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Vital sign
 

Vital sign

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    Vital sign Vital sign Presentation Transcript

    • Vital signmeasurements1
    •  Describe the procedures used to assess the vitalsigns: temperature, pulse, respiration, and bloodpressure. Identify factors that can influence each vitalsign. Identify equipment routinely used to assess vitalsigns. Identify rationales for using different routes forassessing temperature. Take vital signs and interpret the finding. Document the vital signs.2
    •  Vital signs reflect the body’s physiologicstatus and provide information critical toevaluating homeostatic balance. Includes: temperature, Pulse Rate, Respiratory Rate), and Blood Pressure)3
    •  To obtain base line data about the patientcondition for diagnostic purpose For therapeutic purpose4
    •  Vital sign tray Stethoscope Sphygmomanometer Thermometer Second hand watch Red and blue pen Pencil; Vital sign sheet Cotton swab in bowel Disposable gloves if available Dirty receiver kidney dish5
    •  On admission – to obtain baseline date When a client has a change in health status or reportssymptoms such as chest pain or fainting According to a nursing or medical order Before and after the administration of certainmedications that could affect RR or BP (Respiratoryand CVS Before and after surgery or an invasive diagnosticprocedures Before and after any nursing intervention that couldaffect the vital signs. E.g. Ambulation According to hospital /other health institution policy.6
    • it is the hotness or coldness of the body.It is the balance b/n heat production &heat loss of the body.Normal body temperature usingoral 370 Celsius or 98.6 0 F.7
    • 1. Core Temperature Is the temperature of internal organs and itremains constant most of the time (37oc);with range of 36.5-37.5oc. Is the Temperature of the deep tissuesof the body Remains relatively constant measure with thermometer8
    • 2. Surface Temperature:o Surface body temperature: - is the temperature ofthe skin, subcutaneous tissue & fat cells and itrises & falls in response to the environmento (Ranges b/n 20-40oc).o It doesn’t indicate internal physiology.9
    •  Normal body temperature is 370 C or 98.6 0F range is 36-38 0c (96.8 – 100 0F) Body temperature may be abnormal due to fever(high temperature) or hypothermia (lowtemperature). Pyrexia, fever: a body temperature abovethe normal ranges 38 0c – 410 c (100.4 –105.8 F) Hyper pyrexia: a very high fever, such as410 C > 42 0c leads to death. Hypothermia: – body temperature between34 0c – 35 0c, < 34 0c is death10
    • 1. Intermittent fever: the body temperature alternates at regularintervals between periods of fever and periods of normal orsubnormal temperature.2. Remittent fever: a wide range of temperature fluctuation (morethan 2 0c) occurs over the 24 hr period, all of which are abovenormal3. Relapsing fever: short febrile periods of a few days areinterspersed with periods of 1 or 2 days of normal temperature.4. Constant fever: the body temperature fluctuates minimally butalways remains above normal11
    • 1.Age2.Diurnal variations (circadian rhythm3.Exercise4.Hormones5.Stress6.Environment12
    •  Oral Rectal Auxiliary Tympanic Thermometer: is an instrument used tomeasure body temperature13
    •  Obtained by putting the thermometer under thetongue. Its measurement is 0.65 less than rectal To. and 0.65greater than axillary temp. Leave 3 to 5 minutes in place Is the most common site for temp measurement This site is inconvenient for unconscious patients, infants and children, & patients with ulcer or sore of the mouth, pts with persistent cough.14
    •  Advantage – easy access & pt comfort Disadvantage It can lead to a false reading ifa person has taken hot or cold food/ drink bymouth, & has smoked so we have to wait forat least 10-15min, after meal or smoking.15
    •  Pts who cannot follow instruction to keep theirmouth closed Child below 7 yrs Epileptic, or mentally ill patients Unconscious Clients receiving O2 Clients with persistent cough Uncooperative or in severe pain Surgery of the mouth Nasal obstruction If patient has nasal or gastric tubs in place16
    •  Obtained by inserting the thermometer into therectum or anus. It gives reliable measurement & reflects the corebody temperature. Hold the thermometer in place for 3 to 5 minutes More accurate, most reliable, is > 0.650 c (1 0F)higher than the oral temperature. because fewfactors can influence the reading disadvantages are:injure the rectum, it needs privacy,it is inappropriate for patients with diarrhea & anal fissure.17
    • Rectal or perennial surgery;Fecal impactionRectal infectionRectal infection;newborn infants18
    •  it is safe and non-invasive Is recommended for infants and children disadvantagelong time (5-10min.)less accurate as it is not close to major vessels. Is considered the least accurate & least reliableof all the sites because the temp obtained usingthis route can be influenced by a number offactors e.g. bathing & friction during cleaning Is the route of choice in pt’s that cannot havetheir temp measured by other routes.19
    •  Placed in to the client’s outer ear canal. It reflects the core body temperature Is readily accessible and permits rapid tempreadings in pediatric , or unconscious pts It is very fast method 1 to2 seconds. Disadvantages: –it may be uncomfortable involves risk of injuring themembranePresence of cerumen (wax) can affect the reading.Right & left measurements may differ.20
    • 21
    • 22Route Normal Range ºF / ºC SitesOral 98.6 ºF / 37.0 ºC MouthTympanic 99.6 ºF / 37.6 ºC EarRectal 99.6 ºF / 37.6 ºC RectumAxillary 97.6 ºF / 36.6 ºC Axilla (armpit)
    •  Pulse is a wave of blood created by thecontraction of left ventricle. pulse reflects the heart beat Stroke volume and the compliance of arterialwall are the two important factors influencingpulse rate. Pulse rate is regulated by autonomic nervoussystem.23
    •  Peripheral Pulse: is a pulse located in theperiphery of the body e.g. in the foot, and orneck Apical Pulse (central pulse): it is located atthe apex of the heart The PR is expressed in beats/ minute (BPM) The difference between peripheral and apicalpulse is called pulse deficit, and it is usuallyzero.24
    •  Pulse is assessed for rate (60-100bpm), rhythm (regularity or irregularity), Volume, elasticity of arterial wall. The pulse is commonly assessed by palpation(feeling) and auscultation (hearing using astethoscope).25
    •  Age The average pulse rate of an infant ranges from100 to 160 BPM The normal range of the pulse in an adult is 60 to100 BPM Sex: Sex: after puberty the average malesPR is slightly lower than female26
    •  Autonomic Nervous system activity Stimulation of the parasympathetic nervoussystem results in decrease in the PR Stimulation of sympathetic nervous systemresults in an increased pulse rate Sympathetic nervous system activation occurs onresponse to a variety of stimuli including▪ Pain ,anxiety ,Exercise ,Fever▪ Ingestion of caffeinated beverages▪ Change in intravascular volume27
    •  Exercise: PR increase with exercise Fever: increases PR in response to thelowered B/P that results from peripheralvasodilatation – increased metabolic rate Heat: increase PR as a compensatorymechanism Stress: increases the sympathetic nervestimulation28
    • * Position changes: a sitting or standing position blood usuallypools in dependent vessels of the venoussystem. B/c of decrease in the venousblood return to heart and subsequentdecrease in BP increases heart rate.29
    • * Medicationo Cardiac medication such as digoxin decrease heart rateo Medications that decrease intravascular volume such asdivretics may increase pulse rateo Atropine in hibits impusses to the heart from theparasympathetic nervous system, causing increased pusserateo Propranolol blocks sympathetic nervous system actionresulting in decreased heart trate sites used for measuringpulse rate30
    •  Carotid: at the side of the neck below tube ofthe ear (where the carotid artery runs betweenthe trachea and the sternocleidomastoidmuscle) Temporal: the pulse is taken at temporal bonearea. Apical: at the apex of the heart: routinely usedfor infant and children < 3 yrs In adults – Left mid-clavicular line under the4th, 5th, 6th intercostal space31
    •  Brachial: at the inner aspect of the biceps muscle ofthe arm or medially in the antecubital space (elbowcrease) Radial: on the thumb side of the inner aspect of thewrist – readily available and routinely used Femoral: along the inguinal ligament. Used orinfants and children Popiliteal: behind the knee. By flexing the kneeslightly Posterior tibial: on the medial surface of the ankle Pedal (Dorsal Pedis): palpated by feeling the dorsum(upper surface) of foot32
    • 35 A wave ofblood flowcreated by acontractionof the heart...A.B.D.E.F.C. G.H.
    •  Pulse: is commonly assessed by palpation(feeling) or auscultation (hearing) The middle 3 fingertips are used with moderatepressure for palpation of all pulses except apical; Assess the pulse forRateRhythmVolumeElasticity of the arterial wall36
    • 37
    • Pulse RateNormal 60-100 b/min (80/min)Adult PR > 100 BPM is called tachycardiaAdult PR < 60 BPM is called bradycardia38
    • Pulse Rhythm The pattern and interval between the beats,random, irregular beats – dysrythymiaPulseVolume the force of blood with each beat A normal pulse can be felt with moderatepressure of the fingers Full or bounding pulse forceful or full bloodvolume destroy with difficulty Weak, feeble readily destroy with pressure fromthe finger tips39
    • Elasticity of arterial wall A healthy, normal artery feels, straight,smooth, soft, easily bent Reflects the status of the clients vascularsystem40
    •  If the pulse is regular, measure (count) for 30seconds and multiply by 2 If it is irregular count for 1 full minute. Each heart beat consists of two sounds s1 - is caused by closure of the mitral and tricuspidvalves separating the atria from the ventricles S2 – is caused by the closure of the plutonic andaortic values The sounds are often described as a muffled “lub –bub”41
    • 42
    •  Respiration rate (RR):-Respiration is the actof breathing and includes the intake ofoxygen and removal of carbon-dioxide. Ventilation is also another word, which refersto movement of air in and out of the lung. Hyperventilation: - is a very deep, rapidrespiration. Hypoventilation: - is a very shallowrespiration.43
    • 1. Costal (thoracic) Observed by the movement of the chest upward and down ward. Commonly used for adults2. Diaphragmatic (abdominal) Involves the contraction and relaxation of thediaphragm, observed by the movement ofabdomen. Commonly used for children.44
    •  Age Normal growth from infancy to adult hoodresults in a larger lung capacity. As lung capacityincreases, lower respiratory rates are sufficientto exchange Medications Narcotics decrease respiratory rate& depth Stress or strong emotions increases the rate &depth of respirations. Exercise increases the rate & depth ofrespirations45
    •  AltitudeThe rate & depth of respirations athigher elevations (altitude) increase toimprove the supply of oxygen available to thebody tissues Gender Men may have a lower respirationsrate than women because men normally havea larger rung capacity than women Fever increases respiratory rate46
    • o The client should be at resto Assessed by watching the movement of thechest or abdomen.oRate,o rhythm,odepth andospecial characteristics of respirationare assessed47
    • Rate: Is described in rate per minute (RPM) Healthy adult RR = 15- 20/ min. is measured forfull minute, if regular for 30 seconds. As the age decreases the respiratory rateincreases. Eupnea- normal breathing rate and depth Bradypnea- slow respiration Tachypnea - fast breathing Apnea - temporary cessation of breathing48
    • Age Average Range/MinNew born 30-80Early childhood 20-40Late childhood 15-25Adulthood-male 14-18Female 16-2049
    • Rhythm: is the regularity of expiration and inspiration Normal breathing is automatic & effortless.Depth: described as normal, deep or shallow. Deep: a large volume of air inhaled &exhaled, inflates most of the lungs. Shallow: exchange of a small volume of airminimal use of lung tissue.50
    •  It is the force exerted by the blood againstthe walls of the arteries in which it is flowing. It is expressed in terms of millimeters ofmercury (mm of Hg).51
    •  Systolic pressure is the maximum of thepressure against the wall of the vesselfollowing ventricular contraction. Diastolic pressure is the minimum pressureof the blood against the walls of the vesselsfollowing closure of aortic valve (ventricularrelaxation).52
    •  BP is measured by using an instrument called Bpcuff (sphygmomanometer) & stethoscope and the average normal value is 120/80mmHg foradults. brachial artery and popliteal artery are mostcommonly used. It is measured by securing the Bp cuff to theupper arm & thigh placing the stethoscope onbrachial artery in the antecubital space &popliteal artery at the back of the knee. Pulse pressure: is the difference between thesystolic and diastolic pressure53
    •  Fever Stress Arteriosclerosis Exposure to cold Obesity Hemorrhage Low hematocrit External heat54
    •  Upper arm (using brachial artery(commonest) Thigh around popliteal artery Fore -arm using radial artery Leg using posterior tibial or dorsal pedis55
    •  A persistently high Bp, measured for greater thanthree times is called hypertension & thatpersistently less than normal range is calledhypotension. Because of many factors influencing Bp a singlemeasurement is not necessarily significant toconfirm hypertension. When the cause of hypertension is known it iscalled secondary hypertension and when thecause is unknown is called primary/essentialhypertension.56
    • Purpose To obtain base line measure of arterial bloodpressure for subsequent evaluation To determine the clients homodynamicstatus To identify and monitor changes in bloodpressure.57
    • 58
    • StethoscopeBlood pressure cuff of the appropriate sizeSphygmomanometer59
    • 60EarpiecesBinauralsRubber or plastictubingBellChestpieceDiaphragm
    •  Explain the procedure to the patient & removeany light cloth from patient’s arm Make sure that the client has not smoked oringested caffeine, within 30 minutes prior tomeasurement. Position the patient on lying, sitting or standingposition, but always ensure that thesphygmomanometer is at the level of the heartwith the arm supported & the palm facingupwards.61
    •  apply cuff snugly/securely around the arm ,2.5cm above the antecubital space/fossa, at thelevel of the heart (for every cm the cuff sitesabove or below the level of the heart the BPvaries by 0.8mmHg) Palpate the radial pulse and inflate the cuff untilthe radial pulse can no longer be felt, thisprovides an estimation of systolic pressure. Inflate cuff 30mmHg higher than estimatedsystolic pressure.62
    •  palpate the brachial artery & place the bell of thestethoscope over the site & the ear pieces onear, apply enough pressure to keep thestethoscope in place (the bell of the stethoscopeis designed to amplify/intensify low frequencysounds) Deflate the cuff 2-4mmHg per second. The first pulse heard is the systolic reading,continue to deflate until there is a change intone to a muffled beat, this is the diastolicreading.63
    •  Deflate & remove cuff roll neatly and replace. Record the systolic and diastolic pressure onvital sing sheet and compare the presentreading with previous reading. report or treat any change Clear ear pieces and bell of the stethoscopewith antiseptic swab and return allequipments.64
    • Thank you65