Vital Signs PDF

VITAL SIGNS -> NECESSARY TO LIFE 7=PHYSIOLOGICAL OBSERVATION-INEWS V2 Temperature-pulse-respiration-oxygen saturation pulse oximetry-pain assessment TEMPERATURE- is affected by: - HYPOTHALAMUS- centre for temperature regulation - Infection - Inflammatory response - allergic...

VITAL SIGNS -> NECESSARY TO LIFE 7=PHYSIOLOGICAL OBSERVATION-INEWS V2 Temperature-pulse-respiration-oxygen saturation pulse oximetry-pain assessment TEMPERATURE- is affected by: - HYPOTHALAMUS- centre for temperature regulation - Infection - Inflammatory response - allergic reaction - Environment - Brain stem dysfunction-trauma - Drugs-ecstasy-hyperpyrexia-fatal,anaesthetic agents How to measure temperatures= Thermoflash, Tympanic temperature Pyrexia – significant rise in temperature – the presence of infection (pag 151,153,154) Different grades of -Pyrexia: ❖ Low grade pyrexia 36.8- 38.0 degree centigrade ❖ Moderate to high grade pyrexia 38.0-40 degree centigrade ❖ Hyperpyrexia is 40 degree centigrade HOW TO ASSES -> perform temperature measurement HOW TO RECORD-> record the value by placing s dot and exact temperature reading in the corresponding row. Join the dots to the previous dot using a line. Enter the INEWS value (0,1,2,3) for temperature. PULSE->Left ventricle of the heart pumps blood into the aorta and out into the arterial system, causes a wave of expansion throughout the arteries. Where arteries are near the surface of the body, this expansion- the pulse can be felt by palpation. The pulse is an indirect measure of Heart Rate Stroke Volume(SV) X Heart Rate (HR) = Cardiac Output (CO) NORMAL PULSE RATE WHAT ARE WE ASSESSING? Rate-> Speed at which the heart is beating TACHYCARDIA= (> 100 BPM, it increase the work of the heart and performs inefficiently as there is not enough time to the ventricles to fill completely) BRADYCARDIA (< 60 BPM, heart palpitations, shortness of breath, fatigue, fainting) Rhythm-> the sequence of beats REGULAR/NORMAL= equal interval of time between consecutive beats IRREGULAR /ARRHYTHMIA= beats feel random Volume-> reflect pulse strength, pulse can be described as being weak, faint, strong or bounding WHY MEASURE THE PULSE? - To gain information about the general health and wellbeing of the patient and to monitor it during and or following investigations/operation. - To compare and identify and changes - To gain a basic cardiovascular assessment of the patien HEART RATE= PULSE  RESPIRATION RATE Inspiration (intake) of air into the lungs and expiration (breathing out) of air= 1 respiration Controlled by Respiratory centre in Medulla Oblongata which is sensitive to the amount of CO2 in the blood and adapts the rate of ventilation accordingly Inspiration requires action of major respiratory muscles- intercostal muscles between ribs and diaphragm Expiration is passive – inspiratory muscles relax RESPIRATORY ASSESSMENT-> look and listen: rhythm, rate and depth The best time to assess patient respiratory is after taking the pulse LOOK-> chest abdominal movement LISTEN-> BREATH SOUND - STUDOR-> HIGH PITCHED SOUND = LARYNGEAL OR TRACHEAL OBSTRUCTION - INSPIRATORY WHEEZE-> OBSTRUCTION OF THE LOWER AIRWAY - EXPIRATORY WHEEZE->BRONCHOSPASM - GURGLING-> SECRETIONS UPPER AIRWAY  PULSE OXIMETRY & O2 SATURATION Indicates the level of oxygen in the blood- blood oxygenation Measures the oxygen saturation in arterial blood. Oxygen saturation describes the number of oxygen modules bound to each haemoglobin molecule Oxygen saturation is expressed as a percentage = Normal>95% Hypoxia