Vital Signs PDF

Vital Signs By Dr. Entsar kamel  objectives  By the end of this lecture the student will be able to :  Utilize critical thinking skills and clinical competences needed when measuring vital signs considering patient’s rights?  Describe the responsibilities of the...

Vital Signs By Dr. Entsar kamel  objectives  By the end of this lecture the student will be able to :  Utilize critical thinking skills and clinical competences needed when measuring vital signs considering patient’s rights?  Describe the responsibilities of the nurse in meeting the psychological needs of the patients with hypotension?  Formulate nursing care plan to adult individuals with common problems related to vital signs?  Formulate health education for patient with fever  Introduction Vital signs include body temperature, pulse, respiration and blood pressure, , these data are called vital signs because of it is Vital signs importance it is a quick &efficient way of monitoring a client's condition or identifying problems and evaluating the client's response to intervention.  On admission to a health care agency to obtain base line data. On a routine schedule as determined by agency policy. Time to Before and after invasive diagnostic procedure. assess vital When a client has a change in health status. signs Before and after any surgical procedure. Before and after administration of medication that could affect the cardiovascular or respiratory system as digitalis. Before and after any nursing intervention that could affect the vital signs  Body temperature reflects the balance between heat produced and heat lost from the body Core temperature is the temperature of the deep tissues of the body, such as abdominal cavity and pelvic cavity. It remains relatively constant. Body temperature Surface temperature is the temperature of the skin surface, subcutaneous tissue and fat. It rises and falls in response to the environment changes When the amount of heat produced by the body equals the amount of heat lost, the person is in heat balance.  Basal metabolic rate (BMR) In general, the younger the person, the higher the metabolic rate. Muscle activity including shivering, increases Factors the metabolic rate affecting the Thyroxine increased thyroxin output increases the rate of cellular metabolism throughout the body’s heat body production Epinephrine, norepinephrine, and sympathetic stimulation / stress response Fever increases the cellular metabolic rate and thus increases the body temperature future.  Ways of heat loss Radiation: Conduction Convection Evaporation  Normal body temperature orally usually ranges between 36.5° and 37.5°C (97.6° and 99.6°F). To convert Fahrenheit to Centigrade C= (F-32) X 5/9. EX. When Fahrenheit reading is 100 C= (100-32) X5/9 = 68 X 5/9 = 37.8 Temperature To convert Centigrade to Fahrenheit, : measurement F=(C X 9/5)+32 EX. When centigrade reading 40 F= (40 X 9/5) +32 = 72+32= 104  Regulation of body temperature For the core temperature to remain steady, heat production must equal heat loss. The hypothalamus, located in the pituitary gland in the brain, is the body’s built-in thermostat. When hypothalamus sense increase in body temperature impulses is sent to reduce body temperature by sweating and vasodilatation. When hypothalamus senses the body temperature is low signals are sent out to increase heat production by muscle shivering or heat conservation by vasoconstriction to maintain homeostasis (state of dynamic equilibrium).  Age. The infant is greatly influenced by the temperature of the environment and must be protected from extreme changes. Many older people, particularly those over 75 Factors affecting years, are at risk of hypothermia for a variety of reasons, such as inadequate diet, loss of body subcutaneous fat, lack of activity, and reduced thermoregulatory efficiency temperature Diurnal variations). Body temperatures normally change throughout the day, varying as much as 1.0˚C between the early morning and the late afternoon. The point of highest body temperature is usually reached between 4:00 PM and 6:00 Pm, and the lowest point is reached during sleep between 4:00 Am and 6:00 AM.  3-exercise. Hard work or strenuous exercise can increase body temperature to as high as 38.3˚C to 40˚C measured rectally. Factors affecting 4-Hormones. Women usually experience body more hormone fluctuations than men. In women, progesterone secretion at the time temperature of ovulation raises body temperature by about 0.3˚C to 0.6˚C above basal temperature. 5-Stress. Stimulation of sympathetic nervous system can increase the production of epinephrine and norepinephrine, thereby increasing metabolic activity and heat production.  6-Environment. Factors affecting Extreme in body environmental temperature temperatures can affect a person’s temperature regulatory systems.  Alteration in body temperature  Pyrexia  A body temperature above the usual range is called pyrexia, hyperthermia or fever.  hyperpyrexia. A very high fever, such as 41˚C.  febrile. The client who has a fever.  Afebrile The client who doesn’t have fever.  Types of fever Constant fever. Body temperature remains elevated consistently and fluctuate very little. Intermittent fever. Body temperature rise and fall; for example body temperature is subnormal or normal in the morning and is elevated in the afternoon. Remittent fever. Are similar to intermittent fever except doesn't return to normal at all until the patient becomes well.  Clinical Signs and Symptoms of Elevated Body Temperature Thirst Anorexia Flushed warm skin Irritability or excessive sleepiness. Headache Glassy eyes or photophobia(sensitivity to light) or both Increased heart rate and respiratory rate. Increased perspiration. Disorientation, progressing to convulsions in infants and children.  Nursing intervention for clients with fever Monitor vital signs at least every 4 hours Monitor white blood cell count Remove excess blankets when client feels warm Encourage fluids intake Measure intake and output Reduce physical activity to limit heat production Administer antipyretic as doctors ordered Provide oral hygiene to keep the mucus membranes moist. Provide bath to increase heat loss through conduction Provide dry clothing and bed linens  Hypothermia It is a core body temperature below the lowest limit of normal. Death is a risk when the body temperature falls below 35C. The three physiologic mechanisms of hypothermia are: (a) excessive heat loss. (b) Inadequate heat production as in patient with hypothyroidism (c) impaired hypothalamic thermoregulation  Hypothermia The clinical signs of hypothermia Decreased body temperature, pulse, and respirations. Severe shivering Feeling of cold and chills Pale, cool skin Hypotension Decreased urinary out put Lack of muscle coordination Disorientation Drowsiness progressing to coma  Hypothermia Nursing intervention for clients with hypothermia Provide a warm environment (close door and window) or eliminate drafts. Remove wet clothes and replace with dry ones. Cover patient with more warm blankets Keep limbs close to body Cover the client scalp Supply warm oral or intravenous fluids Apply warming pads.  Common site of measuring body temperature is: Oral most accessible site, comfortable for patients, no need for position changes. Rectal more reliable when oral temperature cannot be obtained. Axillary considered safe but not very accurate. Tympanic membrane Skin/temporal artery  Contraindication of oral temperature Infants and children. Unconscious patients. Inflammation or surgery of mouth. Persistent frequent coughing. Methods of Measuring Body Temperature  Pulse The pulse was defined as a wave of blood created by contraction of the left ventricle of the heart. Cardiac out put amount of blood ejected from the heart per minute Stroke volume amount of blood ejected from the heart each beat Cardiac out put ( equal) = stroke volume x heart rate Heart rate (equal) = cardiac out put _  stroke volume For example if heart rate =70 beat per minute and stroke volume = 70 ml blood per beat so cardiac out put = 70x70 4900 ml blood in the body.  Pulse Peripheral pulse is a pulse located away from the heart, for example, in the foot or wrist. Apical pulse : is a central pulse,it is located at the apex of the heart. It is also referred to as the point of maximal impulse (PMI).  Factors affecting pulse: Age: as age increases, the pulse rate gradually decreases overall. Gender: after puberty, the average male pulse rate is slightly lower than the females. Exercise: pulse rate normally increases with activity. Fever: the pulse rate increases (a) in response to the lowered blood pressure that results from peripheral vasodilatation associated with elevated body temperature and (b) because of the increased metabolic rate  Factors affecting pulse: Medications: Some medications decrease it and others increase it as digitalis slow heart rate, while epinephrine increase it. Hypovolemia: blood loss increases the pulse rates. In adults the loss of blood volume results in an adjustment of the heart rate to increase blood pressure as the body compensate for the lost blood volume. Stress: in response to stress, sympathetic nervous stimulation increases the overall activity of the heart. Stress increases the rate as well as the force of the heartbeat. Fear and anxiety as well as the perception of severe pain stimulate the sympathetic system.  Factors affecting pulse: Position changes: when a person assumes a sitting or standing, blood usually pools in the dependent vessels of the venous system that results in a transient decrease in the venous blood return to the heart and subsequent reduction in blood pressure and increase in heart rate. Pathology: certain diseases such as some heart conditions or those that impair oxygenation can alter the resting pulse rate. Metabolism: Certain diseases as chronic hyperthyroidism increase heart rate. Temporal pulse Over temporal bone of Carotid pulse at the site of the neck head, above and lateral to eye between the trachea and sternocleidomastoid muscle.  Brachial pulse Brachial: at the inner aspect of the biceps muscles at of the Apical pulse at the apex of the heart. In an arm or medially to antecubital fossa. adult this is located on the left side of the chest, about 8 cm to the left of the sternum and at the fourth, fifth or sixth intercostal space.  Femoral pulse, where the femoral Radial pulse, where the radial artery runs along the radial bone or thumb side of the inner artery passes alongside the inguinal aspect of the wrist. ligament  Popliteal where the popliteal artery passes behind the knee.  Pedal(dorsalis pedis) pulse Pedal (Dorsalis Posterior tibia pulse Posterior tibial on the medial pedis): over the bone of the foot, on imaginary surface of the ankle, where the posterior tibial artery line drawn from the middle of the ankle to the passes behind the medial malleolus. space between the big and second toes.  Characteristic of pulse In adults, the normal rate is 60 to 100 pulsations per minute Tachycardia pulse more than 100b/min in adults Bradycardia pulse rate less than 60b/min in adults  Characteristic of pulse  Rhythm. Normally, cardiac contractions occur at evenly spaced intervals, resulting in a regular rhythm. Infants and children often have increased pulse rates during inspiration and decreased rates during expiration. Heart disease, medications, or electrolyte imbalances may alter the heart’s normal rhythmic beating, causing an irregular pulse. A pulse with an irregular rhythm is referred to as dysrhythmia or arrhythmia.  Quality (pulse volume):- Pulse quality generally refers to the strength of pulsation and may be rated on a numeric scale.  Name Quality (pulse volume Score bounding (4+) Normal (3+) slightly diminished pulse (2+) than normal Weak difficult to (1) palpate or absent. (0)  Pulse deficit Pulse deficit. The difference between the apical and radial pulse rates, This can confirmed by one nurse listening to apical pulse ,and a second nurse palpating the radial pulse at the same time for full minutes using the same watch. Pulse deficit signifies that the pumping action of the heart is faulty or there is a peripheral vascular issue, this is often seen in atrial fibrillation. Nursing interventions for the patient with an abnormal pulse. If pulse is weak or difficult to palpate. Perform complete assessment of all peripheral pulses. Observe for other symptoms associated with altered tissue perfusion as pallor or cyanosis. Observe for factors associated with decrease cardiac output as hemorrhage, or hypothermia. If the pulse is weak or irregular assess apical pulse for a pulse deficit. If pulse is below normal ask patient if he takes digoxin drug. If pulse is above normal assess for related data as pain, fear, recent exercise, low blood pressure or elevated body temperature.  Respiration: is the act of breathing. Inhalation or inspiration : refers Respiration to the intake of air into the lungs. Exhalation or expiration: refers to breathing out or movement of gases from the lungs to the atmosphere.  Respiration Internal respiration is exchange of gas at the tissue level caused by cellular oxidation and exchange that occur in the alveoli of the lung. External respiration is the breathing movement of the patient that is observed.  types of breathing Costal breathing :involves Diaphragmatic breathing the external intercostal :Involves the contraction muscles and other and relaxation of the accessory muscles, such as diaphragm, and it is the sternocleidomastoid observed by the movement muscles of the abdomen  Mechanics and regulation of breathing Respiration is controlled by (a) respiratory center in the medulla oblongata and pons of the brain chemoreceptors located centrally in the medulla and peripherally in the carotid and aortic bodies During inhalation the following processes normally occur: the diaphragm contracts, the ribs move upward and outward, the sternum moves outward, thus enlarging the thorax and permitting the lungs to expand. During exhalation the diaphragm relaxes, the ribs move downward and inward, and the sternum moves inward, thus decreasing the size of thorax as the lungs are compressed.  Exercise:increases rate and depth to meet the body’s need for additional oxygen and to rid the body of CO2 Factors Acute Pain: Pain alters rate and rhythm of affecting respirations; breathing becomes shallow. respiration Anxiety: increases respiration rate and depth as a result of sympathetic stimulation. Smoking: Chronic smoking changes pulmonary airways, resulting in increased rate of respirations at rest when not smoking.  Body Position A straight, erect posture promotes full chest expansion. A stooped or slumped position  Factors impairs ventilatory movement. affecting Lying flat prevents full chest expansion respiration Medications Opioid analgesics, general anesthetics, and sedative hypnotics depress rate and depth. Bronchodilators slow rate by causing airway dilation  Neurological Injury to brainstem impairs respiratory center and inhibits respiratory rate Factors and rhythm. affecting Hemoglobin Function Decreased hemoglobin levels (anemia) reduce oxygen-carrying respiration capacity of the blood, which increases respiratory rate. Abnormal blood cell function (e.g., sickle cell  disease) reduces ability of hemoglobin to carry oxygen, which increases respiratory rate and depth.  Bradypnea: slow than normal respiratory rate at rest. Rate: Normal: 14-20 cycle/minute.(a Tachypnea: rapid respiratory rate Characteristic of respiration: Depth deep, normal and shallow Rhythm regular or irregular  Characteristic of respiration Hyperpnoea: Respirations are labored, increased in depth, and increased in rate (greater than 20 breaths /min) (occurs normally during exercise).  ApneaRespirations cease for several seconds. Persistent cessation results in respiratory arrest. Dyspnea difficult and labored breathing Characteristic Orthopnea ability to breathe only in upright sitting or standing positions. of respiration Cheyne-Stokes respiration there is alternating periods of apnea and deep rapid breathing. Kussmaul respiration is deep rapid labored breathing  If respiratory rate is abnormal report to health care provider. Nursing Observe for related signs and symptoms intervention for as cyanosis, dyspnea. patient with Consider possible effect of medication or abnormal anesthesia. respirations Assist patient to supported sitting position. Provide Oxygen as ordered by health care provider.  Blood pressure Blood pressure is Arterial blood pressure is a measured in millimeters of measure of the pressure mercury (mm hg) and exerted by the blood as it recorded as a fraction: flows through the arteries systolic pressure over the diastolic pressure.  The diastolic pressure The systolic pressure Blood pressure Pulse Pressure Mean Arterial Pressure (MAP): MAP= 1/3 systolic + 2/3 diastolic  Hemodynamic factors affecting B.P 1-Cardiac output as the cardiac output increase causing elevation in blood pressure 2-Arterial diameter The smaller the vessel lumen size the greater the peripheral resistance the greater the blood pressure 3-Arterial compliance (elasticity): If the elastic and muscular tissues of the arteries are replaced with fibrous tissue leads to increase blood pressure 4-viscosity of the blood: The more viscous the blood the higher the blood pressure. Non Hemodynamic factors affecting B.P Age Newborn have a mean systolic pressure of about 75 mm hg. The pressure rises with age Exercise. Physical activity increases the cardiac output and hence the blood pressure Stress Stimulation of the sympathetic nervous system increases cardiac output and vasoconstriction of the arterioles, thus increasing the blood pressure. Race. African American males over 35 years have higher blood pressures than European American males of the same age Gender After puberty, females usually lower blood pressure than males of the same age; this difference is thought to be due to hormonal variations. Non Hemodynamic factors affecting B.P Medication. Some medications directly or indirectly affect blood pressure. Before blood pressure so asks the patient is receiving antihypertensive or other cardiac medications, which lower blood pressure Diurnal variations Pressure is usually lowest early in the morning, when the metabolic rate is lowest, then rises throughout the day and peaks in the late afternoon or early evening. Disease process Any condition affecting the cardiac output, blood volume, blood viscosity, and or compliance of the arteries has a direct effect on the blood pressure.  Classification of Blood Pressure Classification of Blood Pressure Diastolic BP Category Systolic BP MM HG MM HG Normal < 120 And < 80 Prehypertension 120-139 Or 80-89 Stage 1 140–159 Or 90–99 Hypertension Stage 2 160 Or 100 Hypertension  A blood pressure that is persistently above normal is called hypertension Hypertension An elevated blood pressure of unknown cause is called primary hypertension. An elevated blood pressure of known cause is called secondary hypertension  1-thickening of arterial walls, lifestyle factors as cigarette smoking, Factors obesity, associated heavy alcohol consumption, with hypertension lack of physical exercise, high blood cholesterol levels, and continued exposure to stress Life style modification to prevent and manage hypertension Modification Recommendation -Weight reduction Maintain normal body weight (body mass index 18.5–24.9 kg/m2). (Dietary Approaches to Stop Consume a diet rich in fruits, vegetables, and low-fat dairy Hypertension through eating plan products with a reduced content of saturated and total fat. Dietary sodium reduction Reduce dietary sodium intake to no more than 100 mmol/day (2.4 g sodium or 6 g sodium chloride). Physical activity Engage in regular aerobic physical activity such as brisk walking (at least 30 min/day, most days of the week). Limit consumption to no more than 2 drinks per day in most Moderation of alcohol consumption men and to no more than 1 drink per day in women and Hypotension Hypotension Is a blood pressure that below normal, that is, a systolic reading consistently between 85 and 110 mm hg in an adult whose normal pressure is higher than this. Factors associated with hypotension general anesthesia , bleeding, severe burn ,postural change and dehydration  Orthostatic hypotension Orthostatic hypotension is a blood pressure that falls when the client sits or stands. It is usually the result of peripheral vasodilatation in which blood leaves the central body organs, especially the brain, and move to the periphery, often causing the person to feel faint  Nursing intervention for the patient with hypotension Report finding to health care provider. Nursing If an abnormal blood pressure reading is obtained, measure blood pressure on the other arm. intervention Be certain size of cuff is appropriate. for the patient with Compare your current reading with the patient base line. hypotension Observe for symptoms as weak, thready pulse and confusion. Place client in supine position and limit activity. Assist the client to slowly sit or stand. Support the client in case of faintness.