Fundamentals of Nursing: 6th Lecture (Vital Signs) PDF

Fundamentals of Nursing 6th Lecture (Vital Signs) Ibrahim Rawhi Ayasreh RN, MSN 2011  Vital Signs Body Temperature. Pulse. Respiration. Blood Pressure.  Body Temperature Body temperatu...

Fundamentals of Nursing 6th Lecture (Vital Signs) Ibrahim Rawhi Ayasreh RN, MSN 2011  Vital Signs Body Temperature. Pulse. Respiration. Blood Pressure.  Body Temperature Body temperature reflects the balance between the heat produced and heat lost from the body, measured in heat un its called degrees. There are two kinds of body temperature: Core temperature and Surface temperature. Core temperature: is the temperature of the deep tissues such as the abdominal cavity, and pelvic cavity. Surface temperature : is the temperature of the skin and subcutaneous tissues, and fat.  Body Temperature The body continually produces heat as a by-product of metabolism. When the amount of heat produced by the body equals the amount of heat lost, the person is in heat balance. Factors affect the body’s heat production: - Basal metabolic rate (BMR): is the rate of energy utilization in the body required to maintain essential activates such as breathing. - Muscle activity: including shivering increase metabolic rate. - Thyroxin output: increased thyroxin output leads to increased metabolic rate. - Epinephrine, nor-epinephrine, and sympathetic stimulation. - Fever: fever increases the cellular metabolic rate.  Body Temperature Heat is lost from the body through radiation, conduction, and vaporization. Radiation: is transfer of heat from one surface of one object to the surface of another without contact between two objects. Conduction: is the transfer of heat from on molecule to a molecule of lower temperature. Convection: is the dispersion of heat by air currents. Vaporization: is continuous evaporation of moisture from the respiratory tract, mucous membrane of mouth, and from the skin.( This is what we called insensible heat loss).  Factors Affecting Body Temperature Age: Older people at high risk of hypothermia. Diurnal Variation: Body temperature as much as 1.0 C between the early morning and the late afternoon. Exercise: hard work or strenuous exercise an increase body temperature to as high as 38.3 to 40 C. Hormones: Women usually experience more hormone fluctuations than men. Stress: stimulation of sympathetic nervous system can incerese production of epinephrine and nor-epinephrine. Environment.  Alteration in Body Temperature Pyrexia ( also called Hyperthermia, Fever): occurs when the body temperature above usual range. Hyperpyrexia: is term that describes a very high fever ( such as 41 C). The client who has a fever is referred to as febrile, and the one who has not is afebrile. Four common types of fever: Intermittent, remittent, relapsing, and constant.  Types of fever Intermittent Fever : the body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperature fluctuations. Remittent Fever : a wide range of fluctuations (more than 2 C ,occurs over than 24-hour period, all of which above normal). Relapsing Fever: short febrile periods of a few days are interspersed with periods of 1 to 2 days of normal temperature. Constant Fever: The body temperature remains always above normal. Fever spike: occurs when the body temperature rises to fever rapidly and returns to normal within a few hours.  Clinical Signs of Fever Stage I ( Cold or Chill Stage): - Increased heart rate. - Increased respiratory rate. - Shivering. - Pallid , cold skin. - Complaints of feeling cold. - Cyanotic nail beds. - “Gooseflesh” appearance of skin - Cessation of sweating. Gooseflesh skin  Clinical Signs of Fever Stage II ( Course Stage): - Absence of chills. - Skin that feels warm. - Photosensitivity. - Glassy-eyed appearance. - Increased pulse and respiratory rate. - Increased thirst. - Mild to sever dehydration. - Drowsiness, restlessness, delirium , or convulsions. - Herpetic lesions of mouth. - loss of appetite. - Malaise, weakness.  Clinical Signs of Fever Stage II ( Course Stage): - Skin that appears flushed and feels warm. - Sweating. - Decreased shivering. - Possible dehydration.  Nursing Intervention for Clients with Fever Monitor vital signs. Assess skin color and temperature. Remove excess blankets when the client feels warm, but provide extra blanket when the client feels chilled. Measure intake and output. Provide adequate nutrition and fluids. Reduce physical activity to decrease heat production. Provide oral hygiene to keep mucous membrane of the mouth moist. Provide sponge bath to increase heat loss through conduction. Administer antipyretics (drugs that reduce the level of fever).  Alteration in Body Temperature (Hypothermia) Hypothermia is a core body temperature below the lower limits of normal( less than 36 C). Physiologic mechanisms of hypothermia: - Excessive heat loss. - Inadequate heat production to counteract heat loss. - Impaired hypothalamic thermoregulation. Hypothermia may accidental or induced. Accidental hypothermia occurs as result of exposure to cold environment, immersion in cold water, or lack of adequate clothing, shelter, or heat.  Clinical Signs of Hypothermia Decreased body temperature, pulse, and respirations. Feeling of cold and chills. Pale, cool, waxy skin. Hypotension. Decreased urinary output. Lack of muscle coordination. Disorientation. Drowsiness progressing to coma.  Nursing Interventions for Clients with Hypothermia Provide 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 fluids. Apply warming pads.  Assessing Body Temperature The four most common sites for measuring body temperature are: Oral, Rectal, Axillary, and the Tympanic membrane. Advantages & Disadvantages of Four Sites for Body Temperature Site Advantages Disadvantages Oral Accessible - Can be break in mouth & Convenient - Could injury mouth after oral surgery - Inaccurate if client ingest hot or cold food Rectal ٌ eliable R - Inconvenient and more unpleasant for client Measurement - Could injury the rectum after rectal surgery - Presence of stool may interfere with thermometer placement. Axillary Safe - Need longer time for accurate reading. & Noninvasive Tympanic Membrane Accessible & - Can be uncomfortable and involves risk for Very fast injuring the membrane if placed too far. - Presence of cerumen can affect reading. - Right and left reading may differ.  Types of thermometers Mercury-in-glass thermometer. Electronic thermometer. Chemical disposable thermometer. Temperature-sensitive tape. Infrared thermometer. Mercury-in-glass thermometer Rectal Thermometer Oral & Axillary Thermometer Electronic thermometer Chemical disposable thermometer Temperature-sensitive tape Infrared thermometer.  Temperature Scales The body temperature is measured in degrees on two scales: Celsius (Centigrade), and Fahrenheit. C = (Fahrenheit temperature – 32) * 5/9 F= (Celsius temperature X 9/5) + 32 For example: when the Celsius reading is 40: F = (40 X 9/5) + 32 = 104 F  Pulse The pulse is a wave of blood created by contraction of the left ventricle of the heart. Compliance: is the ability to contract and expand. Cardiac output: is the volume of blood pumped into the arteries by the heart at each minute. Stroke volume: the volume of blood ejected from the heart per each beat. Cardiac output = Heart rate (Pulse) X Stroke volume. Apical pulse: is the central pulse, located at the apex of the heart. Peripheral pulse: is a pulse located away from the heart. Normally heart rate is 60 -100 beats/minute in adults.  Factors Affecting the Pulse Age: As age increases, the pulse rate gradually decreases. Gender: After puberty, the average male’s pulse rate is slightly lower than the female’s. Exercise: The pulse normally increase with activity. Fever: the pulse increases. Hypovolemia: loss of blood from vascular system. Stress: as a result of sympathetic nervous system stimulation.  Peripheral pulses Carotid Pulses Radial Pulse Brachial Pulse Popliteal Pulse Ulnar Pulse Posterior Tibial Femoral Pulse Dorsalis pedis  Assessing the pulse Rate : normally between 60 -100 beats /minute. - If heart rate less than 60 beats/minute , it is called bradycardia. - If heart rate more than 100 beats/ minute it is called tachycardia. Rhythm: pattern of the beats and the intervals between these beats. - Dysrhthmia or Arrhythmia: if the pulse is irregular. Pulse volume: also called pulse strength or amplitude. - Range from absent to bounding. Elasticity of the arterial wall: normally we feels straight , smooth, soft, and pliable. Apical pulse Apical- Radial Pulse  Apical- Radial Pulse Need two nurses. One assess the apical rate, and the another assess radial rate at the same time, to detect if there is any differences between both rates. Assessed in clients with cardiovascular problems. Normally, the apical and radial rate are identical. Pulse deficit: any discrepancy between apical and radial rate.  Respirations Respiration: is the act of breathing. External respiration: is the interchange of oxygen and carbon dioxide between the alveoli of the lungs and pulmonary blood. Internal respiration: is the interchange of oxygen and carbon dioxide between circulating blood and the cells of the body tissue. Inhalation or Inspiration: inhalation of air into the lungs. Exhalation or Expiration: breathing out of the lung. Mechanism of Respiration  Assessing Respirations Do not tell the client that you will assess respiratory rate. Normally, respiratory rate is 14 -24 breathes / minute. Eupnea: when the breathing within normal rate and depth. Bradypnea: Abnormally slow respirations. Tachypnea: Abnormally fast respirations. Apnea: Cessation of breathing. Hyperventilation: very deep respirations. Hypoventilation: very shallow respirations. Dyspnea: difficulty in breathing. Orthopnea: ability to breathe only in sitting or standing position.  Blood Pressure Arterial blood pressure: is a measure of the pressure exerted by the blood as it flows through the arteries. Systolic blood pressure: is the pressure of the blood as a result of the contraction of ventricles. Diastolic blood pressure: is the pressure of the blood when the ventricles are relaxed. Pulse pressure: is the difference between the diastolic and systolic pressures.  Blood Pressure Blood pressure is measured in millimeters of mercury (mmHg). The systolic pressure is written over diastolic pressure. The average blood pressure of healthy adult is 120/80 mmHg. Determinants of blood pressure: - Pumping action of the heart. - Peripheral Vascular Resistance. - Blood Volume. - Blood Viscosity.  Factors Affecting Blood Pressure Age: Newborns have a mean systolic pressure of 75 mmHg. The pressure rises with age, reaching the peak at puberty, and then tends to decline. Exercise: physical activity increases cardiac output and hence the blood pressure. Stress: stimulation of the sympathetic increase cardiac output and vasoconstriction and thus increasing blood pressure. Gender: After puberty, females usually have lower blood pressures than males of same age. Obesity. Diurnal variations: pressure is usually lowest earl in the morning.  Abnormalities in Blood Pressure Hypertension: is persistently above normal blood pressure (above 140/90 mmHg). Primary hypertension: elevated blood pressure of unknown cause. Secondary hypertension: elevated blood pressure of known cause. Hypotension : is a blood pressure below normal. (less than 100/60 mmHg). Orthostatic hypotension: is a blood pressure that falls when the client sits or stands.  Sphygmomanometers Mercury Aneroid Electronic sphygmomanometer sphygmomanometer sphygmomanometer