Vital Signs PDF

VITAL SIGNS PREPARED BY MAGDA YASSIN Introduction: The traditional vital signs are body temperature, pulse respiration, and blood pressure. Many agencies such as the expert's administration, American pain society and the joint commission have designated pain as a fifth vital signs, to be assessed...

VITAL SIGNS PREPARED BY MAGDA YASSIN Introduction: The traditional vital signs are body temperature, pulse respiration, and blood pressure. Many agencies such as the expert's administration, American pain society and the joint commission have designated pain as a fifth vital signs, to be assessed at the same time as each of other Definition of vital signs: Vital (cardinal) signs is an assessment tool for measurements of physiological functioning of the patient's body, specifically body temperature, pulse, respirations, blood pressure, pain ,pulse oximetry, When a nurse can check vital signs?  On admission to health care agency to obtain a baseline data.  When patient has a change in health status or reports symptoms such as chest pain or feeling hot.  Before & after surgery or any invasive procedure.  Before or after administration of medication that could affect the respiration, cardiovascular system (e.g. Digitalis).  Before & after any nursing intervention that could affect the vital signs (ambulating a patient who was in I. BODY TEMPERATURE Body temperature: The balance between the heat produced by the body and the heat lost from the body. It's measured in heat units called degrees Kinds of body temperature:  Core temperature: is the temperature of the deep tissues of the body (e.g. thorax, abdominal cavity, pelvic cavity). It remains relatively constant at 37° C (98.6° F).  Surface temperature: is the temperature of the skin, the subcutaneous tissue, & fat. It rises & falls in response to the environment. Factors affecting body heat production: 1. Basal metabolic rate: is the rate of energy utilization in the body required to maintain essential activity such as breathing. Metabolic rate decrease with age. In general, the younger person the higher metabolic rate. 2. Muscle activity: Muscular activity also produces heat from the breakdown of 3. Fever: increases the cellular metabolic rate and increases the body's temperature in the future. 4. Thyroxin output: The thyroid hormones thyroxin and triiodothyronine increase basal metabolism by breaking down glucose Heat loss: Most body heat is lost from the skin’s surface to the environment by the processes of radiation, conduction, convection, and evaporation.  Method Examples If the temperature of the Radiation: is the transfer body is greater of heat in the form of Than the surroundings, heat waves; body heat is is lost from the body to the continually radiating into environment. cooler surroundings.  Examples Method Bathing a patient in Conduction: Loss of cool or tepid water heat to an object in will lower the patient’s contact with the body temperature.  Examples Method The use of fans enhances Convection: convicted heat loss by air. is the transfer of heat through air currents; cool air currents can cause the body to lose heat.  Examples methods Insensible water loss Evaporation: is continuous. Continuous insensible Insensible loss occurs water loss from the regardless of body skin and lungs when temperature; thus, it water is converted is not a major from a liquid to a gas regulator of Fig: Body temperature represents a balance between heat produced and heat lost. Normal rage for body temperature: Normal body temperature for 5 years to adult is 36 °C to 0 0 37.5°C(96.8 f to 99.5p f), newborn & 1 year is 36.8°C (axillary) and older adult is 36°C. For example, if the Celsius reading is 37°: °F = (9/5 × 37) + 32 °F = 66.6 + 32 °F = 98.6°F (normal body temperature) Factors affecting body temperature: 1)Age:  Infants are greatly affected by the environment temperature & must be protected from extreme changes of temperature  Old people (over 75 yr) are at risk of hypothermia (less than 36°) for many 2)Diurnal variations: Body temperature normally changes throughout the day, varying as much as 1.0° between early morning & the late afternoon. Highest body temperature point usually reached between 8pm & midnights. Lowest body temperature point usually reached during sleep between 4am &6am 3) Exercise: Hard work or strenuous exercise, increases body temperature. 4) Hormones: Women usually experience more hormones fluctuations than men. Progesterone secretion at time of ovulation rises body temperature by about 5) Stress:  Stimulation of sympathetic nervous system can increase production of epinephrine & nor epinephrine leading to an increase of metabolic activity & heat production. 6) Environment:  Changes in environmental temperatures can affect a person's temperature regulating  Temperature Temperature : temp. / T Normal range : Celsius: 36.1 to 37.2 Fahernheit: 97 to 99 F  A febrile Normal body temp. Pyrexia (fever) Hyperpyrexia From 37.5 to 39.5 From 39.5 to 41  Febrile (Fever, pyrexia & hyperthermia) Hyperthermia Overheating The Temp. 41 or more Hypothermia Body temp. is lower than normal range Clinical signs of fever: 1. Increased heart rate. 2. Increased respiratory rate. 3. Shivering. 4. Cold Skin. 5. Complaints of feeling cold. 6. Cyanotic nail beds. 7. "Goose Flesh" appearance of the skin 8. Cessation of sweating. Nursing interventions for patients with hyperthermia: 1- Monitor vital signs. 2- Assess skin color & temperature. 3- Monitor white blood cell count, & other laboratory reports for indications of infection or dehydration. 4- Remove excess blankets when patient 5- Provide adequate nutrition & fluids to meet the increased metabolic demands & prevent dehydration. 6- Measure intake & output. 7- Reduce physical activity to limit heat production. 8- Administer antipyretics as ordered. 9- Provide oral hygiene to keep the People at risk of hyperthermia:  People with infection.  People with disease process of central nervous system that impair thermoregulation. 2) Hypothermia: Is a core body temperature below the usual normal range. Clinical signs of hypothermia: Decreased body temperature, pulse, & respiration. Sever shivering. Feeling of cold & chills. Pale, cool, waxy skin. Hypotension. Decreased urinary output. Disorientation. Drowsiness progressing to coma. Nursing interventions for patients with hypothermia:  Provide a warm environment (room temperature).  Provide dry clothing.  Apply warm blankets.  Keep limbs close to body.  Cover the patients scalp with a cap or turban. Patients at risk for hypothermia:  People who participate in a cold- weather sports.  Elderly people who have insufficient food, clothing or shelter.  People with neurological deficits & are unable to identify or respond to cold.  Alcoholics who have extreme heat loss secondary to vasodilatation.  Site of measuring temp. oral axillary rectal + 1/2 37 - 1/2 Tympanic membrane Temporal artery  Types of thermometer:  Mercury thermometer  Electronic thermometer Sensitive tape Electronic Infrared (tympanic) Fig. : common types of Thermometers Fig. :Forehead Temperature  Oral Temperature: Contraindications for taking an oral temperature: 1. Infant or child under 6 years. 2. Unconscious, confused or disoriented person. 3. Someone who had surgery or injury to the face, neck, nose or mouth. 4. Receiving oxygen (> 6L/min). 5. Paralysis on one side of body. 6. Seizure disorder.  Axillary Temperature: Indications for taking an axillary temperature: 1. mouth-breathing patients. 2. Patients with oral inflammation or who have oral surgery. 3. Oral and rectal routes are contraindicated Rectal Temperature: The rectal temperature provides an extremely accurate measurement of body temperature because few factors can alter the results. The rectum is highly vascular provides the most closed cavity. Indications for taking rectal temperature: 1. The rectal method is generally used for infants and young children. 2. Unconscious patients and mouth-breathing Aural Temperature: The aural (ear) site is used with the tympanic membrane thermometer. The ear provides a closed cavity that is easily accessible. Tympanic membrane thermometers provide instantaneous results, are easy to use, and are comfortable for the patient. They make it easier to measure the temperature of children younger than 6 years, uncooperative patients, ANY QUESTIONS THANK YOU