vital signs I.pdf

Presented by Nurul 'Inayati binti Abdul Rahman VITAL SIGNS(I) PhD (IIUM), MNSc (UM), BNSc (IIUM), RN Credit to: Dr Khin Thandar Aung LEARNING OUTCOME At the end of the session, the student will be able to: Define each v...

Presented by Nurul 'Inayati binti Abdul Rahman VITAL SIGNS(I) PhD (IIUM), MNSc (UM), BNSc (IIUM), RN Credit to: Dr Khin Thandar Aung LEARNING OUTCOME At the end of the session, the student will be able to: Define each vital sign (temperature, heart rate, respiration rate, blood pressure, 1 oxygen saturation, and pain score) and explain its physiological significance in maintaining homeostasis. 2 Describe the normal range for each vital sign across different age groups and identify factors that may influence variations in these measurements. Discuss the clinical implications of abnormal vital sign findings, including potential 3 underlying pathophysiological conditions and the importance of documentation in patient care. Explain the appropriate methods and techniques for accurately measuring and 4 recording each vital sign, including the use of specialized equipment and assessment tools.  Why we need to Vital take Patient’s vital signs/ signs? cardinal To reflect the patient's signs body physiological status To provide information/ baseline data  What are Vital signs? v Temperature v Pulse v Respirations v Blood pressure v Pain v Oxygen saturation(SpO2)  One of the most frequent assessments made as a nurse. Nurse is Vital Signs Responsible for measuring, interpreting significance and making decisions about care Knowing normal ranges. Knowing history and other therapies that may affect vital signs(VS)  Vital Signs Nurse must ØKnow environmental factors that affect vital signs Exercise, stress, anxiety, food/drinks etc. ØUse a systematic, organized approach ØVerify and communicate changes in vital signs ØMonitor Vital Signs regularly ØFrequency determined by Medical Doctor’s order; This Photo by Unknown author is licensed under CC BY-NC. nursing judgement, client condition and facility standards  On admission to obtain baseline data. When a client has a change in health status or report symptoms such as chest pain or feelings hot or faint. When to Before and after any nursing interventions that could assess vital affect the vital signs such as ambulating a client who has been on bed rest. signs? Before and/or after the administration of a medication that could affect the respiratory or Cardiovascular systems. Before and after surgery or an invasive procedure.  Hospital: Every 4-8 hours Frequency Special case = every ½ an hour / 1 hour / 2 hours of Vital Home health: Signs each visit Assessment Clinic: Each visit  OBSERVATION PRIOR VITAL SIGNS MEASUREMENT Take a minute or so to look at the client in total. Does the client seem anxious, in pain, upset? What about their dress & hygiene? Remember! The exam begins as soon as you lay eyes on the client.  VITAL SIGNS All measurement are made while client is seated / lying. Prior to measuring vital signs, the client should have had the opportunity to sit for approximately 5 This Photo by Unknown author is licensed under CC BY-NC-ND. minutes.  PURPOSE qTo detect abnormally low body temperature (hypothermia) in people who have been exposed to cold. qTo detect abnormally high body temperature (hyperthermia) in people who have been exposed to heat. qTo detect fever. qMonitor the effectiveness of a fever-reducing medicine (anti- pyretic) qTo plan for pregnancy by determining if a woman is ovulating. How the body temperature is regulated? Thermoregulation is the maintenance of physiologic core body temperature by balancing heat generation with heat loss.  NORMAL TEMPERATURE Is Modes of Heat Loss  Circadian Rhythms Body temperature is usually lower in the morning than in the evening. Age the body temperature of infants and children changes more rapidly in response to both heat and cold. Hormones Factors women tend to have more fluctuations in body temperature than men as a result of hormonal changes affecting Stress the body respond to both emotional and physical stress as a body threat increasing the production of epinephrine and nor epinephrine as a result the metabolic rate increases raising the temperature: body temperature Environmental temperature Response to a change in environment either by wearing or less clothes. Exercise, hard work or strenuous exercise can increase body temperature.  Pyrexia (fever) A body temperature above the usual Alterations range is called pyrexia, febrile, hyperthermia, or fever. in body temperature Hyperpyrexia (high grade fever) (High body is a very high fever usually above 41 temperature) °C and survival is rare when the temperature Reaches 44 °C and death due to damaging effects on the respiratory center.  Monitor vital signs Assess color and temperature of skin (pink & warm) Remove excess blanket when the client feels warm but provide extra warmth when the client feels chilled. Administer antipyretic as prescribed to reduce body temperature. Provide a tepid sponging to increase heat loss through conduction/ reduce body temperature Nursing Administer IV fluid for hydration as prescribed. Interventions Monitor WBC, and other laboratory (RP, UFEME) reports for indications of infection or dehydration for Client's Encourage for adequate fluid and food intake with fever: Measure intake and output Advise for bed rest to minimise unnecessary energy use that cause heat production. Provide oral hygiene to keep the mucous membrane moist Encourage lightweight clothing and covers. NURSING INTERVENTION: TEPID SPONGING DEFINITION: The application of tepid water to body’s surface with the use of washcloth to provide cooling measures to a patient with high temperature/ fever.  TEPID SPONGING: EQUIPMENT Basin with tepid water (Temperature 37°C Macintosh/ Rubber sheet Towel Wash cloth Gloves (if patient is on body fluids precaution) Thermometer  To reduce fever by dilating superficial bold vessels, thus releasing heat and lowering body temperature. Improve circulation. TEPID SPONGING: PURPOSE Relieve restlessness. Provide comfort to the client  Hypothermia is condition that occurs when core body Alterations temperature drops below 35ºC. in body Physiologic mechanisms of hypothermia are: temperature § Excessive heat loss (Low body § Inadequate heat production to counteract heat loss temperature) § Impaired hypothalamic thermoregulation The clinical signs of hypothermia: 1. Decreased body temperature, pulse, and respiration 2. Severe shivering (rigor) 3. Feelings of cold and chills 4. Pale, cool skin 5. Hypotension 6. Decreased urinary output 7. Lack of muscle coordination 8. Disorientation 9. Drowsiness progressing to coma  Nursing Interventions for Client's with Hypothermia üProvide a warm environment üProvide dry clothing üApply warm blanket This Photo by Unknown author is licensed under CC BY. üKeep limbs close to body üCover the client's scalp with a cap üSupply warm oral or intravenous fluids üApply warming pads WARM BLANKET  Serious variations in temperature v Prolonged exposure to heat v Depression of hypothalamus v Medical emergency v Body temperature may reach as high as 45°C Body Temperature Assessment Most common sites for measuring body temperature are: o oral, o rectal, o axillary, o tympanic membrane o temporal (forehead)  Route Normal Range Sites ºF / ºC Oral 37.0 ºC (± 0.5) Mouth Temperature : normal range Tympanic 37.6 ºC (± 0.5) Ear Rectal 37.6 ºC (± 0.5) Rectum Axillary 36.6 ºC (± 0.5) Axilla (armpit)  TYPES OF THERMOMETERS Contact Remote MERCURY GLASS THERMOMETER  ELECTRONIC / DIGITAL THERMOMETER  CHEMICAL DISPOSABLE THERMOMETER / TEMPERATURE SENSITIVE  TYMPANIC THERMOMETER  TEMPORAL ARTERY THERMOMETER  HOW TO ASSESS BODY TEMPERATURE  PRE- PROCEDURE 1- Greet and explain procedure to the patient 2- Provide privacy and perform hand hygiene 3- Apply ear probe cover to thermoscan probe 4- Ensure the reading in degree Celsius  During- PROCEDURE Press 'START' button until heard 'beep’ sound  During- PROCEDURE TYMPANIC TERMOMETER:  Post- PROCEDURE 1- Remove probe from ear and inform to the patient about his or her body temperature. 2- Remove ear probe cover and discard appropriately 3- Perform hand hygiene 4- Inform SRN or doctor if it is an abnormal result 5- Documentation  Procedure Taking Body temperature Oral Axillary DEMONSTRATION VIDEO Rectal Watch the demonstration videos using this link: https://youtu.be/nvl1qQfgzuw PULSE  DEFINITION The wave of expansion and recoil occurring in an artery in response to the pumping action of heart The number of times the heart beats per minutes (heart rate) PULSE SITES  PURPOSES To establish To identify whether baseline data the pulse rate is for subsequent within normal evaluation. range.  CHARACTERISTIC OF PULSE Pulse rate o A number of pulse beats per minutes (bpm) (normal pulse rate: 60-100 bpm for adult) Rhythm/ regularity o Pattern or regularity of the beats and the length of time between beats Volume o Amount of blood pumped with each beat/ fullness of artery/ force of blodd felt at each beat. Arterial wall elasticity o The artery wall should feel soft and flexible under the fingers.  HEART RATE: NORMAL VALUES Age Heart rate (beats/min) Infants 120-160 Toddlers 90-140 Preschoolers 80-110 School-agers 75-100 Adolescent 60-90 Adult 60-100  HEART RATE RHYTHM Regular Pulse Rhythm Irregular Pulse Rhythm Count for 30 seconds, Count for one full then multiply by 2 minute (a rate of 35 beats in 30 May use stethoscope to seconds equals a pulse listen for apical pulse and rate of 70 beats/minute) count for a full minute  FACTORS AFFECTING THE PULSE FACTORS A FFECTING THE PULSE WHERE TO ASSESS HEART RATE (HR?)  RADIAL PULSE With palm up, look at the area between wrist bone and the tendon on the thumb side of the wrist. Radial pulse can be taken on either wrist. Use the tip of the index and third fingers of the other hand to feel the pulse in the radial artery between the wrist bone and the tendon on the thumb side of thewrist. Apply just enough pressure to feel each beat. Do not push too hard if not it will block the blood flow. Watch the second hand using watch and count how many times you feel the pulse. Record the pulse rate.  BRACHIAL PULSE The brachial pulse can be located by feeling the bicep tendon in the area of the antecubital fossa. Move the pads of three fingers medial (about 2 cm) from the tendon and about 2–3 cm above the antecubital fossa to locate the pulse.  Find the artery on one side of neck near CAROTID windpipe. Carotid pulse can be taken on either side of neck. PULSE Put the tip of index and long finger in the groove of neck along your windpipe to feel the pulse in your carotid artery. Do not press on the carotid artery on both sides of neck at the same time. This may cause to feel lightheaded or dizzy, or possibly faint. Apply just enough pressure to feel each beat. Do not push too hard or it will block the blood flow. Watch the second hand on watch as you count how many times you feel your pulse. Record pulse rate.  APICAL PULSE Ask client to lie down on his/her back or turned slightly to the left. Use fingers to locate the apical pulse at 5th ICS (adult), 4th ICS (infant/ young child) Apply the end of the stethoscope (either the bell or the diaphragm) to client’s chest. Listen for up to 60 seconds. Remove the stethoscope from your chest.  FEMORAL PULSE Cover the genitalia with a sheet and slightly abduct the thigh. Press deeply, below the inguinal ligament and about midway between symphysis pubis and anterior superior iliac spine. Use two hands one on top of the other to feel the femoral pulse Record the pulse.  In a seated or lying position, slightly bend the leg at the knee, but not so bent that the POPLITEAL foot is flat on the floor. Place the hands around the front of the PULSE knee so your fingers are on the back portion of the knee. Find the fleshy middle portion of the back middle of the knee. Press with increasing pressure until you feel a pulsation in the back of the knee. The pulsation will feel like a heartbeat, usually steady and even in nature. Sometimes you may have to press very deep into the popliteal fossa to feel the pulse. Some people have a lot of tissue on the back of their knee.  DORSALIS PEDIS PULSE The dorsalis pedis artery pulse can be palpated lateral to the extensor hallucis longus tendon (or medially to the extensor digitorum longus tendon) on the dorsal surface of the foot, distal to the dorsal most prominence of the navicular bone which serves as a reliable landmark for palpation. POSTERIOR TIBIAL ARTERY HOW TO CHECK PULSE RATE?  PRE-PROCEDURE Greet and explain procedure to the patient  PRE-PROCEDURE Provide privacy and perform hand hygiene  During- PROCEDURE Select pulse point and position patient appropriately  During- PROCEDURE Place 2 or 3 middle fingers tips lightly and squarely over the pulse site. During- PROCEDURE Palpate and count pulsation for 1 minute  Post-PROCEDURE Inform patient about findings  POST PROCEDURE Perform hand hygiene POST PROCEDURE 4- Inform SRN or doctor if it is an abnormal result  POST PROCEDURE Document reading  Variation in Heart Rate (Tachycardia) A rapid heartbeat more than 100 bpm (heart exceed normal range) Variation in Heart Rate (Bradycardia) A slow heartbeat less than 60 bpm (heart below normal range)  Radial pulse Demonstration video Pulse taking Carotid pulse Apical pulse Femoral pulse, https://youtu.be/nhAz84 Popliteal pulse srBvg Dorsalis pedis pulses RESPIRATION RATE (RR)  RESPIRATION The exchange of oxygen and Two separate carbon dioxide in process the body Mechanical chemical  Respiration: Mechanical Mechanical Pulmonary ventilation; breathing Ventilation: Active movement of air in and out of the respiratory system Conduction Movement through the airways of the lung MECHANICS AND REGULATION OF BREATHING During inhalation the diaphragm contracts the ribs move upward and outward, and the sternum moves outward, thus enlarging the thorax and permitting the lungs to expand. During exhalation The diaphragm relaxes, the ribs move downward and inward, and the sternum moves inward, thus decreasing the size of the thorax as the lungs are compressed.  Respiration: Chemical Chemical Exchange of oxygen and carbon dioxide Diffusion Movement of oxygen and CO2 between alveoli and RBC Perfusion Distribution of blood through the pulmonary capillaries  RESPIRATORY Respiration is controlled by: respiratory centers in the medulla oblongata and the Pons of the brain and Chemo receptors located centrally in the medulla and peripherally in the carotid and aortic bodies.  RESPIRATORY RATE The number of breaths a person takes per minute. Try to do this as surreptitiously as possible. Observing the rise and fall of the chest while you appear to be taking their pulse. Should be counted at least 30 seconds.  NORMAL Adults 12-20/ min RESPIRATORY Young 20-25/min children RATE Infants Up to 40/min  ASSESSING RESPIRATORY RATE Nurses should be aware of the following before having respiration rate: The client’s normal breathing pattern The influence of the client’s health problems on respirations Any medications or therapies that might affect respirations The relationship of the client’s respiration to cardiovascular function  Age FACTORS AFFECTING Physical activity and Exercise THE RESPIRATORY RATE Stress Pain Fever and metabolic rate Lung Disease & respiratory condition Medications Environmental factors Hormonal factors Sleep  VARIATION IN RESPIRATION RATE Eupnea. Respiratory rate is normally described in breaths per minute, normal in depth and rate called Bradypnea Slow respiration rate less than