PHTH1143 004 Measurement of Vital Signs - Nelson.pdf

Required reading: Physical Rehabilitation 6th ed. Chapter 2 Gail Nelson School of Physical Therapy The University of the West Indies [email protected]...

Required reading: Physical Rehabilitation 6th ed. Chapter 2 Gail Nelson School of Physical Therapy The University of the West Indies [email protected] Objectives 1. Provide the rationale for the need to measure, interpret, monitor and record a patient’s vital signs 2. Locate and palpate a patient’s arterial pulse at various sites 3. Describe and define blood pressure Objectives (cont’d) 4. Accurately measure and record a patient’s blood pressure (BP), pulse and heart rates (PR & HR), respiration rate (RR), and body temperature; 5. Determine an individual’s sense of pain 6. Describe the expected normal and abnormal changes in BP, HR and RR resulting from exercise and other factors Vital signs (VS): Introduction — VS are indicators of general health and physiological status: 1. Blood pressure (BP) 2. Heart rate (HR) 3. Respiratory rate (RR) 4. Body temperature 5. Patient’s sense of pain (cont’d) — Normal values and ranges for BP, HR, RR and temperature have been established and any variation from these may indicate an abnormal condition. — Measurements must always be interpreted by: — comparison to the normal range — considering the patient’s current condition — consideration of environmental factors Factors affecting vital signs — Patient’s age and gender — Emotional status — Physiological status (i.e. existence of illness, disease, trauma, use of medications) — Level or amount of physical activity/exercise — Environmental temperature cont‘d — Important to take vital signs at rest to: — Establish a baseline/standard for comparison after initiation of activity — Determine if there is any abnormality at rest that would be exacerbated with activity/intervention cont’d — The cause of abnormal values at rest should be thoroughly investigated before the initiation of any activity that could affect the vital signs. — Measurement of vital signs can be used to: — Set goals of treatment — Assist with the development of a treatment plan — Assess patient’s response or treatment effectiveness Pulse Rate  Pulse — Indirect measure of the contraction of the left ventricle of the heart and indicates the heart rate (HR) — Movement of blood in the artery which can be palpated at various sites in the body, or via auscultation over the apex of the heart with a stethoscope — Unit of measurement = beats per min, bpm eg. 18 bpm or 18/min Pulse rate (PR) — Normal range of resting values: — Adult: 60-100 bpm — Neonate: 100-130 bpm — Child 1-7 years: 80-120 bpm  Factors affecting pulse — Age: — > 65 y.o. tend to have a decreased PR relative to younger persons — Gender: — slightly lower in males than age-matched females — Environmental temperature: — increases with higher temperatures — Infection: — increases when an infectious process is underway Factors affecting PR (cont’d) — Physical exercise: — PR should rise rapidly in response to vigorous physical activity; plateau or stabilise as the intensity of exercise plateaus, and decline as exercise intensity declines; — Post-exercise PR should revert to resting 3-5 minutes after cessation of exercise. Factors affecting PR (cont’d) — Emotional status: — increases during episodes of high stress, anxiety or emotion; — may decrease in sleep or in a state of extreme calm — Medications: — cause increase or decrease depending on effect on cardiovascular system Factors affecting PR (cont’d) — Cardiopulmonary disease: — Heart, lungs and peripheral vascular system diseases can affect PR e.g. a patient with gas exchange abnormality such as hypoxia may have an increased HR to compensate. — Physical conditioning: — Physically fit persons exhibit a lower-than-normal PR  Palpation sites: — Temporal pulse: anterior and adjacent to the ear.  Palpation sites (cont’d) — Carotid pulse: inferior to the angle of the mandible and anterior to the sternocleidomastoid muscle Palpation sites (cont’d) — Radial: at the wrist on the volar forearm medial to the stylus process of the radius — Brachial: medial to the biceps in the antecubital fossa or medial aspect midshaft of the humerus  Palpation sites (cont’d) — Femoral pulse: below the inguinal ligament and about midway between symphysis pubis and anterior superior iliac spine (cont’d) — Dorsalis pedis (dorsal pedal) pulse: along the midline or slightly medial on the dorsum of the foot (cont’d) — Popliteal: in the midline of the posterior knee crease between the tendons of the hamstring muscles (Cont’d) — Posterior tibial: on the medial Posterior tibial aspect of the foot inferior to the medial malleolus Descriptive terms — PR is described according to: rate, rhythm and volume: — Strong and regular — Weak and regular — Irregular — Thready — Tachycardic — Bradycardic Equipment — Stopwatch, clock or wristwatch with a sweep second-hand — Count pulse for 1 minute — Materials to record the measured value Respiratory Rate Respiration (pulmonary ventilation) — One respiration comprises one inhalation and one exhalation — Accepted normal ranges: — Adults 12-18 breaths per min — Infants 30-50 breaths per min — Resting values above 20 or below 10 breaths per minute are usually considered abnormal for adults Assessment of respiration — Rate, rhythm, depth and character are assessed — Rate = number of breaths per minute — Rhythm = regularity of pattern — Depth = volume of air exchanged with each breath — Character refers to deviations from normal, resting or quiet respiration Factors affecting RR — Age — Physical activity — Emotional status — Air quality — Altitude — disease Temperature Body temperature — Indication of the intensity or degree of heat within the body — Under normal conditions this remains relatively constant (thermoregulation) Exceptions: — Exposure to extremes of heat or cold — During and immediately after physical exertion Body temperature — Normal range for oral core temperature: — 96.8°F to 99.3°F (36°C to 37.3°C) — Average normal: 98.6°F (37°C) — Normal range for rectal temperature is 97.8°F – 100.3°F (36.6°C – 38.1°C) Body temperature — Norms may vary slightly for each individual — A person with a normal core temp of 98.6°F is considered to have a fever (pyrexia) if he has a temperature >100°F (38°C), hyperpyrexic at >106°F (41.1 degrees Celsius) Factors affecting body temperature Time of day Gender Menstrual cycle Age (cont’d)-Factors affecting body temperature Environmental temperature Infection Emotional status Site of measurement Oral cavity temperature – may be inaccurate if measured orally within 14 to 30 minutes of ingestion of warm or cold substances or smoking (body core temperature not affected) Physical activity Sites of measurement — Oral cavity — Rectum (most accurate) or ear canal: — Used for infants and young (pre-school) children who are unable to maintain the thermometer under the tongue or safely hold it between the lips; unconscious patients or other patients (eg. CVAs) who cannot hold the thermometer in the mouth or under the arm. Sites of measurement — Axilla & Inguinal fold : — Axillary and inguinal folds should only be used when measurement at other sites is neither safe nor possible. — Air currents reduce the accuracy of the measurement taken at the axillary or inguinal folds. — The site of measurement should be recorded in the patient's record, and time of day taken. Equipment — Infra-red ear thermometer — Digital thermometer — Mercury thermometer (no longer available) — Infrared thermometer - these use an infrared scanner to measure temperature. Descriptive terms — Hypothermic — Hyperthermic — Febrile — Afebrile — Pyrexia Blood Pressure Blood pressure (BP) — BP is an indirect measurement of the pressure inside an artery caused by blood flow through the artery. — It is the force exerted by the blood against the vessel wall; — It is composed of the systolic (SBP) and diastolic pressures (DBP). BP — SBP and DBP are indicated by Korotkoff’s sounds heard with a stethoscope — Sounds heard in phases – sometimes not easily distinguishable — Phases I and V are the most important phases to identify  Phases of Korotkoff’s sounds I. First faint clear tapping sounds heard which gradually increase in intensity correspond to the SBP II. Sounds heard have a murmur or “swishing” quality III. Sounds become crisp and louder than those previously heard IV. There is a distinct and abrupt muffling of the sounds until a soft, blowing quality is heard. This is the initial indicator of the DBP V. Sounds disappear totally  BP norms — SBP < 120mmHg — DBP < 80mmHg or Torr Descriptive terms: — Pre-hypertension: SBP = 120-139mmHg; DBP = 80-89 mmHg — Hypertension: SBP >140mmHg, DBP >90mmHg — Hypotension: SBP < 90mmHg, DBP < 60mmHg National Heart Lung and Blood Institute BP norms for age Age SBP (mmHg) DBP (mmHg) 0-3 mths 85-90 35-65 3 mths-1 yr 90-100 60-67 1-4 yr 100-108 60 4-12 yr Add 2 mmHg per 60-70 yr to 100 Adolescents 100-119 65-75 Elderly 120-140 80-90 Factors that affect BP — Age (lower in youth) — Exercise: SBP should gradually increase with exercise, plateau as exercise intensity plateaus, and declines as exercise intensity declines; increase of more than 10-15 DBP during exercise is considered abnormal — Emotional stress — Medications — Size and condition of arteries Factors that affect BP — Muscle contraction — Blood volume — Cardiac output — Site of measurement Blood pressure — Arm position: standard arm position is to maintain the forearm at the level of the heart with the elbow extended — Patient may be seated or standing or lying (record position) — http://www.youtube.com/watch?v=UYcSrcLVJHI (BP measurement Cont’d) Assessment of BP — Most common site used is the brachial artery — Equipment for measurement and recording BP: stethoscope, sphygmomanometer, chairs, object to support the patient’s UE, alcohol wipes and recording materials  Assessment of BP — Width of the bladder of should be 40% of the circumference of the midpoint of the limb. — Cuff size: — If the bladder of the cuff is too narrow in relation to the patient’s arm, the reading will be erroneously high; if the bladder is too wide it will be too low. — In doing repeat measurements, the cuff should be deflated and the patient remain still for 1-2 minutes before repeating. Assessment of BP — Avoid vigorous physical activity 30 minutes before measuring; — Avoid position changes 3 minutes before measuring. Stethoscope parts Pain Pain — Pain is considered in some places to be the 5th vital sign. — Patient’s self-report of the severity and location of pain should be the primary source of information. — The initial assessment of pain should be based on a detailed patient history. — May need to reassess several times in a day to determine effectiveness of intervention Pain (cont’d) — Assessment should include: — Detailed patient history — Characteristics (e.g., intermittent, continuous, cramping, burning, dull) and intensity of pain — Physical examination — Psychosocial assessment — Diagnostic evaluation of signs and symptoms associated with the cause of pain e.g. SOB with chest discomfort Goals of pain management — Eliminate source of pain when feasible — Teach function within pain limitations — Improve pain control thro’ physical and psychological methods — Relieve drug dependency — Treat any underlying depression & improve mental well-being — Address areas of secondary gain Pain assessment — Must document location, onset and temporal pattern of pain (use a pain questionnaire if available) — Determine whether the pain radiates or is referred — Ask patient to describe type of pain — When is the pain least or worst — What factors aggravate and/or relieve — What work/social activity is affected by pain CHARACTERISTICS POSSIBLE CAUSES Morning pain with stiffness that improves with Chronic inflammation with edema, or activity arthritis Pain increasing as the day progresses Increased congestion in a joint Sharp, stabbing pain during activity Acute injury, such as ligament sprain or muscular strain Dull, aching pain aggravated by muscle Chronic muscular strain contraction Pain that subsides during activity Chronic condition or inflammation Pain on activity relieved by rest Soft-tissue damage Pain not affected by rest or activity Injury to bone Night pain Compression of a nerve or bursa Dull, aching, and hard to localize; aggravated by Muscular pain passive stretching of the muscle and resisted muscle contractions Deeply located, nagging, and very localized Bone pain Sharp, burning, or numbing sensation that may Nerve pain run the length of the nerve Aching over a large area that may be referred to Vascular pain another area of the body Pain scales