Transcript VITAL SIGNS
VITAL SIGNS Vital Signs Various factors that provide information about the basic body conditions of the patient. 4 Main VS Temperature Pulse Respirations Blood Pressure Other Vital Signs Pain Scale - 0 to 10 Pts are asked to rate their level of pain on the 0 – 10 scale Skin color Size of the pupil & reaction to light Level of consciousness Patients response to stimuli Pulse oximetry reading Pulse The pressure of the blood felt against the wall of an artery as the heart contracts and relaxes Rate - # of beats per minute Rhythm – refers to regularity Volume – refers to strength Pulse Usually taken on the radial or carotid artery Pulse is taken on an artery Temporal – sides of the forehead Carotid – sides of the neck Brachial – inner aspect of forearm at the antecubital space Radial – inner aspect of the wrist, above thumb Femoral – inner aspect of the upper thigh Popliteal – behind the knee Dorsalis pedis – top of the foot arch Pulse Bradycardia – pulse <60 bpm Tachycardia – pulse >100 bpm (except in children) Rhythm refers to the regularity of the pulse (the spacing of the beats) Regular Irregular - arrhythmia Usually caused by a defect in the electrical conduction pattern Pulse Volume – strength or intensity Strong Weak Thready Bounding Factors that alter pulse rate Increase pulse: exercise, stimulant drugs, excitement, fever, shock, nervous tension (stress) Decrease pulse: sleep, depressant drugs, heart disease, coma, physical training Respirations The process of taking in O2 and expelling CO2 from the lungs and respiratory tract 1 breath consists of 1 inspiration and 1 expiration (exhalation) Normal range:12–20 breaths/minute in adults Respiration Character – depth & quality Deep Shallow Labored Difficult stertorous (abnormal sounds like snoring) Moist Regularity Regular Irregular Respirations Dyspnea – difficult or labored breathing Apnea – absence of respirations Tachypnea – RR >20 bpm Bradypnea – RR <12 bpm Orthopnea – severe dyspnea in which breathing is very difficult in any position other than sitting erect or standing Respirations Cheyne-Stokes Respirations – periods of dyspnea followed by periods of apnea; frequently noted in the dying pt Rales – bubbling or noisy sounds caused by fluids or mucus in the air passages Wheezing – dyspnea with high pitched whistling or sighing sounds during expiration; caused by narrowing bronchioles and/or obstruction or mucus accumulation in the bronchi http://familymedicine.osu.edu/products/physicalexam/exam/ Respirations Cyanosis – a dusky, bluish discoloration of the skin, lips, and/or nail beds as a result of ↓O2 and ↑CO2 in the bloodstream RR should be counted in a way that the pt is unaware of the procedure RR is partially voluntary controlled Apical Pulse Taken with a stethoscope at the apex of the heart Use diaphragm (flat, flexible disk) Actual heartbeat is heard & counted Pulse Deficit – take the apical then the radial pulse, then subtract the radial from the apical = difference is the pulse deficit Occurs with pts with heart conditions Heart is weak & does not pump enough blood to produce a pulse Temperature A measurement of the balance between heat lost and heat produced Heat is lost thru perspiration, respiration, & excretion (urine & feces) Heat is produced by the metabolism of food; and by muscle and gland activity Temperature Homeostasis – constant state of fluid balance The rates of chemical reactions in the body are regulated by body temp. If body temp is too high or too low the body’s fluid balance is affected Temperature Measured: Oral Rectal Axillary Aural (ear) aka tympanic; in O R Ax T auditory canal A low or high reading can indicate disease Temperature Normal range 96.6 to 100.6 F depending on route used Individuals have different body temps Depends on the body’s processes Time of day Lower in am, after resting Higher in pm or after activity or food intake Parts of the body vary O-98.6 R-99.6 Ax-97.6 Temperature Factors that lead to ↑ body temp Illness, infection, exercise, excitement, environmental temp Factors that lead to ↓ body temp Starvation/fasting, sleep, ↓ muscle activity, sleeping, mouth breathing, environmental temp, certain diseases Temperature Hypothermia – body temp <95oF rectally Death usually occurs if temp <93oF rectally Hyperthermia – body temp >104oF rectally Prolonged exposure will cause brain damage or serious infection >106oF will lead to convulsions, brain damage, or death Temperature Fever – elevated body temp >101oF rectally Pyrexia Febrile – fever is present Afebrile - no fever is present, WNL (within normal limits) Clinical Thermometer Glass with mercury or alcohol w/red dye If breaks, mercury can evaporate & create toxic vapor, attacking CNS Never vacuum or sweep to clean – use a mercury spill kit Red – rectal Blue – oral or axillary Temperature Factors that can alter temp in mouth Eating, drinking (hot or cold), smoking Wait at least 15 min before taking temp Clean thermometers in disinfectant solution Blood Pressure BP – measurement of the pressure that the blood exerts on the walls of the arteries during the various stages of heart activity (contraction and relaxation) BP is read in mm of Hg (mercury) Sphygmomanometer is the medical name Blood Pressure Systolic BP Pressure occurs in the walls of the arteries when the left ventricle of the heart is contracting and pushing blood into the arteries Normal range 100 to 120 mm Hg Blood Pressure Diastolic BP The constant pressure in the walls of the arteries when the left ventricle of the heart is at rest, or between contractions. Blood has moved forward into the capillaries and veins, so the volume of blood in the arteries has decreased. Normal range 60 – 80 mm Hg http://familymedicine.osu.edu/products/ physicalexam/exam/ Blood Pressure Pulse Pressure The difference between Systolic BP and Diastolic BP Important indicator of the health and tone of the arterial walls Normal range 30 – 50 mm Hg 120/80 120 – 80 = 40 pulse pressure Blood Pressure Hypertension (HTN) – High BP; 140/90 or higher Causes: stress, anxiety, obesity, high Na intake, aging, kidney disease, thyroid deficiency, vascular conditions (arteriosclerosis) HTN not treated will lead to kidney failure, stroke, heart disease Blood Pressure Prehypertension- BP in the range of 120/80 - 139/89 Don’t have “high blood pressure” but at risk for developing HTN if lifestyle changes do not occur. Blood Pressure Hypotension – low BP; less than 90/60 May occur with heart failure, dehydration, depression, severe burns, hemorrhage, and shock Orthostatic or Postural Hypotension Sudden drop in both SBP & DBP when a person changes positions Caused by the inability of blood vessels to compensate quickly to positional change SS ; lightheaded, dizziness, blurred vision Blood Pressure Factors that ↑ BP Excitement, anxiety, nervous tension Stimulant drugs Exercise & eating Smoking Rest or sleep Depressant drugs Shock Excessive loss of blood Fasting (starvation) Factors that ↓ BP PRACTICE BLOOD PRESSURE As a class practice reading the computerized blood pressures http://familymedicine.osu.edu/products/ph ysicalexam/exam/ After each reach reading discuss if BP is in normal range or not