Download assessing vital signs

ASSESSING VITAL SIGNS
RLE 1a
VITAL SIGNS
• Also known as Cardinal Signs
• Includes TEMPERATURE, PULSE,
RESPIRATION, and BLOOD
PRESSURE
• A person’s physiologic status is
reflected by these indicators of
body function
Vital Signs are commonly assessed:
1. Screenings at health fairs and clinics
2. In the home
3. Upon admission to a healthcare
setting
4. When certain medications are given
Taylor’s p. 4
Vital Signs are commonly assessed:
5. Before and after diagnostic and
surgical procedures
6. Before and after certain
nursing interventions
7. In emergency
situations
Purposes of assessing Vital Signs
1. To obtain baseline measurement of
the patient’s vital signs
2. To assess patient’s response to
treatment or medication
3. To monitor patient’s condition after
invasive procedures
ASSESSING TEMPERATURE
Taylor’s p. 8
TEMPERATURE
•heat of the body measured in
degrees
•Difference between production of
heat and loss of heat
PROCESS OF HEAT PRODUCTION
DONE THROUGH:
1. Food Metabolism and Activity
2. Increased thyroxin production
3. Chemical thermogenesis
PROCESS OF HEAT LOSS IS DONE
THROUGH:
1. Radiation – surface to surface by
waves
2. Conduction – contact between 2
surfaces
3. Convection – mov’t by air currents or
fluid
4. Evaporation – water to steam
5. Elimination – urination, defecation
TYPES of TEMPERATURE
• Core Temperature
measured thru tympanic and rectal
routes
• Surface Temperature
measured thru oral and axillary
routes
FACTORS AFFECTING BODY
TEMPERATURE
1.
2.
3.
4.
5.
6.
7.
Age
Sex
Exercise
Time of day
Emotions
Environment
Others; food, drugs
COMMON SITES FOR ASSESSING
BODY TEMPERATURE
1. Oral – most frequently used, least
disruptive, most convenient
CONTRAINDICATIONS:





Infants and very young children
Patients with oral surgery
Unconscious or irrational patients
Seizure-prone patients
Mouth breathers and pts. with oxygen
COMMON SITES FOR ASSESSING
BODY TEMPERATURE
2. Rectal – most accurate route, but
invasive and uncomfortable to
patient
CONTRAINDICATIONS:




Rectal abnormalities
Diarrhea
Certain heart conditions
Immunosuppressed
COMMON SITES FOR ASSESSING
BODY TEMPERATURE
3. Axillary – safer than the oral method,
non-invasive, least accurate
4. Tympanic – accessible, less invasive
CONTRAINDICATIONS:




Presence of ear ache
Significant ear drainage
Scarred tympanic membrane
Sleeping with the head turned on one side
ROUTE
SPECIAL
CONSIDERATIONS
ORAL
•Done for 3 minutes
•Upon intake of hot/cold fluids,
wait 30 minutes
RECTAL
•Done for 2-3 minutes
•Presence of fecal matter could
result to a false reading
•Lubricate tip prior to inserting
AXILLARY
TYMPANIC
•Done for 10 minutes
•Within two seconds
•Up/back for adult
•Down/back for pedia
ASSESSING TEMPERATURE
(axillary route)
Taylor’s p.14
Unexpected Situations in
assessing TEMPERATURE
Taylor’s p. 16
• Temperature higher/lower than
expected based on how skin feels
(re-assess with new thermometer)
• Feeling lightheaded or passes out
during rectal temp assessment
(remove thermometer immediately,
assess BP & HR, notify doctor, don’t
take another rectal temp)
Pyrexia
Elevated BT
Hyperpyrexia
BT above 41˚C
Intermittent fever
BT alternates regularly between
periods o fever, normal or
subnormal temperature
Remittent fever
Fluctuations of several degrees
above normal, but not reaching
normal between fluctuations
Constant fever
Consistently elevated and
fluctuates very little
Relapsing fever
Returns to normal for at least a
day then the fever occurs
Resolution of Pyrexia
by crisis
Elevated BT returns to
normal suddenly
ASSESSING PULSE
Taylor’s p. 16
T
a
PULSE
y
• A wave of blood being pumped into
l the
o
arterial circulation by the contraction
r
of the left ventricle
’
• Throbbing sensation palpated over a
peripheral artery
ASSESSMENT PARAMETERS /
CHARACTERISTICS OF PULSE
1. Rate – number of beats per
minute
AGE GROUP
Newborn
PULSE RANGE
80-180 bpm
Adults
60-100 bpm
Elderly
60-100 bpm
ASSESSMENT PARAMETERS /
CHARACTERISTICS OF PULSE
2. Rhythm – pattern or regularity of beats
and interval between each beat
Term
Pulsus regularis
Arrhythmia
Premature beat
Heart rhythm
Meaning
Equal rhythm
Irregular rhythm
Beat that occurs
between normal beats
Time interval between
each heartbeat
ASSESSMENT PARAMETERS /
CHARACTERISTICS OF PULSE
3. Volume/amplitude – amount of blood
pumped with each heartbeat
Cardiac Output – 5-6 Liters of blood
is forced out of the left
ventricle per minute
Pulse Deficit – difference
between the apical and
radial counts taken
simultaneously
ASSESSMENT PARAMETERS /
CHARACTERISTICS OF PULSE
Amplitude Interpretation
+4
Bounding:felt by exerting only light
pressure over artery
+3
Normal
+2
weak
+1
Feeble/thready: difficult to feel & easily
obliterated by pressure
0
absent
LOCATION OF PERIPHERAL
PULSES
Taylor’s p. 5
FACTORS AFFECTING PULSE RATE
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Age
Sex
Exercise
Emotions
Prolonged heat application
Body positions
Pain
Decreased BP
Increased temperature
Any conditions resulting to poor
oxygenation of blood ex. CHF
ASSESSING A PULSE
Taylor’s p. 17
ASSESSING RESPIRATION
Respiration
Pulmonary ventilation –(breathing)
movement of air in and out of the lungs
Inspiration –(inhalation) act or breathing in
Expiration –(exhalation) act of breathing out
External respiration – exchange of O2 and CO2
between alveoli and blood
Internal respiration – exchange of O2 and CO2
between blood and tissue cells
ASSESSMENT PARAMETERS /
CHARACTERISTICS OF RESPIRATION
1. Rate – number of breaths per minute
AGE GROUP
RESPIRATORY RANGE
Newborn
30 – 60 bpm
Adults
12-20 bpm
ASSESSMENT PARAMETERS /
CHARACTERISTICS OF RESPIRATION
2. Rhythm – regularity of respiration,
inhalation and exhalation are
evenly spaced
Regular
Effortless, quiet
Irregular
Abnormal
ASSESSMENT PARAMETERS /
CHARACTERISTICS OF RESPIRATION
3. Depth – assessed by watching the
movement of the chest
2 TYPES OF BREATHING
1. Costal/thoracic breathing – involves
external intercostal muscles and
other accessory muscles
• Observed thru upward and outward
movement of the chest
2. Diaphragmatic/abdominal breathing –
involving the contraction and
relaxation of diaphragm
• Observed by the movement of the abdomen
FACTORS AFFECTING
RESPIRATION
1.
2.
3.
4.
5.
6.
Exercise
Certain infections
Age
Emotions
Cardiac illness
stress
TERMINOLOGIES REGARDING
RESPIRATION
Eupnea
Tachypnea
Bradypnea
Apnea
Hyperpnea
Cheyne stokes
Normal, effortless breathing
RR > 24 bpm
RR < 10 bpm
Absence of breathing
Deeper respiration with normal rate
Resp. becomes faster and deeper then slower
with alternate periods of apnea(20-60sec)
Biot’s
Faster and deeper than normal with
abrupt pauses in between each breath
TERMINOLOGIES REGARDING
RESPIRATION
• Kussmaul’s
• Apneustic
• Dyspnea
• Orthopnea
• Wheezing
• Stridor
Faster and deeper respi.
without pauses in between
panting
Prolonged grasping followed by
extremely short insufficient
exhalation
difficulty of breathing
DOB unless sitting
narrowing of airways, causing
whistling or sighing sounds
high-pitched sounds heard on
inspiration
TERMINOLOGIES REGARDING
RESPIRATION
• Rales -
• Rhonchi
sound caused by air passing
thru fluid or mucus in the
airways usually heard on
inhalation
sound caused by air passing thru
airways narrowed by fluids,
edema, muscle spasm usually
heard during exhalation
ASSESSING RESPIRATION
Taylor’s p. 20
BLOOD PRESSURE
-Force of the blood against the
arterial walls
-Measured in millimeters of mercury
(mmHg)
Systole – the highest pressure
Diastole – the lowest pressure
Pulse pressure – difference between the
systole and diastole
BLOOD PRESSURE
Basic Terms:
• Korotkoff’s sound
• Hypertension – above 140/90 mmHg
• Hypotension – below 90/60 mmHg
• Orthostatic Hypotension –
decrease in Bp when changing
position
Factors that control Blood Pressure
1. Cardiac Output – amount of blood
ejected from the heart per
contraction
2. Blood Volume – adult has about
5-6 liters of circulating blood
3. Elasticity of arterial walls – yields
upon systole and retracts upon
diastole
Factors affecting Blood pressure
1.Age
2.Emotions
3.Exercise
4.Drugs
5.Environment
To ensure accuracy in taking the BP,
you must:
1.Let the patient rest for a minimum
of 5 minutes for routine assessment
2. Should not have ingested caffeine
or nicotine 30 minutes before
3.Delay assessing if patient is in pain,
emotionally upset, have just
exercised.
Assessing Blood Pressure
Taylor’s p. 23