = (temp in F 32) 5/9
F = (Celsius temp x 9/5) + 32
-
8/2/2019 Vital Signs RAMJ Feb. 2012
36/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
100 F
C = (100 - 32) 5/9
C = (68) 5/9
C = 340 / 9
37.77 / 37.8 C
convert: 104 FC
C = (fahrenheit temp.32) 5/9
-
8/2/2019 Vital Signs RAMJ Feb. 2012
37/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
F = (celsius temp 9/5) + 32
37.8C
F
F = (37.8 x 9 / 5) + 32
F = (340.2 / 5) + 32
F = 68.04 + 32
100.04 / 100 F
convert: 40.0C
F
-
8/2/2019 Vital Signs RAMJ Feb. 2012
38/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Types of Body Temperature
Core Temp: Surface Temp:
- A/P cavity temp. - S/S/F temp.
- constant - varies
-
8/2/2019 Vital Signs RAMJ Feb. 2012
39/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
-
8/2/2019 Vital Signs RAMJ Feb. 2012
40/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Estimated Variations in Normal Body Temp.
Kozier (2008.
-
8/2/2019 Vital Signs RAMJ Feb. 2012
41/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Heat Balance
Heat Produced bybody
Kozier (2008. P.528)
Amount of Heat Lost=
-
8/2/2019 Vital Signs RAMJ Feb. 2012
42/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Heat Production
1. Basal Metabolic Rate (BMR)
2. Musclar activity / shivering
3. Thyroxin output
4. Epinephrine, norepinephrine & sympathetic
stimulation/stress response
5. Fever
-
8/2/2019 Vital Signs RAMJ Feb. 2012
43/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Heat Loss
1. Radiation
2. Conduction
3. Convection
4. Vaporization
-
8/2/2019 Vital Signs RAMJ Feb. 2012
44/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
1. Radiation
-
8/2/2019 Vital Signs RAMJ Feb. 2012
45/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
2. Conduction
-
8/2/2019 Vital Signs RAMJ Feb. 2012
46/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
3. Convection
-
8/2/2019 Vital Signs RAMJ Feb. 2012
47/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
4. Vaporization
-
8/2/2019 Vital Signs RAMJ Feb. 2012
48/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Regulation of Body Temperature
Systems that regulate body temp.
1. Sensors/Receptors
2. Integrator
3. Effector
-
8/2/2019 Vital Signs RAMJ Feb. 2012
49/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Regulation of Body Temperature
COLD
sensitive receptors
Hypothalamus
initiate Effectors
-
WARM
sensitive receptors
Hypothalamus
initiate Effectors
- Sweating
- Vasodilatation
turns on the A/Cremoves clothing
takes bath
drinks water
-
8/2/2019 Vital Signs RAMJ Feb. 2012
50/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Factor Affecting Body Temperature
1.
2.
3.
4.
-
8/2/2019 Vital Signs RAMJ Feb. 2012
51/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Factor Affecting Body Temperature
5.
6.
7.
8.
-
8/2/2019 Vital Signs RAMJ Feb. 2012
52/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Alterations in Body Temperature
FEVER BUT NOT TRUE
-
8/2/2019 Vital Signs RAMJ Feb. 2012
53/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
FEVER BUT NOT TRUE
-
8/2/2019 Vital Signs RAMJ Feb. 2012
54/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Types of Thermometer
-
8/2/2019 Vital Signs RAMJ Feb. 2012
55/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Sites for Assessing Body Temperature
-
8/2/2019 Vital Signs RAMJ Feb. 2012
56/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Nursing Diagnosis:
-
8/2/2019 Vital Signs RAMJ Feb. 2012
57/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Nursing Diagnosis:
1. Risk for imbalanced body Temp./At risk tomaintain body temp. within normal range.
2. Hyperthermia / Body tem. elevated above
normal range.
-
8/2/2019 Vital Signs RAMJ Feb. 2012
58/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
-
8/2/2019 Vital Signs RAMJ Feb. 2012
59/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
HYPOTHERMIA
Core body temp. below the normal temperaturelimit (
-
8/2/2019 Vital Signs RAMJ Feb. 2012
60/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
-
8/2/2019 Vital Signs RAMJ Feb. 2012
61/62
Faculty / Department to be placed here
Bahrain
Faculty / Department to be placed here
Which SITE would YOU use to m
easure
-
8/2/2019 Vital Signs RAMJ Feb. 2012
62/62
F l / D b l d h
Bahrain
F l / D b l d h
WhichSITE would YOU use to measureTemperature in the following cases?
1. Mr. Saleh came back from surgery with a nasal pack in both
nostrils after removal of a nasal polyp?
2. Mr. Saad is a 89 year old bedridden emaciated patient?
3. Ms. Jones is a 76 year old, confused patient?
4. After examination you found that Ms. Brown has impacted stoolin the rectum?
5. Mr. Saeed was been smoking 10 minutes ago?
6. Maria is a newborn girl who has just been brought into the nursery
from the labor ward?