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Chapter 8 Vital Signs 1 T--temperature P--pulse Vital Signs R--respiration Bp--blood pressure 2 vital signs reflect the body’s physiological status present condition provide information to evaluate homeostatic balance in status be a quick and efficient way to monitor a patient’s condition to identify problems to evaluate the patient’s response to intervention 3 vital signs Vital signs and other physiological measurements are the basis for clinical problem solving. An alteration in vital signs may signal the need for medical or nursing intervention. --Vital signs should be taken at regular intervals. --As nurses we should know the relevant knowledge about vital signs be able to measure vital signs accurately interpret their significance make decisions about interventions 4 SectionⅠ Guidelines for Taking Vital Signs 1. select equipment : be functional and appropriate based on the patient’s condition and characteristics 2. know the patient’s normal range of vital signs ---serve as a baseline for comparison with findings taken later 3. know the patient’s medical history, therapies, and prescribed medications Some illnesses or treatments cause predictable vital sign changes. Most medications affect at least one of the vital signs. 5 SectionⅠ Guidelines for Taking Vital Signs 4. control or minimize environmental factors may affect vital signs 5. use an organized, systematic approach when taking vital signs ---each procedure requires following a step-by-step approach to ensure accuracy 6. the frequency of vital signs assessment --based on the physician and the patient’s condition 6 SectionⅠ Guidelines for Taking Vital Signs 7. use vital sign assessment to determine indications for medication administration ----cardiac drugs 8. analyze the results of vital sign measurement--not interpret them in isolation 9. verify and communicate significant changes in vital signs 7 SectionⅡ Body Temperature Physiology of Body Temperature Factors Affecting Body Temperature Alterations in Body Temperature Nursing Process and Thermoregulation 8 Physiology of Body Temperature Definition of body temperature Heat production and heat loss Regulation of body temperature Average temperature and normal range of adult 9 Definition of body temperature Body temperature is the heat of the body.-- reflects the balance between the amount of heat produced by body processes the amount of heat lost to the external environment 10 Definition of body temperature core temperature : temperature of deep tissues (cranium, thorax, abdominal and pelvic cavity ), relatively constant Surface temperature :the temperature of the skin, the subcutaneous and the fat tissue , fluctuates from 36℃ to 38℃ 11 Heat Production Heat is produced in the body through metabolism. The main heat production organs of the body are liver and skeletal muscles. Heat production occurs during rest, voluntary movements, involuntary shivering, and nonshivering thermogenesis(brown adipose). 12 Heat Loss Heat is lost through physical mode. The main heat loss part of the body is skin. (70%) (R29%,elimination1%) Radiation Conduction Convection Evaporation 13 Radiation Radiation is the transfer of heat between two objects without direct contact by electromagnetic waves. Heat radiates from the skin to any surrounding cooler object. increase T difference between two objects Increase radiating surface area Increase the extent of vasodilation heat loss 14 Conduction Conduction is the transfer of heat from one object to another with direct contact. When the warm skin touches a cooler object(solid; gas; liquid), heat is lost. Heat loss velocity depends on Heat conducting capability T difference between the two objects Contacting area 15 Convection Convection is the transfer of heat away by air or liquid movement. Heat is first transferred to air or liquid molecules directly in contact with the skin. Air or liquid currents carry away the warmed air or liquid. Heat loss velocity depends on current velocity T difference between the object and air or liquid 16 Evaporation Evaporation is the transfer of heat energy when a liquid is changed to a gas. The body continuously loses heat by evaporation. --R;skin 300-400ml/d By regulating sweating, the body promotes additional evaporative heat loss. --febricide Evaporation is the main heat loss mode when environment temperature is higher than body temperature. 17 Regulation of Body Temperature Neural and Vascular Control Behavioral Control 18 Neural and Vascular Control T regulation center :the hypothalamus , controls body temperature the same way a thermostat works in the home (reflex arc) the anterior hypothalamus controls heat loss Via sweating, vasodilation, inhibition of heat production the posterior hypothalamus controls heat production via muscle shivering , heat conservation by vasoconstriction of surface blood vessels 19 Normal Blood Temperature (37℃ ) (to or toward) Factors which increase metabolic rate or Environmental temperature Increased blood temperature above level at which “thermostat” in hypothalamus is set (37℃ ) Decreased blood temperature Stimulated thermal receptors Of heat-dissipating center in hypothalamus, initiating impulses that lead to Increased heat Loss by evaporation Increased sweat secretion Increased heat Loss by radiation Dilation of skin blood vessels Heat loss mechanisms to maintain normal body temperature 20 Behavioral Control environmental temperature fall: add clothing move to a warmer place raise the thermostat setting increase muscular activity by running sit with arms and legs tightly wrapped together 21 Behavioral Control The ability of a person to control body temperature depends on the degree of temperature extreme the person’s ability to sense feeling comfortable or uncomfortable--infants, older adults thought processes or emotions--depression the person’s ability to remove or add clothes —infants, children 22 Average Temperature and Normal Range of Adult site average temperature normal range oral 37℃ 36.3-37.2℃ rectal 37.5℃ 36.5-37.7℃ axillary 36.5℃ 36.0-37.0℃ 23 Factors Affecting Body Temperature Measurement site Circadian rhythms : drops between 2 and 6 AM peaks between 1 and 6PM Age: With age,T tends to fall . infancy: temperature regulation is labile aging: control mechanisms deteriorate 24 Factors Affecting Body Temperature Hormonal influences : progesterone: raise the body temperature Exercise :increase body temperature Medications: anaesthetic: depress T regulation center promote vasodilation T febrifuge: T 25 Factors Affecting Body Temperature Stress: Stimulate sympathetic nervous system -- epinephrine and norepinephrine production , -- metabolic activity heat production --T Environment: the extent of exposure, air temperature and humidity the presence of convection currents Ingestion of hot/cold liquids Smoking: increase body temperature 26 Alterations in Body Temperature Fever or Hyperthermia Hypothermia 27 Fever or Hyperthermia A body temperature above the usual range is called fever. A true fever results from an alteration in the hypothalamic set point. Pyrogens such as bacteria and virus cause a rise in body temperature. Fever is an important defense mechanism. 28 Fever process and manifestation Fever-chill phase: heat production>heat loss; experience tiredness, paleness, dryness, chills, shivers, and feels cold (2 patterns) plateau phase : heat production=heat loss; warm , dry, R , P , headache, faint, inappetence fever break phase: heat production<heat loss; skin -- warm, flushed, diaphoresis (2 patterns) 29 Hyperthermia (clinical) An elevated body temperature related to the body’s inability to promote heat loss or reduce heat production is hyperthermia. Any disease or trauma to the hypothalamus can impair heat loss mechanisms. 30 Classification of Fever (Oral) ℃ ℉ Mild 37.5℃-37.9℃ 99.5℉-100.2℉ Moderate 38.0℃-38.9℃ 100.4℉-102.0℉ Severe 39.0℃-39.9℃ 102.2℉-105.6℉ Profound >41℃ >105.8℉ 31 Patterns of Fever is the modality of a temperature curve. differ depending on the causative pyrogen. The increase or decrease in the amount of pyrogens results in fever spikes and declines at different times of the day. The duration and degree of fever depends on the pyrogen’s strength and the ability of the individual to responds. ----serve a diagnostic purpose. 32 Patterns of Fever Constant Fever Remittent Fever Intermittent fever Irregular Fever 33 Constant Fever sustains between 39~40℃ demonstrates little fluctuation of less than 1℃ within 24 hours. ( pneumonia , typhoid) 34 Remittent Fever has great fluctuation above the normal with more than 1℃ in 24 hours and cannot return to normal temperature level. (septicemia , rheumatic fever) 35 Intermittent fever fluctuates greatly in 24 hours, may suddenly rise above the normal then suddenly fall to or below the normal alternates regularly between a period of fever and a period of normal temperature levels (malaria, tuberculosis) 36 Irregular Fever irregularity alternates between a period of fever and a period of normal temperature values. ( influenza , cancer) 37 Hypothermia A body temperature below the lower limit of normal 35℃ is called hypothermia. Heat loss during prolonged exposure to cold overwhelms the body’s ability to produce heat,causing hypothermia. Hypothermia may be intentionally induced during surgical procedures to reduce metabolic demand and the body’s need for oxygen. 38 Classification of Hypothermia ℃ ℉ Mild 33.1℃-36℃ 91.5℉-96.8℉ Moderate 30.0℃-33℃ 86.1℉-91.4℉ Severe 27℃-30℃ 80.6℉-86.0℉ Profound <27℃ <80.6℉ 39 Manifestation of Hypothermia 34.4-35℃: uncontrolled shivering,loss of memory,depression, poor judgment falls below 34.4℃ heart and respiratory rates blood pressure fall skin ---- cyanotic progress--- cardiac dysrhythmias, loss of consciousness, unresponsive to painful stimuli 40 Nursing Process and Thermoregulation Assessment Nursing Diagnosis Planning Implementation Intervention 41 Assessment Sites: mouth,rectum, axillary tympanic membrane Thermometers Glass Thermometer Electronic Thermometer Disposable Thermometer 42 Glass Thermometer VCD 43 Electronic Thermometer 44 Disposable Thermometer 45 Nursing Diagnosis Nursing diagnosis Hyperthermia Diagnostic foundation Increase body temperature above usual range Flushed skin, skin warm to touch Increased pulse and respiratory rate Herpetic lesions of the mouth Hypothermia Decreased body temperature Pale, cool skin Decreased pulse and respiratory rate Feelings of cold and chill Ineffective Older adults or infants, weak inability to adapt thermoregulation to environmental temperature 46 Planning require an individualized care plan -maintaining normothermia and reducing risk factors. education is important Objects: restoring normothermia minimizing complications promoting comfort care plan should support goals 47 Examples for goals and outcomes Goal Restore and maintain normothermia. Outcome Temperature maintained within normal range during environment changes. 48 Examples for goals and outcomes Goal Outcomes Minimize complications of altered body temperature. patient’s blood pressure, pulse, and respirations are within normal limits patient’s skin integrity maintained patient’s nutritional intake meets body needs patient’s mucous membranes are moist patient is able to participate in ADL activities patient’s skin is warm and pink patient reports sense of rest and comfort 49 Examples for goals and outcomes Goal Reduce risk of altered body temperature. Outcomes patient identifies risk factors for altered body temperature patient practices measures to prevent body temperature alteration 50 Implementation Nursing measures for patient with a fever Nursing Interventions for patient With Hypothermia 51 Nursing measures for patient with a fever Assessment • Obtain body temperature during each phase of febrile episode. •Assess for contributing factors such as dehydration, infection,or environmental temperature. •Identify physiological response to temperature. Obtain a11 vital signs. Observe skin color. Assess skin temperature. Observe for shivering and diaphoresis. Assess patient comfort and well-being. •Determine phase of fever--chill,plateau,fever break. 52 Nursing measures for patient with a fever Intervention 1.Promote heat loss and lower the temperature. Limit physical activity--heat production reduce external covering--heat loss physical therapies:ice packs ; bathing with alcoholwater solutions medication Take temperature after lowering the temperature physically for 30 minutes, record the readings. 53 2.Intensify observation of the patient’s conditions. •take temperature 1 time/4h--severe fever, 4 time/day T<38.5℃ 1-2 times/day for three days after body temperature returns normal. • Observe patient’s face color, pulse, respiration, diaphoresis and other signs when taking patient’s temperature. • Assess for contributing factors such as dehydration, infection,or environmental temperature. • Observe therapeutic effect. • Observe the intake of liquids and the output of urine. • Contact physicians conditions. promptly when find abnormal 54 3. Provide nutrients to meet increased energy needs • Provide measures to stimulate appetite,and offer wellbalanced meals. • Provide fluids at least 3000ml per day for patient with normal cardiac and renal functional to compensate fluids lost through insensible water loss and sweating. 55 4.Promote comfort and prevent complications. • Allow rest periods. • Control temperature of the environment without inducing shivering. • Provide oral hygiene and keep oral moist to prevent oral infection. • Keep clothing and bed sheet dry to increase comfort and heat loss through conduction and convection. 56 5.Provide psychological care. • Meet patient’s reasonable requirements. • Provide health education about fever. 6.Obtain blood cultures when ordered. 7.Provide supplemental oxygen therapy as ordered to improve oxygen delivery to body cells when ordered . 57 Nursing Interventions for patient With Hypothermia • Control environment temperature at 22~24℃. •Elevate body temperature. • patients are monitored closely for cardiac irregularities and electrolyte imbalances. Observe the vital signs, take temperature once at least per hour until the temperature returned normal and stability. • Eliminate pathogeny. • Health education. 58 Evaluation all nursing goals have been met use other evaluative measures such as palpation of the skin and assessment of pulse and respirations If therapies are effective,body temperature will return to a normal range, other vital signs will stabilize and the patient will report a sense of comfort. 59 Section Ⅲ Pulse Physiology and Regulation Character of The Pulse and Observation of Abnormal Pulse Nursing process and Pulse Determination 60 Physiology and Regulation The pulse is the rhythmical throbbing of arteries produced by the regular contraction of the heart. The number of pulsing sensations occurring in 1 minute is the pulse rate. Healthy adult pulse rate can range between 60-100 beats per minute in quiet state. 61 Forming of Pulse Electrical impulses from the sinoatrial node travel through heart muscle to stimulate cardiac contraction. Approximately 60 to 70 ml (stroke volume) of blood enters the aorta with each ventricular contraction. The arterial walls expand to compensate for the increase in pressure. As the ventricle of the heart is in diastole, arterial walls return to original status by its own elasticity and peripheral resistance. 62 Forming of Pulse The expansion and retraction of the aorta sends a wave through the walls of the arterial system that can be felt as a light tap on palpation. The pulse is the palpable bounding of the blood flow. 63 Factors Influencing Pulse Rate Age Normally Pulse Rates at Varies Ages Age normal range of pulse rate (beats/min) Infants 120-160 Toddlers 90-140 Preschoolers 80-110 School ages 75-100 Adolescent 60-90 Adult 60-100 64 Sex : After puberty, the average male pulse rate is slightly lower than the female. 5 times/min Exercise Temperature: Fever ; Emotions: Acute pain ,anxiety -- pulse rate Hypothermia Unrelieved severe pain-- pulse rate Drugs : atropine digitalis Postural changes: Standing or sitting , Lying down Hemorrhage: Pulmonary conditions: poor oxygenation 65 Character of The Pulse and Observation of Abnormal Pulse Pulse Rate Pulse Rhythm Strength Equality 66 Abnormal Pulse Rate Tachycardia is an abnormally elevated heart rate,above 100 beats per minute in adults. (fever, anemia, hemorrhage, hyperthyroidism) Bradycardia is a slow rate, below 60 beats per minute in adults.(atrioventricular block, increased intracranial pressure, hypothyroidism ) 67 Pulse Rhythm Normally a regular interval of time occurs between each pulse or heart beat.An interval interrupted by an early or late beat or a missed beat indicates an abnormal rhythm or dysrhythmia. 68 Abnormal Pulse Rhythm Intermittent Pulse Pulse Deficit 69 Intermittent Pulse one pulse missing during regular or irregular pulse patterns one pulse absents every one pulse-bigeminy one pulse absents two normal pulses be called -- trigeminy occur in cardiomyopathy, myocardial infarction, digitalis intoxication, and transient symptoms caused by excited emotion or fear 70 Intermittent Pulse threatens the heart ability to provide adequate cardiac output An electrocardiogram (ECG) is necessary to define the pulse dysrhythmia. Children often have a sinus dysrhythmia, which is an irregular heartbeat that speeds up with inspiration and slows down with expiration. 71 Pulse Deficit Refers to pulse rate is less than heart rate An inefficient contraction of the heart --fails to transmit a pulse wave to the peripheral pulse site --creates a pulse deficit. To assess a pulse deficit simultaneously --one nurse assess radial rates --a colleague assess apical rates It can be seen in patients with atria fibrillation. 72 Strength reflects the volume of blood ejected against the arterial wall with each heart contraction and the condition of the arterial vascular system leading to the pulse site normally remains the same with each heartbeat may be graded or described as strong, weak,thready,or bounding 73 Abnormal Strength Bounding Pulse Thready Pulse Alternating pulse Water Hammer Pulse Paradoxical Pulse 74 Bounding Pulse an increased stroke volume, which can be palpated by fingertips slightly often be seen with fever, hyperthyroidism, and aortic valve incompetence. 75 Thready Pulse weak and diminished, which is barely by fingertips often occurs with massive hemorrhage, shock, and aortic stenosis 76 Alternating pulse alternates between increased and diminished patterns along with strong and weak contraction of the ventricles common causes are hypertensive heart disease, myocardial infarction 77 Water Hammer Pulse The abrupt distension and quick collapse of the pulse is palpated following the increased cardiac output with resultant pulse pressure surges. It often occurs with hyperthyroidism, aortic valve incompetence. 78 Paradoxical Pulse The pulse is obviously weak or not palpable on inspiration. It results from the declined strokes by the left ventricle on inspiration. Common causes are pericardial effusion and constrictive pericarditis. 79 Equality The nurse should assess both radial pulses to compare the characteristics of each. A pulse in one extremity may be unequal in strength or absent in many diseases, such as thrombosis, aberrant blood vessels, or aortic dissection. The carotid pulse should not be measured simultaneously because excessive pressure may stop blood supply to the brain. 80 Nursing process and Pulse Determination Assessment Nursing Diagnosis Nursing Plan Implementation Evaluation 81 Assessment the nurse should collect the following data: the patient’s general condition, such as age , sex, status of an illness and treatment; the pulse rate, rhythm, strength, equality and factors influencing pulse arterial wall elasticity 82 Nursing Diagnosis Tachycardia; bradycardia; dysrhythmias ; activity intolerance; anxiety; fear; fluid volume deficit; gas exchange impaired; Hyperthermia; and hypothermia 83 Nursing Plan interventions based on the nursing diagnosis identified and the related factors; the expected outcomes generally: patients can tell the normal range and physiological changes of the pulse; patients can cooperate with the treatment and care. 84 Implementation Instruct the patients to rest to decrease heart energy consuming. Oxygen administration is provided, according to the patient’s condition. Observe the patients’ condition closely. 85 Implementation Instruct the patients to take medicine on time and observe the effect and side effect of the medicine. Tell the patients to keep first-aid medicine along with them. Provide mental support, let the patients to keep steady mood. 86 Implementation Health education: stop smoking and drinking take light and digestible diet, keep bowels smooth; teach the patients to monitor the pulse prior to taking medicines that affect the heart rate. Tell the patients to report any notable changes of heart rate or rhythm to health care provider. Teach the patients and family members the basic first-aid skills. 87 Evaluation evaluate the therapeutic effect by assessing the pulse rate, rhythm, strength, and equality; evaluate the patients’ mental status, cooperation with treatment and nursing; evaluate the patients’ knowledge about health. 88