v ital s igns and o ther a ssessment s urveys. d efinition body temperature, pulse ( نبض ),...

VITAL SIGNS AND OTHER ASSESSMENT SURVEYS

DEFINITION

Body temperature, pulse (نبض), respiration and blood pressure are the vital signs ( عالمات.(حيوية

They are indicators (مؤشرات) to distinguish 3ز) between living and non living human (تميbeing.

These signs are used by nurses, paramedics and physicians to follow-up the patient's condition or to detect any variation in them.

PULSE

Reflects the rate of the heart beat. Felt where an artery passes over a bone near

the surface (superficial سطحي ) of the body. For a healthy adult, normal heart rate (HR)

ranges between 60-100 beats per min (bpm).Tachycardia القلب انقباض greater – تسارع

than 100 bpm Bradycardia القلب انقباض less than 60 –تباطؤ

bpm Pulse rate increases with bleeding, exercise,

illness, injury, and emotions.

PULSE SITES

To assess the peripheral pulses by palpation, apply (place) pads on the most distal aspects of the middle three fingers on its location, with moderate pressure.

Apical pulse is usually evaluated by auscultation.

صدغي

سباتي

عضدي

فخذي

شعاعي كعبري)

)

RESPIRATION

It is the means ( طريقة \ by which (واسطةoxygen enters the blood through the lungs during breathing in (inspiration) and carbon dioxide is expelled during breathing out (expiration).

For an adult, normal respiratory rate (RR) is 12-20 breath/minNormal – eupneaAbnormal increase – tachypnea Abnormal decrease – bradypnea Absence of breathing – apnea

TEMPERATURE

Average body temperature is 37 C° Body temperature ranges from 36 to 38 C°.

It is measured by a thermometer ( ميزان.(حرارة

If temperature < 38 hyperthermia. If temperature > 36 hypothermia.

C = (Fahrenheit temperature - 32 ) x 5/9 F = (Celsius temperature x 9/5 ) + 32

SITES OF TEMPERATURE ASSESSMENT

Site Description Time to attain

Oral

Posterior sublingual pocket (under tongue)

No hot or cold drinks or smoking 20 min prior to temp.

Must be awake & alert.

Not for small children (bite down)

Leave in place 2-3 minutes.

SITES OF TEMPERATURE ASSESSMENT

Site Description Time to attain

Axillary

Bulb in center of axilla

Lower arm position across chest

Non invasive – good for children.

Less accurate (no major blood vessels nearby)

Leave in place 5-10 minutes.

Measures 0.5 C lower than oral temperature.

SITES OF TEMPERATURE ASSESSMENT

Site Description Time to attain

Rectal

Side lying on left side with upper leg flexed, insert lubricated bulb (1-11/2 inch adult) (1/2 inch infant)

When unsafe or inaccurate by mouth (unconscious, disoriented or irrational)

Left side lying position – right leg flexedLeft leg straight

Leave in place 2-3 minutes.

Measures 0.5 C higher than oral temperature

SITES OF TEMPERATURE ASSESSMENT

Site Description Time to attain

Ear

Close to hypothalamus – sensitive to core temperature changes.Adult - Pull pinna up & back Child – pull pinna down & back

Rapid measurement

Easy to assess

Cerumen األذن إفرازات impaction distorts الصمغيةreading

Otitis media األذن التهاب can distort المتوسطةreading

2-3 seconds

BLOOD PRESSURE (BP) It means the force required by the heart to pump

blood into the arteries. It is measured in systolic and diastolic pressure. Systolic is the pressure exerted by the contraction

of the ventricles - higher value. Diastolic is the pressure when the ventricles at rest

– lower value

Normal B.P.: 120/80 mmHg

Hypertension: High blood pressure if BP < 140/90 mmHg.

Hypotension : Low blood pressure if BP > 100/60 mmHg.

PUPILS

Check the pupils for size, equality and reactivity to light (both pupils constricted).

Examine both eyes.

COLOUR

Color of the skin and mucous membrane, (e.g., conjunctiva العين inside of the ,ملتحمةlips).

LEVEL OF CONSCIOUSNESS

This is used during cardiac arrest, head injuries and any comatose patient to assess responsiveness

Terms Used to Describe Level of ConsciousnessAlert يقظ Follows commands in a timely : متنبه

fashion.Lethargic كسول Appears drowsy, may : نوامي

drift off to sleep during examination.Stuporous ذهولي: Requires vigorous stimulation

(shaking, shouting) for a response.Comatose غيبوبي : Does not respond

appropriately to either verbal or painful stimuli.

HOW TO ASSESS LEVEL OF CONSCIOUSNESS (LOC) الوعي مستوى

The Glasgow Coma Scale (GCS) provides a more objective way to assess the patient’s LOC.

It evaluates best eye response, best motor response, and best verbal response on a scale of 3 to 15.

Fifteen (highest score) indicates that the patient is awake, alert, oriented, and able to follow simple commands.

Three (lowest score) indicates that the patient does not respond to any stimulus and has no motor or eye response, reflecting a very serious neurologic state with poor prognosis.

A GCS of 8 or less indicates severe head injury (comatose state)

A GCS of 9-12 moderate head injury

A GCS of 13-15 is obtained when the head injury is minor.

ABILITY TO MOVE

If the patient is conscious and if spinal or neck injury is suspected assess the patient's ability to move his upper and lower extremities.