Transcript Vital Signs-KSU

VITAL SIGNS
King Saud University
Nursing College
Vital Signs
 V/S also termed cardinal signs, reflect the body’s
physiologic status and provide information critical
to evaluating homeostatic balance .
 They include:
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Temperature
Pulse
Respiration
Blood pressure
Pain (considered the 5th vital sign)
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 functions.
Maintenance of Body
Temperature
 Thermoregulatory center in the
hypothalamus regulates body temperature.
 The center receives messages from cold
and warm thermal receptors in the body.
 The center initiates responses to produce or
conserve body heat or increase heat loss.
Heat Production
 Primary source is metabolism.
 Hormones, muscle movements, and
exercise increase metabolism.
 Epinephrine and nor-epinephrine are
released and alter metabolism
 Fever: increases the cellular metabolic rate
& thus increases the body temperature.
Heat loss occur through:
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Conduction - heat escapes from or enters into your
body e.g. when lying on a cold or hot surface.
Convection - cooler air currents remove heat from
the surface of your skin, warmer air currents make
the skin hotter.
Evaporation - evaporative cooling occurs when
water (from perspiration or swimming) leaves the
skin surface as a vapour, lowering the body
temperature by taking the heat from the body.
Radiation - e.g. acquisition of heat from solar
radiation or losing heat from the skin.
Factors affecting body temp
 Age: new born have unstable body temp Related
to immature thermoregulatory mechanism. Elderly
body temp drops as a person age going up as
they are more sensitive to temp changes.
 Environment: environment temp not affecting core
temp. if the core temp 25C or 77F death may
happen.
 Time of the day.
 Exercise
 Stress
 Hormones such as progesterone.
 Circadian rhythm (Lowest 1-4 Am, Max at 4-6 Pm)
Factor affecting body temp
measurement
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Site: Oral( most common, easy & convenient, wait
15-30 min if the patient has hot or cold drinks).
Rectal:( most reliable)
Axillary: safe, non-invasive but least accurate
Tympanic: non-invasive, safe & accurate.
 Type of the thermometer: Electronic versus
traditional ones.
Commonly used Terms:
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Pyrexia or fever.
Hyperthermia.
Hypothermia.
Febrile.
Afebrile.
Temperature Conversion
The body temp. is measured in degrees on
two scales: Celsius (Centigrade) &
Fahrenheit.
C=(Fahrenheit temp-32) x 5/9
F= (Celsius temp x 9/5)+32
Convert:
Celsius (C)
Fahrenheit (F)
36
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97.7
Pulse
 Pulse is a wave of blood created by the contraction
of left ventricle of the heart through the arteries.
 It is an index of the heart’s rate and rhythm
 The pulse rate is the number of heartbeats per min.
 Closure of the heart valves creates the sound heart
 A normal adult heart rate= 60-100 beats per min.
 Rates are slight faster in women, and more rapid in
children and infants.
 Tachycardia = HR over 100/m
 Bradycardia= HR below 60/m
Cont. Pulse
 Heart rhythm( the pattern of beats, regular or
irregular) is the time interval between each heart
beat. Normal HR is regular.
 Irregular heart rhythm = arrhythmia or dysarrhythmia
 Cardiac out put= HR/min multiplied by stroke
volume( the amount of blood ejected with one
contraction).
 C.O.P.=HRXSV
Pulse Physiology
 Regulated by the autonomic nervous system
through cardiac sinoatrial node (SA node)
 Parasympathetic stimulation — decreases
the heart rate
 Sympathetic stimulation — increases the
heart rate
 Pulse rate = number of contractions over a
peripheral artery in 1 minute
Factor affecting pulse
 Age: as age increases, the pulse rate decreases.
 Autonomic nervous system ( parasympathetic
decrease HR, sympathetic increase HR)
 Medication
 Exercise
 Fever
 Stress
 Hypovolemia
 Postural changes.
Pulse Sites
 Temporal
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Apical
Carotid
Brachial
Radial
Popliteal
Femoral
Posterior tibial
Dorsalis Pedis (Pedal)
Assessing the Pulse
 Equipment: Stethoscope for apical pulse.
 Methods: palpation( fingers), auscultation
 The nurse should be aware of :
- any medication that could affect HR.
- if the patient has been physically active,
wait for 10-15 min before taking the pulse.
Respiration
 Is the process of bringing oxygen to body tissues and
removing carbon dioxide through the lungs
 Resp. functions: to maintain arterial blood homeostasis by
maintaining the PH of the blood.( lungs accomplish this by
breathing)
 Breathing= inspiration + expiration.
 Inspiration= is an active process in which the diaphragm
descends, the intercostal muscles contract, and the chest
expands to allow air to move into the tracheobronchial tree.
 Expiration= is a passive process in which air flows out of the
respiratory tree.
 Normal breathing is almost invisible, effortless, quiet,
automatic, and regular.
Cont. Respiration
 Resp. center in the medulla of the brain and the level of CO2 in the
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blood both control the rate and depth of breathing.
The diaphragm and the intercostal muscles are the main muscles
used for breathing.
The chest normally expands symmetrically without rib flaring or
retraction.
Tidal volume( depth of breathing)= the amount of air moving in and
out with each breath.= 500 ml in health adult.
Tachypnea= is an abnormally fast respiratory rate (usually above
20-24/min in adult).
Bradypnea= is an abnormally slow respiratory rate (usually less
than 10-12/min in adult).
Apnea= the absence of respiration.
Dyspnea= respirations that require excessive effort. Can be painful
and labored
Factors affecting respiration
Age 12-20= adult, 20-25= children, up to
40/min = infant
Medication
Stress
Exercise
Altitude
Gender
Body temp.
Rate and Depth of Breathing
 Changes in response to body demands.
 Controlled by respiratory centers in the
medulla oblongata and pons of the brain
 Activated by impulses from chemoreceptors
 Increase in carbon dioxide is the most
powerful respiratory stimulant
Blood pressure( BP)
Is the force that blood exerts against the walls of the
vessels.
 The heart generates pressure during the cardiac cycle to
perfuse the organs of the body with blood.
 Blood flow from the heart to the arteries, into the
capillaries, and veins, and then back to the heart.
 Blood pressure in the arterial system varies with the
cardiac cycle, reaching the highest level at the peak of
systole and the lowest level at the end of diastole.
 The difference between the systolic and diastolic pressure
is the pulse pressure, which is normally 30-50mmHg
Physiology of Blood Pressure
 Force of the blood against arterial walls
 Controlled by a variety of mechanism to
maintain adequate tissue perfusion
 Pressure rises as ventricle contracts and
falls as heart relaxes
– Highest pressure is systolic
– Lowest pressure is diastolic
Physiologic factors determining BP
 The contraction of the heart result in a pulsating flow of
blood into the arteries
 The pressure is the highest when the ventricles of the heart
contract and eject blood into the aorta and pulmonary
arteries.
 BP during ventricular contraction= cardiac systole/systolic
BP
 BP during ventricular relaxation= cardiac diastole/diastolic
BP
 BP is a function of the flow of blood produced by the
contraction of the heart & the resistance to blood flow in
the vessels
 Blood flow= blood flow is essentially equal to cardiac out
put (COP)
 COP is the produce of stroke volume ((SV) = the amount of
blood each ventricle pumps with each heart beat )& heart
rate .
 COP= SV X HR
Cont. factors determining BP
 Resistance= friction among the cells & other blood
components & between the blood & the vessels
wall caused resistance to blood flow.
 The friction within the blood components reflects
the blood’s viscosity & is largely due to the number
& shape of the blood cells.
 Hormones
 Enzymes
 Method of measuring BP
Factors Affecting Blood Pressure
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Age, gender, race
Circadian rhythm
Food intake
Exercise
Weight
Emotional state
Body position
Drugs/medications
Normal Temperatures for Healthy
Adults
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Oral – 37.0ºC, 98.6ºF
Rectal – 37.5ºC, 99.5ºF
Axillary – 36.5ºC, 97.6ºF
Tympanic – 37.5ºC, 99.5ºF
Forehead – 34.4ºC, 94.0ºF
Normal ranges for Vital Signs
for Healthy Adults
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Oral temperature — 37.0ºC, 98.6ºF
Pulse rate — 60 to 100 (80 average)
Respirations — 12 to 20 breaths/minute
Blood pressure — 110/70 - 130/85