VITAL SIGNS

MEASURING OF VITAL SIGNS

Definitions of Vital Signs Alterations in body function often are reflected in body temperature, the pulse, respiration, and the pressure. Physiological mechanisms governing them are very sensitive and normally keep them regulated within a narrow range.

MEASURING OF VITAL SIGNS

Any change from normal is considered to be an indication of the persons state of health. Hence, these signs provide excellent clues to the physiological functioning of the body. That is why they are called vital signs or cardinal signs.

Frequency of obtaining vital signs

Obtaining a persons vital signs is part of most agency admission procedures. These data provide part of the baseline information from which a plan of care is developed.

Frequency of obtaining vital signs

After patient is admitted to a health agency, local policies govern when and how frequently vital signs are to be obtained. It is common policy for patient having elevated temperatures and for those who are in the post operative period to have vital signs obtained every 4 hours. Severely ill patients may have these observations made more frequently. In some self care and psychiatric unit. Temperature, or other vital signs disturbances, there seems to be little justification for observations these signs several times a day.

 The introduction of monitoring devices has made it possible to keep patients vital signs under constant surveillance in hospital setting. This has been a lifesaving measure for many patients because it provides a far more accurate means of observations the effects of pathology and therapy.

BODY TEMPERATURE
Humans are homoeothermic; that is they are warm blooded and maintain body temperature independently of their environment. Cold- blooded animals are poikilothermic,, meaning their body temperature is the same as their environment. Fish , frogs and reptiles are poikilothermic.

Temperature Regulation
Body temperature is maintained through a balance between heat production and heat loss.

There are various ways in which the bodys thermal balance is maintained.

Temperature Regulation
Heat is produced through the metabolism of food. More heat is produced when metabolism is increased, and less when metabolism is decreased. Heat production is increased by the bodys secretions of epinephrine , norepinephrine and thyroxin. Exercise produces heat by stimulating metabolism.

 The body gains heat physically from its environment, but this is of lesser significance that heat produced chemically. Heat is dissipated from the body primarily through physical processes. As much as 95% is lost through radiation convection and through evaporation of water from the lungs and skim.

 Heat is loss in small amounts through the urine and feces and in raising the temperature if inspired air to body temperature. Changes in the vascularity of the skin modify body temperature. The construction of smooth muscles when gooseflesh occurs and when the involuntary movement of skeletal muscles when shivering is present, produce heat by stimulating metabolism and conserve heat by constricting superficial vessels in the skin.

Normal Body Temperature

A thermometer is placed in the patients:
mouth to obtain an oral temperature in the anal canal to obtain a rectal temperature in axilla to obtain an axillary temperature and in the esophagus to obtain a core temperature.

The bodys organs require a fairly constant internal or core temperature, for optimal functioning.

Average Normal Temperature Well Adults in various Body Sites

ORAL 37 0C 98.6 0 F

RECTAL 37. 5 0C 99.5 0F

AXILLARY 36.5 0 C 97.6 0F

ESOPHAGEAL 37.3 0C 99.2 0F

Elevated Body Temperature

Pyrexia is am elevation of normal body temperature. The lay term is fever. Hyperpyrexia is a high fever, usually above 41 0C (106 0F )and survival is rare when it reaches 44 0C ( 110 0F ). Pyrexia is a common symptom of illness, and there is sufficient evidence to indicate that an elevation in temperature helps the temperature helps the body fights disease.

Elevated Body Temperature

The patient with fever usually experiences:
loss of appetites headache hot dry skin flushed face Thirst general malaise depression and occasionally periods of delirium.

Observing for other signs as body temperature rises is important, such as decreased urinary output and dehydration of the skin and mucous membranes

The Thermometer
A glass clinical thermometer is most commonly used to measure body temperature. It has two parts, the bulb and the stem. The bulb and the stem. The bulb contains mercury, which, since it is metal, will expand when exposed to heat and therefore, rise in the stem, The stem is calibrated in degrees and tenths of a degrees. The range is approximately 34 0 C. (94 0 F ) to approximately 42.2 0 C ( 1080 F ).

The Thermometer
Fractions of degrees usually are recorded in tenths such as 0.2,0.4, 0.6 and 0.8 If the mercury appears to be a bit more or less than an even tenth, it is common practice to report to the nearest tenth of a degree. The thermometer is calibrated in either degrees of centigrade ( Cesius ) or Farenheit, abbreviated C and F.

Selecting Site for Obtaining Body Temperature

Obtaining an Oral Temperature This is most common.
Contraindication: Unconscious, irrational and seizure prone patients Infants and young children Persons who breath through the mouth Persons with diseases of the oral cavity Patients who have had surgery If pt. has had either hot or cold food or fluids If pt. has been smoking or chewing gum Pts. Receiving nasal oxygen Pts receiving oxygen by mask

Selecting Site for Obtaining Body Temperature

Obtaining a Rectal Temperature - This is ordinarily
recommended whenever obtaining an oral temperature is contraindicated. It is also a recommended practice to check the temperature rectally if the body temperature of the patient having an oral temperature obtained regularly changes considerably and unexpectedly. Some hospitals require rectal readings on small patients with an elevated temperature. Contraindications: Patients having rectal surgery Diarrhea Any disease of the rectum Patients with certain heart diseases

Selecting Site for Obtaining Body Temperature

A rectal temperature has been considered to be more accurate than an oral or axillary temperature. However this opinion is being challenged by some authorities, since studies have that rectal temperature should be delayed, since the temperature of water and the friction created by drying the skin can influence the temperature can be influenced by the presence of fecal matter to cause a false high reading.

Selecting Site for Obtaining Body Temperature

Obtaining an Axillary Temperature - This is generally obtained only when both oral rectal temperatures are contraindicated or when the sites are not accessible. Some hospitals obtain temperature by axillary method on normal newborns.

Selecting Site for Obtaining Body Temperature

If the axilla has just been washed, obtaining temperature should be delayed, since the temperature of water and the friction created by drying the skin can influence the temperature.
Most authorities believe that when proper procedure is used, axillary temperature are as accurate as oral rectal temperatures

PULSE
The stimulus for contraction of the hearts in the sinoauricular or sinoatrial node, which is the upper part of the atrium. Because the node sets the pace of the beat, it is often called the pacemaker.

Each time the left ventricle of the heart contracts to ejects blood into an already full aorta, the arterial walls in the blood system expand or distend to compensate for the increase in pressure. This expansion of the sends a wave through the walls of the arterial system, which on Palpation, can be felt as an impact or light up. The sensation of impact or tap is called the pulse.

Pulse Rate
Upon awakening in the morning. The pulse rate of average healthy adult man is approximately 60 to 65 beats per minute. The pulse rate women is slightly faster about 7 to 8 beats per minute more than me.

Pulse Rate
Pulse rate varies with age, gradually diminishing from birth to adulthood and then increasing somewhat in old age. It has been noted than the body size and built of a person may affect the pulse rate. Tall, slender, persons often have a slower rate than short, stout ones.

Pulse Rate
Very wide variations in pulse rate have been noted in normal people. Many authorities accept 60 to 100 beats per minute at rest as a normal pulse rate. However it has been noted that well- trained athletes may have a normal resting rate of 45 to 50 beats per minute

Factors that will cause an increase in pulse rate:

Pain Strong emotions ( fear,anger,anxiety, surprise ) Exercise Prolonged application of heat Decrease in blood pressure Elevated temperature Condition resulting to poor oxygenation of blood

Average Pulse Rate per Minute for Well Persons

AGE Birth

PULSE RATE PER MINUTE 120

1 Year 5 Year
10 years Adolescent Adult

110 95
85 80 75

Common Sites for Palpating Pulse

Most commonly, the radial artery at the wrist is used for palpating the pulse rate, because it is easily accessible and it can be pressed against the radius. If is not possible to palate the pulse at the wrist, other superficial arteries of the body that overlie a bone may be use . A site should not produce or discomfort to the patient because this could alter the pulse rate.

Common Sites for Palpating Pulse

The carotid, facial and temporal arteries are the most common alternate sites to obtain the pulse rate.

RESPIRATION
Respiration, in its broader sense, begins with act of breathing and includes the bodys use of oxygen and the elimination of carbon dioxide.

RESPIRATION
Inspiration or inhalation is the act of breathing, and expiration or exhalation is the act of breathing out. External respiration includes lung ventilation, the absorption of oxygen, and the elimination of carbon dioxide. Internal respiration , sometimes called tissue respiration includes the use of oxygen by body cells for the production of heat through oxidation and the liberation of energy from the food we eat.

Respiratory Rate
Under normal conditions, healthy adults breathe approximately 16 to 20 times a minute. The respiratory rate is more rapid in infants and young children. It has been noted that the relationship between the pulse rate and the respiratory rate is fairly consistent in well persons, the ratio, being one respiration to approximately four heart beats.

Respiratory Rate
During illness, the respiratory rate may very from normal. When body temperature is elevated, the reparatory rate increases as the body attempt to rid itself of excess heat and as metabolism increases. The rate will increase as much as four breaths per minute with every 0.6 C ( 1 F ) the temperature rises above normal.

Respiratory Rate
Any conditions involving an accumulation of carbon dioxide and a decrease in oxygen in the blood will tend to increase the rate and depth of respiration. There are conditions that characteristically predispose to slow breathing. An increase in intracranial pressure will depress the respiratory center, resulting in irregular or shallow, slow breathing or both. Certain drugs also depress the respiratory rate, morphine sulfate being an example.

VITAL SIGNS: PROCEDURE

Procedure
1. Identify the patient Rationale: Be sure that the patient is well informed regarding of the procedure. Anxiety may alter the result of the procedure. 2. Assess patients readiness for the procedure. Identify factors that may alter 3. Wash your hands

Procedure
4. Prepare the necessary equipment: Thermometer Sphygmomanometer Cotton balls Stethoscope Receptacle for used cotton balls Alcohol Watch with second hand Small notebook and pen

Procedure
5. Explain the procedure
6. Be sure that the room, lightning is adequate. Rationale; To read the calibration accurately, it must be held in a good light.

7. Proceed with the following

Temperature
A.Oral A. Take the thermometer from its container. If disinfectant has not been rinsed, wipe It with one firm rotary motion from the bulb to stem. Discard the cotton balls. Rationale; Direction of wipe is from the cleanest, portion where your fingers are. Note the difference here in direction in wiping thermometer AFTER it has been used

Temperature
B. Check to see that the mercury is 35. O0 C or lower. Shake down the thermometer this way: Rationale; If thermometer are requisitioned from central supply they will have to be shaken down. Stand in a clear space away from furniture. Hold thermometer firmly between thumb and first two fingers. Keep then wrist loose bring hand upward then give the wrist a quick Vigorous jerk downward. Repeat if necessary until the mercury falls to 35 0 C

Temperature
C. Place the thermometer on the sublingual base of the tongue. Wait for 5-7 minutes then remove , wipe with cotton on a Twisting motion from fingers to the bulb and read.
Rationale; If the patient is out on bed, have him sit, on a chair while the temperature is being taken.

Temperature
B. Rectal
A. Shake down the thermometer and lubricate the bulb end. Insert at least 1.5 inches into the rectum. Hold in place for 3-5 minutes. Remove, then read and clean.

Temperature
C. Axillary
A. Place tip of the thermometer in the center of the armpit and keep the arm tight against side of the chest for 3-5 minutes. Remove and read. Rationale; If patient is weak, do not bear weight on the chest.

pulse
PULSE - While waiting for the time for the temperature to lapsed. You can proceed taking the pulse Rationale; Avoid grasping patients wrist in palm of your hand and clamping your fingers tightly around it. Too much pressure can easily erase pulse.

pulse
RADIAL PULSE - Position patients arms along side of the body. Lightly, place two fingers over radial pulse with arm across the chest. Count Pulse for I full minute. Use your watch with second hand.
Rationale; Never use thumb as it has a pulse of its own that may easily be confused with that of the patient.

The selection of the site for taking the pulse will depend on the condition of the patient.

RESPIRATORY RATE
a) Respiration is counter without the patient knowing it. Rationale; Breathing is easily controlled by the Individual and it is difficult for the patient to breathe naturally if he knows his respiration is being counted.

RESPIRATORY RATE
b) Leave your hand on the wrist after finish counting with the pulse. Rationale; Counting respiration is just as important as taking temperature and counting pulse. You may be the first person to notice a sudden change in the breathing rate which may be very important to your patient. c) the respiration and count them by looking at the chest as it rises and falls.

BLOOD PRESSURE
A. Check if the BP cuff is appropriate for the patient . B. Place the patient in a comfortable lying or sitting position with the forearm supported at the level of the heart. Rationale; Reading will be more accurate when person is in reclining position.

BLOOD PRESSURE
C. Position yourself so that the BP apparatus will be on eye level. Rationale; Bending over the arm is a poor body mechanic and places strain on the back. Also, when you are sitting, the thermometer on either type of apparatus will be more nearly at eye level, which means you can take a more accurate reading.

BLOOD PRESSURE
D. Place the cuff snugly at about 1-2 inch above the inner elbow of the patient. Rationale; If the rubber bag inside the material of cuff is twisted, the pressure over the artery may be uneven, and a misleading reading may result.

BLOOD PRESSURE
E. Place the stethoscope earpieces in your ears and close the screw of the bulb. Rationale; The tips of the earpieces should be at the ear not against the skin elsewhere.

BLOOD PRESSURE
G. Inflate accordingly: If the patient is hypersensitive, inflate as much as 200 mmHg or higher and 160 mmHg if not. Rationale; When the cuff is inflated, the blood is cut off entirely ( no sound is heard via the stethoscope ) Inflating the cuff slowly or sending mercury to a higher level than necessary is very uncomfortable for the patient.

BLOOD PRESSURE
F. Palpate for the pulse beat over brachial artery on the inner aspect of the elbow and place the diaphragm of the stethoscope. Do not allow the stethoscope to touch the clothing or cuff. Rationale; To obtain an accurate reading, the stethoscope must be over the artery. Therefore, it is necessary to know where the artery (bronchial) is and where the pulsation is usually strong.

BLOOD PRESSURE
H. To deflate, release the screw evenly and slowly. Note the first soft but distinctive sound as the systolic and the last soft but Distinctive sound as the diastolic. Allow the remaining to escape quickly then remove the cuff Rationale; If air released too fast, there is no way to tell at what level the mercury column was, when the first sound was heard.