INTRODUCTION TO FUNDAMENTALL VITAL SIGNS 2.pptx

FUNDAMENTAL OF NURSING

1. FUNDAMENTALS OF NURSING

2. VITAL SIGNS - PART 2

3. PULSE

4. DEFINITION Pulse is a wave of distention and elongation felt in the arterial wall due to contraction of the left ventricle forcing about 70-100ml of blood into the already full aorta. P ulse reflects the heart beat. The PR is expressed in beats/minute ( BPM )

5. CHARACTERISTICS OF A PULSE A Pulse is assessed for: Rate (60-100bpm) (fast/Tachycardia or slow/Bradycardia) Rhythm (regularity or irregularity) Volume (strong/bounding or weak/thready) Elasticity of arterial wall . (A healthy, normal artery feels straight, smooth, soft, easily bent) The pulse is commonly assessed by palpation (feeling) and auscultation (hearing using a stethoscope).

6. Normal pulse rate varies depending on age. For a healthy adult the normal resting pulse ranges from 60-100 beats per minute. Tachycardia- An abnormal rapid heart rate over 100 beats/min. Bradycardia- An abnormal slow heart rate below 60 beats/min. Bounding- Strong full force pulse. Thready/ weak- Difficult to palpate, a pulse of diminished strength. Absent- No palpable pulse. Irregular- When interval varies between pulse. Dicrotic- A split or double pulse beat the second being weaker than first.

7. FACTORS THAT AFFECT PULSE READING Age: T he average pulse rate of an infant ranges from 100 to 160 BPM. The normal range of the pulse in an adult is 60 to 100 BPM Sex: A fter puberty the average males PR is slightly lower than female Position changes : In a sitting or standing position blood usually pools in dependent vessels of the venous system. B/c of decrease in the venous blood return to heart and subsequent decrease in BP increases heart rate.

8. Exercise: PR increase with exercise Fever: increases PR in response to the lowered B/P that results from peripheral vasodilatation – increased metabolic rate Heat: increases PR as a compensatory mechanism Stress: increases the sympathetic nerve stimulation

9. Medication: Cardiac medication such as digoxin decrease heart rate Medications that decrease intravascular volume such as diuretics may increase pulse rate Atropine inhibits impulses to the heart from the parasympathetic nervous system, causing increased pulse rate Beta Blockers blocks sympathetic nervous system action resulting in decreased heart rate

10. SITES FOR TAKING A PULSE 1. Carotid: at the side of the neck below tube of the ear (where the carotid artery runs between the trachea and the sternocleidomastoid muscle) 2. Temporal: the pulse is taken at temporal bone area. 3. Apical: at the apex of the heart: routinely used for infant and children < 3 yrs. In adults – Left mid-clavicular line under the 4th, 5th, 6th intercostal space.

11. 4. Brachial: at the inner aspect of the biceps muscle of the arm or medially in the antecubital space (elbow crease) 5. Radial: on the thumb side of the inner aspect of the wrist – readily available and routinely used 6. Femoral: along the inguinal ligament. Used on infants and children 7. Popliteal: behind the knee. By flexing the knee slightly at 45 o 8. Posterior tibial: on the medial surface of the ankle 9. Pedal (Dorsal Pedis): palpated by feeling the dorsum (upper surface) of foot

12. METHOD OF CHECKING A PULSE Pulse: is commonly assessed by palpation (feeling) or auscultation (hearing) The middle 3 fingertips are used with moderate pressure for palpation of all pulses except apical Assess the pulse for Rate, Rhythm, Volume and Elasticity of the arterial wall If the pulse is regular, measure (count) for 30 seconds and multiply by 2 If it is irregular count for 1 full minute.

13. RESPIRATION

14. RESPIRATION Respiration is the act of breathing and includes the intake of oxygen (inspiration) and removal of carbondioxide (expiration). Ventilation is also another word, which refers to movement of air in and out of the lung. Hyperventilation: - is a very rapid respiration. Hypoventilation : - is a very slow respiration. It is measured in Cycles-per-minute (CPM) or Times-per-minute (TPM) or Breath-per-minute (BPM)

15. TYPES OF BREATHING 1. Costal (thoracic) Observed by the movement of the chest upward and downward. Commonly used for adults 2. Diaphragmatic (abdominal) Involves the contraction and relaxation of the diaphragm, observed by the movement of abdomen. Commonly used for children.

16. FACTORS AFFECTING RESPIRATION Age: Normal growth from infancy to adulthood results in a larger lung capacity. As lung capacity increases, respiratory rates decreases. RR decreases with increasing age Medications: Narcotics decrease respiratory rate & depth Stress or strong emotions : increases the rate & depth of respirations. Exercise: increases the rate & depth of respirations

17. Altitude: The rate & depth of respirations at higher elevations (altitude) increase to improve the supply of oxygen available to the body tissues Gender: Men may have a lower respirations rate than women because men normally have a larger rung capacity than women Fever: increases respiratory rate

18. CHARACTERISTICS OF RESPIRATION Respiration rate: It indicates the number of times the person breathes in and out in one minute. Healthy adult RR = 14- 20/ min Eupnea - normal breathing rate and depth Bradypnea - slow respiration less than 10 breath/min. Tachypnea - fast breathing more than 20 breath/min in adults . Apnea - temporary cessation of breathing Dyspnea – difficulty in breathing

19. 2. Depth: it is estimated by observing the movement of chest during inspiration. Described as normal, deep or shallow. Deep: a large volume of air inhaled & exhaled, inflates most of the lungs. Shallow: exchange of a small volume of air minimal use of lung tissue. 3. Rhythm: it indicate the equal interval between two respiration. Is the regularity of expiration and inspiration Normal breathing is automatic & effortless.

20. METHOD OF CHECKING RESPIRATION Place the patient in a relaxed position with your hand on the patient’s arm (as if you are taking a pulse) Now observe complete respiratory cycle (Inspiration + expiration). Assess for Rate, rhythm, depth and special characteristics of respiration Count/measure the respiration for one full minute. If regular rhythm, count for 30seconds and multiply by 2

21. BLOOD PRESSURE

22. BLOOD PRESSURE (BP) BLOOD PRESSURE is the force exerted by the blood against the vessel walls (arterial wall), which is measured in millimeter of mercury (mmHg). BP is measured by using an instrument called BP cuff (sphygmomanometer) & stethoscope.

23. Normal blood pressure in an adult varies between 100 to 140 mm of Hg systolic and 60 to 90 mm of Hg diastolic but BP may vary widely depending on individuals other factors.

24. TYPES OF BP READING Systolic Blood Pressure(SBP): is the maximum of the pressure against the wall of the vessel following ventricular contraction. Diastolic Blood Pressure(DBP): is the minimum pressure of the blood against the walls of the vessels following closure of aortic valve (ventricular relaxation). Mean Arterial Pressure(MAP): is the average arterial pressure throughout one cardiac cycle (systole and diastole)

25. FACTORS AFFECTING BP Fever Stress Arteriosclerosis Exposure to cold Obesity Hemorrhage Low hematocrit External heat

26. SITES FOR MEASURING BP Upper arm using brachial artery (commonest) Thigh around popliteal artery Fore -arm using radial artery Leg using posterior tibial or dorsalis pedis artery

27. ASSESSING BLOOD PRESSURE Purpose To obtain base line measure of arterial blood pressure for subsequent evaluation To determine the clients homodynamic status To identify and monitor changes in blood pressure.

28. EQUIPMENT FOR MEASURING BP Stethoscope Blood pressure cuff of the appropriate size Sphygmomanometer

29. Earpieces Binaural Rubber or plastic tubing Bell Chestpiece Diaphragm

30. PROCEDURE TO MEASURE BP Explain the procedure to the patient & remove any cloth from patient’s arm Make sure that the client has not smoked or ingested caffeine, within 30 minutes prior to measurement. Position the patient on lying or sitting position, but always ensure that the sphygmomanometer is at the level of the heart with the arm supported & the palm facing upwards. Apply the cuff securely around the arm , 2.5cm above the antecubital space/fossa, at the level of the heart

31. Palpate the radial pulse and inflate the cuff until the radial pulse can no longer be felt, this provides an estimation of systolic pressure. Inflate cuff 20-30mmhg higher than estimated systolic pressure. Place the diaphragm of the stethoscope over the site & the ear pieces on ear, apply enough pressure to keep the stethoscope in place. Deflate the cuff 2-4mmhg per second. The first beat heard is the systolic reading . Continue to deflate until there is a change in tone to a muffled beat, this is the diastolic reading.

32. Deflate & remove cuff roll neatly and replace. Record the systolic and diastolic pressure on vital sing sheet and compare the present reading with previous reading. report or treat any change Clean ear pieces and chestpiece of the stethoscope with antiseptic swab and return all equipment.

33. ANY QUESTIONS?