Vital Signs Taking
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Vital Signs Taking Presentation Transcript

  • 1. Assessing Vital Signs Dr. Lorena C. Balacanao
  • 2. Introduction
    • Assessing vital signs or cardinal sign is a routine medical procedure. And somehow determines the internal functions of the body
    • Vital signs composes of the following:
      • Body temperature
      • Pulse
      • Respiration and
      • Blood pressure
  • 3. Body Temperature
  • 4.
    • Body temperature
      • It is a balance between the internal and external environment of the body, or
      • It is the balance between the heat produced by the body and the heat lost from the body.
      • It is measured in heat units, called degrees
  • 5. Two types of Body temperature
    • CORE Temperature- it is the temperature of the deep tissues of the body, such as the cranium, thorax, abdominal cavity and pelvic cavity.
    • It remains relatively constant (37 °C/ 98 °F)
    • An accurate measurement is usually done using a pulmonary catheter.
  • 6.
    • SURFACE temperature- is the temperature of the skin, the subcutaneous tissues and fat
    • It constantly rises and falls in relation to the environment
    • It varies from 20 °C (68 °F) to 40 °C (104 °F)
  • 7. Sites commonly used in taking BT
    • Oral- most common
    • Axilla –mostly used in infants and children
    • Rectal- second choice
    • Tympanic membrane- most favorable site
  • 8. Factors that affect heat production
    • 1. BMR- is the rate of energy utilization in the body required to maintain essential activities such as breathing, walking, speaking and others.
    • Metabolic rate decreases with age
    • 2. Muscle Activity- such as shivering increases metabolic rate
    • Example: walking, jogging etc
  • 9.
    • 3. Thyroxine output- increase in thyroxine hormone, increases the rate of cellular metabolism throughout the body.
    • This is called Chemical thermogenesis, the stimulation of heat production in the body through increase cellular metabolism.
    • 4. Sympathetic stimulation- the release of epinephrine and nor epinephrine thus increase the rate of cellular metabolism
    • 5. Fever- it increases metabolic rate and thus increases the body temperature
  • 10. Heat loss
    • 1. Radiation is the transfer of heat from the surface of one object to the surface of another without contact between the two objects
    • 2. Conduction is the transfer of heat from one molecule to another. E.g. the body is immersed in ice water
  • 11.
    • 3. Convection is the dispersion of heat by air currents
    • 4. Evaporation is the continuous evaporation of moisture from the respiratory tract and from the mucosa of the mouth as well as from the skin.
  • 12. Regulation of body temperature
    • System that regulates body temperature
    • 1. Sensors in the skin and in the core
    • 2. An integrator in the hypothalamus and
    • 3. A system that adjusts the production and loss of heat.
    • NOTE: the skin has a more receptor for colds than warmth, it therefore detect cold more efficiently that warmth
  • 13. Factors affecting Body temperature
    • 1. Age – infants greatly influenced by the temperature, children more labile than adult and elderly are extremely sensitive to environmental change due to decreased thermoregulatory control
    • 2. Diurnal variations (circadian rhythms) – Body temperature normally change throughout the day, varying as much as 1.0 °C between early morning and late afternoon
  • 14.
    • The point of highest body temperature is usually reached between 8pm and 12 midnight and the lowest point is reached during sleep between 4 a.m. and 6 a.m.
    • 3. Exercise
    • 4. Hormones –women usually experience more hormone fluctuations than men, progesterone secretion in women raises body temperature.
    • 5. Stress- epinephrine and nor epinephrine increases metabolic activity and heat production
  • 15. Alteration in Body temperature
    • Pyrexia, hyperpyrexia or fever- increase body temperature
      • febrile with fever
      • Afebrile without fever
        • Types of fever
        • Intermittent-alternate body temperature (time)
        • Remittent- wide range of temperature fluctuation
        • Relapsing- short febrile periods few days then normal
        • Constant- continuous
    • Hypothermia- decrease in core temperature below the low limit of normal
  • 16. Types of Thermometer
    • 1 . Mercury in glass
      • Oral thermometer have a long, slender tips
      • Rectal thermometer have a short, rounded tips
    • 2. Electronic thermometer
      • Digital thermometer
    • 3. Chemical thermometer
    • 4 . Temperature sensitive strip
    • 5. Infrared thermometer
      • Tympanic thermometer
  • 17. Oral thermometer (Glass)
  • 18. Digital Thermometer
  • 19. Taking axillary Temperature
  • 20. Digital thermometer is commonly used in infants and children, insert it at the axillary region
  • 21. closed the arm and wait for timer to bustle
  • 22. Remember when taking BT in infants and children make sure that the patient is not in distress mood because any change in the activity will directly affect the BT reading.
  • 23. Taking Oral temperature
  • 24. The Oral Cavity
  • 25. Parts: Oral Vestibule and Oral Cavity Proper
  • 26. Floor of the mouth
  • 27. Insert the tip at the sublingual fossa
  • 28. Positioned the thermometer
  • 29. Let stay for 1 to 2 minutes, tell the patient to close the mouth
  • 30. Temperature conversion
    • °C = (Fahrenheit – 32 ) x 5/9
      • Convert 100 °F
    • °F = (Celsius x 9/5) + 32
      • Convert 40 °C
      • Normal/ Average temperature is between 36-37.9 °C or 96.8 – 100.3 °F
  • 31. Pulse Rate
  • 32. Pulse
    • Is a wave of blood created by contraction of left ventricle of the heart
    • Generally, the pulse wave represents the stroke volume output and the compliance of arteries.
    • Stroke volume output is the amount of blood that enters the arteries with each ventricular contraction.
    • Compliance its the ability of the arteries to contract andexpand.
  • 33.
    • When adult is resting, the heart pumps 4 to 6 liters of blood per minute. This volume is called cardiac output,
    • The cardiac output (CO) is the result of the stroke volume (SV) times the heart rate (HR) per minute
    • CO= SV x HR
    • Note: in healthy person the pulse reflects the heartbeat
  • 34.
    • Peripheral pulse- is a pulse located in the periphery of the body.
    • Apical pulse- is a central pulse located at the apex of the heart.
  • 35. Pulse site
    • 1. Temporal- it is where the temporal artery located, between the upper, lateral part of the eye and upper medial part of the ear
    • 2. Carotid- at the side of the neck, at the carotid triangle. Located between the Anterior/front of SCM and below the angle of the mandible
    • 3. Apical- at the apex of the heart.
      • In adult this is located on the left side of the chest, no more than 8 cm (3 in) to the left sternum under the
  • 36. Carotid pulse
  • 37.
      • 4 th , 5 th or 6 th intercostal space.
      • In Children 7 to 9 years old, the apical pulse is located between the 4 th and 5 th intercostal space.
      • In Young Children below 4 years old , it is located at the left side of midclavicular line and
      • In Children between 4 and 6 years old it is at the midclavicular line.
  • 38.
    • 4. Brachial- at the anterior part of the arm in children and at the ante-cubital space (elbow crease) in adult.
    • 5. Radial – located at the wrist (anterior part), along with the thumb. It is where the radial artery is located
    • 6. Femoral – at the inguinal ligament, the femoral artery is located.
  • 39. Radial and Brachial pulse
  • 40.
    • 7. Popliteal- at the popliteal region, located at the back of the knee
    • 8. Posterior Tibial- at the medial aspect of the ankle, it is where the posterior tibial artery is located
    • 9. Dorsalis pedis- where the dorsalis pedis artery passes over the bones of the foot, at the space between the big toe and the 2 nd toe.
  • 41. Posterior tibial & Dorsalis pedis Pulse
  • 42. Pulse site Reasons for Use Radial Readily accessible & routinely used Temporal Used when radial pulse is not accessible Carotid Used for infants, in cases of cardiac arrest and to determine the circulation to the brain Apical Routinely used in infants and children up to 3 years of age, Used to determine the discrepancies with radial pulse, and Used in conjunction with some medication Brachial Used to measure blood pressure, used for cardiac arrest for infants Femoral Used in cases of cardiac arrest, for infants and children, determine circulation in the leg Popliteal Used to determine the circulation in the lower leg and leg blood pressure Posterior tibial Used to determine the circulation in the foot Pedal Used to determine circulation in the foot
  • 43. Assessing the Pulse
    • 1. A pulse is commonly assessed by palpation or auscultation.
    • 2. 3 middle fingers are used for palpating all pulse site, except for apical pulse.
    • 3. Stethoscope is used in assessing apical pulse and fetal heart tones.
    • 4. Doppler ultrasound is used for pulses that is to difficult to assess.
  • 44.
    • 5. The pulse is normally palpated by applying are moderate pressure with the three fingers of the hand.
    • 6. The pads of the most distal aspect of the fingers are the most sensitive areas of detecting the pulse.
  • 45.
    • 7. When assessing the pulse, there is a need to take note of the following
    • 1. rate
    • 2. rhythm
    • 3. volume
    • 4. arterial wall elasticity
    • 5. presence or absence of bilateral equality.
  • 46. Kozier Barbara, et.al. Fundamentals of Nursing , 5 th ed. (US Addison-Wesley Publishing Company, Inc. 1995) p. 438 Age Average Range Newborn to 1 month 130 80-180 1 year 120 80-140 2 years 110 80- 130 6 years 100 75- 120 10 years 70 50-90 Adult 80 60- 100 Pulse rate/ Minute Variations in Pulse Rate
  • 47.
    • Rate - referred to tachycardia - (over 100 beats/ minute) bradycardia –(60 beats/minute or less)
    • Rhythm - is the patterns of beat and the interval between the beats.
    • Dysrhythmia or arrhythmia is an example of irregular rhythm.
  • 48.
    • Volume - is the pulse strength or the amplitude, refers to the force of blood with each beat. E.g. bounding/full; weak/feeble/thready pulse
    Kozier Barbara, et.al. Fundamentals of Nursing , 5 th ed. (US Addison-Wesley Publishing Company, Inc. 1995) p. 440 Scale Description of pulse 0 Absent 1
      • Thready or weak; difficult to feel
    2 Normal, detected readily, obliterated by strong pressure 3 Bounding; difficult to obliterate
  • 49. Elasticity of the arterial wall
    • It reflects the expansibility of the arterial wall.
    • A healthy, normal artery feel straight, smooth, soft and pliable
    • While, elderly people often have inelastic arteries that feels twisted or tortuous and irregular upon palpation
  • 50. Factors affecting pulse rate
    • 1. Age
    • 2. Sex- after puberty the man’s pulse rate is slightly lower than the female
    • 3. Exercise
    • 4. Fever- pulse rate increases when metabolic rate increases
    • 5. Medications
    • 6. Hemorrhage- loss of blood increase pulse rate
    • 7. Stress
  • 51. Respiration
  • 52.
    • Is the act of breathing; it includes the intake of oxygen and the output of carbon dioxide
    • Types
    • 1. External respiration- the interchange of O2 and CO2 between the alveoli and the pulmonary blood
    • 2. Internal respiration- takes place throughout the body; it is the interchange of gases between the circulating blood and the cells of the body tissues
  • 53. Terminologies
    • Inhalation or inspiration- the act of intake of air into the lungs
    • Exhalation or expiration- the act of breathing out of gases from the lungs to the environment
    • Ventilation- movement of air in and out the lungs
    • Hyperventilation- refers to very deep and rapid ventilation
    • Hypoventilation- refers to very shallow respiration
  • 54. Types of breathing
    • 1. Costal or thoracic breathing
    • 2. Diaphragmatic or abdominal breathing
  • 55. Costal breathing
    • It involves the external intercostal muscle and other intercostal muscle. It can be observed by the movement of the chest upward and outward or downward
  • 56. Diaphragmatic breathing
    • It involves the contraction and relaxation of the diaphragm, it is observed by the movement of the abdomen
  • 57. Control Centers for Respiration
    • 1. Medulla oblongata and Pons
    • 2. Chemoreceptors located centrally in the medulla and peripherally in the carotid and aortic bodies
    • NOTE: These centers and receptors respond to changes in the concentration of O2, CO2 and Hydrogen in arterial blood.
    • Increased CO2 concentration in the blood triggers chemoreceptors thus stimulates respiration
  • 58. Assessing Respiration
    • 1. The client normal breathing pattern is assessed therefore the client should be at resting mode.
    • 2. Identify behavior/ activities of the patient as well as medication or therapies because these will affect the respiration taking.
    • 3. Identify if there are any health problems such as heart problems and others
  • 59. Kozier Barbara, et.al. Fundamentals of Nursing , 5 th ed. (US Addison-Wesley Publishing Company, Inc. 1995) p. 448 Age Average Range Newborn 35 30-80 1 year 30 20-40 2 years 25 20-30 8 years 20 15-25 16 years 18 15-20 Adult 16 12-20 Respiratory rate/ Minute Variations in Respiratory rate
  • 60. Respiratory rate
    • is normally described in breaths per minute
    • Types:
    • Eupnea- Normal Breathing
    • Bradypnea- Abnormally slow
    • Tachypnea or polypnea- Abnormally fast
    • Apnea- cessation of breathing
  • 61. Respiratory depths
    • is established by watching the movement of the chest.
    • It is generally describe as normal, deep or shallow, deep respiration are those in which a large volume of air is inhaled and exhaled. Shallow respiration involve the exchange of small volume of air
    • NOTE: in normal inspiration and expiration, an adult takes in about 500ml of air. This volume is called Tidal volume
  • 62. Respiratory rhythm/ pattern
    • It refers to regularity of expiration and inspiration
    • Types
    • Regular
    • Irregular
      • Dsypnea- difficulty in breathing
      • Orthopnea- ability to breath in an upright position
  • 63. BLOOD PRESSURE
  • 64. Heart Sound
    • 1. First Sound-occurs at the beginning of ventricular systole. It is caused by the closure of the tricuspid and mitral valves
    • 2. Second Sound- marks the beginning of ventricular diastole and is caused by the closure of aortic and pulmonary valves.
  • 65. Arterial blood Pressure
    • is a measure of the pressure exerted by the blood as it flows through the arteries.
    • Two blood pressure measurements
    • 1. Systolic pressure- is the maximum pressure developed on the ejection of blood from the left ventricle into the arteries
    • 2. Diastolic Pressure-is the lowest pressure and is a measure of the peripheral resistance.
  • 66. In measuring the BP
    • By means of auscultation- the systolic pressure is taken at the point when beats becomes audible. As the mercury continues to fall, the sound of the beats becomes louder, then gradually diminishes until a point is reached at which there is a sudden, marked diminution in intensity.
    • The average BP is about 120/80 at 20 yrs old and at the age of 60 is 160/90
  • 67. Aneroid manometer with stethoscope
  • 68. Part of the sphygmomanometer
  • 69. Taking BP
    • It is measured with a blood pressure cuff, a sphygmomanometer and a stethoscope
    • The BP cuff has a bladder than can be inflated with air, it is covered with cloth and has two tubes attached to it (sometimes it’s three), one tube is connected to the rubber bulb.
    • To introduce air turn the valve clockwise and to release air turn it counterclockwise, the second tube to the sphygmomanometer and the third to stethoscope
  • 70. Auscultatory method of obtaining BP
    • First the health care provider must determine the Korotkoff’s sound- this is a series of sounds heard during BP assessment.
    • Phases of Korotkoff’s sound
    • Phase 1- The first faint clear tapping sound is heard. This sound gradually becomes strong and deep
    • Phase 2- This is the period during deflation when the sounds have a swishing quality.
  • 71.
    • Phase 3- The period during which the sounds are forceful and powerful
    • Phase 4- The time when the sounds begins to decrease in intensity, and has a less bounding force
    • Phase 5- The pressure level wherein the sound disappear.
  • 72. Reading Blood Pressure
    • The first sound heard is the systolic pressure and the last sound heard is the diastolic pressure
  • 73. Mercury manometer and cuff Aneroid manometer and cuff
  • 74. 2 types of sphygmomanometer
    • Aneroid and mercury manometer
    • Aneroid is a calibrated dial with a needle that points to the calibrations while the other is a calibrated cylinder filled with mercury.
  • 75. Other types
    • Electric sphygmomanometer
    • Doppler stethoscope
  • 76. Variations in BP cuff
    • If the bladder is too narrow, the obtained BP reading is erroneously elevated; if it is too wide the reading will be erroneously low
    • The width should be 40% of the circumference or 20% wider than the diameter of the midpoint of the limb on which it is used
    • The length of the bladder should be sufficiently long almost to encircle the limb and to cover at least 2/3 of its circumference
  • 77. Variations in BP by Age Kozier Barbara, et.al. Fundamentals of Nursing , 5 th ed. (US Addison-Wesley Publishing Company, Inc. 1995) p. 452 Age Mean BP (mm Hg) Newborn 73/55 1 year 90/55 6 years 95/57 10 years 102/62 14 years 120/80 Adult 120/80 Elderly (over 70 years) Diastolic pressure may increase
  • 78. The End