Vital Signs PDF

 Vital signs Vital signs are a person temperature , pulse ,respiration. And blood pressure (pain are often called the fifth vital signs). A change in vital signs may indicate a change in health. Frequency of vital signs assessments : If patient's condition is stable ……..check vi...

 Vital signs Vital signs are a person temperature , pulse ,respiration. And blood pressure (pain are often called the fifth vital signs). A change in vital signs may indicate a change in health. Frequency of vital signs assessments : If patient's condition is stable ……..check vital signs every 4 hours. But if patient's condition is unstable or patients who are taking medications that affects on cardiovascular or respiratory function or who had surgery. Vital signs taken signs taken more frequently.  Assessing body temperature Definition: Body temperature is the heat of the body. temperature measured in degrees is regulated by thermoregulatory center in the hypothalamus that receive the messages from thermal receptors , located in skin surface either to produce or conserve body heat to maintain body temperature within a range of 36.4°C-37.3°C   Heat is lost when heat from the body's inner is transferred to the skin surface by circulating blood.  Temperature in the deep tissues of the body remains relatively constant, measured at rectal site.But surface temperatures May vary in response to the environment are measured at oral & axillaries sites. Body temperature is regulated by balancing heat production & heat loss to maintain homeostasis.  If temperature is too high or too low, body’s fluid balance is also affected. Types of Thermometers (1)electronic thermometer : Measure body temperature in 25-50 seconds, appropriate for oral , rectal or axillaries temperature measurement , they are equipped with disposable covers which minimize cross infection. 2.Tympanic thermometer Use infrared sensors to detect heat , inserted into ear canal , the reading takes less than 2 seconds ( young less than 6 years ). With disposable cover to prevent cross contamination from patient to patient. (3)glass thermometer:  Consist of a slender glass tube containing mercury, which expands when exposed to heat & contract when exposed to cold. (4)temperature sensitive patch or tape: Applied to the abdomen or forehead , change color on the patch indicate temperature reading, but need re-assess the temperature by thermometer.  (5)automated monitoring devices: Used in various health care to measure temperature pulse& blood pressure.  Factors affecting body temperature (1)circadian rhythms: Body temperature is usually about 0.6°C lower in early morning than in the late afternoon. (2)age : Very young &very old are more sensitive to changes in environmental temperature. (3) gender : Woman tend to have more fluctuations in body temperature than male due to changes in hormones.Such as ↑ in progesterone secretion at ovulation ↑body temperature as much as 0.5°C (4)stress : ↑ production of epinephrine & nor epinephrine ↑ metabolic rate &↑ temperature. (5) environmental temperature : Respond to changes in environmental temperature by wearing clothing either allows ↑heat loss when it is hot or retains heat when it is cold. Terms & definitions for types of fever ͏ intermittent : The body temperature alternates regularly between period of fever & period of normal or subnormal temperature. Constant :͏ The body temperature remains elevated & fluctuates less than 2°C Relapsing :͏ The body temperature returns to normal for at least a day but then fever recurs. Crisis :͏ The fever returns to normal suddenly. Lysis :͏ The fever returns to normal gradually. Areas to measure temperature from  Oral temperature Patient must be able to close his mouth. Placed under the tongue & left 3 minutes. Cotra-indication: Unconscious –seizures –infants –young -people with diseases of oral cavity. But (If patient has either hot or cold food or fluids or smoking or chewing gum , it generally recommended to wait 15-30 minutes to allow the oral tissues to return to normal temperature ). Rectal temperature  Rectal temperature most accurate because it is an internal measurement, use lubricate during insertion, left 1 minute. Contra-indication: -rectal surgery –diarrhea –disease of rectum – cardiac surgery because the insertion of the thermometer can slow the heart rate by stimulating the vagus nerve. Axillaries temperature Used when both oral & rectal sites contra indication. Some hospitals used axillaries measure to newborn to avoid perforating the wall of the rectum with thermometer.  Average normal temperatures for healthy adults at various sites Oral rectal axillary 37.°C 37.5°C 36.5°C  Assessing respirations Respiration: Breathing …..movement of in &out of the lungs Inspiration…..(inhalation)is the act of breathing in Expiration……(exhalation)is the act of breathing out External respiration……exchange O2 &CO2 between alveoli and circulating blood. Internal respiration……..exchange O2&CO2 between circulating & cells in tissues.  Factors affecting respiration exercise –respiratory , cardiovascular disease – medications –trauma –infection –pain – anxiety. (1) respiratory rate :  Eupenia …normal breathing 16-20 breaths /min., the relationship between HR &Res. Is consistent. One breath :4 heart beats.  Tachypnea ….due to ↑metabolic rate during pyrexia , cells require more O2 or may have more CO2 that must be removed. N,B.: Each 0.6°C of temperature elevated : 4 breaths more each minutes.  Breadypnea : Slow breathing due to depression in respiratory center , certain drugs i.e. morphine (2) respiratory depth: Varies from shallow to deep  -apnea ….refers to period there is no breathing , if apnea lasts longer than 4: 6 min., brain damage & death may occur  -dyspnea ….is difficult in breathing , breathing rapid , shallow & appears anxious  -orthopnea ….dyspnea in flat position , the patient can breath easily in upright position. Normal variation in vital signs , at various ages Age Temp.(°C) Pulse B/min. Res. Blood pressure (breath/min) (mmhg) New born 36.8°C 80-180 30-80 72/54 1-3 years 37.7°C 80-140 20-40 90/54 6-8 years 37.0°C 75-120 15-25 96/74 10 years 37.0°C 75-110 15-25 102/62 Teen 37.0°C 60-100 15-20 102/80 Adults 37.0°C 60-100 12-20 120/80