Vital Signs PDF

Vital signs BY Dr. Mohamed Taha Said Assistant Professor of Physical Therapy for Cardiovascular/Respiratory Disorder and Geriatrics. Aqaba University of Technology, Jordan 1  Part 2 3-RESPIRATORY RATE Def: * Rate of ve...

Vital signs BY Dr. Mohamed Taha Said Assistant Professor of Physical Therapy for Cardiovascular/Respiratory Disorder and Geriatrics. Aqaba University of Technology, Jordan 1  Part 2 3-RESPIRATORY RATE Def: * Rate of ventilation *Number of breaths taken within a set amount of time (60 sec.) Respiratory rate =Ventilation rate = pulmonary ventilation = breathing rate = breathing frequency *It also can be defined as taking oxygen in and getting carbon dioxide out of the body. Regulation of respiration This process is regulated by centers in: 1- Medulla: In which is inspiratory and expiratory centers. 2- Pons: In which there's both apneustic and pneumotaxic centers, which modulate activity of both medullary centers. Normal value of respiratory rate=eupnea is 12-20 cycle\min Assessing respiration: Ideally, Respiration should be assessed with the chest exposed, but if it's impossible we maintain fingers as if we take radial pulse and place the patient's arm across the chest, to take respirations for 60 seconds. 2  Factors affecting respiratory rate: 1- Age: *Newborn: 30-60 cycle\min *Adults: 12-20 cycle \min *Elderly: increased R.R (why?!): a) decreased lung elasticity b) decreased lung efficiency. c) decreased oxygen supply. 2- Sex: men have lower respiratory rate than females due to: a) Large vital capacity. b) High thoracic musculature. 3- Exercise: it leads to increased R.R due to: - Increased O2 consumption and O2 produced. 4- Metabolism: increase metabolism leads to increased R.R. 5- Body position: a) Supine: increased R.R due to pressure of viscera on diaphragm and decreased vital capacity. b) Long sitting: best position that decrease pressure on diaphragm so allowing free breathing. 3  Parameters of respiratory assessment: 1- Rate 2- Rhythm 3- Depth 4- Pattern 5- Character of breathing 1- Rate: Number of breath /min Normal:12-20 cycle | minute Abnormal: a) Tachypnea (rapid rate of respiration): More than 24 cycle/minute, as in exertion, fever and anemia b) Bradyapnea (slow rate of respiration): Less than 10 breath/minute, as in excess alcohol &morphine 2- Rhythm: Refers to the regularity of inspiration and expiration. a) Regular: Inspiration……. Expiration b) Irregular: Hypoventilation or Hyperventilation. 4 2- Depth: Refers to the amount of air exchanged with each breath a) Hyperpnea: increase depth of respiration as in case of acidosis b) Oligopnea: decrease depth of respiration(shallow) breathing as in case of inhibition of respiratory center ❖ N.B -Hyperventilation: increase in depth and rate as in case of: - Encephalitis, Acute anxiety and Emotional stress 3- Pattern: I) Male: "Abdominal thoracic breathing" as male has well developed diaphragm. If thoracic abdominal that is because; Abdominal pain- Ascites –Paralysis of the phrenic nerve- Peritonitis II) Female: "Thoracic abdominal breathing" as females have well developed chest muscle. If abdominal thoracic that is because; Rib fracture- myositis-chest pain-intercostal paresis 5 4- Character of breathing Normal: a) Regular b) Does not require conscious effort c) Reduce discomfort d) Reduce pain Abnormal: a) Additional/adventitious (abnormal). wheeze: due to narrowing of the bronchi as in asthma. Crepitation /Crackles: as in suppurative lung disease which characterized by presence of secretions. b) Dyspnea: difficulty breathing. 6  4-BLOOD PRESSURE What is blood pressure?! It's known that P=F/A (Pressure = Force/ Area) So, blood pressure is the force of the blood exerted against vessels walls during cardiac cycle. ❖ B. P = Cardiac output * peripheral resistance. Peripheral resistance depends on viscosity of blood and elasticity of vessels. Cardiac cycle consists of systole and diastole, so there are systolic blood pressure and diastolic blood pressure. ❖ Systolic: Arterial pressure when your heart beats and fills arteries with blood. ❖ Diastolic: Arterial pressure when your heart’s at rest or between beats. *Normal blood pressure: Systolic pressure ranges between 100-140 Diastolic pressure ranges between 60-90 So Average Blood Pressure Equals 120/80. Factors affecting blood pressure : 1- Age: a) Newborn: 80/45 as their vessels are highly elastic. b) 12 years: 115-135/65-80. c) Adult: 110-140/60-80 d) Old people: as adults but have higher systolic BP due to atherosclerosis. 2- Sex: males have higher blood pressure than females till the age of 45 after that females also have higher blood pressure. 7 3- Diameter of vessels: - Vasoconstriction leads to increasing blood pressure - Vasodilatation leads to decreasing blood pressure 4- Blood Volume: - Increased blood volume will increase blood pressure as in blood transfusion. - Decreased blood volume will decrease blood pressure as in hemorrhage or diarrhea. 5- Elasticity of vessels: - Decreased elasticity means more pressure on the vessels wall so this leads to increasing blood pressure. - Increased elasticity means less pressure on the vessels wall so leads to decreasing blood pressure. 6- Cardiac output: ❖ Cardiac output: is the amount of blood that is pumped through the heart in a minute. It is dependent on heart rate and stroke volume Cardiac output = (stroke volume x heart rate) ❖ Stroke volume is defined by the amount of blood that is expelled from the left ventricle with a single beat of the heart. It is calculated by subtracting the end-systolic volume from the end- diastolic volume. Stroke volume = end diastolic volume– end systolic volume so increased cardiac output means increased blood volume and so increasing blood pressure & vice versa 7- Exercise: - increase heart rate so increasing cardiac output and blood pressure. ❖ Athletes have no raised blood pressure due to physiological cardiac hypertrophy and opening of more collaterals. 8 8- Arm position: - The dominant hand has higher blood pressure than the non-dominant hand due to increased muscle mass and increased blood volume there. - Arm should be at the heart level during measuring blood pressure. 9- Body position: systolic pressure is commonly increased by 10-15 min. on standing, diastolic may increase by 5 mm. 10- Valsalva maneuver: Performing Valsalva maneuver causes an increase in intrathoracic pressure, leading to a reduction in preload to the heart. - At first it leads to increasing blood pressure with prolonged performance of the maneuver. It leads to decreasing venous return to the heart due to prolonged vasoconstriction then it decreases blood pressure body - Finally, the body reacts to protect himself, so blood volume is increased leading to increased blood pressure again. 11- Lower extremities: -have higher blood pressure than upper limb ranges 20 mmHg Gravity pulls blood downward, so it increases blood volume. Bulky muscles create higher contraction so increase blood volume length of blood vessels increases peripheral arterial system. ❖ Blood pressure of lower limb/blood pressure of upper limb ≥ 1 12- Emotional stress: as anxiety, fear ….etc. leads to increasing BP. 13- hyperdynamic state: as fever, exercise ….etc. leads to increasing blood pressure 9  Regulation of blood pressure This process is done by: 1- short term regulation (neural). 2-long term regulation (hormonal). Measuring of blood pressure : Blood pressure is measured by: 1) Mercury sphygmomanometer which consists of: *Mercury monometer *Inflated cuff differs in size and length (infant, adult, thigh). *Inflated bulb. *2 tubes. *Control valve. 10  2-Stethoscope: * Earpiece which must be directed forward (at same line of auditory canal) * Rubber tube. * Flat or Chest piece which consists of: a) Diaphragm for chest exam and cardiac examination for high frequency sounds b) Bell for cardiac exam of low frequency sounds, and murmurs. Methods of measuring blood pressure: 1. Posture of the patient - Routing measurement may be made with the patient either sitting or recumbent with his arm supported horizontally at the level of heart - Measurement during standing is necessary to detect "Postural hypotension". The blood pressure is measured twice: On lying and after standing for more than 5 minutes. If the drop of BP is more than 20 mm it is expected the test will be positive" Postural hypotension". 2. Placing the cuff - Fit the cuff uniformly and tightly around the upper arm, with the lower edge about 3 cm, above the elbow. - Loose applications will result in overestimation of BP - There must be no wrinkles in the cuff, which must not be permitted to bulge beyond the cloth- cover of the bag. - The mercury reservoir should be at the same level as that of the arm. 3. Techniques: - 11 before the auscultatory method. A. Palpatory method: Used ❖ Advantages: - Measuring systolic blood pressure with no error. - Avoiding auscultatory gab. - It is quick and can be done in a noisy environment as well. ❖ Disadvantages: - It is less accurate, since there is a lag of about 10 mm between it and the auscultatory method. - Difficult measuring diastolic blood pressure   Application: -by sphygmomanometer with appropriate cuff size. - Place your fingers of one hand to palpate the radial, or brachial artery below the cuff, and the other hand inflates the cuff - The cuff is rapidly inflated until the pulse disappears, and then deflated slowly. The level at which the pulse first reappears is near to systolic pressure. B. Auscultatory method : This is done by using a stethoscope & sphygmomanometer. ❖ Advantage: - is that we can measure both systole and diastole blood pressure. ❖ Disadvantage: - is that miss errors may occur with patients who have atherosclerosis and hypertension & auscultatory gab may present. How to apply auscultatory method?! - Explain the procedure to the patient simply - Assist the patient to the desired position (sitting is preferred). - Expose the arm and place it at heart level with an extended elbow. - Wrap the cuff with a suitable size around the arm 2.5 cm above antecubital fossa. - Check that sphygmomanometer registers zero. - - Locate and palpate the brachial artery then place the stethoscope over it in the antecubital fossa slightly medial to biceps tendon. - -The cuff then rapidly inflated till the brachial pulse disappears and raise the pressure above the normal systole by at least 20 mmHg. - -Slowly open the valve and deflate the cuff till a series of sounds (Korotkoff sounds) will be recognized + The first sounds heard represent the systolic pressure. - This is followed on further lowering the pressure by a bruit and then by loud sharp sounds. They remain at this intensity of some 20-30 mm below the systolic level. - The sounds then become weak and a few millimeters - below this, they disappear. The point of complete disappearance of the sound is considered the best index of diastolic 12 pressure. - The reading should be repeated after 1-2 minutes, and the average is taken SUMMARY: Steps in taking blood pressure 1 - Snug application of compression cuff. 2 - Palpation of radial artery as compression cuff is inflated. 3 - Palpation of radial artery as cuff is deflated at 2 to 3 mm Hg per heartbeat. 4 - Careful placement of stethoscope receiver. 5 - Inflation of compression cuff above systolic pressure. 6 - Deflation of the cuff at a rate of 2 to 3 mm Hg per heartbeat to determine systolic and diastolic blood pressure. JNC Classification of blood pressure in adults Classification BP (mm Hg) Normal systolic: less than 120 diastolic: less than 80 Pre-hypertension 120-139/80-89 Stage 1 hypertension 140-159 (systolic) or 90-99 (diastolic) 13 or more than 160 (systolic) equal Stage 2 hypertension equal or more than 100 (diastolic) Korotkoff sounds: 5 phases Korotkoff sounds: 5 phases ◼ Phase 1: The first appearance of faint, repetitive, clear tapping sounds which gradually increase in intensity for at least two consecutive beats is the systolic blood pressure. (1st systole) ◼ Phase 2: A brief period may follow during which the sounds soften and acquire a swishing quality. ◼ Phase 3: The return of sharper sounds, which become crisper to regain, or even exceed, the intensity of Phase I sounds. (second systole) ◼ Phase 4: The distinct abrupt muffling of sounds, which become soft and blowing in quality. ◼ Phase 5: The point at which all sounds finally disappear completely is the diastolic pressure. (diastole) 14 Auscultatory Gab : Is that interval of absolute or relative silence occasionally found on listening over an artery during deflation of the blood pressure cuff; it usually begins at a variable point below the systolic pressure and continues for from 10 to 50 mm. of mercury. Mainly occurs in (old aged-sever HTN & diabetic patients). In the previous cases when measuring their blood pressure, the systole may not be reached and then detecting phase 3 of korotkoff sounds as the true systole this leads to error during taking the measurement of blood pressure. Precautions of measuring blood pressure: 1- Make sure that the mercury is at zero point before starting. 2- Arm should be at the level of the heart. 3- Patient should be relaxed at a comfortable position. 4- Cuff should be deflated and with appropriate size for the patient. 5- Tubes of cuff should be placed medially &cuff is above cubital fossa by 2.5 cm. 6- Inflating the cuff is done with closed valve. ❖ Note that there's physiological difference between right and left arms by about 5-10 mmHg & maximally by 15-20 mmHg. 15 Variations: - Hypertension: persistent elevation of blood pressure more than 140/90 in young adult Hypotension: lower pressure to 90/60mmHg Postural hypotension The blood pressure is measured twice: on lying and after standing for more than 5 min. a drop of at least 20 mmHg is expected if the test is positive. Orthostatic hypotension: Feeling dizziness and nausea when standing up after long bed recumbency so the patient should arise from bed edge of bed slowly and gradually, i.e. supine, long sitting, sitting at edge of the bed then standing. 16  Pulse Oximetry Measures oxygen saturation through the use of a transcutaneous device attached to the finger or earlobe. *Uses photodiode to measure absorption of light/infrared by blood. *Normal pulse oximetry measurements at room air: 98- 100%. Oxygen saturation (SpO2): - Is a measurement of how much oxygen your blood is carrying as a percentage of the maximum it could carry. For a healthy individual, the normal SpO2 should be between 96% to 99%. Mild hypoxemia: Spo2 91% to 94%. Moderate hypoxemia: Spo2 86% to 90%. Sever hypoxemia: Spo2 below 85%. 17  Pain Index (on a 0-10 scale) Makes sure that physicians address pain issues Allows us to quantify pain over time and in response to treatment. Questions Define blood pressure, respiration, temperature and pulse rate. mention factors affecting blood pressure mention factors affecting respiration mention factors affecting temperature mention factors affecting pulse rate 18