Vital Signs PDF

# Vital Signs ## Definition of Vital Signs Vital signs are physical signs that indicate an individual is alive, and used to monitor the functions of the body. - Heartbeat (pulse) HR - Breathing rate (respiration) RR - Body temperature, T - Blood pressure, BP - Age, Sex, - Weight, ## Factors Influ...

# Vital Signs ## Definition of Vital Signs Vital signs are physical signs that indicate an individual is alive, and used to monitor the functions of the body. - Heartbeat (pulse) HR - Breathing rate (respiration) RR - Body temperature, T - Blood pressure, BP - Age, Sex, - Weight, ## Factors Influencing Vital Signs: - Age & Sexual - Race & Heredity - Exercise - Medication - Pain Tolerance, - Patient's Condition, ## Times to Assess Vital Signs On admission to a health care agency to obtain baseline data. - When a client has a change in health status or reports symptoms such as chest pain or feeling light or faint. - Before and after administration of meds. - Before and after surgery or an invasive diagnostic procedure that could affect the respiratory or the cardiovascular systems. - Before and/ or after administration of a medication that could affect the respiratory or cardiovascular system. - Before ambulating a client who has been on bed rest. ## Body Temperature ### Definition of Body temperature: - It is the degree of heat maintained by the body. - It is the balance between heat produced in the tissues and heat lost to the environment. ### Temperature Regulation: - Body temperature is maintained within a fairly constant range by the Hypothalamus in the central nervous system that is located in the base of the brain and plays an important role as the body thermostat. ### Sites and Normal Ranges of Measuring Body Temperature: - The acceptable body temperature of human being ranges from 36°C to 37.5°C. - Sites of measuring body temperature are oral, axillary and rectal. ### Contraindication of Oral Temperature: - Infants and children - unconscious patients - Inflammation or surgery of mouth. - Persistent frequent coughing. - Mouth breathing patients. - Very old and weak patient. - Patient with seizure disorder. - After drinking hot fluids or cold fluids. ### Contraindication of Axillary Temperature: - Skin disease. - Axillary operation. - Inflammation under axillary. - Excessive hair. ### Contraindication of Rectal Temperature: - Patients with surgical operation in the rectum or perineal region. - Disease or inflammation of the rectum. - Diarrhea. - Pelvic mass ### Body Temperature Regulation: - There are various regulating factors that affect body temperature. These are: #### 1. Physical control - The body gains heat from its environment, for example clothing, sun and ingestion of hot food. #### 2. Chemical control. - The body produces heat through the metabolism of food. #### 3. Nervous System Control. - Body temperature is maintained by the hypothalamus in the central nervous system, located at the base of the brain. ### Mechanisms of Heat Loss: - Body heat is lost through the skin, lungs, and excretion (digestive &urinary tracts), the loss through the skin accounts about 85% of the total. #### Heat loss takes place by four Mechanisms: - **Radiation:** Heat is given in rays by the body. - **Convection:** Heat is moved away from the body on currents of air. - **Conduction:** Body heat is carried away through contact with an object. - **Evaporation:** Body heat is converted into a vapor in the form of perspiration (sweating). ### Factors Increasing Heat Production: 1. Muscular activity e.g. shivering, muscular exercises. 2. Ingestion of food: body heat is increased. 3. Time of day: Body temperature tends to be at its highest in the late afternoon or early evening. 4. Emotion: stimulates the sympathetic nervous system with release of epinephrine and nor epinephrine, which increases the metabolic activities of body tissues which in turn increases heat production. 5. Hormones: increase in the production of thyroxin by the thyroid gland increases basal metabolic rate thereby stimulates heat production. 6. Infections: cause increase in body temperature. 7. Increased temperature of the environment. ### Factors Decreasing Heat Production: a. Prolonged illness. b. Fasting c. Depression of the nervous system: Mental depression, unconsciousness and Narcotic drugs, d. Time of day: body temperature tends to be at its lowest in the morning e. Age: the body temperature of young children tends to vary more than adults ## Fever (Hyperthermia) - It is abnormal elevation of body temperature above the normal range. It is common symptom of illness. It may be: - **Low grade fever:** Temperature slightly elevated 37.3 to 38.3 °C - **Moderate grade fever:** Temperatures above 38.3°C-39.3°C - **(Pyrexia):** Temperatures above 39.3°C - 40.5 °C. - **Hyperpyrexia:** Body temperature is above 40.6°C ### Causes of Fever: - Damage to heat regulating center, due to head injuries, cerebrovascular accidents - Acute infectious disease e.g. Malaria: - Acute inflammatory conditions - Acute and prolonged pain - Extreme exercise - Emotional stress - Trauma or injury to body tissues. - Conditions that increase metabolic rate which causes elevation of body - Conditions that decrease heat loss eg. dehydration which results in decreased secretion of sweat. ### Signs and Symptoms of Fever: - Rapid pulse - Rapid shallow respiration - Cold, then hot skin - Flushed face - Headache - Malaise restlessness - Sweating and shaking chill - Thirst - Dehydration - Anorexia ### Measures to Reduce Body Temperature: 1. Bed rest and inactivity to decrease the rate of the metabolic process and also muscular activity, 2. Putting the patient's body in cool solution of water and alcohol to promote heat loss by evaporation. 3. Ice bags on the groin, axilla and forehead to promote heat loss by conduction 4. Cool quiet environment to promote heat loss by radiation and convection. 5. Force cold fluids up to 2.500 to 3000 cc/day, in small amount and frequencies. 6. Administration of antipyretic drug according to doctor's order **NB. Fluids increase sweating, which promotes heat loss through evaporation.** ## Hypothermia - A condition in which temperature is abnormally lower than normal ### Causes of Hypothermia: 1. Lowered metabolism. 2. Circulatory failure. 3. Decreased activity usually occurs in elderly. 4. Heavy sedation. 5. Exposure to extremely cold environmental temperature or may happen to a person drowning in cold water or buried by snow. ### Signs and Symptoms of Hypothermia: - Pale skin and cyanosed lips. - Cold hands and feet. - Chilling - Drowsiness - Slow pulse rate. - Slow respiration. - Decreased physical and mental capabilities. - Patient feels sleepy and may become comatose ### Nursing Care of Patient with Hypothermia: - Increase physical activity. - Warm the patient by: Use of more blankets, extra clothes, heaters, hot application to the skin such as: - hot water bottles and heating pads to the skin - friction of body surface - warm food and drinks ## Respiration - The purpose of respiration is to provide for the exchange of oxygen and carbon dioxide between the atmosphere and the blood through expiration and inspiration. ### Inspiration - Inspiration is the act of breathing in oxygen that is distributed to the cells of the body. ### Expiration - Expiration is the act of breathing out carbon dioxide. ### Normal R.R. in adults is 16 - 20 c/min. ### Respiratory Patterns: - **Eupnea:** Regular, normal respiration. - **Apnea:** A temporary cessation of breathing. If apnea lasts longer than 4 to 6 minutes, brain damage and death may occur. - **Dyspnea:** Difficulty or painful breathing. - **HyperApnea:** Increase respiration - both rate and depth may be increased. - **Orthopnea:** Inability to breath or difficulty in breathing while lying in a horizontal position. - **Cyanosis:** Blueness or discoloration of the skin and mucus membrane caused by lack of 0.2 in the blood. - **Air hunger:** A characteristics symptom indicating a lack of sufficient oxygen for the proper functioning of tissue cells. - **Deep respiration:** When the volume of air inspired and expired is more than 500 cc with each respiration. - **Shallow respiration:** If the nature of air inspired and expired is less than 500 cc with each respiration. - **Cheyne-Stokes:** Where the depth of respirations gradually increases, followed by patterns of gradual decrease, and then periods when breathing stops briefly, before resuming. ### Points to Observe When Taking Respiration: - Rate - The movement of the chest and abdomen - The patient's color. - The position that the patient may instinctively assume. - Character ### Factors Affecting Respiration: - **Age:** Rate rapid in infancy. - **Sex:** Females have more rapid rate. - **Exercise:** Increase respiratory rate. - **Emotions:** Increase respiratory rate. - **Certain drugs depress the respiratory rate as morphine.** - **Body temperature.** When body temperature is elevated the respiratory rate increases 4 breathes/m with every .6 c. ## Pulse ### Definition: - A wave like sensation that can be palpated or felt in a peripheral artery that is produced by the movement of blood through the aorta and then into smaller arteries during the heart's contraction. ### Normal Heart Rate: - **Newborns:** Have a higher HR than adults - **Newborns:** 120-160 - **Teens and adults:** 60-100 - **Elderly:** 80-100 ### Assessment the Pulse: - **Tachycardia:** More than 100 b/min - **Bradycardia:** Less than 60 b/min. ### Factors Affecting Pulse Rate: #### Tachycardia: - **Tachycardia** is a rapid heart rate. Adult has tachycardia when the pulse rate is 100 to 180 beats/min. The following factors contribute to an increase in the pulse rate - Pain - Strong emotions, such as fear, anger, anxiety, and surprise - Prolonged application of heat - An elevated temperature, which usually causes an increase of about 7-10 beats/min for each 0.6°C of elevation above normal - Some medications, such as epinephrine - Any condition resulting in poor oxygenation of blood, such as chronic pulmonary disease or anemia - Exercise, when the heart compensatory ability attempts to meet the need for increased blood circulation - A decrease in blood pressure, such as occur with blood loss #### Bradycardia: - **Bradycardia** is a slow pulse rate below 60 beats/min in an adult. The following factors may slow the pulse: - Rest and on awakening - Male have a slower pulse rate than females - People with thin body size tend to have slower heart rates - Increasing age may be associated with slower pulse - Medications, such as cardiotonic glycoside slow the pulse rate ### Sites of the Pulse (Most popular pulse site): 1. **Radial:** - The most common site for measuring the pulse, which is located in a groove on the inner aspect of the wrist just below the thumb. 2. **Apical:** - The apical pulse has a stronger beat and is easier to measure than the other pulse sites. The apical pulse is measured using a stethoscope. The chest piece of the stethoscope is placed lightly over the apex of the heart, which is located in the fifth intercostal (between the ribs) space at the junction of the left mid clavicular line. 3. **Brachial:** - Located at the front of the elbow. This site is used to take blood pressure. 4. **Ulnar:** - The ulnar pulse is located on the ulnar (little finger) side of the wrist. It is used to assess the status of circulation to the hand. 5. **Temporal:** - The temporal pulse is located in front of the ear and above eye level. 6. **Carotid:** - The carotid pulse is located on the anterior side of the neck, slightly to one side of the midline, and is the best site to find a pulse quickly. 7. **Femoral:** - The femoral pulse is in the middle of the groin. 8. **Popliteal:** - The popliteal pulse is at the back of the knee and is detected most easily when the knee is slightly flexed. 9. **Posterior Tibial:** - The posterior tibial pulse is located on the inner aspect of the ankle just posterior to the ankle bone. 10. **Dorsalis Pedis:** - The dorsalis pedis pulse is located on the upper surface of the foot, between ## Blood Pressure ### Definition: - Blood pressure is the pressure exerted by the blood on the walls of the blood vessels within the systemic arterial system. ### Systolic Blood Pressure - Systolic blood pressure is greatest. It is the pressure against the wall of the blood vessels following ventricular contraction. ### Diastolic Blood Pressure: - Diastolic blood pressure is lowest. It is the pressure against the blood vessels when the heart is relaxed before it begins to contract again. ### Normal Blood Pressure: - 120/80 - 120 + or - 20 mm/hg - 80+ or-15 mm/hg ### What Abnormal Results Mean: - **Hypertension:** High blood pressure greater than 140/90mmhg - **Hypotension:** Lower blood pressure below normal (may be indicated by a systolic pressure lower than 90). ### What Factors Affect BP?: - **Age:** Blood pressure is low in children and high in old age. - BP rises with atherosclerosis - **Gender:** Women have lower BP than men in the same age. ### Factors that Affect Blood Pressure: - **Exercise:** Vessels open up to feed the body more O2 while working out, this keeps the heart muscle healthy - **Emotions and Pain:** BP goes up - **Position:** A person's blood pressure tends to be lower in lying down than in sitting or standing. - **Drugs:** That stimulate heart, affect BP, they constrict the arteries like nicotine, caffeine and cocaine. - **Full bladder:** BP is higher when bladder is full ### Pulse Pressure - It is the difference between systolic and diastolic blood pressure. - Normally from 30-50 mmhg. ### Sites Used for Measuring Blood Pressure 1. Brachial artery on the inner aspect of the elbow is commonly used 2. Popliteal artery behind the knee 3. Posterior tibial artery or dorsalis near the ankle 4. The radial artery at the wrist.