Vital Signs and.pptx charting and reporting

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vital signs

1. Vital Signs and Physical Assessment 5/7/2012 1

2. The measurement of vital signs and the execution of the physical examination as part of the assessment process are done to gather information regarding the physiological functioning of the body. 5/7/2012 2

3. VITAL SIGNS The “taking of vital signs” refers to measurement of the client’s body temperature (T), pulse (P) and respiratory (R ) rates, and blood pressure (BP ). Vital signs are fundamental to physical assessment (the first step in the physical examination) to establish baseline values of the client’s cardio-respiratory integrity. 5/7/2012 3

4. Baseline values establish the norm against which subsequent measurements can be compared. Variations from normal findings may indicate potential problems with the client’s health status. 5/7/2012 4

5. The frequency of vital sign measurements for the hospitalized client is determined by the client’s health status, physician orders, and the established standards of care for the particular clinical setting or service . The sequence for recording vital signs measurement in the nurses’ notes is T-P-R and BP. 5/7/2012 5

6. Special graphic forms used to record vital signs findings. These forms facilitate data comparison at a glance because the data are plotted on a graph. 5/7/2012 6

7. Physiological Function Healthy people have the ability to meet their own needs; however, during illness, people need assistance (in proportion to the degree of dysfunction) in meeting their basic needs. 5/7/2012 7

8. Thermoregulation Thermoregulation is the body’s physiological function of heat regulation to maintain a constant internal body temperature. The heat of the body is measured in units called degrees. The “core” internal temperature of 98.6° Fahrenheit (F) (37° centigrade [C]) does not vary more than 1.4°F (0.77°C) and is higher than the skin and external temperature. In contrast, the skin temperature rises and falls in accordance with changes in environmental temperature. 5/7/2012 8

9. Heat Production Heat is produced in the body’s cells through food metabolism that results in the release of energy. The body converts energy supplied by metabolized nutrients to energy forms that can be used directly by the body One form of this energy is thermal energy for regulation of body temperature 5/7/2012 9

10. Body temperature is controlled by balancing metabolic heat production with heat loss . Most heat production comes from the deep tissue organs (brain, liver, and heart) and the skeletal muscles. The skin, subcutaneous tissues , and fat of the subcutaneous tissues serve as heat insulators for the body. Sweat glands in the dermis are innervated by sympathetic nerves of the autonomic nervous system and are controlled by the anterior hypothalamus to regulate sweating. 5/7/2012 10

11. Heat Loss Most body heat is lost from the skin’s surface to the environment by the processes of radiation, conduction, convection, and evaporation Insensible heat loss is the heat that is lost through the continuous, unnoticed water loss that occurs with vaporization, accounting for 10% of basal heat production. 5/7/2012 11

12. Behavioral Control of Body Temperature the person makes appropriate environmental adjustments to reestablish comfort. Recognize this mechanism as the most effective mechanism for body heat control in severely cold environments. 5/7/2012 12

13. Respiration Respiration is the act of breathing. Respiration is defined by physiological functioning as: External respiration Internal respiration Inspiration (inhalation) Expiration (exhalation) Vital capacity— the amount of air exhaled from the lungs after a minimal full inspiration 5/7/2012 13

14. Five major physiological pulmonary functions provide oxygen to the tissues and remove carbon dioxide: 1. Ventilation —the inflow and outflow of air between the atmosphere and the lung alveoli. 2. Circulation —the quantity of blood flowing through the lungs is approximately 4 to 6 L/min. 5/7/2012 14

15. 3. Diffusion —the exchange of oxygen and carbon dioxide between the alveoli and the blood. 4. Transport —the carrying of oxygen and carbon dioxide in the blood and body fluids to and from the cells 5. Regulation —the neurogenic system that adjusts the rate of alveolar ventilation to meet the demands of the body. 5/7/2012 15

16. Hemodynamic Regulation The physiological function of blood circulating to maintain an appropriate environment in tissue fluids. When the body’s circulatory needs change, the heart rate either accelerates or decelerates. This is a compensatory mechanism under the control of the cardiac centers that are located in the medulla of the brain stem. 5/7/2012 16

17. Stroke volume is the measurement of blood that enters the aorta with each ventricular contraction. With each ventricular contraction, the heart ejects 60 to 70 ml of blood into the aorta. Cardiac output is the volume of blood pumped by the heart in 1 minute. measured by multiplying the heart rate by the ventricle’s stroke volume. 5/7/2012 17

18. Pulse The pulse is the bounding of blood flow in an artery that is palpable at various points on the body. The pulse is caused by the stroke volume ejection and distension of the walls of the aorta, which creates a pulse wave as it travels rapidly toward the distal ends of the arteries. Pulse pressure is a measurement of the ratio of stroke volume to compliance (total distensibility) of the arterial system. 5/7/2012 18

19. Pulse Points Temporal Carotid Brachial Apical Radial Femoral Popliteal Posterior tibial Dorsalis pedis 5/7/2012 19

20. 5/7/2012 20

21. Blood Pressure Blood pressure is the measurement of pressure pulsations exerted against the blood vessel walls during systole and diastole. Both the blood pressure and pulse are measurements that determine the volume of ejected blood into the arterial system with each ventricular contraction. 5/7/2012 21

22. Blood pressure is measured in terms of millimeters of mercury (mm Hg). In a healthy young adult, the pressure at the height of each pulse (the systolic pressure) is approximately 120 mm Hg, and the pressure at the lowest point of each pulse (diastolic pressure) is approximately 80 mm Hg. The pulse pressure is the difference between these pressures, which is 40 mm Hg. 5/7/2012 22

23. The body has four hemodynamic regulators for blood pressure control: 1. Blood volume —the volume of blood in the circulatory system. Blood pressure is proportional to the blood volume. 2. Cardiac output— the major factor that influences systolic pressure. 5/7/2012 23

24. 3. Peripheral vascular resistance— the size and distensibility of the arteries, which is the most important determinant of diastolic pressure. Arterial resistance (decreased distensibility) is encountered when the left ventricle pumps blood from the heart under pressure during the systolic phase. 5/7/2012 24

25. 4. Viscosity— the thickness of the blood based on the ratio of proteins and cells to the liquid portion of blood. The greater the viscosity, the harder the heart must work to pump blood, with a resultant increase in blood pressure. Blood pressure is a result of the cardiac output and peripheral vascular resistance. 5/7/2012 25

26. Normal arteries expand during systole and contract during diastole, creating two distinct pressure phases: Systolic blood pressure is a measurement of the maximal pressure exerted against arterial walls during systole (when myocardial fibers contract and tighten to eject blood from the ventricles), primarily a reflection of cardiac output. 5/7/2012 26

27. Diastolic blood pressure is a measurement of pressure remaining in the arterial system during diastole (period of relaxation i.e. the pressure remaining in the blood vessels after the heart has pumped), primarily a reflection of peripheral vascular resistance 5/7/2012 27

28. FACTORS INFLUENCING VITAL SIGNS Can cause changes in one or more of the vital signs: Age, gender, heredity, race, lifestyle, environment, medications, pain, and other factors such as exercise and metabolism, anxiety and stress, postural changes, diurnal variations, and hormones. 5/7/2012 28

29. Age The normal values and variations in vital sign measurement are usually based on age. 5/7/2012 29

30. NORMAL AGE-RELATED VARIATIONS IN BODY TEMPERATURE Age: Normal Range 5/7/2012 30 Celsius Fahrenheit Newborn Axillary 35.5–39.5°C 96.0–99.5°F 1 yr Oral 37.7°C 99.7°F 3 yr Oral 37.2°C 99.0°F 5 yr Oral 37.0°C 98.6°F Adult Oral 37.0°C 98.6°F Axillary 36.4°C 97.6°F Rectal 37.6°C 99.6°F 70+ yr Oral 36.0°C 96.8°F

31. The normal aging process causes changes in the elderly person’s respiratory functions. Major physiological alterations include: • Ventilation— Bony changes in the thorax and vertebrae and the decline in respiratory and abdominal musculature reduce the ability of the lungs to distend. • Circulation and diffusion— The increase in dead air space in the respiratory tree decreases the quantity of blood flowing through the lungs and gaseous exchange. 5/7/2012 31

32. • Transport —Atherosclerosis (plaques in the inner walls of arteries) and dysrhythmia (irregular heartbeat) reduce the amount of blood flow available to tissues. • Regulation —The inability of lung function to perform maximal breathing for extended periods of time reduces the rate of alveolar ventilation to meet the demands of the body. 5/7/2012 32

33. Gender Women usually experience greater temperature fluctuations than men because of hormonal changes. Temperature variations occur during the menstrual cycle mainly in response to the progesterone level. Males in general have higher blood pressure than do females of the same age. 5/7/2012 33

34. Heredity hereditary factors linked to specific cardiovascular disease occurrence . Race Some ethnic groups are more susceptible than others to hemodynamic alterations. Lifestyle Lifestyle factors, such as cigarette smoking, cause chronic changes in the lungs as manifested by impaired ventilation. Stimulants such as caffeinated beverages and tobacco elevate heart rate. 5/7/2012 34

35. Environment Environmental factors such as temperature and noise level can alter heart rate. Medications Some medications can directly or indirectly alter the pulse, respirations, or blood pressure. Digitalis preparations (cardiac glycosides) decrease the pulse rate. Narcotic analgesics (pain medications) can depress the rate and depth of respirations and lower the blood pressure 5/7/2012 35

36. Pain With acute pain, sympathetic stimulation increases the heart rate, which increases the cardiac output and vasoconstriction, causing an increased peripheral vascular resistance. 5/7/2012 36

37. Other Factors Exercise and metabolism, anxiety and stress, postural changes, and diurnal (daily) variations (also called circadian) on the vital sign measurements. 5/7/2012 37

38. MEASURING VITAL SIGNS Equipment The measurement of the client’s vital signs requires the appropriate instruments. 5/7/2012 38

39. Measurement of Height and Weight Routine measurement provides data related to growth and development in infants and children and signals the possible onset of alterations that may indicate illness in all age groups. 5/7/2012 39

40. Height Measurement of height is expressed in inches (in.), feet (ft), centimeters (cm), or meters (m). CONVERSION EQUIVALENTS FOR HEIGHT MEASUREMENT 1 in. = 2.5 cm 1 cm = 0.4 in. 1 ft = 30.5 cm or 0.3 m 1 m = 39.4 in. or 3.28 ft 5/7/2012 40

41. Weight Measurement of weight is expressed in ounces (oz), pounds (lb), grams (g), or kilograms (kg) 1 lb = 0.45 kg 1 kg = 2.2 lb 1 oz = 28.4 g 1 g = 0.35 oz 5/7/2012 41

42. Nursing Considerations Accurate recordings of weight are imperative because they are used in drug dosage calculations and to evaluate the effectiveness of drug, fluid, and nutritional therapy. 5/7/2012 42

43. Body Temperature Body temperature is measured during the routine physical examination Frequent monitoring is required for clients who have or are at risk for infection; for example, postoperative clients or those with suppressed white blood cell count. Accuracy is essential because it guides nursing and medical decision making and interventions. 5/7/2012 43

44. Assess the client for the most appropriate site and gather the necessary equipment CENTIGRADE AND FAHRENHEIT CONVERSION FORMULAS • Centigrade to Fahrenheit conversion: multiply the centigrade reading by 9/5 and add 32: °F = (°C × 9/5) + 32 • Fahrenheit to centigrade conversion: deduct 32 from the Fahrenheit reading and multiply by 5/9: °C = (°F – 32) × 5/9 5/7/2012 44

45. 5/7/2012 45

46. Sites Traditional sites for measuring the body’s internal (core) temperature are oral (OT), rectal (RT), and axillary (AT), using either glass or electronic thermometers. Advanced -pulmonary artery temperature (PAT) and infrared thermometers for ear canal temperature (ET). ET is the most common site used for in adults because it is a safe and efficient method; however, it is less sensitive in detecting fever in infants and young children. 5/7/2012 46

47. The most reliable measure of core temperature is PAT. PAT requires placement of a thermodilution pulmonary artery catheter, it is impractical for routine care. The axilla is commonly used as a site for infants and children with disabilities Axillary or rectal sites are used for clients who are uncooperative, comatose, or who have a nasogastric or feeding tube in place. 5/7/2012 47

48. Alterations in Thermoregulation When heat production exceeds heat loss and body temperature rises above the normal range pyrexia occurs. When the body’s temperature rises above 37.4°C (101°F) orally or 38°C (100.4°F) rectally, the client is said to be febrile. 5/7/2012 48

49. Documentation Record the temperature measurement and the site on the designated medical record form. Important - both consistency in the measurement process for the purpose of establishing a client’s temperature trend and awareness of the method used when interpreting clinical data. 5/7/2012 49

50. Temperature measurements are usually plotted on a graph to identify alteration patterns, such as sharp elevations and declines in temperature (a condition known as spiking ). 5/7/2012 50

51. A.Insert thermometer into center of axilla . 5/7/2012 51

52. B. Place client’s arm across chest. 5/7/2012 52

53. Place the tip of thermometer under client’s tongue in posterior sublingual pocket lateral to center of lower jaw. 5/7/2012 53

54. Preparation for the Insertion of a Rectal Thermometer 5/7/2012 54

55. Pulse Pulse assessment is the measurement of a pressure pulsation created when the heart contracts and ejects blood into the aorta. Assessment of pulse characteristics provides clinical data regarding the heart’s pumping action and the adequacy of peripheral artery blood flow. 5/7/2012 55

56. Sites There are multiple pulse points. The most accessible peripheral pulses are the radial and carotid sites. Variances exist among health care agencies regarding which pulse sites to assess. 5/7/2012 56

57. The common sites for each type of assessment are: • Complete physical assessment— apical and all bilateral peripheral pulses • Initial assessment— apical and bilateral peripheral radial and dorsalis pedis pulses • Routine vital sign assessment —apical and radial pulses in adults and apical and temporal pulses in infants and children 5/7/2012 57

58. Assessing Pulse Rate begin the assessment by speaking with the client about the normal pulse rate. Note any medications that could affect the heart rate. Physical activity increases the heart rate, ensure that the client rests 5 to 10 minutes before the pulse is assessed. 5/7/2012 58

59. Clinical data regarding the efficacy of blood circulation to an extremity are obtained by assessing the characteristics of the peripheral pulses. Palpate a peripheral pulse by placing the first two fingers on the pulse point with moderate pressure . Normal radial and apical pulses are identical in rate. 5/7/2012 59

60. A Doppler ultrasound stethoscope (DUS) is used on superficial pulse points to detect and magnify heart sounds and pulse waves when the peripheral pulse cannot be palpated. pulse deficit exists when the apical pulse rate is greater than the radial pulse rate. A pulse deficit results from the ejection of a volume of blood that is too small to initiate a peripheral pulse wave. 5/7/2012 60

61. Pulse Characteristics A normal pulse has defined characteristics: quality , rate, rhythm , and volume . Pulse quality refers to the “feel” of the pulse, its rhythm and forcefulness. Pulse rate is an indirect measurement of cardiac output obtained by counting the number of apical or peripheral pulse waves over a pulse point. 5/7/2012 61

62. A normal pulse rate for adults is between 60 and 100 beats per minute. Bradycardia is a heart rate less than 60 beats per minute in an adult. Tachycardia is a heart rate in excess of 100 beats per minute in an adult. 5/7/2012 62

63. Pulse rhythm is the regularity of the heartbeat. It describes how evenly the heart is beating: regular (the beats are evenly spaced) or irregular (the beats are not evenly spaced). Dysrhythmia (arrhythmia) is an irregular rhythm caused by an early, late, or missed heartbeat 5/7/2012 63

64. Pulse volume is a measurement of the strength or amplitude of force exerted by the ejected blood against the arterial wall with each contraction. It is described as normal (full, easily palpable), weak (thready and usually rapid), or strong (bounding). 5/7/2012 64

65. PULSE VOLUME SCALE Scale Description of Pulse 0 Absent pulse 1+ Weak and thready pulse 2+ Normal pulse 3+ Bounding pulse 5/7/2012 65

66. Nursing Considerations An irregular pulse rate, if not previously documented in the medical record, should be reported immediately. Electrocardiogram (ECG or EKG) provides an electrical representation of the heart’s activity. The ECG identifies the type of dysrhythmia causing the irregular heartbeat. The primary pacemaker of the heart is the sinoatrial (SA) node. 5/7/2012 66

67. If another site within the heart initiates the electrical activity, the ECG tracing will identify the area serving as the pacemaker. 5/7/2012 67

68. Place index and middle finger on inner aspect of client’s wrist over the radial artery. 5/7/2012 68

69. Palpating the Apical Pulse 5/7/2012 69

70. Place diaphragm of stethoscope over the PMI to auscultate for sounds. 5/7/2012 70

71. Point of maximal impulse (PMI) The area between fourth intercostal space left of the sternal border and the fifth intercostal space, left of the midclavicular line. 5/7/2012 71

72. Place diaphragm of stethoscope over the PMI and auscultate for sounds S1 and S2 to hear lub-dub sound. 5/7/2012 72

73. Documentation All pulse measurements are documented by recording in the client’s medical record on the appropriate forms. Report and document an irregular pulse. 5/7/2012 73

74. Respirations Respiratory assessment is the measurement of the breathing pattern. Assessment of respirations provides clinical data regarding the pH of arterial blood. 5/7/2012 74

75. Sites Normal breathing is slightly observable, effortless, quiet, automatic, and regular. It can be assessed by observing chest wall expansion and bilateral symmetrical movement of the thorax. Also assessed by placing the back of the hand next to the client’s nose and mouth to feel the expired air. 5/7/2012 75

76. Assessing Respirations When assessing respirations ascertain the rate, depth, and rhythm of ventilatory movement. Assess the rate by counting the number of breaths taken per minute. Note the depth and rhythm of ventilatory movements by observing for the normal thoracic and abdominal movements and symmetry in chest wall movement. 5/7/2012 76

77. Normal respirations are characterized by a rate ranging from 12 to 20 breaths per minute. One inspiration and expiration cycle is counted as one breath. Observe the rise and fall of the chest wall and count the rate by placing the hand lightly on the chest to feel its rise and fall. 5/7/2012 77

78. Characteristics of Normal and Abnormal Breath Sounds Respiratory wave patterns are characterized by their rate, rhythm, and depth. Eupnea refers to easy respirations with a normal rate of breaths per minute that are age-specific. Bradypnea is a respiratory rate of 10 or fewer breaths per minute. Hypoventilation is characterized by shallow respirations. Tachypnea is a respiratory rate greater than 24 breaths per minute. Hyperventilation is characterized by deep, rapid respirations. 5/7/2012 78

79. Observe alterations in the movement of the chest wall: Costal (thoracic) breathing - when the external intercostal muscles and the other accessory muscles are used to move the chest upward and outward. Diaphragmatic (abdominal) breathing - when the diaphragm contracts and relaxes as observed by movement of the abdomen. 5/7/2012 79

80. Dyspnea refers to difficulty in breathing as observed by labored or forced respirations through the use of accessory muscles in the chest and neck to breathe. 5/7/2012 80

81. Nursing Considerations Respiratory alterations may cause changes in skin color as observed by a bluish appearance in the nail beds, lips, and skin. The bluish color ( cyanosis) results from reduced oxygen levels in the arterial blood. Noninvasive oxygen assessment can be performed with an oximeter (a machine that measures the oxygen saturation of the blood through a probe clipped to the fingernail or earlobe) or an apnea monitor (a machine with chest leads that monitors the movement of the chest). 5/7/2012 81

82. Documentation Document the assessment findings for the respiratory rate, depth, rhythm, and character on the appropriate form. 5/7/2012 82

83. Blood Pressure Blood pressure measurement is performed during a physical examination, at initial assessment, and as part of routine vital signs assessment. The blood pressure is measured by either a direct or an indirect technique. The direct method requires an invasive procedure. 5/7/2012 83

84. The indirect method requires use of the sphygmomanometer and stethoscope for auscultation and palpation as needed. 5/7/2012 84

85. Sites The most common site for indirect blood pressure measurement is the client’s arm over the brachial artery. Others - in the forearm or leg sites. 5/7/2012 85

86. CONTRAINDICATIONS FOR BRACHIAL ARTERY BLOOD PRESSURE MEASUREMENT Venous access devices, such as an intravenous infusion or arteriovenous fistula for renal dialysis Surgery involving the breast, axilla, shoulder, arm, or hand Injury or disease to the shoulder, arm, or hand, such as trauma, burns, or application of a cast or bandage 5/7/2012 86

87. The popliteal artery, becomes the site of choice if the upper extremities arteries are not accessible. 5/7/2012 87

88. Assessing Blood Pressure Selecting the proper equipment and following procedural technique are basic to ensuring an accurate reading. Psychomotor skills, acquired with practice, are needed to manipulate the blood pressure equipment. An accurate reading also requires the correct width of the blood pressure cuff as determined by the circumference of the client’s extremity. 5/7/2012 88

89. Wrap the blood pressure cuff on the arm 1 inch above client’s brachial pulsation, with bladder centered over brachial artery. 5/7/2012 89

90. Palpate the brachial artery with fingertips below the pressure cuff. 5/7/2012 90

91. Place bell chestpiece over brachial artery below blood pressure cuff. 5/7/2012 91

92. Auscultation A stethoscope is used to auscultate the blood pressure (hear the sounds created by blood flowing through the artery). Bilateral readings should be done with the initial blood pressure assessment. A pressure variance of 5 to 10 mm Hg normally exists between arms. The arm with the higher reading should be used for routine measurements. 5/7/2012 92

93. Hypotension Hypotension refers to a systolic blood pressure less than 90 mm Hg or 20 to 30 mm Hg below the client’s normal systolic pressure. Hypotension is caused by a disruptionin hemodynamic regulation, such as: Decreased blood volume (e.g., hemorrhage) Decreased cardiac output (e.g., myocardial infarction [heart attack]) Decreased peripheral vascular resistance (vascular dilation) (e.g., shock) 5/7/2012 93

94. If the falling pressure is untreated, the body’s compensatory mechanisms will fail and the client will exhibit the symptoms of shock: cool, clammy skin; fast, thready pulse; Gradual decrease in urinary output; and disruption to cerebral blood flow that causes confusion, progressing to coma. 5/7/2012 94

95. Orthostatic hypotension Also called (Postural hypotension) refers to a sudden drop of 25 mm Hg in systolic pressure and 10 mm Hg in diastolic pressure when the client moves from a lying to a sitting or a sitting to a standing position. 5/7/2012 95

96. Hypertension Hypertension refers to a persistent systolic pressure greater than 135 to 140 mm Hg and a diastolic pressure greater than 90 mm Hg. 5/7/2012 96

97. Faulty techniques that constrict blood flow will produce a false high pressure reading: A cuff too narrow for the extremity A cuff that does not fit snugly around the extremity A cuff that is deflated too slowly Others causing false high pressure. when the mercury column in the manometer is not positioned flat on a firm surface or is read above eye level the extremity is below the heart’s apex level. 5/7/2012 97

98. False low readings occur when: the extremity is above the heart’s apex level, the cuff is too wide for the extremity, or the mercury column in the manometer is read below eye level. 5/7/2012 98

99. Documentation Record the blood pressure measurement on the appropriate form. If the brachial artery is not used for the measurement, indicate the site when recording the results. 5/7/2012 99