ASSESSING VITAL SIGNS RLE 1 a VITAL SIGNS

ASSESSING VITAL SIGNS RLE 1 a

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 Ømeasured thru tympanic and rectal routes • Surface Temperature Ømeasured 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: ü ü ü 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: ü ü 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: ü ü 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 Meaning Equal rhythm Irregular rhythm Heart rhythm Time interval between each heartbeat Beat that occurs between normal beats

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 Bounding: felt by exerting only light +4 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 ØPulmonary ventilation –(breathing) movement of air in and out of the lungs ØInspiration –(inhalation) act or breathing in ØExpiration –(exhalation) act of breathing out ØExternal respiration – exchange of O 2 and CO 2 between alveoli and blood ØInternal respiration – exchange of O 2 and CO 2 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 -60 sec) 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 (mm. Hg) 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 mm. Hg • Hypotension – below 90/60 mm. Hg • 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