Transcript Vital Signs By Dr. Aida Abd El-Razek

Vital Signs
Dr. Abdul-Monim Batiha
Assistant Professor
Critical Care Nursing
Philadelphia University
1
Learning Objectives
 Describe
factors that affect the
vital
signs
and
accurate
measurement of them.
 Identify the normal range for each
vital sign.
 Identify the variations in normal
body temperature, pulse,
2
Describe
factors influencing
the body heat production and
loss.
Describe appropriate nursing
care for alterations in body
temperature.
3
Identify
nine sites used to
assess the pulse.
List the characteristics
that should be include
when assessing pulses.
4
Describe
the mechanics of
breathing and the
mechanisms that control
respirations.
Identify the components of
respiratory assessment.
5
Differentiate
systolic from
diastolic blood pressure.
Describe various methods
and sites used to measure
blood pressure.
6
Introduction

The vital or cardinal signs are
body temperature, pulse, respirations,
and blood pressure. Recently, many
agencies such as the Veterans
Administration have designated
pain as a fifth vital sign, to be
assessed at the same time as each of
the other four.
7
Body Temperature

Body temperature reflects the
balance between the heat produced
and the heat lost from the body,
measured in heat units called
degrees. There are two kinds of
body temperature: core temperature
and surface temperature.
8
Core temperature
 Is
the temperature of the deep
tissues of the body, such as the
abdominal cavity and pelvic
cavity. It remains relatively
constant. The normal core body
temperature is a range of
temperature 37C.
9
Surface temperature
Is
the temperature of the
skin, the subcutaneous
tissue, and fat. It, by
constant, rises and falls in
response
to
the
environment.
10
The
body
continually
produces heat as a byproduct
of
metabolism.
When the amount of heat
produced by the body equal
the amount of heat lost, the
person is in heat balance.
11
Factors affect the body's heat
production. The most important are
these five:
 1.
Basal metabolic rate (BMR). Is
the rate of energy utilization in the
body required to maintain essential
activities such as breathing, BMR
decrease with age. In general, the
younger the person, the higher the
BMR.
12
2. Muscle activity.
Including shivering
increases the MR.
13
 3.
Thyroxine output. Increased
thyroxine output increases the
rate of cellular metabolism
throughout the body. This effect
is
called
chemical
thermogenesis, the stimulation
of heat production in the body
through
increased
cellular
metabolism.
14
4.Epinephrine,
norepinephrine,
and sympathetic stimulation.
These hormones immediately
increase the rate of cellular
metabolism in many body tissues.
15
Fever.
Fever increases the
cellular metabolic rate
and thus increases the
body's
temperature
further.
16
Factors affect the body's heat
loss. The most important are:
1.
Radiation is the transfer of
heat from the surface of one
object to the surface of another
without contact between the
two objects.
17
 2.
Conduction is the transfer of
heat from one molecule to a
molecule of lower temperature. For
example, when a body is immersed
in cold water the amount of heat
transferred
depends
on
the
temperature difference and the
amount and duration of the contact.
18
3. Convection
 Is
the dispersion of heat by air
currents. The body usually has a
small amount of warm air adjacent
to it. This warm air rises and is
replaced by cooler air, and so people
always lose a small amount of heat
through convection.
19
4. Vaporization
Is
continuous evaporation
of moisture from the
respiratory tract and from
the mucosa of the mouth
and from the skin.
20
Regulation
of
body
temperature
The
system
that
regulates
body
temperature has three
main parts:
21
sensors
in the shell and in
the core, an integrator in
the hypothalamus, and an
effectors system that
adjusts the production
and loss of heat.
22
 Most
sensors or sensory receptors
are in the skin. The skin has more
receptors for cold than warmth.
Therefore, skin sensors detect
cold more efficiently than
warmth.
 When the skin becomes chilled
over the entire body.
23
Three physiologic processes to
increase the body temperature
take place
24
Shivering
increases heat
production.
Sweating is inhibited to
decrease heat loss.
Vasoconstriction
decreases heat loss.
25
 The
hypothalamic integrator, the center
that controls the core temperature, is
located in the preoptic area of the
hypothalamus. When the sensors in the
hypothalamus detect heat, they send out
signals intended to reduce the
temperature that is to decrease heat
production, and increase heat loss.
When the cold sensors are stimulated,
signals are sent out to increase heat
production and decrease heat loss.
26
Factors
affecting
body temperature
27
28
1. Age
 The
infant is greatly influenced by the
temperature of the environment and
must be protected from extreme
changes. Older people are also
particularly sensitive to extremes in the
environmental temperature due to
decreased thermoregulatory controls.
29
Diurnal variations
 Body
temperatures normally change
throughout the day, varying as much
as 1.0C between the early morning
and the late afternoon. The point of
highest body temperature is usually
reached between 8:00 PM and
midnight, and the lowest point is
reached during sleep between 4:00
and 6:00 AM.
30

Exercise. Hard work or
strenuous exercise can
increase body temperature
to as high 38.3 to 40C
measured rectally.
31
Stress.
Stimulation of the
sympathetic nervous system
can increase the production of
epinephrine
and
norepinephrine,
thereby
increasing metabolic activity
and heat production.
32
Hormones.
The
women
usually
experience
more
hormone fluctuations than
men. In women, progesterone
secretion at the time of
ovulation
raises
body
temperature by about 0.3 to
0.6C above basal temperature.
33

Environment. Extremes
in
environmental
temperatures can affect a
person's
temperature
regulatory systems.
34
Sites for Measuring
Body Temperature
Oral
 Rectal
 Axillary
 Tympanic membrane
 Skin/Temporal artery

35
Copyright 2008 by Pearson Education, Inc.
Types of Thermometers






Electronic
Chemical disposable
Infrared (tympanic)
Scanning infrared (temporal artery)
Temperature-sensitive tape
Glass mercury
36
Copyright 2008 by Pearson Education, Inc.
Alterations
in body
temperature
37
Pyrexia
A
body temperature above the
usual range is called pyrexia
38 to 40C, hyperthermia, or
fever. A very high fever, such
as 41C is called hyperpyrexia.
38
Four common types of fevers
are
Intermittent
fever, the
body temperature alternate
at regular intervals between
periods of fever and periods
of normal or subnormal
temperatures.
39
Relapsing
fever, short
febrile periods of a few
days are interspersed with
periods of 1 or 2 days of
normal temperature.
40
 Constant
fever, the body
temperature fluctuates minimally
but always remains above normal.
 A temperature that rises to fever
level rapidly following a normal
temperature and then return to
normal within a few hours is
called a fever spike.
41
Remittent
fever, a wide
range
of
temperature
fluctuations more than 2C
occurs over the 24-hour
period, all of which above
normal.
42
Clinical Signs of Fever
The clinical signs of fever vary with
the onset, course, and abatement
stages of the fever. These signs occur
as a result of changes in the set point
of
the
temperature
control
mechanism
regulated
by
the
hypothalamus.
43
Onset (cold or Chill Stage)
 Increased
heart rate.
 Increased respiratory rate and depth.
 Pallid, cold skin and shivering.
 Complaints of feeling cold.
 Cyanotic nail beds.
 Gooseflesh appearance of the skin.
 Cessation of sweating.
44
Course Stage
Absence
of chills.
Skin that feels warm.
Glassy eyed appearance.
Increased pulse and
respiration rates.
Increased thirst.
45
 Mild
to sever dehydration
 Drowsiness, restlessness, delirium,
or convulsions.
 Herpetic lesions of the mouth.
 Loss of appetite.
 Malaise, weakness, and aching
muscles.
46
Abatement stage of fever
 Skin
that appears flushed and feels
warm.
 Sweating.
 Decreased shivering and possible
dehydration.
47
Nursing Interventions for clients
with Fever
Monitor
vital signs.
Assess skin color and
temperature.
Monitor white blood cell count,
hematocrit value.
48
Remove
excess blankets when
the client feels warm, but
provide extra warmth when the
client feels chilled.
Provide adequate nutrition and
fluids.
49
Measure
intake and output.
Reduce physical activity to
limit heat production,
especially during the flush
stage.
Administer antipyretics as
ordered.
50
 Provide
oral hygiene to keep the
mucous membranes moist.
 Provide a tepid sponge bath to
increase that loss through
conduction.
 Provide dry clothing and bed
linens.
51
Hypothermia:
is a core
body temperature below the
lower limit of normal 35C.
The three physiologic
mechanisms
of
hypothermia are:
52
Excessive
heat loss.
Inadequate heat
production to counteract
heat loss.
Impaired hypothalamic
thermoregulation.
53
The Clinical Signs of
Hypothermia
Decreased
body temperature,
pulse, and respirations.
Severe shivering (initially)
Feelings of cold and chills.
Pale, cool, waxy skin.
54
Hypotension
and
disorientation.
Decreased urinary output.
 Lack of muscle coordination.
Drowsiness progressing to
coma.
55
Nursing Interventions for Clients
with hypothermia
Provide
a warm
environment.
Provide dry clothing.
Apply warm blankets.
56
Keep
limbs close to body.
Cover the client's scalp with
a cap or turban.
Supply warm oral or
intravenous fluids.
Apply warming pads.
57
58
 The
Pulse is a wave of blood
created by contraction of the
left ventricle of the heart.
Generally the pulse wave
represents the stroke volume
output and the amount of blood
that enters the arteries with
each ventricular contraction.
59
Compliance
of the arteries
is their ability to contract
and expand. When a
person's arteries loss their
distensibility as can happen
in old age, greater pressure
is required to pump the
blood into the arteries.
60
 Cardiac
output is the volume of
blood pumped into the arteries by
the heart and equals the result of the
stroke volume (SV) times the heart
rate (HR) per minute.
 SV: The amount of blood ejected
with each cardiac contraction
61
 For
example, 65mL x70 beats per
minute = 4.55 L per minute. When
an adult is resting, the heart pumps
about 5 liters of blood each minute.
62
 In
a healthy person, the pulse
reflects the heartbeat that is the
pulse rate is the same as the
rate
of
the
ventricular
contractions of the heart.
However, in some types of
cardiovascular disease, the
heartbeat and pulse rate can
differ.
63
 For
example, a client's heart
may produce very weak or
small pulse waves that are not
detectable in a peripheral pulse
far from the heart. In these
instances, the nurse should
assess the heartbeat and the
peripheral pulse.
64
A
Peripheral pulse is a pulse
located away from the heart, for
example, in the foot, wrist, or
neck.
 Apical
pulse, in contrast, is a
central pulse, that it is located
at the apex of the heart.
65
Pulse Sites
Radial
Temporal
Readily accessible
Carotid
During cardiac arrest/shock in adults
Determine circulation to the brain
Infants and children up to 3 years of age
Discrepancies with radial pulse
Monitor some medications
Apical
When radial pulse is not accessible
66
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Pulse Sites
Brachial
Blood pressure
Cardiac arrest in infants
Femoral
Cardiac arrest/shock
Circulation to a leg;
Circulation to lower leg
Popliteal
Posterior
tibial
Dorsalis
pedis
Circulation to the foot
Circulation to the foot
67
Factors
Affecting the
Pulse
68
Age.
Specific variations in
pulse rates from birth to
adulthood.
69
Gender.
After puberty, the
average male's pulse rate is
slightly lower than the
female's.
70
Exercise.
The pulse rate
normally increases with
activity.
71
Fever
 The
pulse rate increases:
a. in response to the lowered blood
pressure
that
results
from
peripheral vasodilatation associated
with elevated body temperature.
b. because of the increased metabolic
rate.
72
Medications
Some
medications decrease the
pulse rate, and others increase it.
For example, cardiotonics
(digitalis) decrease the heart
rate, whereas epinephrine
increase it.
73
 Hypovolemia.
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.
74
 Position
changes. When a person
is sitting or standing, 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 subsequent reduction in
blood pressure and increase in
heart rate.
75
Pathology.
Certain
diseases such as some
heart conditions or those
that impair oxygenation
can alter the resting pulse
rate.
76
When
assessing the pulse,
the nurse collects the
following data:
77
 Tachycardia.
An excessively fast
heart rate over 100 BPM in adult
is referred to as tachycardia.
 Bradycardia.
A heart rate in an
adult of 60 BPM or less is called.
78
The pulse rhythm.
 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.
79
Pulse volume
 Also
called the pulse strength or
amplitude, refers to the force of
blood with each beat.
 The elasticity of the arterial wall
reflects its expansibility or its
deformities. A healthy, normal
artery feels straight, smooth, soft,
pliable.
80
Pulse deficit

The difference between the apical and
radial pulse
81
Pulse pressure

The difference between systolic and
diastolic blood pressure.
82
83
 Respiration
is the act of breathing.
External respiration refers to the
interchange of oxygen and carbon
dioxide between the alveoli of the
lungs and pulmonary blood.
 Internal respiration, by contrast,
takes place throughout the body; it is
the interchange of these same gases
between the circulating blood and the
cells of the body tissues.
84
 Inhalation
or inspiration refers
to the intake of air into the lungs.
Exhalation or expiration refers
to breathing out or the movement
of gases from the lungs to the
atmosphere. Ventilation is also
used to refer to the movement of
air in and out of the lungs.
85
 There
are basically two types of
breathing:
Costal
(thoracic)
breathing
involves the external intercostals
muscles and other accessory
muscles,
such
as
sternocleidomastoid muscles. It
can be observed by the movement
of the chest upward and outward.
86
Diaphragmatic
(abdominal)
breathing
involves
the
contraction and relaxation of
the diaphragm, and it is
observed by the movement of
the abdomen, which occurs
as
a
result
of
the
diaphragm's contraction and
downward movement.
87
 Mechanics
and
Regulation
of
breathing
 During inhalation, the diaphragm
contracts (flattens), the ribs move
upward and outward, and the
sternum moves outward, thus
enlarging
the
thorax
and
permitting the lungs to expand.
88
 During
exhalation, the diaphragm
relaxes, the ribs move downward
and inward, and the sternum
moves inward, thus decreasing the
size of the thorax as the lungs are
compressed.
 Normally breathing is carried out
automatically and effortlessly.
89
Respiration is controlled
 Respiratory
centers in medulla
oblongata and the pons of the
brain.
 by
chemoreceptors located
centrally in the medulla and
peripherally in the carotid and
aortic bodies.
90
These
centers and receptors
respond to changes in the
concentrations of oxygen
(O2), carbon dioxide (CO2)
and hydrogen (H) in the
arterial blood.
91
Factors
Affecting
Respiration
92
 Several
factors
influence
respiratory rate. Those that
increase the rate include exercise
(increase metabolism), stress
(readies the body for fight or
flight), increased environmental
temperature, and lowered oxygen
concentration
at
increased
altitudes.
93
Factors
that may decrease the
respiratory
rate
include
decreased
environmental
temperature, certain medications
e.g. narcotics and increased
intracranial pressure.
94
Altered Breathing Patterns
and Sounds
 1.
Breathing Patterns Rate
 Tachypnea -----quick, shallow
breaths. Usually more than 24R/M
 Bradypnea------abnormally slow
breathing. Usually less than 10R/M
 Apnea---------cessation of breathing.
95
Volume
 Hyperventilation------overexpansion
of the lungs characterized by rapid and
deep breath.
 Hypoventilation-------under-expansion
of the lungs, characterized by shallow
respirations.
96
Rhythm
Cheyne-stokes
breathing-----Rhythmic waxing and waning
of respiration, from very deep
to very shallow breathing and
temporary apnea.
97
Ease or Effort
 Dyspnea
-----difficult and labored
breathing during which the individual
has a persistent, unsatisfied need for
air and feels distressed.
 Orthopnea-------ability to breathe
only in upright sitting or standing
positions
98
Breath sounds
 Audible
without amplification
 Stridor ------a shrill (high-pitch),
harsh sound heard during inspiration
with laryngeal obstruction.
 Stertor-------snoring
or sonorous
(loud) respiration, usually due to a
partial obstruction of the upper
airway.
99
 Wheeze------continuous,
highpitched musical squeak or whistling
sound occurring on expiration and
sometimes on inspiration when air
moves through a narrowed or
partially obstructed airway.
 Bubbling-------gurgling
sounds
heard as air passes through moist
secretions in the respiratory tract.
100
 Chest
movements
 Intercostal retraction---indrawing
between the ribs
 Substernal retraction---indrawing
beneath(under) the breastbone
 Suprasternal retraction----indrawing above the clavicles
101
 Secretions
and coughing
 Hemoptysis -------the presence of
blood in the sputum.
 Productive cough-------a cough
accompanied by expectorated
secretions.
 Nonproductive cough------a dry,
harsh cough without secretions.
102
Blood pressure

Arterial blood pressure is a measure of
the pressure exerted by the blood as it
flows through the arteries. Because the
blood move in waves.
103
There are two blood pressure:



Systolic pressure, which is the pressure of the
blood as a result of contraction of the ventricles,
that is, the pressure of the height of the blood
wave.
Diastolic pressure, which is the pressure when
the ventricles are at rest. Diastolic pressure is
the lower pressure, present at all times within
the arteries.
Pulse pressure, the difference between the
diastolic and the systolic pressures.
104

Blood pressure is measured in
millimeters of mercury (mmHg) 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.

105
Korotkoff’s Sounds
106
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
First the nurse pumps the cuff 30 mm Hg
above the point where the pulse is no
longer felt , that is the point when the
blood flow in the artery is stopped.
107
Korotkoff’s Sounds

Phase 1
First faint, clear tapping or thumping sounds
 Systolic pressure


Phase 2

Muffled (muted), whooshing, or swishing
sound
108
.
Korotkoff’s Sounds

Phase 3




Phase 4


Blood flows freely
Crisper and more intense sound
Thumping quality but softer than in phase 1
Muffled and have a soft, blowing sound
Phase 5



Pressure level when the last sound is heard
Period of silence
Diastolic pressure
109
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Measuring Blood Pressure


Direct (Invasive Monitoring)
Indirect



Auscultatory
Palpatory
Sites


Upper arm (brachial artery)
Thigh (popliteal artery)
110
Copyright 2008 by Pearson Education, Inc.



Factors Affecting Blood Pressure
Age : Newborns have a mean systolic pressure
of about 75 mm Hg. The pressure rises with age,
reaching a peak at the onset of puberty, and
then tends to decline somewhat.
Exercise: Physical activity increases the cardiac
output and hence the blood pressure, thus 20 to
30 minutes of rest following exercise is indicated
before the resting blood pressure can be reliably
assessed.
111

Stress: Stimulation of the sympathetic
nervous system increases cardiac output
and vasoconstriction of the arterioles, thus
increasing the blood pressure reading.
However, severe pain can decrease blood
pressure greatly by inhibiting the
vasomotor center and producing
vasodilatation.
112
Race: African American males over 35
years have higher blood pressure than
European American males of the same
age.
 Gender: After puberty, females usually
have lower blood pressure than males of
the same age this difference is thought to
be due to hormonal variations. After
menopause women generally have higher
blood pressure than before.

113




Medication: Many medications may increase or
decrease the blood pressure.
Obesity: Both childhood and adult obesity
predispose to hypertension.
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 condition affecting the
cardiac output blood volume, blood viscosity
and/or compliance of the arteries has a direct
effect on the blood pressure.
114





Hypertension: A blood pressure that is
persistently above normal.
Primary hypertension an elevated blood
pressure of unknown cause
Secondary hypertension an elevated blood
pressure of known cause.
Hypotension is a blood pressure that is below
normal.
Orthostatic hypotension is a blood pressure
that falls when the client sits or stands.
115











Common Errors in Assessing Blood Pressure
Bladder cuff too narrow
Bladder cuff too wide
Arm unsupported
Insufficient rest before the assessment.
Repeating assessment too quickly.
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 smoker or has
pain.
116

Variations in Normal Vital Signs by
AgeAgeOral temperature in degree Pulse
Average and RangesRespirationsAverage
and RangesBlood pressure (mm
Hg)Newborns36.8130 (80-180)35(30-80)73/551
year36.8120 (80-140)30 (20-40)90/555-8
years37100 (75-120)20 (15-25)95/5710
years3770 (50-90)19 (15-25)102/62Teen3775
(50-90)18 15-20)120/80Adult3780 (60-100)16
(12-20)120/80Older adult (>70 years)3770 (60100)16 (15-20)Possible increased diastolic
117
Pulse Oximetry
118
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Pulse Oximetry
Noninvasive
 Estimates arterial blood oxygen saturation
(SpO2)
 Normal SpO2 85-100%; < 70% life
threatening
 Detects hypoxemia before clinical signs
and symptoms
 Sensor, photodetector, pulse oximeter unit

119
Pulse Oximetry

Factors that affect accuracy include:
Hemoglobin level
 Circulation
 Activity
 Carbon monoxide poisoning

120
Pulse Oximetry
Prepare site
 Align LED and photodetector
 Connect and set alarms
 Ensure client safety
 Ensure accuracy

121