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Vital Signs

Rashid Hussain Nursing Instructor RMISON

Objectives
Define Vital Signs. Identify the reasons/situations necessary to take vital signs. Enlist the components of vital signs. Explain each component in detail.

Temperature Pulse Respiration Blood pressure

Discuss the normal & abnormal values of vital signs Describe the factors affecting vital signs.

History of nurses taking vital signs

No reference to any form of vital sign monitoring by nurses pre 1893 Concept of nurses taking vital signs evolved - 1893 to 1950 Codified into nursing text of the 1950s
Zeitz & McCutcheon (2003)

Vital Signs
Vital from Latin word vita, which means Life Sign means indicator. So vital signs are the indicators of Life. Vital signs are physical signs that indicate an individual is alive, such as Heart beat (Pulse), Breathing rate (Respiration), Temperature, Blood pressure and recently oxygen saturation.

Vital Signs
These signs may be observed, measured, and monitored to assess an individual's level of physical functioning. Used to determine response to treatment

Normal vital signs change with age, sex, weight, exercise tolerance, and condition.

Vital Signs

Prior to measuring vital signs, the patient should have had the

opportunity to sit for


approximately five

minutes.

When to take vital signs


On a clients admission According to the physicians order or the institutions policy or standard of practice When assessing the client during home health visit Before & after a surgical or invasive diagnostic procedure Before & after the administration of meds or therapy that affect cardiovascular, respiratory & temperature control functions. E.g. Blood Transfusion When the clients general physical condition changes LOC, pain Before, after & during nursing interventions influencing vital signs When client reports symptoms of physical distress

Observation
Before diving in, take a minute or so to look at the patient in their entirety. Does the patient seem anxious, in pain, upset? What about their dress and hygiene? Remember, the exam begins as soon as you lay eyes on the patient.

Health Assessment

A nursing assessment consist of collection of subjective and objective data, which includes health history, measurement of vital signs and physical examination:

A bodily assessment from head to toe or systemic examination by using the techniques of Inspection, Auscultation, Palpation and Percussion.

Methods of Physical Examination

Inspection The visual examination of the body using the eyes and a lighted instrument if needed. The sense of smell may also be used. Auscultation The process of listening to sounds that are produced in the body. Direct auscultation uses the ear alone,

Indirect auscultation involves the use of a stethoscope to amplify the sounds from within the body, like a heartbeat.

Methods of P.E

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Palpation The examination of the body using the sense of touch. There are two types: light and deep. Percussion An assessment method in which the surface of the body is struck with the fingertips to obtain sounds that can be heard or vibrations that can be felt. It can determine the position, size, and consistency of an internal organ.

Vital Signs

The vital signs are body temperature, pulse, respirations blood pressure and recently the pulse oximetry and the pain are also included in the list of vital signs. Temperature Pulse Respiration Blood pressure Oxygen saturation Pain

Temperature
Is a state of hotness and coldness of the body. BODY TEMPERATURE is the balance between the heat produced by the body and the heat lost from the body. The temperature of the body is measured by thermometer in units called degrees. Centigrade (C) or Fahrenheit (F)

Body Temperature

Core Temperature temperature of the body tissues, is controlled by the hypothalamus (control center in the brain) maintained within a narrow range. Surface or Skin temperature rises & falls in response to environmental conditions & depends on blood flow to skin & amount of heat lost to external environment. The bodys tissues & cells function best between the range from 36 C to 38 C. Temperature is lowest in the morning, highest during the evening.

Regulation of Temperature

Neural control
Hypothalamus acts as thermostat

Vascular control
Vasoconstriction ---hypothalamus directs the body to decrease heat loss and increase heat production If cold, vasoconstriction will conserve heatshivering will occur

Regulation of temperature

Vasodilatation
If body temp is above normal, the hypothalamus will direct the body to decrease heat production; Perspiration and increased respiratory rate

Body heat production


Bodys cells produce heat from food releasing energy. Kilocalorie= energy value; BMR= rate of energy used in the body to maintain essential activities

Heat lost from the body through


Conduction Transfer of heat from a warm to cool surface by direct contact Convection Transfer of heat through currents of air or water Radiation Loss of heat through electromagnetic waves from surfaces that are warmer than the surrounding air Evaporation Water to vapor lost from skin or breathing

Types of Thermometers

Glass Thermometer
Oral Thermometer Rectal Thermometer

Electronic Thermometer Digital Thermometer Disposable Thermometer Tympanic Thermometer

A small hollow glass tube that contains mercury in a bulb at one end. When heated the mercury rises in the tube.

Reading a Glass-Thermometer

The scale is marked from 94 to 108 The long lines represent one degree The short lines represent two tenths of a degree

Only every other degree is marked with a number

o Battery operated o Have an oral probe and a rectal probe o Disposable probe cover is placed on the probe o The temperature is recorded in about 30 seconds

Use a disposable sheath

o Measures the temperature in the tympanic membrane (eardrum) o Fast and accurate - 1 to 3 seconds
INFANTS PULL THE EAR STRAIGHT BACK

ADULTS AND CHILDREN OVER ONE YEAR PULL THE EAR UP AND BACK

Sites of taking Temperature


Sites Things to consider
No hot or cold drinks or smoking 20 min prior to temp. Must be awake & alert. Not for small children (bite down)

Duration of Placement
Leave in place 3 min

Oral
Posterior sublingual pocket under tongue (close to carotid artery)

Axillary
Bulb in center of axilla Lower arm position across chest

Non invasive good for children. Leave in place 5-10 min. Less accurate (no major bld vessels Measures 0.5 C lower than nearby) oral temp.

When unsafe or inaccurate by Side lying with upper leg flexed, mouth (unconscious, disoriented or irrational) insert lubricated bulb (1-11/2 Side lying position leg flexed inch adult) (1/2 inch infant)

Rectal

Leave in place 2-3 min. Measures 0.5 C higher than oral

Rapid measurement Easy accessibility Close to hypothalamus sensitive to core temp. changes Cerumen impaction distorts reading Adult - Pull pinna up & back Otitis media can distort reading Child pull pinna down & back

Ear

2-3 seconds

Factors Affecting Temperature


Exercise Illness Age Time of day Medications

Infection Emotions Hydration Clothing Environmental temperature/air movement

Alterations in body temperature:


o

Pyrexia/Hyperthermia/Fever a body temperature above the normal range. >100 F Hyperpyrexia a very high fever. 104 F and above.

o
o o

Hypothermia Body temp below 95 F


Febrile referred to a client who has a fever Afebrile referred to a client who has no fever

4 Common types of fever:


o

Constant Fever When the fever dose not fluctuate more than about two degree Fahrenheit during 24 hours, but at no time touches the normal. Intermittent When the temperature is only present for several hours in 24 hours and touches the normal for few hours. E.g. Malaria. Remittent When the daily fluctuation of temp is more than two F and never touches the normal. In this fever the evening temp is usually higher than morning one. E.g. Typhoid fever Rigor Fever sever attack of shivering. 3 stages.
o Shivering stage o Hot stage o Cold stage

Clinical signs of fever


o o

o
o o o o o o o

Onset (cold or chill stage) Increased heart rate Increased respiratory rate and depth Shivering due to increased skeletal muscle tension and contractions Pallid, cold skin due to vasoconstriction Complaints of feeling cold Cyanotic nail beds due to vasoconstriction Gooseflesh appearance of the skin due to contraction of the arrectores pilorum muscles Cessation of sweating Rise in body temperature

Clinical signs of hypothermia


o o o o o o o o

Decreased body temperature Severe shivering (initially), feelings of cold and chills Pale, cool, waxy skin Hypotension Decreased urinary output Lack of muscle coordination Disorientation Drowsiness progressing to coma

Centigrade and Fahrenheit Conversion Formulas


Centigrade to Fahrenheit conversion: Multiply the centigrade reading by 9/5 and add 32: F = (C 9/5) + 32

Fahrenheit to centigrade conversion: Deduct 32 from the Fahrenheit reading and multiply by 5/9: C = (F 32) 5/9

Contraindications for oral temps


o o

o
o

o
o o o o

An infant or young child ( under age 6) An unconscious patient A patient that has had oral surgery or an injury to the face, neck, nose, or mouth A person receiving oxygen A patient with a nasogastric tube in place A patient who is confused or restless A patient who is paralyzed on one side of the body Has a history of seizures A patient who breathes through the mouth

Assignment:
Sign

& Symptoms of Hyperpyrexia and Hypothermia.


Nursing

care of a patient with high grade fever.

What is Pulse
Pulse is a wave of expansion felt in the arteries when the heart pumps blood in the vessels, that though always full or distensible. It can be felt in any artery near the surface of the body with the fingers pads. OR The pulse is caused by the stroke volume ejection and distension of the walls of the aorta. The bounding of blood flow in an artery is palpable at various points in the body (pulse points).

Terms related to Pulse

Peripheral pulse located in the periphery of the body (ex. foot, hand, neck). Apical pulse central pulse; located at the apex of the heart. Compliance of the arteries the ability of the arteries to contract and expand. Stroke volume output the amount of blood that enters the arteries with each ventricular contractions. Cardiac output the volume of blood pumped into the arteries by the heart. It is the result of the stroke volume (SV) x the heart rate (HR) per minute.

Pulse Assessment

Pulse Points
Temporal:
Over the temporal bone, superior and lateral to eye

Carotid:
Bilateral, under the lower jaw in neck along medial edge of sternocleidomastoid muscle

Apical:
Left midclavicular line at fourth to fifth intercostal space

Brachial:
Inner aspect between groove of biceps and triceps muscles at antecubital fossa.

Radial:
Inner aspect of forearm on thumb side of wrist

Pulse Points

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Ulnar:
Outer aspect of forearm on finger side of wrist

Femoral:
In groin, below inguinal ligament (midpoint between symphysis pubis and antero-superior iliac spine)

Popliteal:
Behind knee, at center in popliteal fossa

Posterior Tibial:
Inner aspect of ankle between Achilles tendon and tibia (below medial malleolus)

Dorsalis Padis:
Over in step, midpoint between extension tendons of great and second toe

Factors that increase pulse

Exercise Strong emotions fear, anger, laughter, excitement Infection Fever Pain Shock Hemorrhage, Hypovolemia

Factors that decrease pulse

Sleep/rest Old age Heart Diseases e.g. Heart block Depression Drugs digitalis, morphine Athletes in good physical condition may have a lower pulse, probably <60 beats/min. This is normal

Pulse counting
Normal pulse rate for adults is 60 to 100 beats/min & is regular in rhythm..
Regular Pulse Rhythm
Count for 30 seconds, then multiply by 2 (a rate of 35 beats in 30 seconds equals a pulse rate of 70 beats/minute)

Irregular Pulse Rhythm


Count

for one full minute May use stethoscope to listen for apical pulse and count for a full minute

Assess: rate, rhythm, strength

Rate N 60-100, average 80 bpm Tachycardia greater than 100 bpm Bradycardia less than 60 bpm Rhythm the pattern of the beats (regular or irregular) Strength or size or amplitude, the volume of bld pushed against the wall of an artery during the ventricular contraction weak or thready (lacks fullness) Full, bounding (volume higher than normal) Imperceptible (cannot be felt or heard)

0----------------- 1+ -----------------2+--------------- 3+ ----------------4+ Absent Weak NORMAL Full Bounding

What is Respiration?

Respiration is the act of breathing; it includes the intake of oxygen and the output of carbon dioxide from the body. refers to the intake of

Inhalation/Inspiration

air into the lungs. Exhalation/Expiration refers to the breathing out or the movement of gases from the lungs to the atmosphere.

Respiration
Ventilation

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another word that is used to refer to the movement of air in and out of the lungs. External respiration refers to the interchange of oxygen and carbon dioxide between the alveoli of the lungs and the pulmonary blood. Internal respiration takes place throughout the body; the interchange of same gases between the circulating blood and the cells of the body tissues.

Assessing Respiration
Rate
# of breathing cycles/minute (inhale/exhale-1cycle) N 12-20 breaths/min adult - Eupnea normal rate & depth breathing Abnormal increase tachypnea Abnormal decrease bradypnea Absence of breathing apnea Amt. of air inhaled/exhaled normal (deep & even movements of chest) shallow (rise & fall of chest is minimal) SOB shortness of breath (shallow & rapid) Regularity of inhalation/exhalation Normal (very little variation in length of pauses b/w I&E

Depth

Rhythm

Character Digressions from normal effortless breathing


Dyspnea difficult or labored breathing Cheyne-Stokes alternating periods of apnea and hyperventilation, gradual increase & decrease in rate & depth of

Major Factors Influencing Respiratory Rate


Exercise (increases metabolism) increase RR Stress (readies the body for fight or flight) increase RR Environment (increase temperature) increase RR Increased altitude (lower oxygen concentration) increase RR Certain medications (ex. narcotics, analgesic) decrease RR

Breathing Patterns:

Rate:

Eupnea normal respiration that is quiet, rhythmic, and effortless


Tachypnea rapid respiration marked by quick, shallow breaths Bradypnea abnormally slow breathing Apnea cessation of breathing

Breathing Patterns:

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Volume:
Hyperventilation an increase in the amount of air in the lungs, characterized by prolonged and deep breaths; may be associated with anxiety. Hypoventilation a reduction in the amount of air in the lungs; characterized by shallow respirations

Breathing Patterns:

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Rhythm: Cheyne-stoke breathing rhythmic waxing and waning of respirations, from very deep to very shallow breathing and temporary apnea; often with associated with cardiac failure, increased ICP, or brain damage Effort o Dyspnea difficulty in breathing, in which an individual has a persistent, unsatisfied need for air and feel distressed o Orthopnea ability to breath only in upright sitting or standing positions

BLOOD PRESSURE

Blood pressure is the force or pressure of the blood exerted on the walls of the arteries at which the blood is pushed out of heart. OR Arterial blood pressure is a measure of the pressure exerted by the blood as it flows through the arteries. It is measured in millimetres of mercury (mmHg).

Blood Pressure

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Blood pressure consist of:


Systolic Pressure Diastolic Pressure Systolic pressure the pressure of the blood as a result of contraction of the ventricles, that is the high pressure of the blood wave Diastolic pressure the pressure when the ventricles are at rest; it is the lower pressure Pulse pressure Difference b/w systolic & diastolic pressure. Normal pulse pressure 30 to 40 mm Hg

Equipments used to assess Blood Pressure

Stethoscope; is used to auscultate and assess body sounds including the apical pulse and the blood pressure

Sphygmomanometer; is used to assess blood pressure consist of cuff, good selection of the cuff in order to obtain accurate blood pressure.

Factors Affecting Blood Pressure


Age BP increases as person grows older. BP continuous to increase with aging. Gender women usually have lower BP than men. BP rises in women after menopause. Blood volume Severe bleeding lowers blood volume, therefore BP lowers. Rapid administration of IV fluids increases the blood volume, therefore the BP rises. Stress HR and BP increases as part of the bodys response to stress. Pain generally increases BP. However, severe pain can cause shock. BP is seriously low in the state of shock.

Factors Affecting B.P

Exercise increases HR and BP; so BP should not be measured right after exercise. Weight BP is higher in overweight persons. BP lowers with weight loss. Race black persons generally have higher BP than white persons. Diet a high-sodium diet increases the amount of water in the body. Extra fluid volume increases BP. Medications drugs can be given to raise or lower BP. Other drugs have side effects of high or low BP.

Factors Affecting B.P

Position BP is lower when lying down and higher in standing position. (orthostatic hypotension).

Alcohol excessive alcohol intake can raise BP.


Smoking increases BP. Nicotine in cigarettes causes blood vessels to narrow.

Diurnal variations BP s usually lowest early in the morning, when the metabolic rate is lowest; then rises throughout the day and peaks in the late afternoon or early evening.
Disease process any condition affecting the cardiac output, blood viscosity, and/or compliance of the arteries has a direct effect on the BP.

Hypertension
An abnormally high blood pressure, over 140 mmHg systolic and 90 mmHg diastolic. Factors associated with hypertension Thickening of the arterial walls, which reduces the size of the arterial lumen Elasticity of the arteries Lifestyle as cigarette smoking Obesity Lack of physical exercise High blood cholesterol level Continued exposure to stress

Hypotension
Blood pressure below normal, when the systolic reading less than110 mmHg. It occurs as a result of peripheral vasodilatation in which blood leaves the central body organs especially the brain and moves to the periphery. Factors associated with hypotension Analgesics Bleeding Severe burn Dehydration.

Oxygen Saturation

Oxygen is carried in the blood attached to haemoglobin molecules. Oxygen saturation is a measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry. Oxygen Saturation provide important information about cardio-pulmonary dysfunction and is considered by many to be a fifth vital sign.

Pulse Oximetery

Pulse Oximeter is a non invasive device that measures a client's arterial blood oxygen saturation by means of a sensor attached to the client's finger, toe, nose, earlobe, or forehead. The pulse oximeter can detect hypoxemia before clinical signs and symptoms such as dusky skin color and dusky nail bed color. Normal SpO2- 92% to 100%

Measurement of Height and Weight

Height
Height is expressed in inches (in), feet (ft), centimeters (cm), or meters (m).
A scale for measuring height is usually attached to a standing weight scale. Infants length is measured from vertex (top) of head to soles of feet while infant is lying with knees extended.

Measurement of Height and Weight

Weight
Measurement of weight is expressed in ounces (oz), pounds (lb), grams (g), or kilograms (kg). Daily weights should be obtained at the same time of the day, on the same scale, with the client wearing the same type of clothing.

Measurement of Height and Weight

Nursing Considerations
Accurate recordings are necessary for drug dosage calculations and evaluation of effectiveness of drug, fluid, and nutritional therapy. Intake and output records provide information on fluid balance and kidney function.