Chapter 4. Vital Signs (5) 2.pdf

Vital Signs  OBTAINING VITAL SIGNS 4 Classical VS Temperature Pulse Respirations Blood Pressure Also included in initial assessment: Height Weight Level of consciousness (LOC) and responsiveness General clinical impression Pulse oximetry...

Vital Signs  OBTAINING VITAL SIGNS 4 Classical VS Temperature Pulse Respirations Blood Pressure Also included in initial assessment: Height Weight Level of consciousness (LOC) and responsiveness General clinical impression Pulse oximetry and ECG are also monitored  FREQUENCY OF VITAL SIGN MEASUREMENTS Baseline measurement should be taken: Upon admission Beginning of the shift Prior to treatment or procedure When there is a change in the patient’s condition Can be assessed intermittently or continuously Respiratory care: before and after tx Frequency dependent on the patient’s acuity  TRENDING THE VITAL SIGNS A trend is a series of VS measurements over time Any abnormal measurement should be compared with previous measurements before institution or change in therapy The key is to look for change constantly Look Listen Touch Reassess and analyze Trend Info  DIFFERENTIAL DIAGNOSIS The process of weighing the probability of one disease versus that of other diseases possibly accounting for a patient's illness The differential diagnosis of rhinitis (a runny nose) includes allergic rhinitis (hayfever), the abuse of nasal decongestants and, the common cold  SIGNS OF HYPOXEMIA ASSESSED DURING VITAL SIGN MEASUREMENT  HEIGHT AND WEIGHT Routinely measured as part of the physical exam 1 inch = 2.54 cm Should be recorded in kg (1kg = 2.2lb) Intake and output sometimes monitored along with weight  CLINICAL PRESENTATION General appearance gives information about level of distress and severity of illness, personality, hygiene, culture, reaction to illness If patient in distress, the priority is to evaluate the problem rapidly and intervene If not in distress, head-to-toe inspection Information obtained may include apparent age, posture, motor activity, nutritional status, mental acuity Documentation SIGNS OF DISTRESS  LEVEL OF CONSCIOUSNESS Orientation is evaluated as to: time, place, and person As cerebral blood flow becomes inadequate: restless, confused, disoriented, comatose Lethargic: sleepy, easily aroused, responds appropriately Obtunded: difficult to arouse, but responds appropriately Stupor: do not wake up completely, respond to pain, slow respirations Comatose: unconscious, have loss of reflexes Glasgow Coma Scale Used to assess patient’s level of consciousness CLINICAL USE OF GCS  TEMPERATURE Normal: 98.6º F (37 C). Range: 97º-99.5º F (36.0º-37.5º C) Afebrile: without fever Normal to have elevation in temperature in some cases THERMAL BALANCE TO MAINTAIN NORMAL BODY TEMPERATURE  FEVER Hyperthermia (febrile): temperature above normal If temp > 102º F most likely from infection Causes increase in: metabolic rate oxygen consumption carbon dioxide production Every 1º C elevation = 10% in O2 consumption and CO2 production  HYPOTHERMIA Body temperature below normal Can occur in: severe head injury exposure to cold environment Hypothalamus initiates shivering to generate energy, and vasoconstriction to conserve body heat Decreased O2 consumption and CO2 production Patient presents with shallow breathing and bradycardia  MEASUREMENT OF BODY TEMPERATURE Sites: mouth, tympanic (ear), axillary, or rectum Most common: tympanic and oral 10-15 min. waiting after liquids or smoking. Axillary temperature: infants and small children. Tympanic thermometry, Infrared  PULSE RATE Evaluate for: rate rhythm strength Varies with age Tachycardia (HR > 100 bpm) Bradycardia (HR < 60 bpm)  MEASUREMENT OF PULSE RATE ❖ Most common non emergency site is the radial artery ❖ Pulse rate should be assessed for 1 minute ❖ Pulse volume/fullness: ❖ 0: absent ❖ 1+: weak, thready ❖ 2+: slightly reduced ❖ 3+: normal ❖ 4+: bounding PULSE MEASUREMENT  PULSE OXIMETRY Measures both heart rate and oxygen saturation Good for spot checking oxygen saturation to: Reduce oxygen liter flow at the bedside Check HR during short term therapy Continuous monitoring during walking or exercising Trending  PULSE OXIMETRY  Varies with age Tachypnea: RR above normal RESPIRATORY Bradypnea: RR below normal RATE Terms for respiration Apnea Eupnea Hypopnea Hyperpnea Intermittent  Visualization of abdominal or thoracic movement MEASURING Must be counted when the RESPIRATORY patient is not aware RATE Count for one minute because it may be variable between rate and rhythm  BLOOD PRESSURE Systolic pressure measures peak force during ventricular contraction Diastolic pressure measures force during relaxed phase Pulse pressure is the difference between systolic and diastolic Varies with age Adults: 120/80 (90/60 – 140/90)  MEASURING BLOOD PRESSURE Use of sphygmomanometer Cuff applied around arm and pressurized to exceed systolic BP until blood flow to the artery is stopped As pressure is released, pulsations can be felt by palpation The partial obstruction of the arterial blood flow + turbulence produce the Korotkoff sounds (audible with stethoscope)  KOROTKOFF SOUNDS Stethoscope  ERRORS IN BP MEASUREMENT High pressure reading if: Too narrow a cuff Cuff applied too tight or too loose Excessive pressure to the cuff or incomplete deflation A low pressure reading if cuff is too wide Systolic BP decreases slightly during inspiration EFFECTS OF Paradoxic Pulse THE RESPIRATORY Present in asthma and cardiac CYCLE ON BP tamponade (Fluid around the heart causing it to be compressed) Due to negative intrathoracic pressure, increases blood return to right heart, decreased arterial flow from left Heart EFFECT OF RESPIRATORY CYCLE ON BP EFFECTS OF RESPIRATORY CYCLE ON BP Hypotension occurs when the left ventricle of the heart is weak Can occur as a side effect of certain medications Beta blockers diuretics PORTABLE BP MACHINE  BLOOD PRESSURE MONITORING IN ICU