introduction assessing vital signs or cardinal sign is a routine medical procedure. and somehow...

ASSESSING VITAL SIGNS

Introduction

Assessing vital signs or cardinal sign is a routine medical procedure. And somehow determines the internal functions of the body

Vital signs composes of the following: Body temperature

Pulse

Respiration and

Blood pressure

pain

Vital Signs(continued)

Abbreviations:Temperature – T

Pulse – P

Respirations – R

Blood Pressure – BP

Vital signs - TPR and BP

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Vital Signs(continued)

PurposeMeasured to

detect any changes in normal body function

Used to determine response to treatment

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Assessing a Client’s Health Status

Body Temperature

Body temperature◦It is a balance between the internal and

external environment of the body, or◦It is the balance between the heat produced by

the body and the heat lost from the body.◦It is measured in heat units, called degrees

Body Temperature

Shell temperature: the warmth at the skin surface

Core temperature: the warmth in deeper sites within the body like the brain and heart

Temperature Measurement

Fahrenheit scale: uses 32˚F as the temperature at which water freezes and 212˚F as the point at which it boils

Centigrade scale: uses 0˚C as the temperature at which water freezes and 100˚C as the point at which it boils

Normal Body Temperature

In normal, healthy adults, shell temperature generally ranges from 96.6˚F to 99.3˚F or 35.8˚C to 37.4˚C

Chances of survival diminish if body temperatures exceed 110˚F (43.3˚C) or fall below 84˚F (28.8˚C)

Normal Body Temperature (cont’d)

Based on temperature, animals are either:◦Poikilothermic: temperature fluctuates depending on environmental temperature

◦Homeothermic: structural and physiologic adaptations keep body temperature within a narrow stable range

Factors Affecting Body Temperature

Food intake, age, genderClimate, exerciseCircadian rhythmEmotionsIllnessMedications

Assessment Sites

Accurate assessment site: ◦ Brain, heart, lower third of the

esophagus, and urinary bladder Practical and convenient assessment

sites:◦ Ear, mouth, rectum, and axilla◦ Ear provides the temperature closest

to the core temperature

Taking axillary

Temperature

Digital thermometer is commonly used in infants and children, insert it at the axillary region

closed the arm and wait for timer to bustle

Remember when taking BT in infants and children make sure that the patient is not in distress mood because any change in the activity will directly affect the BT reading.

The Oral Cavity

Parts: Oral Vestibule and Oral Cavity Proper

Floor of the mouth

Insert the tip at the sublingual fossa

Positioned the thermometer

Let stay for 1 to 2 minutes, tell the patient to close the mouth

Clinical Thermometers

Instruments used to measure body temperature

Electronic Infrared Chemical Digital Glass

Types of Clinical Thermometers

(Refer to Table 12-3 in the textbook).

Electronic Thermometers

Infrared Tympanic Thermometer

Chemical Thermometer

Digital Thermometer

Glass thermometer (Glass)

Automated Monitoring Devices

Equipment that allows for the simultaneous collection of multiple data

Measure the temperature, blood pressure, pulse, heart rhythm, and pulse oximetry

Portable to save time and money

Continuous Monitoring Devices

Used primarily in critical care areas

Measure body temperature using internal thermistor probes within the esophagus of anesthetized clients, inside the bladder, or attached to a pulmonary artery catheter

Elevated Body Temperature

Fever is a condition in which the body temperature exceeds 99.3˚F (37.4˚C)

Pyrexia is a condition in which the temperature is warmer than the normal set point

Hyperthermia is a condition in which core temperature is excessively high and the temperature exceeds 105.8˚F (40.6˚C)

Symptoms of Fever

Pinkish, red (flushed) skin that is warm to the touch

Restlessness in some; excessive sleepiness in others

Irritability; poor appetite Glassy eyes and sensitivity to light Increased perspiration Headache

Symptoms of Fever (cont’d)

Above-normal pulse and respiratory rates

Disorientation and confusion (when the temperature is high)

Convulsions in infants and children (when the temperature is high)

Fever blisters about the nose or lips in clients who harbor the herpes simplex virus

Phases of Fever

Prodromal phase

Onset or invasion phase

Stationary phase

Resolution or defervescence phase

Phases of Fever and Physiologic Changes

Question

Is the following statement true or false?

Fever is a condition where the body temperature exceeds 105.8˚F.

Answer

False.

Fever is a condition where the body temperature exceeds 99.3˚F.

Hypothermia

Core body temperature less than 95˚F (35˚C)

Mildly hypothermic: 95˚F to 93.2˚F (35˚C to 34˚C)

Moderately hypothermic: 93˚F to 86˚F (33.8˚C to 30˚C)

Severely hypothermic: below 86˚F (30˚C)

Symptoms of Hypothermia

Shivering until body temperature is extremely low

Pale, cool, and puffy skin

Impaired muscle coordination

Listlessness and irregular heart rhythm

Slow pulse and respiratory rates

Incoherent thinking and diminished pain sensation

Pulse Rate

Pulse

Produced by the movement of blood during the heart’s contraction

In most adults, the heart contracts 60 to 100 times per minute at rest◦ Pulse rhythm◦ Pulse volume◦ Pulse rate

Pulse Assessment Techniques

Primary pulse assessment site: radial artery located at inner (thumb) side of the wrist

Alternate assessment techniques◦ Counting the apical heart rate◦ Obtaining an apical–radial rate◦ Using a Doppler ultrasound device over

a peripheral artery

Age Average Range

Newborn to 1 month

130 80-180

1 year 120 80-140

2 years 110 80- 130

6 years 100 75- 120

10 years 70 50-90

Adult 80 60- 100

Pulse rate/ Minute

Variations in Pulse Rate

Kozier Barbara, et.al. Fundamentals of Nursing , 5th ed. (US Addison-Wesley Publishing Company, Inc. 1995) p. 438

Peripheral Pulse Sites

5. The pulse is normally palpated by applying are moderate pressure with the three fingers of the hand.

6. The pads of the most distal aspect of the fingers are the most sensitive areas of detecting the pulse.

Pulse site Reasons for Use

Radial Readily accessible & routinely used

Temporal Used when radial pulse is not accessible

Carotid Used for infants, in cases of cardiac arrest and to determine the circulation to the brain

Apical Routinely used in infants and children up to 3 years of age, Used to determine the discrepancies with radial pulse, and

Used in conjunction with some medication

Brachial Used to measure blood pressure, used for cardiac arrest for infants

Femoral Used in cases of cardiac arrest, for infants and children, determine circulation in the leg

Popliteal Used to determine the circulation in the lower leg and leg blood pressure

Posterior tibial

Used to determine the circulation in the foot

Pedal Used to determine circulation in the foot

Respiration

• Rapid respiratory rate

– Tachypnea accompanies elevated temperature or diseases affecting cardiac and respiratory systems

• Slow respiratory rate

– Bradypnea can result from medications; observed in clients with neurologic disorders or hypothermia

Respiratory Rate

• Hyperventilation• Hypoventilation• Dyspnea• Orthopnea• Apnea• Stertorous breathing• Stridor

Abnormal Breathing Characteristics

• Exchange of oxygen and carbon dioxide

• Respiratory rate is the number of ventilations per minute

• Cheyne-Stokes respiration: a breathing pattern in which the depth of respirations gradually increases, followed by a gradual decrease, and then a period when breathing stops briefly before resuming again

Respiration

Age Average Range

Newborn 35 30-80

1 year 30 20-40

2 years 25 20-30

8 years 20 15-25

16 years 18 15-20

Adult 16 12-20

Respiratory rate/ Minute

Variations in Respiratory rate


BLOOD PRESSURE

Blood Pressure

Force that the blood exerts within the arteries

Lower-than-normal volumes of circulating blood cause a decrease in blood pressure

Excess volumes cause an increase in blood pressure

Regular aerobic exercise increases tone of heart muscle and increases efficiency

Cardiac output

Blood Pressure (cont’d)

Cardiac output is approximately 5 to 6 L in adults at rest

Blood pressure measurements provide physiologic data about:

◦ Ability of arteries to stretch

◦ Volume of circulating blood

◦ Amount of resistance heart must overcome when it pumps blood

Factors Affecting Blood Pressure

Age

Circadian rhythm

Gender

Exercise and activity

Emotions and pain

Factors Affecting Blood Pressure (cont’d)

Lower blood pressure

◦ Lower when lying down than when sitting or standing

Higher blood pressure

◦ When urinary bladder is full, when the legs are crossed, when the person is cold

◦ When drugs that stimulate the heart are taken

Pressure Measurements

Systolic pressure Diastolic pressure Blood pressure is expressed in millimeters

of mercury (mm Hg) as a fraction; systolic pressure/diastolic pressure

Pulse pressure: difference between systolic and diastolic blood pressure measurements

Assessment Sites

Usually assessed over the brachial artery

Lower arm and radial artery Measured over the popliteal artery

behind the knee in case:◦ Client’s arms are missing

◦ Both of a client’s breasts have been removed

◦ Client has had vascular surgery

Equipments for Measuring Blood Pressure

Sphygmomanometer Aneroid manometer Electronic oscillometric

manometer Inflatable cuff Stethoscope

Aneroid and Electronic Oscillometric Manometer

Alternate Techniques for Assessing Blood Pressure

Palpation Using a Doppler stethoscope Automatic blood pressure

monitoring Measuring thigh blood pressure

Abnormal Blood Pressure Measurements

Blood pressures above or below normal ranges indicate significant health problems

Hypertension: high blood pressure Hypotension: low blood pressure Postural or orthostatic hypotension:

sudden but temporary drop in blood pressure when rising from a reclining position

Abnormal Blood Pressure Measurements (cont’d)

Hypertension or high blood pressure is associated with:

◦ Anxiety

◦ Obesity

◦ Vascular diseases

◦ Stroke, heart failure

◦ Kidney diseases

Documenting Vital Signs

Once vital sign measurements are obtained:◦ Document the data in medical record for

analysis of patterns and trends◦ Enter the data, along with any other

subjective or objective information in narrative nursing notes

Nursing Implications

Vital sign assessment is the basis for identifying problems

Nurses identify from the nursing diagnoses:◦ Hyperthermia, hypothermia, ineffective

thermoregulation, decreased cardiac output, risk for injury, or ineffective breathing pattern

Gerontologic Considerations

Lower “normal” or baseline temperature Changes in thermoregulation system Delayed or diminished febrile response to

illnesses Change in cognitive function,

restlessness, or anxiety may be initial sign of illness

Gerontologic Considerations (cont’d)

Susceptible to hypothermia and heat-related conditions; elevated blood pressure readings in clinical settings

Blood pressure assessment in bilateral arms; document subsequent trends

Older adults are more susceptible to arrhythmias and postural and postprandial hypotension

Gerontologic Considerations (cont’d)

If older client is hypotensive, plan for limited activities during the hour following eating or for frequent smaller food consumption throughout the day

More profound responses to cardiovascular medications than younger adults

Aneroid manometer with stethoscope

Part of the sphygmomanometer

Mercury manometer and cuff

Aneroid manometer and cuff

Variations in BP by AgeAge Mean BP (mm Hg)

Newborn 73/55

1 year 90/55

6 years 95/57

10 years 102/62

14 years 120/80

Adult 120/80

Elderly (over 70 years) Diastolic pressure may increase


The EndMy best wishes educator : Ekhlas abu hasna

introduction assessing vital signs or cardinal sign is a routine medical procedure. and somehow...

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