8.1 VITAL SIGNS.pdf

Sri Rahaya Nafitri Badul Razak (U6240037) 8. VITAL SIGNS Learning outcomes After completing this chapter, you will be able to: 1. Describe factors that affect the vital signs and accurate measurement of them. 2. Identify the variations in normal body temperature, puls...

Sri Rahaya Nafitri Badul Razak (U6240037) 8. VITAL SIGNS Learning outcomes After completing this chapter, you will be able to: 1. Describe factors that affect the vital signs and accurate measurement of them. 2. Identify the variations in normal body temperature, pulse, respiration, and blood pressure that occur from infancy to old age. 3. Verbalize the steps used in: a) Assessing body temperature b) Assessing a peripheral pulse c) Assessing the apical pulse and the apical-radial pulse d) Assessing respirations e) Assessing blood pressure f) Assessing blood oxygenation using pulse oximetry 4. Describe appropriate nursing care for alterations in vital signs 5. Identify nine sites used to assess the pulse and state the reasons for their use. 6. List the characteristics that should be included when assessing pulse. 7. Describe the mechanics of breathing and the mechanisms that control respirations. 8. Demonstrate appropriate and reporting of vital signs. Define key terms 1) Afebrile: absence of fever 2) Apical pulse: a central pulse located at the apex of the heart 3) Apical-radial pulse: measurement of the apical and radial pulse simultaneously 4) Apnea: a complete absence of respiration 5) Arrhythmia: an irregular heart rhythm 6) Arterial blood pressure: The measure of the pressure exerted by the blood as it pulsates through the arteries 7) Arteriosclerosis: a condition which the elastic and muscular tissues of the arteries are replaced with fibrous tissue 8) Auscultatory gap: the temporary disappearance of sounds normally heard over the brachial artery when the sphygmomanometer cuff pressure is high, followed by the reappearance of sounds at a lower level 9) Basal metabolic rate (BMR): the rate of energy utilization in the body required to maintain essential activities such as breathing 10) Body temperature: the balance between the heat produced by the body and the heat lost from the body 11) Bradycardia: abnormally slow pulse rate, less than 60 beats per mins 12) Bradypnea: abnormally slow respiratory rate, usually less than 10 respirations per mins 13) Cardiac output (CO): the amount of blood ejected by the heart with each ventricular contraction 14) Compliance: the extent to which an individual's behaviour coincides with medical or health advice 15) Conduction: the transfer of heat from one molecule to another in direct contact 16) Constant fever: a state in which the body temperature fluctuates minimally but always remains above normal 17) Convection: the dispersion of heat by air currents 18) Core temperature: the temperature of deep tissues of the body (e.g : abd cavity, pelvic cavity). When measured orally, the average body temp of adult is between 36.7°C and 37°C (98°F and 98.6°F 19) Costal (thoracic) breathing: movement of the chest upward and outward 20) Diaphragmatic (abd) breathing: breathing that involves the contraction and relaxation of the diaphragm, as observed by the movement of the abd 21) Diastolic pressure: the pressure of the blood against the arterial walls when the ventricles of the heart are at rest 22) Dysrhythmia: a pulse with an irregular rhythm 23) Evaporation: the process of turning form liquid into vapour 24) Exhalation (expiration): breathing out, or the movement of gases from the lungs to the atmosphere 25) Expiration (exhalation): the outflow of air from the lungs to the atmosphere 26) Febrile: pertaining to a fever, feverish 27) Fever: elevated body temp 28) Heat stroke: life-threatening condition with body temp greater than 41°C(106°F) 29) Haematocrit: the proportion of red blood cells (erythrocytes) to the total blood volume 30) Hyperpyrexia: an extremely high body temp (e.g. 41 °C or 105.8°F) 31) Hypertension: an abnormally high blood pressure; over 140mmHg systolic and/or 90 mmHg diastolis. 32) Hyperthermia: a body temp above the usual range  33) Hyperventilation: very deep, rapid respirations 34) Hypotension: an abnormally low Bp; less than 100mmHg systolic in adult 35) Hypothermia: a core body temp below the lower limit of normal 36) Hypoventilation: very shallow respirations 37) Inhalation(aspiration): the intake of air into the lungs 38) Insensible heat loss: heat loss that occurs from evaporation(vaporization) of moisture from the respiratory tract, mucosa of the mouth and skin 39) Insensible water loss: continuous and unnoticed water loss 40) Intermittent fever: a body temp that alternates at regular intervals between periods of fever and periods of normal or subnormal temp 41) Korotkoff’s sounds: the five phases of blood pressure sounds 42) Mean arterial pressure (MAP): the average arterial pressure throughout one cardiac cycle, systole, and diastole 43) Orthostatic hypotension: decrease in Bp related to positional/postural changes from lying to sitting or standing positions 44) Oxygen saturation (SaO2): a measure of how much haemoglobin is currently bound to oxygen compared to how much haemoglobin remains unbound. 45) Peripheral pulse: a pulse located in the periphery of the body e.g.; foot, hand, neck 46) Pulse: the wave of blood within an artery that created by contraction of the left ventricle of the heart 47) Pulse oximeter: a noninvasive device that measures the arterial blood oxygen saturation by means of a sensor attached to the finger or other location 48) Pulse pressure: the difference between the systolic and and the diastolic Bp 49) Pulse rhythm: the pattern of the beats and intervals between the beats 50) Pulse volume: the strength or amplitude of the pulse, the force of blood exerted with each heartbeat 51) Pyrexia(fever): a body temp above normal range 52) Radiation: the transfer of the heat from the surface of one object to the surface of another without contact between the two objects 53) Relapsing fever: the occurrence of short febrile periods of a few days interspersed with periods of 1or 2 days of normal temp 54) Remittent fever: the occurrence of a wide range of temp fluctuations, more than 2°C (3.6°F) over a 24hrs period, all of which are above normal 55) Respiration: the act of breathing; includes the intake of o2 and the output of co2from the cells to the atmosphere 56) Respiratory character (respiratory quality): refers to those aspects of breathing that are different from normal, effortless breathing, includes the amount of effort exerted to breath and the sounds produced by breathing 57) Respiratory rhythm: the regularity of expirations and inspirations 58) Sphygmomanometer: used to indirectly measure arterial blood pressure. 59) Systolic pressure: the pressure of the blood against the arterial walls when the ventricles of the heart contract 60) Tachycardia: an abnormally rapid pulse rate; greater than 100 beats per mins 61) Tachypnea: abnormally fast respirations; usually more than 24v respirations per mins 62) Tidal volume: the volume of air that is normally inhaled and exhaled 63) Ventilation: the movement of air in and out of the lungs; the process of inhalation and exhalation 64) Vital signs: body temp, pulse, respiration, and Bp. Many agencies have designated pain as the fifth vital sign INTRODUCTION Vital signs are body temperature, pulse, respiration, and blood pressure, pain assessment and oxygen saturation. Times to assess vital signs 1. On admission to a health care agency to obtain baseline data 2. When a client has a change in health status or reports symptoms such as chest pain or feeling hot or faint 3. Before and after surgery or an invasive procedure 4. Before and/or after the administration of a medication that could affect the respiratory or cardiovascular systems; e.g.; before giving a digitalis preparation 5. Before and after any nursing intervention that could affect the vital signs e.g.; ambulating a client who has been on bed rest BODY TEMPERATURE Body temperature reflects the balance between the heat produced and the heat lost from the body, and is measured in heat units called degrees. Two kind of body temp: explain differences 1) Core temp – temp of the deep tissues of the body, e.g.; abd cavity, pelvic cavity. It remains relatively constant. The normal core body temp is a range temp 2) Surface temp – is the temp of skin, subcutaneous tissue and fat The body continually produces heat as a by product of metabolism. When the amount of heat produced is equals to heat lost , the person is in heat balance. Factors affect the body’s heat production; explain 5 factors a) Basal metabolic rate (BMR) - the rate of energy utilization in the body required to maintain essential activities such as breathing b) Muscle activity – including shivering, increases the metabolic rate c) Thyroxine output – increased thyroxine output increase the rate of cellular metabolism throughout the body d) Epinephrine, norepinephrine, and sympathetic stimulation/stress response – these hormones immediately increase the rate of cellular metabolism in many body tissue e) Fever – fever increase the cellular metabolic rate and thus increase the body’s temp further Heat lost from body 1. Radiation – the transfer of heat from the surface of one object to the surface of another without contact between two objects, mostly in the form of infrared rays 2. Conduction – the transfer of heat from one molecules to a molecule of lower temp. Conductive transfer cannot take place without contact between molecules and normally accounts for minimal heat loss except, for example, when a body is immersed in cold water. The amount of heat transferred depends on the temp difference and the amount and duration of the contact 3. Convection – the dispersion of heat by air currents. The body usually has a small amount of warm air adjacent to it. This warm air rises and is replaced by cooler air, so people always lose a small amount of heat through convection 4. Evaporation – continuous vaporization of moisture from the respiratory tract and from the mucosa of the mouth and from the skin a) Insensible water loss: continuous and unnoticed water loss b) Insensible heat loss: accompanying heat loss Regulation of body temperature The system that regulates body temperature; 1. Sensors in the periphery and in the core 2. An integrator in the hypothalamus 3. An effectors system that adjusts the production and loss of heat. Physiological process to increase the body temp 1) Shivering(thermogenesis) increases heat production – when the body senses a drop in internal temperature, the muscles contract and relax rapidly, generating heat as a byproduct of muscle activity. This process, known as thermogenesis, helps to raise the body’s core temperature. 2) Sweating is inhibited to decrease heat loss – the evaporation of sweat provides by far the greatest potential for heat loss and it represents the only means of heat loss when air temperature exceeds skin temperature. 3) Vasoconstriction decreases heat loss - In this process, the blood vessels under the skin become narrower, reducing blood flow to the skin’s surface. By minimizing heat loss through the skin, vasoconstriction helps retain heat within the body’s core, thus raising overall body temperature. Describe factors affecting body temp 1) Age  Infants are greatly influenced by the temp of the environment and must be protected from extreme changes  Older people ere at risk of hypothermia for a variety of reasons; inadequate diet, loss of subcutaneous fat, lack of activity and reduce thermoregulatory property 2) Diurnal variations (circadian rhythm)  Body temp normally changes throughout the day, varying as much as 1.0°C between the early morning and the late afternoon  The point of highest body temp is usually reached between 4.00pm to 6.00pm and the lowest is reached during asleep between 4.00am to 6.00am 3) Exercise  Hard work or strenuous exercise can increase body temp t as high as 38.3°C to 40°C 4) Hormones  Woman usually experience more hormones fluctuations than men. Progesterone raises body temp by about 0.3°C to 0.6°C above basal temp 5) Stress stimulation  Stimulation of the sympathetic nervous system can increase the production of epinephrine and norepinephrine, thereby increasing metabolic activity and heat production  Highly stressed or anxious client could have an elevated body temp for that reason 6) Environment  Extremes in the environment temp can affect a person’s temp regulatory system Alterations (not normal/abnormal) in body temp Normal range 36°C – 37.2°C a) Pyrexia/hyperthermia/fever/febrile: 38°C b) Hyperpyrexia: 41°C c) Hypothermia: less than 36°C A. Pyrexia  Pyrexia(fever): a body temp above normal range  Hyperthermia: a body temp above the usual range  Hyperpyrexia: an extremely high body temp (e.g. 41 °C or 105.8°F)  Febrile: pertaining to a fever, feverish  Afebrile: absence of fever/no fever 4 common types of fever 1. Intermittent fever: a body temp that alternates at regular intervals between periods of fever and periods of normal or subnormal temp 2. Remittent fever: the occurrence of a wide range of temp fluctuations, more than 2°C (3.6°F) over a 24hrs period, all of which are above normal 3. Relapsing fever: the occurrence of short febrile periods of a few days interspersed with periods of 1or 2 days of normal temp 4. Constant fever: a state in which the body temperature fluctuates minimally but always remains above normal 5. Fever spike: a temperature that rises to fever level rapidly following a normal temp and then returns to normal temp within a few hrs 6. Heat exhaustion: condition that is the result of excessive heat and dehydration 7. Heat stroke: life-threatening condition with body temp greater than 41°C(106°F) State clinical manifestations of febrile(fever) 1. Onset (cold/chill phase)  Increased heart rate  Increased respiratory rate and depth  Shivering  Pallid(pale), cold skin  Complaints of feeling cold  Cyanotic nail beds  “Gooseflesh” appearance of the skin  Cessation of sweating 2. Course (plateau phase)  Absence of chills  Skin that feels warm  Photosensitivity  Glassy-eyed appearance  Increased pulse and RR  Increased thirst  Mild to severe dehydration   Drowsiness, restlessness, delirium (mengigau), convulsions (sawan)  Herpetic lesions of the mouth (ulcers)  Loss of appetite (if the fever is prolonged)  Malaise, weakness, aching muscle 3. Defervescence (fever abatement/flush phase)  Skin that appears flushed and fells warm  Sweating  Decreased shivering  Possible dehydration Nursing Intervention for Clients with Fever B. HYPOTHERMIA Hypothermia is a core body temperature below the lower limit of normal. State 3 physiological mechanism of hypothermia i. Excessive heat loss ii. Inadequate heat production to counteract heat loss iii. Impaired hypothalamic thermoregulation Clinical manifestation for hypothermia  Decrease body temp, pulse, respiration  Severe shivering (initially)  Feelings of cold and chills  Pale, cool, waxy skin  Frostbite (discolored, blister nose, fingers, toes)  Hypotension  Decreases urinary output  Lack of muscle coordination  Disorientation  Drowsiness process to coma Nursing intervention for hypothermia  Provide a warm environment  Provide dry clothing  Apply warm blankets  Keep limbs close to body  Cover the client’s scalp with a cap or turban  Supply warm oral or intravenous fluid  Apply warming pads Assessing body temp The common sites for measuring body temp: oral, rectal, axillary, tympanic membrane, skin/temporal artery Advantages and disadvantages of sites used for body temp Site Advantages Disadvantages Oral Accessible and convenient  Thermometers can break if bitten  Inaccurate if client has just ingested hot or cold food or fluid or smoked  Could injure the mouth following oral surgery Rectal Reliable measurement  Inconvenient and more unpleasant for client; difficult for client who cannot turn to the side  Could injure the rectum  Presence of stool may interfere with thermometer placement Axillary Safe and noninvasive  The thermometer may need to be left in place a long time to obtain an accurate measurement Tympanic Readily accessible; reflects the core  Can be uncomfortable and involves risk of injuring membrane temp; very fast the membrane if the probe is inserted too far  Repeated measurements may vary. Right and left measurements can differ  Presence of cerumen can affect the reading Skin/temporal Safe and noninvasive; very fast  Requires electronic equipment that may be artery expensive or unavailable. Variation in technique needed if the client has perspiration (sweating) on the forehead State the type of thermometers TEMPERATURE SCALES Body temperature reading Celsius (Centigrade) “C” /Fahrenheit “F” Convert: 1. C to F: to convert from Celsius to Fahrenheit, multiply the Celsius reading by the fraction 9/5 and then add 32; F = (Celsius temp × 9/5) + 32 E.g.; Celsius reading is 40: F = (40 × 9/5) + 32 = (72 + 32) = 104 2. F to C: to convert from Fahrenheit to Celsius, deduct 32 from the Fahrenheit reading and then multiply by the fraction 5/9; C = (Fahrenheit temp – 32) × 5/9 E.g.; Fahrenheit reading is 100: C = (100-32) × 5/9 = (68) × 5/9 = 37.8 DOCUMENTATION for Temperature  Site designated “O” (oral), “R” (rectal), “A” (axillary), “T” (tympanic), or “TA” (temporal artery)