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11-Vital Signs Unit 12 To 17
11-Vital Signs Unit 12 To 17
Objectives
Define Vital Signs. Identify the reasons/situations necessary to take vital signs. Enlist the components of vital signs. Explain each component in detail.
Discuss the normal & abnormal values of vital signs Describe the factors affecting vital signs.
No reference to any form of vital sign monitoring by nurses pre 1893 Concept of nurses taking vital signs evolved - 1893 to 1950 Codified into nursing text of the 1950s
Zeitz & McCutcheon (2003)
Vital Signs
Vital from Latin word vita, which means Life Sign means indicator. So vital signs are the indicators of Life. Vital signs are physical signs that indicate an individual is alive, such as Heart beat (Pulse), Breathing rate (Respiration), Temperature, Blood pressure and recently oxygen saturation.
Vital Signs
These signs may be observed, measured, and monitored to assess an individual's level of physical functioning. Used to determine response to treatment
Normal vital signs change with age, sex, weight, exercise tolerance, and condition.
Vital Signs
Prior to measuring vital signs, the patient should have had the
minutes.
On a clients admission According to the physicians order or the institutions policy or standard of practice When assessing the client during home health visit Before & after a surgical or invasive diagnostic procedure Before & after the administration of meds or therapy that affect cardiovascular, respiratory & temperature control functions. E.g. Blood Transfusion When the clients general physical condition changes LOC, pain Before, after & during nursing interventions influencing vital signs When client reports symptoms of physical distress
Observation
Before diving in, take a minute or so to look at the patient in their entirety. Does the patient seem anxious, in pain, upset? What about their dress and hygiene? Remember, the exam begins as soon as you lay eyes on the patient.
Health Assessment
A nursing assessment consist of collection of subjective and objective data, which includes health history, measurement of vital signs and physical examination:
A bodily assessment from head to toe or systemic examination by using the techniques of Inspection, Auscultation, Palpation and Percussion.
Inspection The visual examination of the body using the eyes and a lighted instrument if needed. The sense of smell may also be used. Auscultation The process of listening to sounds that are produced in the body. Direct auscultation uses the ear alone,
Indirect auscultation involves the use of a stethoscope to amplify the sounds from within the body, like a heartbeat.
Methods of P.E
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Palpation The examination of the body using the sense of touch. There are two types: light and deep. Percussion An assessment method in which the surface of the body is struck with the fingertips to obtain sounds that can be heard or vibrations that can be felt. It can determine the position, size, and consistency of an internal organ.
Vital Signs
The vital signs are body temperature, pulse, respirations blood pressure and recently the pulse oximetry and the pain are also included in the list of vital signs. Temperature Pulse Respiration Blood pressure Oxygen saturation Pain
Temperature
Is a state of hotness and coldness of the body. BODY TEMPERATURE is the balance between the heat produced by the body and the heat lost from the body. The temperature of the body is measured by thermometer in units called degrees. Centigrade (C) or Fahrenheit (F)
Body Temperature
Core Temperature temperature of the body tissues, is controlled by the hypothalamus (control center in the brain) maintained within a narrow range. Surface or Skin temperature rises & falls in response to environmental conditions & depends on blood flow to skin & amount of heat lost to external environment. The bodys tissues & cells function best between the range from 36 C to 38 C. Temperature is lowest in the morning, highest during the evening.
Regulation of Temperature
Neural control
Hypothalamus acts as thermostat
Vascular control
Vasoconstriction ---hypothalamus directs the body to decrease heat loss and increase heat production If cold, vasoconstriction will conserve heatshivering will occur
Regulation of temperature
Vasodilatation
If body temp is above normal, the hypothalamus will direct the body to decrease heat production; Perspiration and increased respiratory rate
Types of Thermometers
Glass Thermometer
Oral Thermometer Rectal Thermometer
A small hollow glass tube that contains mercury in a bulb at one end. When heated the mercury rises in the tube.
Reading a Glass-Thermometer
The scale is marked from 94 to 108 The long lines represent one degree The short lines represent two tenths of a degree
o Battery operated o Have an oral probe and a rectal probe o Disposable probe cover is placed on the probe o The temperature is recorded in about 30 seconds
o Measures the temperature in the tympanic membrane (eardrum) o Fast and accurate - 1 to 3 seconds
INFANTS PULL THE EAR STRAIGHT BACK
ADULTS AND CHILDREN OVER ONE YEAR PULL THE EAR UP AND BACK
Duration of Placement
Leave in place 3 min
Oral
Posterior sublingual pocket under tongue (close to carotid artery)
Axillary
Bulb in center of axilla Lower arm position across chest
Non invasive good for children. Leave in place 5-10 min. Less accurate (no major bld vessels Measures 0.5 C lower than nearby) oral temp.
When unsafe or inaccurate by Side lying with upper leg flexed, mouth (unconscious, disoriented or irrational) insert lubricated bulb (1-11/2 Side lying position leg flexed inch adult) (1/2 inch infant)
Rectal
Rapid measurement Easy accessibility Close to hypothalamus sensitive to core temp. changes Cerumen impaction distorts reading Adult - Pull pinna up & back Otitis media can distort reading Child pull pinna down & back
Ear
2-3 seconds
Pyrexia/Hyperthermia/Fever a body temperature above the normal range. >100 F Hyperpyrexia a very high fever. 104 F and above.
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Constant Fever When the fever dose not fluctuate more than about two degree Fahrenheit during 24 hours, but at no time touches the normal. Intermittent When the temperature is only present for several hours in 24 hours and touches the normal for few hours. E.g. Malaria. Remittent When the daily fluctuation of temp is more than two F and never touches the normal. In this fever the evening temp is usually higher than morning one. E.g. Typhoid fever Rigor Fever sever attack of shivering. 3 stages.
o Shivering stage o Hot stage o Cold stage
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Onset (cold or chill stage) Increased heart rate Increased respiratory rate and depth Shivering due to increased skeletal muscle tension and contractions Pallid, cold skin due to vasoconstriction Complaints of feeling cold Cyanotic nail beds due to vasoconstriction Gooseflesh appearance of the skin due to contraction of the arrectores pilorum muscles Cessation of sweating Rise in body temperature
Decreased body temperature 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
Fahrenheit to centigrade conversion: Deduct 32 from the Fahrenheit reading and multiply by 5/9: C = (F 32) 5/9
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An infant or young child ( under age 6) An unconscious patient A patient that has had oral surgery or an injury to the face, neck, nose, or mouth A person receiving oxygen A patient with a nasogastric tube in place A patient who is confused or restless A patient who is paralyzed on one side of the body Has a history of seizures A patient who breathes through the mouth
Assignment:
Sign
What is Pulse
Pulse is a wave of expansion felt in the arteries when the heart pumps blood in the vessels, that though always full or distensible. It can be felt in any artery near the surface of the body with the fingers pads. OR The pulse is caused by the stroke volume ejection and distension of the walls of the aorta. The bounding of blood flow in an artery is palpable at various points in the body (pulse points).
Peripheral pulse located in the periphery of the body (ex. foot, hand, neck). Apical pulse central pulse; located at the apex of the heart. Compliance of the arteries the ability of the arteries to contract and expand. Stroke volume output the amount of blood that enters the arteries with each ventricular contractions. Cardiac output the volume of blood pumped into the arteries by the heart. It is the result of the stroke volume (SV) x the heart rate (HR) per minute.
Pulse Assessment
Pulse Points
Temporal:
Over the temporal bone, superior and lateral to eye
Carotid:
Bilateral, under the lower jaw in neck along medial edge of sternocleidomastoid muscle
Apical:
Left midclavicular line at fourth to fifth intercostal space
Brachial:
Inner aspect between groove of biceps and triceps muscles at antecubital fossa.
Radial:
Inner aspect of forearm on thumb side of wrist
Pulse Points
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Ulnar:
Outer aspect of forearm on finger side of wrist
Femoral:
In groin, below inguinal ligament (midpoint between symphysis pubis and antero-superior iliac spine)
Popliteal:
Behind knee, at center in popliteal fossa
Posterior Tibial:
Inner aspect of ankle between Achilles tendon and tibia (below medial malleolus)
Dorsalis Padis:
Over in step, midpoint between extension tendons of great and second toe
Exercise Strong emotions fear, anger, laughter, excitement Infection Fever Pain Shock Hemorrhage, Hypovolemia
Sleep/rest Old age Heart Diseases e.g. Heart block Depression Drugs digitalis, morphine Athletes in good physical condition may have a lower pulse, probably <60 beats/min. This is normal
Pulse counting
Normal pulse rate for adults is 60 to 100 beats/min & is regular in rhythm..
Regular Pulse Rhythm
Count for 30 seconds, then multiply by 2 (a rate of 35 beats in 30 seconds equals a pulse rate of 70 beats/minute)
for one full minute May use stethoscope to listen for apical pulse and count for a full minute
Rate N 60-100, average 80 bpm Tachycardia greater than 100 bpm Bradycardia less than 60 bpm Rhythm the pattern of the beats (regular or irregular) Strength or size or amplitude, the volume of bld pushed against the wall of an artery during the ventricular contraction weak or thready (lacks fullness) Full, bounding (volume higher than normal) Imperceptible (cannot be felt or heard)
What is Respiration?
Respiration is the act of breathing; it includes the intake of oxygen and the output of carbon dioxide from the body. refers to the intake of
Inhalation/Inspiration
air into the lungs. Exhalation/Expiration refers to the breathing out or the movement of gases from the lungs to the atmosphere.
Respiration
Ventilation
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another word that is used to refer to the movement of air in and out of the lungs. External respiration refers to the interchange of oxygen and carbon dioxide between the alveoli of the lungs and the pulmonary blood. Internal respiration takes place throughout the body; the interchange of same gases between the circulating blood and the cells of the body tissues.
Assessing Respiration
Rate
# of breathing cycles/minute (inhale/exhale-1cycle) N 12-20 breaths/min adult - Eupnea normal rate & depth breathing Abnormal increase tachypnea Abnormal decrease bradypnea Absence of breathing apnea Amt. of air inhaled/exhaled normal (deep & even movements of chest) shallow (rise & fall of chest is minimal) SOB shortness of breath (shallow & rapid) Regularity of inhalation/exhalation Normal (very little variation in length of pauses b/w I&E
Depth
Rhythm
Exercise (increases metabolism) increase RR Stress (readies the body for fight or flight) increase RR Environment (increase temperature) increase RR Increased altitude (lower oxygen concentration) increase RR Certain medications (ex. narcotics, analgesic) decrease RR
Breathing Patterns:
Rate:
Breathing Patterns:
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Volume:
Hyperventilation an increase in the amount of air in the lungs, characterized by prolonged and deep breaths; may be associated with anxiety. Hypoventilation a reduction in the amount of air in the lungs; characterized by shallow respirations
Breathing Patterns:
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Rhythm: Cheyne-stoke breathing rhythmic waxing and waning of respirations, from very deep to very shallow breathing and temporary apnea; often with associated with cardiac failure, increased ICP, or brain damage Effort o Dyspnea difficulty in breathing, in which an individual has a persistent, unsatisfied need for air and feel distressed o Orthopnea ability to breath only in upright sitting or standing positions
BLOOD PRESSURE
Blood pressure is the force or pressure of the blood exerted on the walls of the arteries at which the blood is pushed out of heart. OR Arterial blood pressure is a measure of the pressure exerted by the blood as it flows through the arteries. It is measured in millimetres of mercury (mmHg).
Blood Pressure
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Stethoscope; is used to auscultate and assess body sounds including the apical pulse and the blood pressure
Sphygmomanometer; is used to assess blood pressure consist of cuff, good selection of the cuff in order to obtain accurate blood pressure.
Age BP increases as person grows older. BP continuous to increase with aging. Gender women usually have lower BP than men. BP rises in women after menopause. Blood volume Severe bleeding lowers blood volume, therefore BP lowers. Rapid administration of IV fluids increases the blood volume, therefore the BP rises. Stress HR and BP increases as part of the bodys response to stress. Pain generally increases BP. However, severe pain can cause shock. BP is seriously low in the state of shock.
Exercise increases HR and BP; so BP should not be measured right after exercise. Weight BP is higher in overweight persons. BP lowers with weight loss. Race black persons generally have higher BP than white persons. Diet a high-sodium diet increases the amount of water in the body. Extra fluid volume increases BP. Medications drugs can be given to raise or lower BP. Other drugs have side effects of high or low BP.
Position BP is lower when lying down and higher in standing position. (orthostatic hypotension).
Diurnal variations BP s usually lowest early in the morning, when the metabolic rate is lowest; then rises throughout the day and peaks in the late afternoon or early evening.
Disease process any condition affecting the cardiac output, blood viscosity, and/or compliance of the arteries has a direct effect on the BP.
Hypertension
An abnormally high blood pressure, over 140 mmHg systolic and 90 mmHg diastolic. Factors associated with hypertension Thickening of the arterial walls, which reduces the size of the arterial lumen Elasticity of the arteries Lifestyle as cigarette smoking Obesity Lack of physical exercise High blood cholesterol level Continued exposure to stress
Hypotension
Blood pressure below normal, when the systolic reading less than110 mmHg. It occurs as a result of peripheral vasodilatation in which blood leaves the central body organs especially the brain and moves to the periphery. Factors associated with hypotension Analgesics Bleeding Severe burn Dehydration.
Oxygen Saturation
Oxygen is carried in the blood attached to haemoglobin molecules. Oxygen saturation is a measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry. Oxygen Saturation provide important information about cardio-pulmonary dysfunction and is considered by many to be a fifth vital sign.
Pulse Oximetery
Pulse Oximeter is a non invasive device that measures a client's arterial blood oxygen saturation by means of a sensor attached to the client's finger, toe, nose, earlobe, or forehead. The pulse oximeter can detect hypoxemia before clinical signs and symptoms such as dusky skin color and dusky nail bed color. Normal SpO2- 92% to 100%
Height
Height is expressed in inches (in), feet (ft), centimeters (cm), or meters (m).
A scale for measuring height is usually attached to a standing weight scale. Infants length is measured from vertex (top) of head to soles of feet while infant is lying with knees extended.
Weight
Measurement of weight is expressed in ounces (oz), pounds (lb), grams (g), or kilograms (kg). Daily weights should be obtained at the same time of the day, on the same scale, with the client wearing the same type of clothing.
Nursing Considerations
Accurate recordings are necessary for drug dosage calculations and evaluation of effectiveness of drug, fluid, and nutritional therapy. Intake and output records provide information on fluid balance and kidney function.