Vital Signs.ppt for nursing students chapter

vitals sings for students

1. Vital Signs Lecturer: Dr. Omar Abdillahi (MBBS)

2. Vital signs reflect the body’s physiologic status and provide information critical to evaluating homeostatic balance. The term (vital) is used because the information gathered is the clearest indicator overall health status. A change in vital signs may indicate a change in health status. Definition

3. T (Temperature) PR (Pulse Rate) RR (Respiratory Rate) BP (Blood Pressure) Sp02 (Oxygen Saturation) Types of vital signs

4. To obtain base line data about the patient condition. To aid diagnosing patient condition (diagnostic purpose) For therapeutic purpose so that to intervene accordingly Purpose

5. Sthescope Syphygmanometer Second hand water Vital sign sheet Cotton swab Disposable glove Dirty receiver kidney dish Pen Thermometer Pulse oximeter Equipment

6. On admission When clients health status changes or reported symptoms According to nursing or medical doctor order Before and after administration of certain medications that effect vitals Before and after surgery Before and after any nursing procedure that affects V/S. Time to asses vital signs

7. Body temperature is the measurement of heat inside a person’s body (core temperature). Is the balance between heat produced and heat lost Normal body temperature using measurement remains as appropriate 37c or 98.6 F. Temperature

8. Core temperature: is the temperature of deep tissue of the body such as cranium, thorax, abdominal cavity and pelvic cavity. Remains relatively constant is the temperature we measure a thermometer. Surface temperature: The temperature of the skin, the subcutaneous tissue and fat. It rises and falls in response to the environment. Two types of body temperature

9. Normal body temperature is 37c or 98.6F Average range is 36.5-37.5c (96.8-100F). Pyrexia: a body temperature above normal range 38c-41c (100.4-105.8F) Hyper-pyrexia: a very high fever such as 41c. More than 42c leads to death. Hypothermia: low body temperature between 34 – 35c Less than 34 leads to death Alterations in Body Temperature

10. Intermittent fever (fever that rises, subsides, then returns again in the day) Remittent fever (body temperature fluctuates but does not return to normal) Relapsing fever (rises then returns about 2 – 3 days later) Constant fever (always above normal. Common types of fevers

11. The sings and symptoms of fever are; Loss of appetite headache, hot and dry skin Flushed face Young children or other people with high fevers may experience periods of delirium or seizures

12. Monitor vital signs Assess skin colour and temperature Monitor WBC, Hbg and other lab results for indications of infection or dehydration Remove excess blanket when patient feels hot Measure intake and output Provide adequate nutrition and fluid Give antipyretic Interventions with Patients with fever

13. Age: Children’s temperature continue to be more labile than those of adults until puberty Exercise: Hard or strenuous exercise can increase body temperature to as high Hormones: In women progesterone secretion at the time of ovulation raises body temperature Stress: Stimulation of skin can increase the production of epinephrine and nor epinephrine – which increases metabolic activity and heat production Diurnal variations: Body temperature varies through out the day Environment: Extremes in temperature can affect a person’s temperature regulatory systems. Factors affecting body temperature

14. Oral site Rectal site Axillary site Tympanic site Sites of measuring temperature

15. Is instrument used to measure body temperature Types of thermometer Mercury thermometer Digital thermometer Electronic thermometer Thermometer

16. Readings are considered to be more accurate most reliable Contraindication Rectal surgery Fecal impaction Rectal infection Neonates Rectal temperature

17. The most accurate & reliable. Read normal range of temp 37 – 38c Maintain thermometer in place for 2 – 3 minutes averagely for 3 minutes Position laterally Lubricate 2.5 cm above the bulb Insert the thermometer 2.5-4 cm into the rectum For infant 2.5 cm, 3.7 for children & 4 cm for adult Rectal site

18. Most accessible and convenient The thermometer tip is placed below the tongue The recommended time is 2-3 minutes Contraindications Child below 7 yrs Delirious patient, mentally ill Unconscious Uncooperative or in severe pain Mouth surgery Nasal obstruction Oral

19. The axillary method is safest and most non invasive. The bulb of thermometer is placed in the clients axillary hollow Leave it in place for 5 Minutes Axillary

20. It is a wave of blood created by contraction of the left ventricle of the heart. Peripheral pulse: is a pulse located in the periphery of the body e.g in the foot or neck Apical pulse: (central pulse): it locates at the apex of the heart. Pulse is expressed in beats/minute Pulse deficit: is difference that exists between the apical and radial pulse. Pulse

21. Age Sex Exercise Fever Medication Heat Stress Position change Factors affecting pulse rate

22. Temporal artery Carotid artery Apical pulse Branchial artery Radial artery Femoral artery Popliteal artery Posterior tibia artery Pedis artery ( dorsalis pedis ) Pulse sites

23. 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; the most distal parts are more sensitive. Method

24. Rate Rhythm Quality Assess the pulse for

25. Adult 60 – 100 beats/minute Children 70 – 150 beats/minute Infants 100 – 160 beats / minute How to measure Measures in beats per minute Count the waves for 60 seconds Or count the waves for 30 seconds and multiply by 2 Normal pulse rates

26. Time interval between each beating may be regular or irregular Quality Force of blood in the artery may be strong or weak Rythm

27. Respiration is the act of breathing includes intake of o2 and removal of co2. Ventilation is another word, which refer to the movement of the air in and out of the lungs. Hyperventilation: breathing at an abnormally rapid rate at rest Hypoventilation: breathing at an abnormally shallow and slow rate. Respiration

28. 1. Costal (thoracic) Involves the external muslces and other accessory muscles observed by the movement of the chest upward and downward commonly used for adults 2. Diaphragmatic (abdominal) Invloves contraction and relaxation of the diaphragm observed by the movement of abdomen commonly used for children. Types of breathing

29. The client should be at rest Assessed by watching the movement of chest or abdomen Rate, rhythm, depth and special characteristics of respiration are assessed Assessment

30. Rate: is described in rate per minute (RPM) healthy adult RR is: 15-20 b/m is measured for full time minute, if regular for 30 seconds as the age decreases the respiratory rate increase. Respiratory characteristics

31. Eupnoea: normal breathing rate and depth Bradypnea : slow respiration Tachypnea: fast breathing Apnea: temporary cessation of breathing Rhythm: is the regularity of expiration and inspiration. Normal breathing is automatic and effortless.

32. Depth: described as normal, deep or shallow Deep – large volume of air inhaled and exhaled inflates most of the drugs Shallow – exchange of a small volume of air minimal use lung tissue.

33. Definition: is the force excreted by blood against the wall of the blood vessel in which it is contained. Purpose To determine the patient BP on admission as baseline for comparison to the future measurement To monitor fluctuation of BP Blood pressure

34. Systolic pressure: is the pressure of the blood as a result of contraction of the ventricle Diastolic pressure: is the pressure when ventricles are at rest Types of blood pressure

35. Pulse pressure: is the difference between the systolic and diastolic pressure Blood pressure is measured in mmHg and recorded as fraction. Expected blood pressure values: Expected SBP – 100-140 mmHg Expected DBP – 60-90 mmHg Types of syphygnanometer : Mercury Aneroid

36. Hypertension: an abnormally high blood pressure, over 140 mmHg systolic and 90 mmHg diastolic. Factors associated with hypertension Thickening of the arterial walls, which reduces the size of the arterial lumen Elasticity of the arteries Lifestyle as cigarette smoking Hypertension

37. Obesity Lack of physical exercise High blood cholesterol level Prolonged exposure to stress

38. Hypotension: blood pressure below normal that is systolic reading between 85 – 100 mmHg. It occurs as a result of peripheral vasodilation in which blood leaves the central body organs especially the brain and moves to the periphery. Factors associated with hypotension: Bleeding Severe burn Dehydration Hypotension

39. It’s important to monitor hypotensive patiens carefully to prevent falling down. When assessing the orthostatic hypotension: Place the patient in a supine position for 2 – 3 minutes Record the clients pulse and blood pressure Assist the client to slowly sit or stand. Support the client in case of fainting

40. Factors that increase BP Increase in heart rate Exercise Fever Stress Obesity Vasoconstriction Conditions affecting blood pressure

41. Factors that decrease BP Decreased heart rate Hemorrage Dehydration Alcohol Vasodilation

42. Sites for measuring blood pressure Upper arm – using brachial artery (common site) Thigh around (using femoral artery) Fore arm (using radial artery) Auscultatory method is the commonest method used in health activities.