Vital Signs PDF

 Vi t a l s i g n s Dr. Manal Mohamed Mostafa Prof. of Medical Surgical Nursing  Learning Outcomes Describe factors that affect the vital signs and its accurate measurement. Identify the variations in normal body temperature, pulse, respirations, and blood pressure. Descri...

 Vi t a l s i g n s Dr. Manal Mohamed Mostafa Prof. of Medical Surgical Nursing  Learning Outcomes Describe factors that affect the vital signs and its accurate measurement. Identify the variations in normal body temperature, pulse, respirations, and blood pressure. Describe appropriate nursing care for alterations in vital signs. Explain how to assess body temperature and the different site utilized.  Learning Outcomes Identify major sites used to assess the pulse & state indication for each. List the characteristics that should be included when assessing pulses. Explain how to assess respiration. List the characteristics that should be included when assessing respiration. Discuss how to measure blood pressure and factors to consider to ensure accurate readings. Demonstrate appropriate documentation and reporting of vital signs.  Introduction Taking Vital Signs is very important to determine a client’s baseline data, Identify nursing diagnosis to implement nursing interventions and to evaluate need &/or success of medical intervention  Introduction Vital signs are an objective measurement of the essential physiological functions of a living organism. They have the name "vital" as their measurement and assessment is the critical first step for any clinical evaluation. The first set of clinical examinations is an evaluation of the vital signs of the patient.  Introduction Vital signs reflect essential body functions, including heartbeat, breathing rate, temperature, and blood pressure. The health care provider may measure, or monitor the vital signs to check the level of physical functioning. Vital signs can be influenced by a number of factors. It can vary based on age, time, gender, medication, or a result of the environment.  Introduction Vital signs measure the body's basic functions. These include: Temperature. Heart rate. Respiratory rate. Blood pressure. Recently, many agencies have designated pain as a fifth vital sign. Also add oxygen saturation. Vital Signs: When….??  When to take vital signs?? On admission. Change in client’s health status Client reports symptoms such as chest pain, feeling hot, or faint Before and after surgery/invasive procedure Before and after medication administration that could affect respiratory or CV system. Before and after nursing intervention that could affect vital signs  Vital Signs: By whom….?? The nurse caring for the client, & may be delegated to assistive personnel  Body temperature Definition: Is the difference between the amount of heat produced by the body processes and the amount of heat lost to the external environmental. Body temperature = Heat produced - Heat lost  Body temperature: is the balance between heat production and heat loss from the body. Heat Production: Heat Loss: - Basal metabolism - Radiation - Muscular activity - Conduction - thyroxin (Hormones) - Convection - Cellular metabolic - Evaporation - Insensible water loss/ heat loss  Temperature regulation Physical control factors Chemical control factors Nervous system control factors (Hypothalmus) Radiation Transfer of heat from one object to another without direct contact Conduction Transfer of heat from one object to another with direct contact Convection Transfer of heat away with air movement Evaporation Transfer of heat when changing from liquid to gas Factors affecting body temperature: Age Exercise Hormone: e.g. Thyroxin, Epinephrine Stress Gender Circadian rhythms: change throughout the day, The point of highest body temperature is usually reached between 4:00pm and 6:00pm hours Environment  Sites of Body Temperature Oral temperature.(3min) Axillary temperature.(5 min add 0.5) Rectal temperature( 1min subtract 0.5) Tympanic temperature Contraindication for oral temperature Infant or child under 6 yrs. And old age. Unconscious person. Clients with surgery or injury in the face, neck, nose or mouth. Clients receiving oxygen. Client have vomting. Clients breathes through the mouth. Has a seizure disorder. Clients take hot /cold fluides immediately before measuring.  Contraindication for Tympanic temperature Requires removal of hearing aids Clients with ear surgery Requires disposable probe cover Expensive Clients with otitis media Inaccurate for newborns Affected by other devices Contraindication for Rectal temperature Clients with diarrhea. Rectal surgery. Patient have fissure. Patient have hemorrhoids Clients with heart disease  Reading of thermometers * Celsius → Cº * Fahrenheit → F  To convert Fahrenheit to Celsius: Cº = (F -32) x 5/9  To convert Celsius to Fahrenheit: F = (5/9 x C) + 32 Normal Range Of Body Temperature: 36.5 -37.5 Cº  Body temperature alterations 1. Fever (Hyperthermia) → is an important defense mechanism 39 Cº enhance the body’s immune system. Stimulates WBCs → ↓Hb% → ↓ bacteria growth Stimulates interferon the body’s natural virus-fighting substance.  Body temperature alterations There are two primary alterations in body temperature: Pyrexia. Hypothermia Pyrexia: A body temperature above the usual range is called pyrexia, hyperthermia, fever  Patterns of fever Intermittent → body temp. alternates at regular intervals between periods of fever and periods of normal or subnormal temperatures. Constant /Sustained → The body temperature fluctuates minimally but always remains above normal.  Patterns of fever Remittent → Body temp. fluctuations occurs over the 24-hours intervals without a return to normal temp level. Relapsing → periods of febrile episodes interrupted by period (1-2 days) of normal temp  Body temperature alterations Heatstroke → prolonged exposure to the sun or high environmental temperatures Signs & symptoms: Confusion, excess thirst, nausea, muscle cramps, no sweat (severe loss of electrolyte), temp ↑45 Cº, ↑ heart rate, ↓ B.P, may be loss of consciousness  Body temperature alterations Heat Exhaustion → when the profuse diaphoresis results in excess water & electrolyte loss. Hypothermia →  Mild 34-36 Cº  Moderate 30-34 Cº  Severe < 30 Cº Frostbite → when exposed to subnormal temperatures (ice crystals forming inside the cell result in tissue damage).  Body Temperature Variations: A febrile: normal body temperature Pyrexia: a body temperature above normal Hyperpyrexia: high fever usually above 41C Hypothermia: decreased body temperature; death may occur below 34C  Clinical signs of fever Increased heart rate Increased respiratory rate and depth Shivering Complaints of feeling cold Increased pulse and respiratory rates Increased thirst, Mild to severe dehydration Loss of appetite Malaise, weakness. Skin that appears flushed and feel warm. Sweating.  Nursing care Monitor vital signs Monitor laboratory reports for indications of infection or dehydration. Remove excess blankets when the client feels warm, but provide extra warmth when the client feels chilled. Provide adequate nutrition and fluids (e.g., 2,500-3,000 mL/day) to meet the increased metabolic demands and prevent dehydration. Measure intake and output.  Nursing care Reduce physical activity to limit heat production, especially during the flush stage. Administer antipyretics (drugs that reduce the level of fever) as ordered. Provide oral hygiene to keep the mucous membranes moist. Provide a bath to increase heat loss through conduction. Provide dry clothing and bed linens.  Hypothermia A core body temperature below the normal limits. May be induced (OR) or accidental (Exposure to cold environment) causing frostbite Excess heat loss Inadequate heat production Impaired hypothalamic thermoregulations Clinical Manifestation of hypothermia Decreased body temperature, pulse, and respirations Severe shivering (initially) Feelings of cold and chills Pale, cool, waxy skin Hypotension Decreased urinary output Lack of muscle coordination Disorientation Drowsiness progressing to coma  Nursing Care of hypothermia Provide dry clothing and apply warm blankets. Remove patient from the cold and provide a warm environment. Keep limbs close to body. Cover the client's scalp with a cap. Supply warm oral or intravenous fluids. Apply warming pads. Heart  Pulse Definition of pulse: The wave of blood created by the contraction of the left ventricle of the heart. Definition of Stroke volume: The amount of blood that enters the arteries with each ventricular contraction Stroke volume- about 70 ml in the adult The heart pumps the stroke volume into the aorta. Cardiac Output (CO): volume of blood plumbed in one minute, HR X stroke volume Compliance: is the ability of arteries to contract and expand Sites of pulse  Factors Affecting Pulse Rate Age: age pulse rate Gender: After puberty, the average male's pulse rate is slightly lower than the female's Exercise: pulse with activity Fever: pulse rate blood pressure due to vasodilatation Medication: some medication pulse and other e.g. digitalis, epinephrine Stress: pulse rate Hypovolemia: pulse rate. Position change: pulse rate.  Characteristics of pulse Rhythm Regular Irregular Regular irregularity Irregular irregularity Rate 60-100 beat/ min. 100 Tachycardia 60 Bradycardia Force & volume of pulse: +3 (Bounding), +2 (Normal), +1 (weak), 0 (absent)  Pulse Variations: Tachycardia: abnormally elevated heart rate, above 100 b/m in adults. Bradycardia: a slow rate, below 60 b/m in adults. Pulse deficit:-It is the difference between a peripheral pulse rate and an apical pulse rate at the same minute by two nurses.  Before assessing Pulse Patient should be resting, in comfortable position Be aware of: any medication could affected the HR If patient has been active, wait 10-15 minutes Baseline data Effect of different positions  Pulmonary ventilation (Breathing) Movement of air in and out of the lungs Inspiration (inhalation) Expiration exhalation) the act of breathing in. the act of breathing out Respiratory  Mechanisms and Regulation Respiration is controlled by: Respiratory center in the medulla oblongata (the primary respiratory center) and the pons of the brain (the quality and rhythm) Central Chemoreceptor (in medulla) Peripheral Chemoreceptor (carotid and aortic bodies) in response to changes of O2, Cao2, and H2 in arterial blood Assessment of respiration: General Appearance Skin Color Chest Contour Fingertip Assessment Speech Pattern  Normal respiration must be 1. Automatic 2. Regular 3. 0f normal depth and rhythm 4. Noiseless 5. Painless 6. Effortless  Assessment of Respiration Including the rate, depth of breathing & the rhythm of ventilatory movement 1. Rate → Acceptable range of adult respiratory rate * Adult: 14-20 b/m * Infant: 30-50 b/m  Assessment of Respiration cont. 2. Ventilatory depth → assessed by observing the degree of excursion or movement in the chest wall. Described as: * Deep respiration * Normal respiration * Shallow respiration  Assessment of Respiration cont. 3. Ventilatory Rhythm → observing the chest or abdomen Described as: * Regular rhythm * Irregular rhythm  Assessing Respirations Inspection Listening with stethoscope Monitoring arterial blood gas results Using a pulse oximeter or cardio- respiratory monitors  Factors Affecting Respirations Exercise Respiratory and cardiovascular disease Alterations in fluid, electrolyte, and acid balances Medications Trauma Infection Pain Anxiety  Alterations in Breathing pattern 1. Bradypnea → rate less than 12 b/m 2. Tachypnea → rate more than 20 b/m 3. Hyperpnea → ↑ rate & ↑ depth (e.g. exercise) 4. Apnea → respiration cease for several seconds 5. Hyperventilation → ↑ rate & ↑ depth of resp. 6. Hypoventilation → ↓ rate & ↓ depth of resp. 7. Dyspnea Difficult and labored breathing, Patient feel persistent distresses and unsatisfied with air 8. Hemoptysis: the presence of blood in the sputum  Blood Pressure Definition: Is the force or the amount of pressure exerted by the blood against walls of the arteries when left ventricle contract.  Determinants  Pumping action of the heart: BP  Peripheral vascular resistance: BP  Elasticity of blood vessels: BP  Blood volume BP  Blood Viscosity BP  Measuring Blood Pressure Direct Invasive Monitoring Indirect Auscultatory Palpatory Sites Upper arm (brachial artery) Thigh (popliteal artery) Systolic pressure: It is the greatest amount of pressure exerted by the blood against the wall of arteries during maximum ventricular contraction. 120 ______ Diastolic pressure: It is the lowest amount of pressure exerted by the blood against the wall of arteries during the relaxation of the ventricular contraction. _________ 80  Blood Pressure Normal adult reading120/80 +or – 20/15mmHg Normal systolic = 100 – 140 mmHg Normal diastolic = 65 – 95 mmHg Abnormal readings – Hypertension : BP > 140/90 mmHg – Hypotension : BP < 95/65 mmHg  Factors affecting pulse & B.P. Age. Sex Exercise Stress Fever Posture Blood disease Drugs  Factors decreasing BP Rest/sleep Lying down Depression Shock Hemorrhage Improperly sized cuff Medication  Procedure for BP Guidelines  Measure BP at brachial artery  Do not use injured arm, arm with IV, or casted.  The client has an arteriovenous fistula (e.g.for renal dialysis) in that limb.  Patient should be at rest  Position arm at the level with heart  Apply cuff to bare arm NOT over clothing  Use appropriate size cuff  Position sphygmomanometer at eye level  Common Errors Bladder/cuff too narrow or too wide Arm unsupported; arm above heart level Insufficient rest before assessment or repeated assessment too soon Cuff too loose or unevenly wrapped Cuff deflated too quickly/too slowly Failure to measure in same arm Assessing while client eats, smokes, or is in pain Failure to identify auscultatory gap  Blood Pressure Variations: Hypertension: Blood Pressure 140/90 mm Hg Hypotension : Systolic blood pressure 90 mm Hg or below Orthostatic (postural) hypotension: occurs when a normotensive person develops symptoms and low Blood pressure when rising to an upright position. Pulse pressure: is the difference between systolic and diastolic pressure. Thank You