Transcript Vital Signs
The most frequently measured objective data for monitoring physiologic function Used to identify ◦ Relative status of organs ◦ Physiologic abnormalities ◦ Response to treatment ◦ Trends ◦ Need for further tests or evaluations The four classic vital signs ◦ ◦ ◦ ◦ pulse respiratory rate body temperature blood pressure Also often reported as part of the vital signs ◦ Pulse oximetry ◦ Sensorium ◦ ECG monitoring results are. Routine vital signs typically measured every 4 to 6 hours Usually recorded before and after each respiratory care treatment Vital signs are measured more often when the patient’s condition may change abruptly A series of vital sign measurements over time establishes a trend and is far more important than a single measurement Recording the vital signs on a graph allows better visualization of changes over time Abrupt and gradual changes over time are important to note Comparing the vital signs to other clinical findings such as chief complaints and other physical examination findings helps determine a more exact cause of the abnormalities. Height and weight are routinely measured as part of the initial physical examination and as part of every outpatient visit. They are often recorded in the patient chart in the same general location as the vital signs. Part of the vital sign assessment is to document the patient’s general clinical presentation. This is determined by observation of the patient’s breathing pattern, facial expression, level of consciousness, nutritional status, etc. A single summary statement about the patient’s general presentation is included with the vital sign measurement for the initial evaluation of the patient. “Oriented × 3” Patients who are alert and oriented to; ◦ time ◦ place ◦ person The GCS is one of the most popular tools used to document the patient’s level of consciousness The GCS is the gold standard for assessing the neurological function of patients 1 2 3 4 5 6 Does not open eyes Opens eyes in response to painful stimuli Opens eyes in response to voice Opens eyes spontaneously N/A N/A V Makes no sounds e r b a l Incomprehensible sounds Utters inappropriate words Confused, disoriented Oriented, converses normally N/A M Makes no o movemen ts t o r Extension to painful stimuli Abnormal flexion to painful stimuli Flexion / Withdrawal to painful stimuli E y e s Localizes Obeys painful stimuli Comma nds Normal body temperature is 37o C, or 97° to 99.5o F. Body temperature is maintained by the hypothalamus in the brain The respiratory system plays a role in temperature balance by providing another method for heat release Fever is the abnormal elevation of body temperature due to disease One of the most common causes of fever is infection Patients with a poor immune system may not generate a fever when infection is present Elevation of body temperature increases oxygen consumption and increases the demand for CO2 removal Hypothermia is present when the body temperature drops below normal Body temperature is measured at several sites Rectal temperatures are not often used but may be measured in comatose patients Axillary temperatures are popular for pediatric patients Axillary temperatures run about one degree F below oral measurements Oral temperature measurements are very popular. They are affected by recent oral ingestion of cold or hot liquids and food Tympanic (ear) sites are common practice today ROUTE SPECIAL CONSIDERATIONS ORAL •Done for 3 minutes •Upon intake of hot/cold fluids, wait 30 minutes RECTAL •Done for 2-3 minutes •Presence of fecal matter could result to a false reading •Lubricate tip prior to inserting AXILLARY TYMPANIC •Done for 10 minutes •Within two seconds •Up/back for adult •Down/back for pedia Measurement of Pulse Rate Pulse is often measured by palpating the radial or brachial impulse It should be measured for 30 seconds and the total multiplied by two ◦ If the pulse is irregular, measuring it for 1 full minute is recommended Rapid heart rate is tachycardia ◦ (>100 beats/min); slow heart rate is bradycardia (<60 beats/min) The pulse normally is very regular with only slight variations seen with breathing Irregular pulse could be a sign of serious heart disease and should be investigated The volume of the pulse is also important to note ◦ Weak peripheral pulses are a sign of heart failure Extreme drops in the strength of the pulse with inspiration are known as pulsus paradoxus The respiratory rate should be counted without the patient being aware of the measurement Watching the patient’s chest move up and down while continuing to palpate the radial pulse is a good approach Rapid respiratory rate is known as tachypnea Slow respiratory rate is bradypnea Age Pulse Beats / Min RR Breaths/min Newborn 90-70 35-45 up to 70 1 Year 80-160 25-35 Preschool 80-120 20-25 10 Years 70-110 15-20 Adult 60-100 12-20 One of the first signs of cardiopulmonary disorders ◦ Caused by; Exercise Lung Disease (Chronic or Acute) Fever Decreased blood pressure Metabolic Acidosis Anxiety Pain Neurological insult Metabolic alkalosis Medications CHI (closed head injury) End stage respiratory failure Eupnea- normal Dyspnea- SOB Labored – using accessory muscles Apnea – cessation of breathing for >10 sec Kussmaul – rapid and deep Cheyne Stokes – increases and decreases in breathing patterns with apneic periods Biots – periods of apnea between four to five equal depth but irregular breaths Apneustic – prolonged inspiration Bradypnea – increased rate Tachypnea – increased respiratory rate Hypopnea – increased depth Paradoxical – abdominal paradox Arterial blood pressure has two components ◦ The peak pressure that results during ventricular systole ◦ The baseline pressure that occurs during ventricular diastole The peak pressure is known as the systolic pressure and the resting pressure is the diastolic pressure The difference between the systolic and diastolic pressures is the pulse pressure Hypotension is present when the BP is below 90/60 mm Hg Hypertension is present when the BP is 140/90 mm Hg Most commonly measured with a blood pressure cuff The cuff is wrapped around the patient’s arm and inflated to a pressure believed to be higher than the patient’s systolic pressure The cuff pressure is released slowly while monitoring a pressure monometer The initial Korotkoff sound is the systolic pressure, and when the Korotkoff sounds disappear, the diastolic pressure is noted Normally the changes in blood pressure with breathing are very slight The systolic pressure drops slightly with normal inspiration Pulsus Paradoxus - when BP drops significantly with inspiration ◦ This may be a sign of cardiac (e.g., cardiac tamponade) or respiratory problems (e.g., asthma) Pulsus alternans – alternating pulse strength not related to breathing Can be caused by ◦ ◦ ◦ ◦ Stress Obesity Renal disease Vascular disease Can lead to ◦ ◦ ◦ ◦ CVA CHF CAD MI Can be caused by ◦ ◦ ◦ ◦ Cor 0 Vasodilatation Ventricular failure Low blood volume Can lead to ◦ Multi organ dysfunction Vital signs are one small piece of a large clinical picture. One measurement alone is not sufficient enough to make clinical judgment of therapeutic intervention