Download Chapter 4 Vital Signs and Pain Assessment Anatomy and

Chapter 4
Vital Signs and Pain Assessment
Anatomy and Physiology
Temperature
Pulse rate
Respiratory rate
Blood pressure
Pain
Measurement of Vital Signs
Temperature: indirect measure of body’s core temperature
Pulse: measure of heart rate
Respiration: measure of inspiration and expiration
Blood pressure: peripheral measurement of cardiovascular function
Use appropriate size.
Pain: uncomfortable sensation and emotional experience associated with tissue damage
Temperature
Regulated by hypothalamus
Pyrexia – (fever) – triggered by the production of prostaglandins
Shivering – rapid contraction and relaxation of muscles reduces heat loss through the skin
Vasodilation – increases heat loss through the skin
Pulse
Arterial pulse results when the ventricular heart contraction pushes a pressure wave of blood
throughout the arterial system.
Respiratory Rate
Primary muscles of respiration are the diaphragm and intercostal muscles
Inspiration
Diaphragm moves downward
External intercostal muscles
Expiration
Internal intercostal muscles
Blood pressure
Force of the blood against the wall of an artery as the ventricles contract and relax
Systolic
Force exerted when the ventricles contract
Diastolic
Force exerted by peripheral resistance when the heart is filling or relaxed
Pain
Acute pain is sudden, of short duration, and usually associated with surgery, injury, or acute
illness.
Chronic pain is persistent, lasting weeks or months, or longer; usually associated with prolonged
disease.
Nociceptors are free nerve endings activated to transmit pain impulses.
Pain (Cont.)
Biochemical mediators
Bradykinin
Prostaglandin
Leukotrienes
Serotonin
Histamine
Catecholamines
Substance P
Pain (Cont.)
Biochemical mediators produced in response to tissue damage help move the pain impulse from
the nociceptors (pain receptors) to:
Dorsal horn of the spinal cord
Lateral spinothalamic tract and reticulospinal and spinomesencephalic nerve pathways
Brain where pain is perceived
Nociception
Mediated by two specialized nerve fibers:
Myelinated A-delta fibers (large): carry sharp, well-localized pain, which is quickly
transmitted
Unmyelinated C-polymodal fibers (small): carry dull, burning, diffuse, and chronic pain,
which is slowly transmitted
Pain (Cont.)
Nociceptors transmit pain impulses along A-delta and C fibers to the dorsal horn of the spinal
cord.
After the sensory information reaches the dorsal horn of the spinal cord, there is two-way control
of nociceptive transmission within the spinal tracts.
The pain signal may be modified depending on the presence of other stimuli, from either
the brain or the periphery.
Pain (Cont.)
Response to pain is individualized because it is physiologic, behavioral, and an emotional
phenomenon.
Nonpain impulses (e.g., ice, massage) can compete with pain impulses for transmission along the
spinal tracts to the brain and alter the perception of pain.
Physical Examination
Temperature
Pulse rate
Respiratory rate
Blood pressure
Assessing pain
Infant and children pain scales
Temperature
Expected range – 97.2° to 99.9° F (36.2° to 37.7° C)
Commonly performed:
Oral
Rectal
Axillary
Tympanic
Forehead
Pulse Rate
Best palpated over carotid, brachial, radial, femoral, popliteal
Count pulsations for 30 seconds (multiply x 2)
Average adult pulse 60 to 100
Determine steadiness of the heart rhythm
Respiratory Rate
Count the number of breaths per minute
Best to count after counting the pulse
Count for 30 seconds and multiply x 2
Expected adult rate is 12 to 20 breaths per minute
Blood pressure
Measured when the patient is seated using the right arm
Cuff size
Blood pressure
Check palpable systolic BP first
Korotkoff sounds
Assessment of Pain
Subjective symptom that can be from many different conditions
The pain experience and its characteristics and intensity are unique for each individual
Assessment of the pain character and intensity
Pain Scales
Samples of self-reporting pain scales
Assessing pain behaviors
Guarding
Facial mask of pain
Vocalizations
Body movements
Vital sign changes
Pallor
Dry mouth
Abnormalities
Hypertension
Most common disease in the world
Defined as BP consistently above 140/90
Essential HTN poorly understood
Secondary HTN underlying diseases – renal disease, renal artery stenosis, thyroid disorders,
coarctation of the aorta, pheochromocytoma
Neuropathic Pain
Causes – postherpetic neuralgia, diabetic peripheral neuropathy, trigeminal neuralgia, or
radiculopathy
Damaged peripheral nerves fire repeatedly
Doral horn neurons are hyperexcited and transmit enhanced pain to the brain
Complex Pain Syndrome
No relationship between the original trauma severity, and the severity and cause of the symptoms
Cause is unknown
Sympathetic nervous system helps maintain symptoms
Question 1
How does an examiner determine the correct size of a blood pressure cuff on an adult? The cuff
should:
A. Be 2½ to 3 times the length of the arm
B. Be able to wrap around the arm once
C. Cover 25% of the upper arm
D. Be 80% of the circumference of the arm
Question 2
Potential causes of secondary hypertension include all of the following except:
A. Increased water intake
B. Renal artery stenosis
C. Thyroid disorders
D. Coarctation of the aorta
Question 3
The primary muscles of inspiration are:
A. Diaphragm and intercostal
B. Ribs and sternum
C. External intercostal
D. Internal intercostal
Question 4
Infants are more susceptible to hypothermia due to:
A. Higher pulse rate
B. Thinner skin, large body surface area for weight ratio
C. Limited ability to cope with warm environments
D. Undeveloped A-delta fibers at birth
Question 5
The best method to determine the presence of Korotkoff sounds is:
A. Use the diaphragm of the stethoscope
B. Use the first and second fingers to palpate
C. Use the bell of the stethoscope
D. Use the sphygmomanometer
Question 6
The perception of pain:
A. Is the same across cultures
B. Does not apply to neonates
C. Is predictable with the same circumstances
D. Is impacted by emotions and quality of sleep