vital signs · 2015. 10. 13. · monitor vital signs. assess skin color and temperature. monitor...

Ra'eda Almashagba 1

Vital signs

Chapter 27

Ra'eda Almashagba 2

Vital sign

Vital sign are: a body temperature

pulse

respiration

and blood pressure

May add pulse oximetery and pain

Monitoring a client vital sign should note be an automatic or routine procedure, it should be thoughtful and scientific assessment.

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Times to assess vital signs

On admission to a health care agency to obtain baseline data.

When a client has a change in health status or reports symptoms such as chest pain or feeling hot or faint.

Before and after surgery or an invasive procedure. Before and/or after the administration of a

medication that could affect the respiratory or cardiovascular systems, e.g., before giving digitalis.

Before and after any nursing intervention that could affect the vital signs (e.g. ambulating a client who has been on bed rest).

Measure vital signs more often if the client’s health status requires it.

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Body temperature Body temperature reflect the balance between

the heat produced and the heat lost from the body.

Tow kind of body temperature: core temperature : is the temperature of the

deep tissue of the body (such as abdominal cavity and pelvic cavity .it remain relatively constant ).

surface temperature : is the temperature of the skin ,the subcutaneous tissue and the fat.

Heat balance: when the amount of heat produced by body equal the amount of heat lost.

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Heat BalanceThe state a person is in when the amount of heat produced by

the body exactly equals the amount of heat loss.

Heat LossHeat Production

RadiationBasal Metabolism

Conduction/ConvectionMuscular activity (shivering)

Evaporation (vaporization)

Thryoxine and epinephrine (stimulating effects on metabolic rate)

Fever

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Heat is lost from the body through radiation: is the transferee of heat from the

service of one object to another object without contact between the tow object.

conduction :is the transfer from one molecule to molecule of lower temperature, contact between material, when body put on cold water.

convection :is the dispersion of heat by air current.

vaporization: : is the continuous evaporation of moisture from respiratory tract and from the mucosa of mouth and from the skin.

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Regulation of body temperature

sensors in the shell and the core in skin .the skin has more receptor for cold than warmth

When the skin become chilled: shivering increase heat production

Swatting is inhibited to decrees heat loss

Vasoconstriction decreased heat loss

the hypothalamus integrator

effectors system that adjust the production and loss of heat

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Factor affecting body temperature

age : The infant is greatly influenced by the

temperature of the environment and must be protected from extreme changes.

Children’s temperature continue to be more labile than those of adults until puberty.

Elderly people are at risk of hypothermia for variety of reasons. Such as lack of central heating, inadequate diet, loss of subcutaneous fat, lack of activity, and reduced thermoregulatory efficiency.

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Factor affecting body temperature continuo…

exercise : Hard work or strenuous exercise can increase body temperature.

diurnal variation : This refers to the sleep – wake rhythm of the

body, a pattern that varies slightly from person to person.

Body temperature normally changes throughout the day, varying as much as 1.0C between the early morning and the late afternoon

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Factor affecting body temperature continuo…

hormone: Women usually experience more hormone fluctuations

than men do. Progesterone secretion at the time of ovulation raises

body temperature above basal temperature.

stress : Stimulation of the SNS can increase the production of epinephrine and norepinephrine, thereby increasing metabolic activity and heat production.

Environment. Extremes in environmental temperatures can affect a person’s temperature regulatory systems.


Alteration in body temperature

Pyrexia: a body temperature above the usual range is called pyrexia, hyperthermia or fever. Avery high fever such as 41C is called hyperpyrexia

febrile: client who has a fever

a febrile a person who has not fever

Hypothermia: Excessive heat loss.

Inadequate heat production by body cells.

Increasing impairment of hypothalamic thermoregulation.


Clinical Signs of Fever

Onset (Cold or chill stage): chills

feeling of coldness

cold skin (due to vasoconstriction)

and shivering.

Course. Defervescence (fever abatement): excessive sweating and a hot

flushed skin due to sudden vasodilation.


Nursing Interventions for Clients with

fever

Monitor vital signs. Assess skin color and temperature. Monitor white blood cell count, hematocrit value,

and other pertinent laboratory records. Remove excess blankets when the client feels

warm, but provide extra warmth when the client feels chilled.

Provide adequate food and fluids to meet the increased metabolic demands and prevent dehydration, if health permits. Clients who sweat profusely can become dehydrated.


Nursing Interventions for Clients with

fever continuo…

Measure intake and output. Maintain prescribed intravenous fluids. Reduce physical activity to limit heat producing,

especially the flush stage. Administer antipyretics as ordered. Provide oral hygiene to keep the mucous

membranes moist. They can become dry and cracked because of excessive fluid loss.

Provide a tepid sponge bath to increase heat loss through conduction.

Provide dry clothing and bed linens to increase heat loss through conduction.


Four most common sites fore

measuring body temperature:

Oral

Rectal

Auxiliary

and tympanic membrane:


Oral: This is the most accessible and convenient However, because of the mercury in glass

thermometer, this is contraindicated for children under 6 years and clients who are confused or who have convulsive disorder.

Rectal: This is considered the most accurate However, it is inconvenient and more unpleasant

for client It is contraindicated for clients who are

undergoing rectal surgery or have diarrhea or diseases of the rectum.


Auxiliary: This is the safest and most noninvasive.

It is the preferred site for measuring temperature in newborns because there was no possibility of rectal perforation.

tympanic membrane: This is readily accessible and reflects the core

temperature.

The tympanic has an abundant arterial blood supply, primarily from branches of the external carotid artery.

The noninvasive infrared thermometers are now used for this purpose.


Temperature Scales

Celsius © = (Fahrenheit (F) temperature –32) X 5/9.

Fahrenheit= (Celsius temperature X 9/5) + 32.


Type of thermometer

1- Electronic thermometer.2- Chemical disposable thermometer.3- Temperature sensitive tape. 4- Mercury in glass thermometer:- can be

hazardous due to exposure to mercury which is toxic to human. oral thermometer may have long short slander or

rounded tip. A rounded thermometer can be used as rectal as

well as other site.


Pulse

This is a wave of blood created by contraction of the left ventricle of the heart.

The heart is a pulsating pump, and the blood enters the arteries with each heartbeat, causing pressure pulses or pulse waves.

Generally, the pulse wave represents the stroke volume and the compliance of the arteries.


Stroke volume is the amount of blood that enters the arteries with each contraction in a healthy adult.

Compliance of the arteries is their ability to contract and expand. When a person’s arteries lose their dispensability, greater pressure is required to pump the blood into the arteries.

Peripheral pulse is the pulse located in the periphery of the body, for example in the foot, hand and neck.

Apical pulse is a central pulse. It is located at the apex of the heart.


Factor affecting the pulse

Age As age increases, the pulse rate gradually decreases.

Sex After puberty, the average male’s pulse rate is slightly

lower than the female’s.

Exercise Pulse rate normally increases with activity.

Fever The pulse rate increases in response to the lowered

blood pressure that results from peripheral vasodilation associated with elevated body temperature, and because of the increased metabolic rate.


Factor affecting the pulse continuo…

Medications Some medications decrease the pulse rate, and others

increase it. Hemorrhage

Loss of blood from the vascular system normally increases pulse rate.

Stress In response to stress, sympathetic nervous stimulation

increases the overall activity of the heart. Stress increases the rate as well as the force of the heartbeat.

Position changes When a person assumes a sitting or standing position, blood

usually pools in dependent vessels of the venous system. Pooling results in a transient decrease in the venous blood return to the heart and a subsequent reduction in blood pressure reduction in blood pressure and increase in the heart rate.


Characteristics of Normal Pulse

Rate This is the number of pulse beats per minute (70 – 80

beats/min in the adult). An excessively fast heart rate (100 beats/min) is referred to

as tachycardia. A heart rate in the adult of 60 beats/minute or less is called

bradycardia.

Pulse rhythm This is the pattern of the beats and the intervals between

the beats. Equal time elapses between beats of a normal pulse. A pulse with an irregular rhythm is referred to as a

dysrhythmia or arrhythmia. It may consist of random, irregular beats or a predictable

pattern of irregular beats.


Characteristics of Normal Pulse continuo…

Pulse volume This is also called the pulse strength or amplitude.

It refers to the force of blood with each beat. It can range from absent to bounding.

A normal pulse can be felt with moderate pressure of the fingers and can be obliterated with greater pressure.

A forceful or full blood volume that is obliterated only with difficulty is called a full or bounding pulse.

A pulse that is readily obliterated with pressure from the fingers is referred to as weak, feeble, or thready.

A pulse volume is usually measured on a scale 0 to 3.


Pulse Sites

Temporal, Carotid Apical Brachial Radial Femoral, Popliteal, Poserior tibial Pedal (dorsalis pedis),


Respirations

Respiration is the act of breathing external respiration: interaction of oxygen and

carbon dioxide between the alveoli of the lung and the pulmonary blood

Internal respiration: is the exchange between oxygen and carbon dioxide between the circulating blood and the cells of the body tissue

Inhalation or inspiration: intake of air into the lung

Exhalation or expiration: movement of the gas from the lung to the atmosphere

Ventilation: movement of air in and out the lung


Type of breathing:

costal (thoracic breathing ): involve the external intercostals muscle and

the other accessory muscle such as sternocledomastoied.

it observe by the movement by the chest upward and downward.

Diaphragmatic breathing: involve the contraction and relaxation of the

diaphragm. it observed by the movement of the abdomen.


Assessing Respirations

Resting respirations should be assessed when the client is at rest .

Respiration may also need to be assessed after exercise to identify the client’s tolerance to activity.

Before assessing a client’s respirations, a nurse should be aware of: The client’s normal breathing pattern. The influence of the client’s health problems on

respirations. Any medications or therapies that might affect

respirations. The relationship of the client’s respirations to

cardiovascular function.


Characteristics of Normal Respiration

Respiratory rate This is described in breaths per minute.

A healthy adult normally takes between 15 and 20 breaths per minute.

Breathing that is normal in rate is eupnea.

Abnormally slow respirations are referred to as bradypnea,

and abnormally fast respirations are called tachypnea or polypnea.


Factor influence respiratory rate: exercise

stress

increased environmental temperature

lowered oxygen concentration

Factor decrease respiratory rate decrease environmental temperature

certain medication(narcotic)

increased intracranial pressure


Characteristics of Normal Respiration continuo…

Depth This can be established by watching the movement of

the chest.

It is generally described as normal, deep, or shallow.

Respiratory rhythm or pattern This refers to the regularity of the expirations and the

inspirations.

Normally, respirations are evenly spaced.

Respiratory rhythm can be described as regular or irregular.


Characteristics of Normal Respiration continuo…

Respiratory quality or character

This refers to those aspects of breathing that are different from normal, effortless breathing. It includes: Amount of effort a client must exert to

breathe. Usually, breathing does not require noticeable effort.

The sound of breathing . Normal breathing is silent, but a number of abnormal sounds such as a wheeze are obvious to the nurse’s ear .


BLOOD PRESSURE


BLOOD PRESSURE

This is the force exerted by the blood against a vessel wall.

Arterial blood pressure is a measure of the pressure exerted by the blood as it flows through the arties.

There are two blood pressure measures: Systolic pressure. This is the pressure of the blood because

of contraction of the ventricles, which is the height of the blood wave.

Diastolic pressure. This is the pressure when the ventricles are at rest. It is the lower pressure present at all times within the arteries.

Pulse pressure is the difference between the diastolic and systolic pressures.


Blood pressure is measured in millimeters of mercury (mm Hg) and recorded as a fraction.

The systolic pressure is written over the diastolic pressure.

The average blood pressure of a healthy adult is 120/80 mm Hg.

A number of conditions are reflected by changes in blood pressure. The most common is hypertension, an abnormally high blood pressure.

Hypotension is an abnormally low blood pressure below 100min Hg systolic.


Physiology of Arterial Blood Pressure

Pumping action of the heart Cardiac output is the volume of blood pumped into

the arteries by the heart. When the pumping action of the heart is weak,

less blood is pumped into arteries, and the blood pressure decreases.

When the heart’s pumping action is strong and the volume of blood pumped into the circulation increases, the blood pressure increases.

Cardiac output increases with fever and exercise.


Physiology of Arterial Blood Pressure continuo…

Peripheral Vascular Resistance This can increase blood pressure. The diastolic pressure is especially

affected. The following are factors that create

resistance in the arterial system: Size of the arterioles and capillaries. Compliance of the arteries. Viscosity of the blood.



Size of the arterioles and capillaries. This determines in great part the peripheral resistance

to the blood in the body pressure, whereas decreased vasoconstriction lowers the blood pressure.

Compliance of the arteries. The arteries contain smooth muscles that permit them

to contract, thus decreasing their compliance (distensibility).

The major factor reducing arterial compliance is pathologic change affecting the arterial walls. The elastic and muscular tissues of the arteries are replaced with fibrous tissues.

The condition, most common in middle-aged and elderly adults, is known as arteriosclerosis.



Viscosity of the blood. Blood volume. When the blood volume decreases, the

blood pressure decreases. Conversely, when the volume increase, the blood pressure increases .

Blood viscosity. This is a physical property that results from friction of

molecules in a fluid.

The blood pressure is higher when the blood is highly viscous.

that is, when the proportion of RBC’s to the blood plasma is high. This ratio is referred to as the hematocrit is more than 60 to 65%


Factors Affecting Blood Pressure

Age. Newborn have a mean systolic pressure of 78mmHg. The pressure rises with age. The pressure rises with age, reaching a peak at the onset of

puberty, and then tends to decline somewhat.

Exercise. Physical activity increase both the cardiac output and hence the

blood pressure. Thus, a rest of 20 to 30 minutes is indicated before the blood

pressure can be readily assessed. Stress.

Stimulation of the sympathetic nervous system increase cardiac output and vasoconstriction of the arterioles.

thus increasing the blood pressure.


Factors Affecting Blood Pressure continuo…

Race. African – American males over 35 years have higher

blood pressure than European – American males of the same age.

Obesity. Pressure is generally higher in some overweight and

obese people than in people of normal weight.

Sex. After puberty, females usually have lower blood

pressures than males of the same age this difference is thought to be due to hormonal

variations After menopause, women generally have higher blood

pressures than before.


Factors Affecting Blood Pressure continuo…

Medications. Many medications may increase or decrease the blood

pressure nurses should be aware of the specific medications a

client is receiving and consider their possible impact when interpreting blood pressure readings.

Diurnal variations. Pressure is usually lowest early in the morning, when the

metabolic rate is lowest then rises throughout the day and peaks in the late

afternoon or early evening.

Disease process. Any conditions affecting the cardiac output, viscosity,

and or compliance of the arteries have a direct effect on the blood pressure.


Hypertension

blood pressure above the normal value.

Usually asymptomatic and contributing factor to myocardial infarction .

Primary hypertension: elevated blood pressure of unknown cause.

Secondary hypertension: elevated blood pressure of known causes


Factor associated with hypertension

include thickening of arterial wall.

inelasticity of the arteries.

lifestyle factor as cigarette smoking heavy alcohol.

Obesity.

lack of physical exercise.

high blood cholesterol level.

continued exposure to stress.


Hypotension

It is a blood pressure that is below normal may caused by analgesia, bleeding, sever

burn and dehydration

Orthostatic hypotension: is the bloodPressure that falls when the client'sSite or stand, (change their position

suddenly).


Common Errors in Blood Pressure

Assessment

Bladder cuff too narrow.

Bladder cuff too wide.

Arm unsupported.

Insufficient rest before the assessment.

repeating assessment too quickly.

Cuff wrapped too loosely or unevenly.

Deflating cuff too quickly.

Deflating cuff too slowly.

Failure to use the same. arm consistently

Arm above level of the heart.

Assessing immediately after a meal or while client smokes.

Failure to identify auscultatory gap pressure.


Oxygen saturation

A pulse oxymetr is a non invasive device that measure a client's arterial blood saturation

sensor attached to the client finger, toe, nose, earlobe, or forehead

can detect hypoxemia before clinical signs and symptom .


A pulse oxymetr


Factors affecting oxygen saturation

reading

A client could be severely anemic and have inadequate oxygen to supply the tissues, but the pulse oximeter would return a normal value.

Circulation: The oximeter will not return an accurate reading if the

area under the sensor has impaired circulation.

Activity: Shivering or excessive movement of the senor site may

interfere with accurate readings.

vital signs · 2015. 10. 13. · monitor vital signs. assess skin color and temperature. monitor...

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