Vital Signs - 2017


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Vital Signs - 2017

  1. 1. Nelia B. Perez, RN, MSN PCU – Mary Johnston College of Nursing
  2. 2. reflects changes in body functions that otherwise might not be observed  Temperature  Pulse  Respiration  Blood pressure  Pain
  3. 3. Vital Signs  One of the most frequent assessments made as a nurse  Nurse is  Responsible for measuring, interpreting significance and making decisions about care  Knowing normal ranges  Knowing history and other therapies that may affect VS
  4. 4. Vital Signs  Nurse must  Know environmental factors that affect vital signs  Exercise, stress, etc.  Use a systematic, organized approach  Verify and communicate changes in vital signs  Monitor VS regularly  Frequency determined by  MD order; nursing judgement, client condition and facility standards
  5. 5. Vital Signs: Facility standards  Hospital:  Every 4-8 hours  Home health:  each visit  Clinic:  Each visit  Skilled facility  Daily and as needed
  6. 6. When to Assess Vital Signs  Upon admission to any healthcare agency  Based on agency institutional policy and procedures  Any time there is a change in the patient’s condition  Before and after surgical or invasive diagnostic procedures  Before and after activity that may increase risk  Before administering medications that affect cardiovascular or respiratory functioning
  7. 7. Special Nursing Interventions:  Wash hands before and after a procedure to maintain asepsis  Gather equipment needed including watch with a second hand to maximize time and reduce effort  Greet client and introduce oneself to promote client’s sense of well-being
  8. 8. Special Nursing Interventions:  Inform client what you will do to elicit cooperation and allay anxiety  Check for proper lighting and diminish noise when necessary to obtain accurate baseline data  Assist to a comfortable resting position, for a child, have the parent remain close by and position the child comfortably in the parent’s arm to ensure comfort  Record/document appropriately and transfer readings to TPR sheet
  10. 10. Body Temperature  the balance between the heat produced by the body and the heat lost from the body  Types:  Core Temperature – temperature of the deep tissues of the body measured by taking oral and rectal temperature  Surface Temperature – temperature of the skin, subcutaneous tissue and fat measured by taking axillary temperature
  11. 11. Maintenance of Body Temperature  Thermoregulatory center in the hypothalamus regulates temperature  Center receives messages from cold and warm thermal receptors in the body  Center initiates responses to produce or conserve body heat or increase heat loss
  12. 12. Heat Production  Primary source is metabolism  Hormones, muscle movements, and exercise increase metabolism  Epinephrine and norepinephrine are released and alter metabolism  Energy production decreases and heat production increases
  13. 13. Factors affecting Heat Production  Basal metabolic rate (BMR)  Muscle activity  Thyroxine output  Epinephrine, norepinephrine and sympathetic stimulation  Increased temperature of the body cells (fever)
  14. 14. Sources of Heat Loss Skin (primary source) Evaporation of sweat Warming and humidifying inspired air Eliminating urine and feces
  15. 15. Processes involved in Heat Loss  Radiation  transfer of heat loss from the surface of one object to the surface of another without contact between two objects  Convection  dissipation of heat by air currents  Evaporation  continuous vaporization of moisture from the skin, oral mucous, respiratory tract; insensible heat loss  Conduction  Transfer of heat from one surface to another  transfer of heat from one surface to another, which requires temperature difference between two surfaces
  16. 16. Factors affecting TEMPERATURE Age Diurnal variations Exercise Hormones Stress
  17. 17. TYPES of FEVER (pyrexia):  Intermittent  temperature fluctuates between periods of fever and periods of normal/subnormal temperature  Remittent  temperature fluctuates within a wide range over the 24 hour period but remains above normal range  Relapsing  temperature is elevated for few days, alternated with 1 or 2 days of normal temperature  Constant  body temperature is consistently high
  18. 18. Decline of FEVER (pyrexia):  Crisis/flush/defervescent stage  sudden decline of fever which indicates impairment of function of the hypothalamus  Lysis  gradual decline of fever which indicates that the body is able to maintain homeostasis
  19. 19. Clinical Signs of FEVER (pyrexia): Onset (cold or chill stage) of fever Course of fever Defervescence (fever abatement)
  20. 20. TEMPERATURE CONVERSION  To change from Fahrenheit to Celsius:  subtract 32 degrees from the Fahrenheit reading  Multiply by 5/9 or divide by 9/5 (1.8)  oC = (oF – 32) x 5/9  To change from Celsius to Fahrenheit  Multiply the Celsius reading by 9/5 or 1.8  Add 32  oF = (9/5 x oC) + 32 or (oC x 1.8) + 32
  21. 21. Special Nursing Interventions:  Remove thermometer from its container and check the temperature reading. Shake down the mercury as necessary (until mercury is below 35 C) by holding the thermometer between the thumb and forefinger at the end farthest from the bulb. Snap the wrist downward.  Wash/wipe the thermometer in a rotating manner before use, from the bulb to the stem, after use, from the stem to the bulb. This practice ensures medical asepsis.
  22. 22. Special Nursing Interventions:  Hold the thermometer at eye level, and rotate it until the mercury column is visible  Rinse the thermometer in tap water, dry it, shake it down and return to its container
  23. 23. METHODS of Temperature Taking:  ORAL: most accessible and convenient method  Nursing Considerations:  Allow 15 minutes to elapse between client’s intake of hot or cold food or smoking and the measurement of oral temperature
  24. 24. METHODS of Temperature Taking:  ORAL: most accessible and convenient method  Nursing Consideration:  Place the thermometer under the tongue, directed towards the side and instruct client to gently close the lips not the teeth around the thermometer
  25. 25. METHODS of Temperature Taking:  ORAL: most accessible and convenient method  Nursing Consideration:  Wash the thermometer before use, from the bulb to the stem, after use, from the stem to the bulb. This practice ensures medical asepsis.
  26. 26. METHODS of Temperature Taking:  ORAL: most accessible and convenient method  Nursing Consideration:  Take oral temperature for 2 – 3 minutes. This ensures adequate time for recording of the temperature  Normal value:  97.6 o – 99.6 oF (36.5 o – 37. 5 oC)
  27. 27. METHODS of Temperature Taking:  Contraindications to Oral Temperature Taking:  oral lesions or oral surgery  dyspnea  cough  nausea and vomiting  presence of oro-nasal pack, nasogastric tube  seizure prone  very young children  unconscious  restless, disoriented, confused
  28. 28. METHODS of Temperature Taking: Oral Thermometers
  29. 29. METHODS of Temperature Taking:  RECTAL: most accurate measurement of temperature  Indications:  When there is respiratory obstruction which prevents closure of the      mouth When the mouth is dry, parched and inflamed When there is oral/nasal surgery or disease For very young, restless and irrational children For mentally disturbed, unconscious, dyspneic, irrational, restless and convulsive patients When a patient is mouth breather and with oxygen
  30. 30. METHODS of Temperature Taking:  RECTAL: most accurate measurement of temperature  Nursing Considerations:  Assist client to assume lateral position/sims position. To expose anal area  Lubricate thermometer about 1 inch above the bulb with water soluble jelly before insertion. To reduce friction and prevent trauma to the mucous membrane in the anus
  31. 31. METHODS of Temperature Taking:  RECTAL: most accurate measurement of temperature  Nursing Considerations:  Insert thermometer by 0.5 – 1.5 inches (1.5 – 4 cm) for adults, 0.9 inch (2.5 cm) for a child and 0.5 inch (1.5 cm) for an infant or insert beyond the internal anal sphincter  Instruct the client to take a deep breath during the insertion of the thermometer. To relax the internal anal sphincter
  32. 32. METHODS of Temperature Taking:  RECTAL: most accurate measurement of temperature  Nursing Considerations:  Hold the thermometer in place for 2 minutes (for neonates, 5 minutes). To ensure recording of temperature  Do not force the insertion of thermometer. To prevent trauma in the area  Normal value:  98.6 o – 100.6 oF (37.0 o – 38.1 oC)
  33. 33. METHODS of Temperature Taking:  Contraindications to Rectal Temperature Taking  Anal/rectal conditions or surgeries, e.g. anal fissure, hemorrhoids, hemorrhoidectomy  Diarrhea  Quadriplegic clients. Vagal stimulation may occur, causing bradycardia and syncope
  34. 34. METHODS of Temperature Taking: Rectal Thermometers
  35. 35. METHODS of Temperature Taking:  AXILLARY: safest and most non-invasive method  Nursing Considerations:  Pat dry the axilla. Rubbing causes friction and will increase temperature in the area  Place the thermometer in the client’s axilla  Place the arm tightly across the chest to keep the thermometer in place for 9 minutes (for infants and children, 5 minutes  Normal value:  96.6 o – 98.6 oF (35.8 o – 37.0 oC)
  36. 36. METHODS of Temperature Taking: Axillary Thermometers
  37. 37. METHODS of Temperature Taking:  Tympanic: readily accessible, reflects the core temperature, very fast  Nursing Considerations:  Can be very uncomfortable and involve risks of injuring the membrane if the probe is inserted too far  Repeated measurements may vary (right and left ears may differ)  Presence of cerumen can affect the reading  Normal value:  98.2 o – 100.2 oF (36.8 o – 37.9 oC)
  38. 38. METHODS of Temperature Taking:  Tympanic Thermometers
  39. 39. METHODS of Temperature Taking:  Other Thermometers
  40. 40. PULSE
  41. 41. PULSE  wave of blood created by contraction of left ventricle of the heart  Regulated by the autonomic nervous system through cardiac sinoatrial node  Parasympathetic stimulation — decrease heart rate  Sympathetic stimulation — increases heart rate  Pulse rate = number of contractions over a peripheral artery in 1 minute
  42. 42. Factors affecting the PULSE rate  Age  Sex/Gender  Exercise  Fever  Medication  Hemorrhage  Stress  Position changes
  43. 43. PULSE sites:  Temporal  Carotid  Apical  Brachial  Radial  Femoral  Popliteal  Dorsalis Pedis  Pedal
  44. 44. PULSE site: TEMPORAL
  45. 45. PULSE site: CAROTID
  46. 46. PULSE site: APICAL
  48. 48. PULSE site: RADIAL
  49. 49. PULSE site: FEMORAL
  50. 50. PULSE site: POPLITEAL
  53. 53. ASSESSMENT of the Pulse:  If pulse is regular, count for 30 seconds and multiply by 2. If irregular, count for 1 minute. When obtaining baseline date, count for the pulse for a full minute  Assess pulse rhythm by noting the pattern and intervals of beat. Dysrhytmia is irregular rhythm
  54. 54. ASSESSMENT of the Pulse:  Asses the pulse volume (amplitude) – strength of the pulse  Normal pulse ca be felt with moderate pressure  Full or bounding pulse can be obliterated only by great pressure  Thready pulse can easily be obliterated (weak or feeble)
  55. 55. ASSESSMENT of the Pulse:  Arterial wall elasticity: the artery feels straight, smooth, soft and pliable  Presence/absence of bilateral equality: absence of bilateral equality indicates cardiovascular disorder
  56. 56. ASSESSMENT of the Pulse:  Pulse pressure:  Systolic pressure MINUS diastolic pressure  Pulse deficit  Apical pulse MINUS peripheral pulse  Pulsus paradoxus  Systolic pressure falls by more than 15 mmHg during inhalation  Pulsus alternans  Alternating strong and weak pulses
  57. 57. ASSESSMENT of the Pulse: Age Normal Pulse Rate Newborn to 1 month 80 – 180 beats/min 1 year 80 – 140 beats/min 2 years 80 – 130 beats/min 6 years 75 – 120 beats/min 10 years 60 – 90 beats/min Adult 60 – 100 beats/min Tachycardia – pulse rate above 100 beats/min Bradycardia – pulse rate below 60 beats/min
  59. 59. Respiration  the act of breathing  carbon dioxide is the primary chemical stimulus of breathing; when carbon dioxide level in the blood is high, there is stimulation for breathing  Pulmonary ventilation — movement of air in and out of lungs  Inhalation: breathing in  Exhalation: breathing out
  60. 60. Respiration  Three processes Ventilation: movement of gases in and out of the lungs  Diffusion: exchange of gases from an area of higher pressure to an area of lower pressure and occurs in the alveolo-capillary membrane  Perfusion: the availability and movement of blood for transport of gases, nutrients and metabolic waste products 
  61. 61. Respiration  The exchange of oxygen and carbon dioxide in the body  Two separate process  Mechanical  chemical
  62. 62. respiration  Mechanical  Pulmonary ventilation; breathing  Ventilation:  Active movement of air in and out of the respiratory system  Conduction  Movement through the airways of the lung
  63. 63. Respiration  Chemical  Exchange of oxygen and carbon dioxide  Diffusion  Movement of oxygen and CO2 between alveoli and RBC  Perfusion  Distribution of blood through the pulmonary capillaries
  64. 64. Mechanics of ventilation  Inspiration  Drawing air into the lung  Involves the ribs, diaphragm  Creates negative pressure-allows air into lung  Expiration  Relaxation of the thoracic muscles and diaphragm causing air to be expelled
  65. 65. Variations in assessment of respirations  Rate: regulated by blood levels of O2, CO2 and ph  Chemial receptors detect changes and signal CNS (medulla)  Normal: 12-20 breaths per minute  Apnea: no breathing  Bradypnea: abnormally slow  Tachypnea: abnormally fast  Observe for one full minute
  66. 66. Variations in assessment findings  Depth  Normal: diaphragm moves ½ inch  Deep  Shallow  Rhythm  Assessment of the pattern  Abnormal  Cheyne stokes, Kusmaul,
  67. 67. Variations in assessment of respirations  Effort  Work of breathing  Dypsnea: labored breathing  Orthopnea: inability to breath when horizontal  Observe for retractions, nasal flaring and restlessness
  68. 68. Variations in breath sounds  Wheeze  High pitched continuous musical sound; heard on expiration  Rhonchi  Low pitched continuous sounds caused by secretions in large airways  Crackles  Discontinuous sounds heard on inspiration; high pitched popping or low pitched bubbling
  69. 69. Variations in breath sounds  Stridor  Piercing, high pitched sound heard during inspiration  Stertor  Labored breathing that produces a snoring sound
  70. 70. oxygenation  Hyperventilation  Rapid and deep breathing resulting in loss of CO2 (hypocapnea); light headed and tingly  Hypoventilation  Rate and depth decreased; CO2 is retained  Cheyne Stokes  Irregular, alternating periods of apnea and hyperventilation
  71. 71. Tools to measure oxygenation ABG directly measures the partial pressures of oxygen, carbon dioxide and blood ph normal= paCO2 80-100) Pulse oximetry non invasive method for monitoring respiratory status; measures O2 saturation normal= >95%
  72. 72. Respiration Two Types of Breathing: Costal (thoracic) Diagphragmatic (abdominal)
  73. 73. Respiratory Centers:  Medulla Oblongata – primary center for respiration  Pons – (1) Pneumotaxic center; responsible for rhythmic quality of breathing (2) Apneustic center; responsible for deep, prolonged inspiration  Carotid and aortic bodies – contain peripheral chemoreceptors, which take up the work of breathing when central chemoreceptors in the medulla are damaged, oxygen level concentration is low and respond to pressure.  Muscle and joints contain proprioreceptors, e.g. exercise
  74. 74. Factors Affecting Respiratory Rate:  Exercise  Pain/Stress/Anxiety  Environment  Increased altitude  Medication  Respiratory and cardiovascular disease  Alterations in fluid, electrolyte, and acid balances  Trauma  Infection
  75. 75. Assessment of Respiration:  With fingers still in place, after taking pulse rate, note the rise and fall of patient’s chest with respiration. You may place the client’s arm across the chest and observe chest movement and for infants, observe the movement of the abdomen, these observes for depth of respiration  Observe rate. Count for 30 seconds if respirations are regular and multiply by 2. If irregular, count for 60 seconds.
  76. 76. Assessment of Respiration:  Observe the respiration (inhalations and exhalations) for regular or irregular rhythm  Observe the character or quality of respiration – the sound of breathing and respiratory effort
  77. 77. Assessment of Respiration: Normal rate in adult  12 – 20 breaths/minute Normal rate in infant  20 – 40 breaths/minute Normal rate in preschool  20 – 30 breaths/minute
  78. 78. Assessment of Respiration: Types of Breathing Eupnea Tachypnea Bradypnea Hyperventilation Hypoventilation Description Normal respiration that is quiet, rhythmic and effortless Rapid respiration, above 20 breaths/min in an adult Slow breathing, less than 12 breaths/minute in an adult Deep rapid respiration, carbon dioxide is excessively exhaled (resp. alkalosis) Slow, shallow respiration, carbon dioxide is excessively retained (resp. acidosis) Difficult and labored breathing Ability to breathe only in an upright position Absence/cessation of breathing Quick, shallow inspiration followed by regular or irregular periods of apnea Very deep and labored breathing; acetone breath (metabolic acidosis) Dyspnea Orthopnea Apnea Biot’s respiration Kussmaul respiration Apneustic Deep, gasping inspiration with a pause at full inspiration followed by respiration insufficient release
  80. 80. Physiology of Blood Pressure  Force of the blood against arterial walls  Controlled by a variety of mechanism to maintain adequate tissue perfusion  Sound of Korotkoff  Pressure rises as ventricle contracts and falls as heart relaxes  Highest pressure is systolic  Lowest pressure is diastolic
  81. 81. Physiology of Blood Pressure: ..Pictures3DScience_Human_Heart.jpg   systolic pressure – pressure of blood as a result of contractions of the ventricles (100 – 140 mmHg); systole (contraction of the heart); numerator in BP reading diastolic pressure – pressure exerted when the ventricles are at rest (60 – 90 mmHg); diastole (relaxation of the heart); denominator in BP reading
  82. 82. Physiology of Blood Pressure    pulse pressure – difference between the systolic and diastolic pressures, normal is 30 – 40 mmHg hypertension is an abnormally high blood pressure for at least two consecutive readings hypotension is an abnormally low blood pressure, systolic pressure below 100/60 mmHg
  83. 83. Determinants of Blood Pressure  Blood volume  Peripheral resistance  Cardiac output  Elasticity or compliance of blood vessels  Blood viscosity
  84. 84. Factors Affecting Blood Pressure:  Age, gender, race  Circadian rhythm  Food intake  Exercise  Weight  Emotional state  Body position  Drugs/medications  Disease process
  85. 85. Sphygmomanometers
  86. 86. Sphygmomanometers
  87. 87. Parts of the Stethoscope: stethoscopebasics.pdf 30 – 35 cm (12-14 inches) long 0.3 cm (1/8 inch) internal diameter
  88. 88. Stethoscope
  89. 89. ASSESSING Blood Pressure:  Ensure that the client is rested  Allow 30 minutes to pass if the client had engaged in exercise or had smoked or ingested caffeine before taking the BP (might tend to increase BP)  Use appropriate size of the BP cuff. Too narrow cuff causes high false reading and too wide cuff causes false low reading.  Position the client in sitting or supine position
  90. 90. ASSESSING Blood Pressure:  Position the arm at the level of the heart, with the palm of the hand facing up. The left arm is preferably used because it is nearer the heart  Apply/warp the deflated cuff snugly in upper arm, the center of the bladder directly over the medial aspect or 1 inch above the antecubital space or at least 2 – 3 fingers above the elbow
  91. 91. ASSESSING Blood Pressure:  Determine palpatory BP before auscultatory BP to prevent auscultatory gap  Use the bell of the stethoscope since the BP is a low frequency sound  Inflate and deflate BP cuff slowly, 2 -3 mmHg at a time  Wait 1 -2 minutes before making further determinations
  92. 92. ASSESSING Blood Pressure:  Palpate the brachial artery with your fingertips  Close the valve on hand pump by turning the knob clockwise  Insert the ear attachment of the stethoscope in your ears so they tilt slightly forward an ensure it hangs freely from the ear to the diaphragm
  93. 93. ASSESSING Blood Pressure:  Place the diaphragm of stethoscope over brachial pulse and hold with the thumb and index finger  Pump out the cuff until the sphygmomanometer registers about 30 mmHg above the point where the brachial pulse disappeared  Release the valve on the cuff carefully so that the pressure decreases at the rate of 2 – 3 mmHg per second
  94. 94. ASSESSING Blood Pressure:  As the pressure falls, note the first sound, muffling, and last sound heard  Deflate the cuff rapidly and completely after noting the last sound
  95. 95. ASSESSING Blood Pressure:  Read lower meniscus of the mercury level of the sphygmomanometer at eye level to prevent error of parallax  Error of parallax happens if the eye level is higher than the lever of the lower meniscus of the mercury, this causes false low reading, if the eye level is lower, this causes false high reading
  96. 96. Tools  Indirect  Equipment  Sphygomanometer and stethescope  Korotkoff’s sounds      1st 2nd 3rd 4th 5th
  97. 97. Korotkoff’s sounds  1st  As you deflate the cuff; occurs during systole  2nd  Further deflation of the cuff; soft swishing sound  3rd  Begins midway through; sharp tapping sound  4th  Similar to 3rd sound but fading  5th  Silence, corresponding with diastole
  98. 98. Other BP issues  Orthostatic or postural hypotension  Sudden drop in BP on moving from lying to sitting or standing position  Primary or essential hypertension  Diagnosed when no known cause for increase  Accounts for at least 90% of all cases of hypertension
  99. 99. Vital signs  Combination of skills which provide an indication of state of health and body functionality  Nurses can delegate the activity of VS, but are responsible for interpretation, trending and decisions based on the findings
  100. 100. Pain  5th vital sign  It is what the client says it is  Nurse must know  how to assess for it  Establish acceptable comfort levels  Follow up within appropriate time frame after intervention
  101. 101. Pain  Data collection  Location (place and position)  Intensity   1-10 Strength and severity  What is your pain at present? What makes it worse? What is the best that it gets?
  102. 102. Pain data collection  Describe  Aching, stabbing, tender, tiring, numb,……..  Duration  When did it start? Is is always there?  Aggrevate/alleviate  What makes it better/worse?
  103. 103. How does the pain affect…  Energy  Appetite  Sleep  Activity  Mood  Relationships  Memory  concentration  Nurse checks for  VS  Knowledge of pain  Med history  Side effects of meds  Use of non pharmacological therapies
  104. 104. References: Fundamentals of Nursing, Kozier, Erb et al Lippincott William and Wilkins Fundamental of Nursing, Udan World wide web END