Vital Signs - BUC PDF

Presented By: Dr. Eglal Hakeim& Dr. Liliane Narouz Assistant professor Faculty of Nursing BUC Intended Learning Outcomes(ILOs): At the end of this lecture the students will be able to:  Recognize the importance of vital signs  Identify the different methods...

Presented By: Dr. Eglal Hakeim& Dr. Liliane Narouz Assistant professor Faculty of Nursing BUC Intended Learning Outcomes(ILOs): At the end of this lecture the students will be able to:  Recognize the importance of vital signs  Identify the different methods of measuring body temperature  List the characteristics of pulse  Identify the components of a respiratory assessment  Describe various methods for measuring blood pressure  Discuss the pain assessment method  Explain Methods of vital sings documentation  Vital signs (VS) are physical indications that an individual is alive: And baseline data about individual T Temperature P Pulse R Respiration BP Blood pressure Fifth vital signs is Pain Assessment These signs can be observed, measured and monitored to assess an individual’s level of physical functioning  Vital signs are taken: 1 On admission and discharge 2 According to written medical prescription 3 Once per shift when patient stable 4 Every 4 hr. when one or more vital signs is abnormal 5 When you suspect any abnormality 6 Before, during, after blood transfusion 7 Before administering of medications that affect vital signs  Provide information about patient’s overall condition Taken at each visit and compared to baseline  Temperature is the degree of heat maintained by the body. It is the balance between the heat production and heat loss and it is measured in heat unit called degrees. It’s transfer of heat from the surface of one object to the surface of another, without actual contact between the two. It transfers of heat to any object or surface in contact with the body. e.g. Sitting on chair. Cold compresses The dissemination of heat by motion between areas of unequal density The Heat regulation center is the Hypothalamus.  Normal body temperature 36.5 –37.5 C Sites and Duration of Reading methods of measuring measuring -Orally 3 min. = -Axillary 5 min. +0.5 -Rectally 1 min. -0.5 Types of Thermometers Electronic/digital  sensitive skin tape Tympanic Glass Temporal artery  Age Gender Exercise Factors Environment Stress / emotion Circadian Hormones rhythm 1. Unconscious patient. 2. Mentally ill patient. 4.Very young and very old patient. 5. Irritable patients. 6. Patient with persistent cough. 7. Mouth breather patient. 8. Patients with oral or nasal problems or surgery.  Pyrexia Fever Hyperthermia Normal range Hypothermia  Signs and symptoms of fever : 1. Flushed face and skin 6.Headache and drowsiness 2. Increased heart rate 7.Perspiration 3. Dry mouth 8.Increase respiratory rate 4. Loss of appetite 9.Thirst 5. Shivering 10.fatigue ❖Nursing care of patient with fever : 1- Check temperature /15min. at 1st hr. and / 30min. at 2nd hr. then / 1 hr. 2- Increases fluid to 3 L/ day 3- Fluid balance chart 4- Cold drink 5- Frequent mouth wash 7- Bath 8- Fan & good ventilation & quiet environment 9- Decrease cover 10- Cold compresses 11- Report to doctor 12- Give antipyretic as Dr. order 13- Decrease fat, increase protein, increase salt in diet Relation among Temperature, pulse, and respiration Increase ONE degree in body temperature affect on the following: Increase pulse 10 b/min Increase respiration 4 b/min  Respiration Respiration : It is the exchange of O2 &CO2 between an organism & it’s environment Inspiration : It is the act of breathing in Expiration : It is the act of breathing out External respiration : It is the interchange of gases in lung Internal respiration : It is the interchange of gases in tissues  Patent airway Intact nervous system Intact musculature Diaphragm Intercostal Accessory Diaphragm: thin, dome shaped muscle that separates the thoracic and abdominal cavities Intercostal muscles between the ribs: allow for chest expansion Accessory muscles lift the sternum and upper ribs  Mechanics of Breathing During inspiration The external intercostal muscles contract, moving the rib cage up and out. The diaphragm moves down at the same time, creating negative pressure within the thorax. The lungs are held to the thoracic wall by the pleural membranes, and so expand outwards as well. This creates negative pressure within the lungs, and so air rushes in through the upper and lower airways.  Mechanics of Breathing During expiration Expiration is mainly due to the natural elasticity of the lungs, Relaxation of respiratory muscles (main muscles intercostal and diaphragm muscles ) result in recoil of lungs.  Characteristics of respiration 1-Rate : Newborn 30 -80 breath / minute Adult 16 – 24 breath / minute  Characteristics of Respiration Rhythm : a- Regular b-Irregular Depth : a- Deep b-Shallow c- Normal depth Characteristics of Normal Respiration Regular with normal depth Hypoventilation: reduced rate and depth of breathing that results in retention of CO2. Dyspnea: subjective feeling of shortness of breath or difficulty breathing Tachypnea: abnormally rapid respiratory rate Wheezes: “whistling” sound created by air movement through constricted bronchioles Rhonchi: sound created by fluid or mucous in the larger airways Stridor: abnormal “crowing” sound as air moves past an upper airway obstruction Orthopnea is a respiratory condition of severe dyspnea (labored breathing). It is a Difficult in respiration in flat position  Factors affecting respiration 1- Which increase respiration rate : Age Pain Drugs Smoking Factors Exercise Disease Stress / Fever fear The pulse is palpable bounding of blood flow noted at various points on the body , resulting from left ventricular contraction. It's an indicator of the circulatory status.  Methods of counting pulse : Palpation. Auscultation.  Rate 1 Rhythm 2 Volume 3  Rate Is the number of peripheral pulsations palpated in one minute ✓60 - 100 b./min normal range for adult ✓more than 100 b./min tachycardia ✓less than 60 b./min Bradycardia  2-Rhythm pattern of the pulsations and pauses between them Regular Irregular  3- Volume: Quality of pulsation felt Absent 0 No pulsation is felt Weak 1 Difficult, to felt light pressure causes it to disappear Normal 2 Felt easily, moderate pressure causes it to disappear Bounding 3 Strong, does not disappear with pressure N.B. Pulse deficit = Apical pulse - Radial pulse Normal ( 5 -10 b./min. ) e.g. If apical pulse = 100 b./min. and radial pulse = 90 b./min... Pulse deficit = 100 - 90 = 10b./min. within normal Factors affecting pulse rate A-Which increase the pulse rate : 1-Exercises 2-Gender : female more than male 3-Age : Young age more than old age 4-Emotions : fear, anger, stress and emotional changes 5-Position : in standing position than in flat position 6-Metabolism : during eating 7-Pain 8-Caffeine 9-Fever 10-Bleeding :decrease blood pressure 11-Some drugs B-Which decrease the pulse rate : 1-Calmness 2-Rest and sleep 3-Fasting 4-Age : P.R. decrease with increase in age 5-Medications : e.g. digitalis 6-Parasympathetic stimulation 7-Some diseases Definition Blood Pressure :- it’s the force that blood exerts against the wall of blood vessels resulting from contracting of Lt. ventricle Blood vessel Blood Blood vessel Pulse Pressure :- The difference between systolic and diastolic pressure Stroke Volume :- the amount of blood pumped from each ventricle with each heart beat Physiology of Blood Pressure:- During ventricle contraction the maximum pressure exerted against the arterial walls is called “systolic B.P.” When the ventricle relaxation the minimum pressure exerted against the arterial walls it is called “diastolic B.P.” A B C  Blood pressure Measured in mmHg – (millimeters of mercury) Now, elevated blood pressure (without a diagnosis of hypertension) is systolic blood pressure (the top number) between 120 and 129. That used to be a vague category called “prehypertension.” Stage 1 high blood pressure (a diagnosis of hypertension) is now between 130 and 139 systolic or between 80 and 89 diastolic (the bottom number). Stage 2 high blood pressure is now over 140 systolic or 90 diastolic. The measurements must be obtained from at least two careful readings on at least two different occasions. Blood pressure normal value: Normal value From 90/60 to less than 120/80 mmHg Less than 90/60 mmHg called hypotension Factors affecting of blood Pressure:- ( A ) which increase the B.P. :- 1. Age ---------> B.P ↑ with age old age due to ↓ elasticity of blood vessels. ↑ sympathetic Activity as in Anxiety, pain ,stress, Exercises --> ↑ H.B. -----> bl. Volume. ↑ B.P. 2. Position ---------> in standing than lying position. 3. Diet ---------> Salty food, & fatty food. 4. Exercises. 5. Alcohol & smoking 6. Some Diseases e.g. Renal & Cardiac disease 7. Some Drugs e.g. Anti-hypotensive ( Effortel ) ( B ). Which decrease the B.P.:- 1-Fasting. 2-B.P. lower at night than the day. 3-Is lower in hot weather. 4-Medications e.g. Diuretics, Analgesics, Antihypertensive. 5-Some diseases e.g. Anemia, bleeding & shock. Assessing B.P. :- 1. Site 2. Equipment 3. Method Abnormalities of B.P. :- Hypertension : B.P. more than normal. ( over 140/95 mmhg. ). Hypotension:- B.P. less than normal. ( lower than 90/60 mmhg. ). Orthostatic hypotension: in an adult, moving from a flat, horizontal position to a vertical position resulting of pooling the blood in the lower extremities and decrease blood to the brain causing hypotension. Pain assessment: