Vital sign

Vital sign

1. Presented by, Mrs. Laxmi Kamat Senior tutor KAHER Institute OF Nursing Sciences, Belagavi

2. Introduction: vital signs are basic components and objective of assessment of physiological and psychological health of a client. These are the signs of life: Temperature Pulse Respiration Blood pressure

3. Purposes: Identify specific life threatening conditions and plan for needed nursing interventions Detect changes in the clients health status (improvement or regression may be detected by the observing of these things) Through these signs ,specific information may be obtained that helps in diagnosis of disease.

4. Why these signs are called as vital? These findings are governed by vital organs and often reveal even the slightest deviation from the normal body function. These signs helps to identify the specific life threatening conditions and plan needed nursing interventions. To detect changes in the client’s health condition

5. Normal body temperature - 98.6°F or 37°C in adults (97 to 99° F) Normal pulse is – 72 beats / minute in adult ( 60 to 100) Normal respiration is – 16 breaths / minute in adult (12 to 20) Normal blood pressure is – 120/80 mm of Hg in adults.

6. Temperature: Body temperature may be defined as the degree of heat maintained by the body, or it is balance between the heat production and the heat lost by the body. -The heat regulating center is the hypothalamus situated in the brain. By balancing between producing heat and loss of heat in the body.

7. The regulation of the body temperature is maintained by two mechanisms: Thermogenesis: a chemical regulation by the production of heat. Thermolysis: a physical regulation by loss of heat.

8. Ways of producing heat: Oxidation of food Specific dynamic action of the food Exercise Strong emotions such as excitement, anxiety, nervousness etc. Hormonal effects Changes in the environment Disease condition

9. Ways of losing heat from the body: The heat is lost from the body through different organs: Through the skin Through the lungs Through the kidneys Through the bowels

10. Normal variations in the body temperature In the healthy individual, the body temperature may vary between 97 to 99 F The following factors may influence the variations in the body temperature: Time of the day Time of the month Age of person Part of the body where the temperature is taken Emotions Exercises Fasting Environmental factors

11. Temperature alteration: Body temp. that fall between 99°F and 100.4° F is termed as a low grade fever. Body temp. that is above 100.4° F is termed as a normal fever. Temp. that reaches 105.8° F is a serious condition . Temp. that reaches 109.4° F is generally fetal condition.

12. Types of thermometer: Glass thermometer (mercury thermometer) Electronic thermometer Tympanic membrane thermometer Disposable paper thermometer Temperature sensitive strips and Chemical Dot

13. The common site for taking body temp. are- Mouth Axilla Groin Vagina rectum

14. Temperature by mouth Advantages Disadvantages Good blood supply under the tongue. Less chance for the bulb coming in contact with the outside air. The thermometer can be held easily under the tongue, so there is less chance of the thermometer falling down from the mouth. No privacy is need. The nurse may not know whether the bulb of the thermometer is in place. The children and insensible persons may bite the thermometer. If thermometer are not adequately disinfected, there is possibility of cross infection. If the disinfectant is not removed completely, the client will get the bad taste of the disinfectant . The client will get tired if the thermometer is kept for a long time.

15. Contraindications: The temperature is not taken by mouth in the following clients: Extremely nervous clients , Ex- unconscious, mentally confused, and those who cannot follow the instruction. The client having convulsion . Mouth breather . Client who have injuries, inflammation or operations of the mouth. Extremely weak persons , who are not able to hold the thermometer under the tongue. Persons suffering from frequent attacks of cough. Children under 6 years of age.

16. Advantages Disadvantages Less discomfort for the client Nurse will be able to keep thermometer in position without difficulty Taking hot or cold drinks will not affect the temperature reading The client does not get the ill taste of the disinfectants There is no fear of biting the thermometer Presence of moisture can give a false reading You may get false reading if the thermometer is not placed correctly Temperature by Axilla:

17. Advantages Disadvantages It is used when the oral method is contraindicated It is most reliable method. It contains large amount of blood supply It is not influenced by external air It fully surrounded by the body tissue and we get a more accurate reading The client needs privacy Needs lubrication of the bulb There is a chance of soiling the hands of the nurses If the rectum is loaded with fecal matter we get a false reading. Temperature by Rectum:

18. Contraindications: The temperature is not taken by rectum in the following clients: The client who have rectal surgery or inflammation of the rectum The client who are having diarrhea . When the rectum is packed with faecal matter. the client who are having some kinds of treatment , Ex: bowel wash, enema etc.

19. Advantages Disadvantages Tympanic temperature reflects the core body temperature. The ear is readily accessible It can use for very young, confused and unconscious clients. Smoking, drinking and eating do not affect tympanic temperature measurments Cerumen in the ear and presence of otitis media may alter temperature reading Temperature by Ear:

20. Frequency of taking temperature in the hospital: frequency of taking temperature is determined by the condition of the client Who not seriously ill it needs to be taken in the morning and evening The temperature is to be checked every 4 hours or even more frequently for those who are acutely ill. Ex: high fever, post operative client

21. Pulse: Pulse is an alternate expansion (rise) and recoil (fall) of an artery as the wave of blood is forced through it during the contraction of the left ventricle. The pulse is measured by applying moderate pressure with the sensitive pads located on the tips of the three middle fingers. Place your three fingers on radial artery located on the inner portion of the thumb. Count how many heart beats you feel in one minute.

22. SITES FOR TAKING PULSE

23. THE PULSE MAY BE FELT AT: The Radial artery in front of the wrist. Temporal artery over the temporal bone. Carotid artery at the sides of the neck. The Brachial artery above the elbow and in the antecubital fossa ( inner part of the elbow) Femoral artery in the groin. Poplitial artery in the poplitial fossa (back of the knee) The Dorsalis Pedis artery on the foot. The Posterior Tibial artery behind the medial malleolus.

24. Characteristics of the pulse: Before assessing the pulse, nurse must be familiar with the normal characteristics of a pulse – the Rate, Rhythm, Volume and Tension. Rate: Is the number of pulse beats in a minute. The normal rate in the resting adult is 60 to 100 beats per minute. If pulse rate over 100 per minute is referred to be “Tachycardia” If pulse rate below 60 per minute is referred to be “Bradycardia”

25. Factors causing variations in pulse rate are: Age Sex Physique Exercise Food Posture Emotions Application of heat Pain Increased body temperature Disease condition Drugs Cold application

26. Rhythm: It refers to the regularity of beats. Normally the heart beats are spaced at equal intervals and they are said to be regular. When the interval varies between the beats it said to be irregular. If irregularity is present the pulse should be counted for one full minute. Volume: It refers to the fullness of the artery It is the force of the blood felt at each beat Volume depends upon the amount of blood in the arteries If arteries contains normal volume of blood the pulse is said to be full or large in volume. If the volume of the blood is decreased as by haemorrhage, the pulse will be weak, small feeble or flickering.

27. Tension: Is the degree of compressibility It said to be high tension when the artery is difficult to compress Low tension when it is easy to compress. Frequency of taking pulse: The pulse is taken along with the body temperature twice a day for clients who are not seriously ill. It may be taken frequently for clients who had surgeries, accidents or who are critically ill.

28. Methods of taking pulse: Palpation Auscultation

29. Abnormal Pulse: For healthy adult the normal pulse ranges from 60 to 100 beats per minute TACHYCARDIA: is characterized as a fast heart rate which is more than 100 b/m. this may indicates that a patient having some sort of heart diseases or the person just finishing with vigorous exercise. BRADYCARDIA: is characterized as an abnormally low heart rate which is below 60 b/m. this may occurs during sleep

30. Respiration: Respiration is the act of breathing. It is the process of taking oxygen and giving out carbon dioxide. Respiration maybe external and internal External respiration (Pulmonary respiration) : the exchange of gases between the blood and air in the lunges Internal respiration ( T issue respiration) : the exchange of gases between the blood and the tissue cells of the body.

31. To asses the respiration you need to watch the chest movements (chest rise and fall) as the person breaths. Then count for the one minute how many times the chest falls. This will be how many respiration s the patient has per minute. Each respiration is divided into two phases INHALATION: which is breathing in EXHALATION: which is breathing out

32. Characteristics of Respiration: respiration is observed to determine the Rate, depth, rhythm and easiness of respiration. Normal breathing is effortless, automatic, regular, even and produces no noise.it is called as Eupnoea. Rate: is the number of full respiration in a minute. Normal rate of respirations for an adult will be between 16 to 20 breaths per minute.

33. Factors causing variations in Respiration rate are: Age Sex Emotions Exercise Ingestion of food and digestion Change in the atmospheric pressure Change in the external temperature Disease condition Drugs

34. Rhythm: It refers to the regularity of breathing. In normal respiration the rhythm is normal. Critically ill clients and persons nearing death are found to have irregular respiration.

35. Abnormal respiration: Tachypnea(Polypnoea) : Is characterized as an abnormal increase in respirations which is more than 24 breaths per minute. Bradypnea: Is characterized as an abnormal decrease in respiration which is less than 10 breaths per minutes. Apnoea: Total cessation of breathing.

36. What to observe when taking respiration: Rate of respiration Regularity and rhythm of respiration Easiness of respiration Movement of the muscles of the chest, nose and abdomen Position of the client during breathing

37. RESPONSIBILITY FOR TAKING T.P.R Identify the patient . Check the diagnosis, date & type of surgery, if any. Ability to follow direction. Ability to retain thermometer in place.

38. PREPARATION OF THE ARTICLES Sl.No Articles Purpose 1 Thermometer in a jar containing some cotton at the bottom of the jar. Cotton at the bottom of the jar prevents the bulb of the thermometer from breaking. 2 Bowl with soapy swabs/jar containing Dettol lotion 1: 40 To disinfect the thermometer 3 Bowl with wet Swabs To clean the thermometer 4 Bowel with dry swabs To dry the thermometer 5 Kidney try To discard the soiled swabs 6 Pen, Chart , watch with second hand To record T.P.R before forgetting.

39. PROCEDURE Sl.No Steps of procedure Reasons 1 Wash hands. To prevent cross infection 2 Remove the thermometer from the jar and wipe with soapy swab or dip it in antiseptic lotion and rinse it in cold water. To remove the disinfectant lotion. 3 Wipe the thermometer from bulb upwards with a rotating movement, using a clean cotton swab. Discard the swab. To maintain the asepsis of the bulb end. 4 Read the level of mercury in good light. To read the level of the mercury in the thermometer, hold the thermometer with the fingers of the right hand, very slowly rotating back & forth until the silvery mercury line comes into view & read the measurement to the nearest line. The thermometers are made in such a way that the lines are magnified & visible on one side.

40. Sl.No Steps of procedure Reasons 5 Shake the thermometer , if the mercury level is above 35 c or 95 F. Shake it with the quick movements of the wrist. To shake the thermometer, hold it firmly by its stem and move away from the wall, furniture & equipment. Wipe the axilla from perspiration, Presence of moisture can give a false reading To record the temperature correctly, the level of the mercury should be well below the actual temperature of the patient. 6 ask the client to open his mouth & place the thermometer under the tongue. ask the client to close his lips & not biting thermometer. 7 Have the thermometer in place for TWO minutes. To allow enough time to register the body temperature. 8 Count the pulse & respirations while the thermometer is still in place. PROCEDURE

41. Sl.No Steps of procedure Reasons 9 Place the patient’s hand over his chest with the wrist extended & the palm downwards. Place the finger tips over the pulse point. Arm placed over the chest helps to count the respirations with out the patient’s knowledge.(after counting the pulse) 10 Holding the watch or pulsometer in the left hand, start to count the pulse rate with zero’ then1, 2,etc. Zero begins the time interval and the next pulse felt is ‘1’ of the sequence. 11 If the pulse is regular, count the number of pulsation for HALF minute & multiply by 2. If irregular count for 1 minute complete. 12 With the right hand still on the pulse count respiration by watching the rise &fall of the chest, without the knowledge of the patient. If the patient is aware that his respiration are counted, he may hold the breath & the rate may be altered. PROCEDURE

42. Sl.No Steps of procedure Reasons 13 Count the respiration for one minute. 14 Remove the thermometer after two minutes. 15 Wipe the thermometer from stem to the bulb with wet swab, then with soapy swab, again with wet swab, using a rotating movements. Discard the swab. Read the level of mercury. Return the thermometer to the container, after shaking it down again. Wipe from the area of least contamination to that of greatest contamination. This prevents dirtying the hands. PROCEDURE

43. AFTER CARE OF THE PATIENT & ARTICLES Make the patient comfortable. Tidy up the unit. Take the tray to the procedure room. Put the used swabs in dustbin. If the thermometer is broken it should be replaced. Wash the hands. Record the TPR in the chart.

44. Blood pressure: BP is the pressure is the force exerted by the blood against the walls of the blood vessels as it flows through them. Types of BP SYSTOLIC BP: Is the highest degree of pressure exerted by the blood against the walls of the blood vessels when the left ventricle is forcing the blood in to the aorta. DIASTOLIC BP: Is the lowest pressure that occurs when the heart is in its resting period just before the contraction of the left ventricle.

45. Factors causing variation in blood pressure: Age Sex Body build ( body weight) Climate Time of the day Exercise Emotions Posture Disease condition Drugs Hemorrhage Increased intracranial pressure

46. BP ranges: BP less than 120/80 is considered normal BP is between 120/80-139/80 is considered prehypertension BP above 139/80 is considered high blood pressure or hypertension BP below 95/60 is considered low blood pressure or hypotension

47. Mercury Sphygmomanometer Electronic Sphygmomanometer Electronic Sphygmomanometer Automatic Blood Pressure Monitor ( Dinamap Vital Sign Monitor) Stethoscope BLOOD PRESSURE RECORDING ARTICLES

48. Nurses responsibility in measurement of B.P: Preliminary assessment: Identify the client Check the diagnosis, reason for taking B.P and schedule frequency of obtaining B.P Previous measurement and range of blood pressure Physical and mental state of the client Postponed B.P taking on a client who is angry, anxious or in pain and a crying child. 2. Preparation of articles 3. Preparation of the client

49. Do not take B.P reading on a clients arm if: The arm has an intravenous infusion on it. The arm is injured and diseased. The arm has a shunt or fistula for the renal dialysis. On the same side of the body where a female client had a radial mastectomy. Check defects in the B.P apparatus.

50. PROCEDURE Sl. No Steps of procedure Reasons 1 Wash hands To prevent cross infection 2 Take the equipment to the beside. Apply deflated cuff evenly with rubber bladder over the brachial artery, the lower edge being 2 inch above the antecubital fossa. The two tubes turning towards the palm. An uneven or too loose cuff gives a falsely high reading because excessive amount of pressure is needed to occlude brachial artery. 3 Palpate the brachial artery with the finger tips. Place the bell of the stethoscope on the brachial pulse. The stethoscope must hang freely from the ears. Any rubbing of the tubes can mislead the sounds.

51. Sl. No Steps of procedure Reasons 4 Close the valve on the pump by turning the knob clockwise, Pump up air in the cuff until the sphygmomanometer registers about 20mm above the point at which the radial pulsation disappears. If the cuff not inflated high enough, true systolic pressure may be missed. Inflating the cuff too high causes unnecessary pain and may produce vasospasm, which distorts pressure reading. 5 Open the valve slowly by turning the knob anti clock wise. Permit the air to escape very slowly. Note the number on the manometer where the sound first begins. This is the systolic pressure. The first sound is heard when the blood begins to flow through the brachial artery again. PROCEDURE

52. Sl. No Steps of procedure Reasons 6 Continue to release the pressure slowly. The sound become louder & clearer. Note the point on the manometer where the sound cease. This is the diastolic pressure. 7 Allow the air to escape & the mercury to fall zero. Wait for one minute with the cuff deflated. Occlusion of blood during the pressure reading causes venous congestion in the forearm. 8 Repeat the procedure if there is any doubts about the reading. Venous blood must be allowed to drain or it will falsely elevate the succeeding blood pressure reading. PROCEDURE

53. AFTER CARE OF THE PATIENT & ARTICLES Remove the cuff by rolling it & replace it in box. Assist the patient to cover the arm which was exposed. Take the apparatus to the duty room & keep it safely in the cupboard. Wash hands. Record the reading immediately, with the date & time.

54. Thanking you