Transcript File - Respiratory Therapy Files

CHAPTER 4
VITAL SIGNS
Overview
2

Vital signs (VS) are used to:
Determine the general status of the
patient
Establish a baseline
Monitor response to therapy
Observe for trends
Determine the need for further
evaluation or intervention
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Obtaining VS and Clinical Impression
3

Four classic VS
 Temperature
 Pulse
 Respirations
 Blood
pressure
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Additional Observations
4
 Height
and weight
 LOC
 Level
and type of pain
 General
 Pulse
appearance
oximetry
Frequency of VS Measurement
5
Depends on patient’s condition
 Baseline measurement

 On
admission
 At beginning of each shift
 Before and after procedure
 Any time patient’s condition changes
 Based on protocol or physician's order
 As often as necessary for patient safety
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Trends in Vital Signs
6



Isolated measurement provides limited information
Normal VS for a patient depend on:
 Age
 Presence of chronic disease
 Treatment protocols
Trend = baseline + measurements over time
 Multiple-day graph
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Trending
7
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9
Comparing VS Information
10

Shows change in patient’s condition:
 Comparing
changes in VS, signs, and symptoms
 Establishing
differential diagnosis
 Determining
if patient is improving or
deteriorating
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Comparing VS Information (Cont.)
11

Key to expert assessment:
Constant awareness of change
Look
Listen
Touch
Reassess and analyze
Trend, trend, trend
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12
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Height and Weight
13
Routinely measured
 Pt needs an admission weight
 Document in kilograms (1 kg = 2.2 lb)
 Follow up every 24 to 48 hours
 Dehydration or fluid overload
Follow intake/output (I&O)
 Scales must be age appropriate and regularly
calibrated

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General Clinical Impression
14



Gives clues to levels of distress and
severity of illness
Information about personality, hygiene,
culture, and reaction to illness
May dictate order of care, physical
examination
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General Clinical Impression (Cont.)
15

Cardiopulmonary distress suggested by:
Labored,
rapid, irregular, or shallow
breathing
Coughing,
Chest
choking, and/or wheezing
pain and/or cyanosis
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General Clinical Impression
16

Anxiety may be suggested by:
 Restlessness
 Fidgeting
 Tense
look
 Difficulty
communicating
General Clinical Impression (Cont.)
17

Pain may be suggested by:
 Drawn
features
 Moaning
and guarding
 Shallow
breathing and/or refusal to take
deep breath
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Head-to-toe inspection
18
Hearing
Smelling
Seeing
Touching
Perception
19
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Pain Level and Type
20
“Fifth vital sign”
 Pain intensity scales
 Ranking of 1 to 10
 Quantifies a subjective measure
 Corresponding facial expressions and verbal
description to assess pain level
 Find associated symptoms as well as
alleviating and aggravating factors

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21
Level of Consciousness
22

Measure cerebral oxygenation

Evaluation of time, place, and person
 “Oriented

× 3”
Deterioration from restlessness to coma
 Cerebral
hypoxia
 Side effect to medications or drug overdose
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LOC
23

Status of sensorium
 Directs
treatment plan
 Patient cooperation, coordination

Glasgow Coma Scale
24
Temperature
25

Normal:
 98.6°
F (37° C), range (97°-99.5° F)
 Daily
variations (1°-2° F)
 Lowest
in morning
 Highest
late afternoon
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Temperature
26



Normal increase during exercise, ovulation,
and first months of pregnancy
Balance of heat production and loss
Dissipation through sweating, peripheral
vasodilation, and hyperventilation
Fever
27

Elevation of temperature (febrile)
 From
normal activities (exercise) = hyperthermia
 From disease (infection) = fever
Body temperature of >102° F usually
indicates infection
 Not all infections result in fever

 Immunocompromised
patients may not be able to
generate fever despite infection
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Fever (Cont.)
28

Increases O2 consumption and CO2
production
 O2 consumption
and CO2 production increase
10% for each 1 C elevation in body
temperature
 Patients
with limited respiratory function may
develop respiratory failure in response to fever
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Hypothermia
29

Body temperature below normal
 Head
injury
 Cold exposure

Compensatory mechanisms
 Shivering
 Peripheral

vasoconstriction
Reduces O2 consumption and CO2 production
 Slow
and shallow breathing
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30
Inducing mild therapeutic
hypothermia in selected patients
surviving out-of-hospital sudden
cardiac arrest can significantly
improve rates of long-term
neurologically intact survival and
may prove to be one of the most
important clinical advancements in
the science of resuscitation.
31
Measuring Body Temperature
32


Sites: Mouth, ear, axilla, rectum, forehead
 Axillary: Safe and accurate in infants and
small children
1 F lower than oral, 2 F lower than rectal
Fahrenheit and Celsius conversion
 ° F = (° C × 9/5) + 32
 ° C = (° F – 32) × 5/9
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Pulse
33


Evaluate:
Rate, rhythm, and strength
Normal rate: 60-100 beats/min for
adults
The younger the patient, the faster
the rate
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Heart Rate - Tachycardia
34
 HR
 HR
greater than 100 b/min
can increase from hypoxemia, pain,
anxiety, stress, fever, drug reactions, MI,
hypovolemia, or cardiac output defects.
Heart Rate
35

Bradycardia = <60 beats/min
 Diseased heart, athletes, medication side
effects, hypoxemia in infants, low CO
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Arrhythmia = Irregular rhythm
36
37
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Measurement of Pulse Rate
38
Right radial artery = Most common site
 Index and middle fingers
 Avoid thumb: examiner’s own pulsation
 Central pulses if hypotension present
 Carotid, femoral
 Pulse counted for a full minute
 If regular, counted for 15 sec × 4
or 30 sec × 2

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Taking a Pulse
39
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40
Pulse Rhythm and Pattern
41

Regular, regularly irregular, irregularly
irregular
 Irregularly
irregular is unfavorable finding
 Bigeminy = Rhythm coupled in pairs
 Trigeminy = Rhythm grouped in three beats

Pulse deficit = Auscultated – Palpated
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42
Pulse Rhythm
and Pattern (Cont.)

Volume of the pulse
 Described
as: bounding, full, normal, weak,
thready, absent

Pulsus paradoxus
 Strength
decreases with inspiration
 Alternans = strong and weak pulses
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Respiratory Rate and Pattern
43

Sensitive Marker of Acute Respiratory Distress

Tachypnea = rate above normal
 Atelectasis,
 Anxiety,
hypoxemia, hypercapnia
pain, exertion, metabolic acidosis
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Respiratory Rate and Pattern
44

Bradypnea = rate below normal
Uncommon
Head
injury, hypothermia, side effect of
medications (narcotics), drug overdose
45
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Measurement of Respiratory Rate
46

Watching abdomen or chest wall
movement
Can be done as you assess radial pulse

When regular = Count for 30 sec × 2

Assess depth and pattern
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Blood Pressure
47
Blood Pressure (BP)
48

Force exerted against arterial walls
 Systolic:
peak force during ventricular
contraction
 Diastolic:

force during ventricular relaxation
Normal: 120/80 mm Hg
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Blood Pressure
Pulse pressure = P systolic – P diastolic
Normal: 35-40 mm Hg
<30 mm Hg: poor peripheral
perfusion
49
50
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Hypertension and Hypotension
51

Hypertension
 BP
of >140/90 mm
Hg
 Risk
factor for heart,
vascular, renal disease
 Major modifiable risk
factor for stroke, CAD,
CHF, peripheral
vascular disease
 Cause in most cases is
unknown

Hypotension
 BP
of <90/60 mm Hg
 If
symptomatic:
dizziness, fainting
 Causes: left ventricular
failure, blood loss,
peripheral vasodilation
 Orthostatic hypotension:
resulting from changes
in posture
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52
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Measurement of Blood Pressure
53

Sphygmomanometer
Occluding cuff, stethoscope, manometer
Continuous
noninvasive arterial pressure
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Blood Pressure
54
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55
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Errors in Blood Pressure Measurement
56

Erroneously High
 Too
narrow a cuff
 Cuff applied too
tightly or too loosely
 Excessive pressure in
cuff during
measurement
 Incomplete deflation of
cuff between
measurements

Erroneously Low
 Too
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wide a cuff
Blood Pressure
57
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58
Effects of the Respiratory
Cycle on BP


Systolic pressure decreases (2-4 mm Hg) with
inspiration
Pulsus paradoxus: if BP drops >10 mm Hg
 Asthma, cardiac tamponade are two common
causes
 Pulsus paradoxus in asthma signifies a more
severe case
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