Vital Signs3_111527- NURSING CARE UNIT.ppt

EXPLAINS ON HOW TO TAKE VITAL SIGNS

1. Vital signs
C. MWALWENI

2. Learning objectives
By the end of this lesson, students will be
able to:
Define vital signs and explain their clinical
significance.
Identify normal ranges of all vital signs.
Demonstrate proper techniques for
measuring vital signs.
•.

3. Learning objectives cont..
Interpret abnormal vital signs and
understand their implications.
Document and communicate vital sign
findings accurately.
Recognize factors influencing vital signs.
Apply critical thinking to assess changes in
vital signs and respond appropriately
•.

4. General
Vital signs

5. Vital signs
Vital signs are
physical signs that
indicate an individual
is alive, such as
heart beat, breathing
rate, temperature,
blood pressures and
recently oxygen
saturation

6. Vital signs
These signs may
be observed,
measured, and
monitored to
assess an
individual's level of
physical
functioning.

7. Vital signs
The tasks involved in checking vital
signs are simple and easily learned
However the interpretation of
measurements and incorporation
into ongoing care requires
knowledge, problem solving skill
and experience.

8. Vital signs
The frequency at which vital signs
are assessed for each patient
should be individualised.
Institutional policies stipulates the
frequency of checking vital signs.

9. Vital signs
Normal vital signs change with age, sex,
weight, exercise tolerance, and condition.

10. Importance of taking vital signs
Provides Baseline Data: Establishes a
reference for the patient’s normal health
status.
Monitors Health Changes: Detects early
signs of deterioration or improvement in a
patient’s condition.
Guides Clinical Decisions: Helps
healthcare make informed decisions about
treatment and interventions.

11. Importance of taking vital signs
Detects Medical Emergencies: Identifies
life-threatening situations such as shock and
heart attacks.
Tracks Treatment Effectiveness:
Assesses how medications are working.
Assesses Physiological Response: how
the body is responding to stress & illness.
Facilitates Communication: Provides
standardized information for the healthcare
team to ensure coordinated care.

12. Guidelines for Obtaining
Vital Signs
The nurse must be able to do all of the
following:
Measure vital signs correctly
Understand and interpret the values
Communicate findings appropriately
Begin interventions as needed

13. Temperature
Vital sign

14. Temperature
Temperature is measured in either
Celsius or Fahrenheit.
ºF = (ºC x 9/5) + 32
Normal body temperature 36ºC –
37.4ºC
Fever/hyperthermia is temperature
above normal.
Hypothermia is temperature below
normal.

15. Temperature
Two Types of Body Temperature

Core Temperature
Temperature of the deep tissues of the body
Remains relatively constant unless exposed to severe
extremes in environmental temperature
Assessed by using a thermometer
Surface Temperature
Temperature of the skin
May vary a great deal in response to the environment
Assessed by touching the skin

16. Temperature
Temperature measurements are obtained
by several methods.

Heat-sensitive patches
Patch placed on the skin; color changes on the patch
indicate temperature readings

Electronic thermometers
Consist of a rechargeable battery-powered display
unit, a thin wire cord, and a temperature processing
probe

Tympanic thermometer
Special form of electronic thermometer; inserted into
auditory canal

17. Alteration in body Temperature
Pyrexia, Febrile, or Hyperthermia
When the temperature is above normal
Fever is actually a body defense; it will destroy invading
bacteria.
Classification of Fevers
Constant: remains elevated consistently
Intermittent: rises and falls
Remittent: temperature never returns to normal
until the patient becomes well
Hypothermia
An abnormally low body temperature

18. Hypothermia
Hypothermia is
defined as a drop
in body
temperature below
35ºC (95°F).

19. Heat production
Major factors that affect heat
production include:
Basal metabolic rate: this is the rate
of energy utilization in the body
required for essential activities such
as breathing.
 It decreases as the age advances.

20. Heat production cont..
Muscle activity: including shivering
Thyroxine output: it increases cellular
metabolism.
Stress response/Epinephrine,
norepinephrine and sympathetic
stimulation: these hormones increases
cellular metabolism.
Fever: elevated body temperature
increases cellular metabolic rate.

21. Heat loss
Heat is lost from the body through:
Radiation : heat loss from one surface to
another inform of infrared rays.
Conduction : heat loss from one surface
area to another through contact.
Convection is dispersion of heat by air
currents.
Evaporation is heat loss inform of vapour

22. Regulation of body temperature
Body temperature is regulated by
Sensors in periphery and in the core
An integrator in hypothalamus
Effector system that adjusts the
production and heat loss

23. Factors that affect body temperature
Age
Circadian rhythms(diurnal variations)
Exercise
Hormones
Stress
Environment

24. Factors Affecting the Measurement
of The Temperature
Smoking
Oxygen administration
Drinking hot or cold liquid

25. Sites for checking Temperature
Oral route
Rectal
Axillary
Tympanic membrane
Skin/temporal artery

26. Equipment
Thermometer
Swabs ,Spirit
Tray and second hand wrist watch
Receiver for dirty swabs
Pen and vital signs documentation
record
Gloves

27. Procedure
Identify the patient and introduce
self
Explain the procedure to the
patient and ask for consent
Wash hands

28. Procedure cont..
Provide privacy for client
Assist patient to a comfortable
position
Remove thermometer from the
storage container and wipe it with a
spirit swab
Switch on the thermometer
Expose the axilla and dry the arm pit if
wet.

29. Procedure cont..
Place the thermometer into the
middle of the axilla, fold patient’s arm
down and place across the chest.
Hold thermometer in place for 3-4
minutes or wait for the beep/alarm
Remove and read the thermometer

30. Procedure cont..
Clean thermometer with spirit
swab
Document / Record the findings
Explain the findings to the
patient/client
Report your findings to the seniors

31. Pulse
Vital sign

32. Pulse Rate
The pulse is a wave of blood
created by contraction of the left
ventricle of the heart.
The pulse wave or pulsation can
be felt as a throb or a tap where
the arteries lie close to the skin
surface

33. Factors affecting the pulse
Exercise
Fever
Medications
Hypovolemia/dehydration
Stress
Position
pathology

34. Pulse
Pulse sites
Radial

Carotid

Temporal

Brachial
Femoral
Popliteal
Dorsalis pedis
Apical
Posterior tibial

35. Pulse rate
The normal
pulse for
healthy adults
ranges from 60
to 100 beats
per minute.

36. Characteristics of the pulse
These include:
Rate or frequency refers to the
number of pulsations per minute
Pulse rhythm refers to the regularity
with which pulsation occurs
Pulse quality refers to the strength of
the palpated pulsation

37. Pulse: Quantity
If the rate is
particularly slow
or fast, it is
probably best to
measure for a full
60 seconds in
order to minimize
the error.

38. Pulse: Regularity
Is the time
between beats
constant?.
Irregular
rhythms, are
quite common.

39. Pulse: Volume
Does the pulse volume feel normal? This
reflects changes in stroke volume. In
hypovolemia, the pulse volume is
relatively low

40. Pulse
Tachycardia
The pulse is faster than 100 beats per minute.
It may result from shock, hemorrhage,
exercise, fever, acute pain, and drugs.
Bradycardia
The pulse is slower than 60 beats per minute.
It may result from unrelieved severe pain,
drugs, resting, and heart block.

41. Apical pulse
A, Point of maximum impulse is at fifth intercostal space. B,
Assessing apical pulse.
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3
rd
ed.]. St.
Louis: Mosby.)

42. Pulse
Apical pulse represents the actual
beating of the heart.
Pulse deficit: difference between the
radial and apical rates; signifies that
the pumping action of the heart is
faulty.

43. Procedure
Methods:-
Palpation
Auscultation
Equipment :-
Stethoscope
Ultrasonic Doppler device
Wrist watch with second hand
Vital sign flow sheet and pen

44. Procedure cont..
Palpate pulse at a selected site
using the three middle fingers
Using a second hand watch, note
time
Count pulse for a minute

45. Respiration rate
Vital sign

46. Respirations
Respiration is the mechanism the
body uses to exchange gases
between the atmosphere, blood and
cells.
Normal respirations for an adult is
12 – 20 breaths/minute.

47. Factors affecting respirations
Medications
Stress/ anxiety
Exercise
Altitude
Body position
Haemoglobin function

48. Characteristics of respirations
Rate
Rhythm
 Depth/quality

49. Student activity
Define the following terms: tachypnea,
bradypnea, apnea, biot’s respirations,
cheyne stokes, kussmaul repirations,
aponeustic respirations,
dyspnea,Eupnea,
Hyperventilation ,Hypoventilation

50. Procedure
Equipment:
watch with second hand minute & a
documentation sheet.
Procedure:
After assessment of the pulse,
keep your fingers resting on the
patient’s wrist.

51. Procedure cont..
Observe or feel the rising of the chest with
respirations.
Do not explain the procedure. Explaining the
procedure may cause alteration in
respiratory pattern.
When one cycle completes or inspiration
and expiration has been observed.

52. Respiratory Rate
Try to do this as
surreptitiously as
possible.
Observing the rise
and fall of the
patient's hospital
gown while you
appear to be taking
their pulse.

53. Procedure cont..
Look at the second of the watch and count
the number of complete cycles.
Note depth and rhythm of the respiratory
cycle
Inform the patient your findings

54. Procedure cont..
Document the findings.
In children, count the respirations when the
child is calm.

55. Abnormal Respiratory Rate
Respiration rates
over 20 or under
12 breaths per
minute (when at
rest) may be
considered
abnormal
under 12 breaths
over 20 breathsover 20 breaths

56. Blood pressure
Vital signs

57. Remember the following for
accuracy of your readings
Instruct your
patients to avoid
coffee, smoking or
any other
unprescribed drug
with
sympathomimetic
activity on the day
of the measurement

58. Blood Pressure
It is the force that blood exerts
against the walls of blood vessels.
It is stated in millimetres of
mercury (mm Hg)

59. Blood Pressure cont..
Systolic blood pressure is the pressure when
the ventricles of the heart contract and eject
blood into the aorta and pulmonary arteries.
Diastolic pressure is the pressure during
ventricular relaxation, blood pressure is due to
the elastic recoil of the vessels.
Pulse pressure is the difference between the
systolic and diastolic

60. Determinants of Blood pressure
1.Pumping action of the heart
2.Peripheral vascular resistance
3.Blood volume
4.Blood viscosity

61. Common alterations in blood pressure
Hypertension is the blood pressure that
is persistently above normal( 120/80
mmhg)
hypotension is blood pressure that is
below normal( less than 90/60mmhg)

62. Procedure
Sites:
upper extremity,
lower extremity
Equipment:
stethoscope,
sphygmomanometer

63. Assessment:
Assess blood pressure on initial patient
examination
Identify factors that may alter Bp
Assess best site for obtaining Bp
Determine correct size of blood pressure
cuff
Review previous Bp readings if available.

64. Assessment cont..
Assist patient to a comfortable position with
forearm supported at heart level and palm
up.
Expose the upper arm completely
Wrap deflated cuff snugly around the arm
with centre of bladder over the brachial
artery.

65. Assessment cont..
Placing the bladder directly over brachial
artery ensures proper compression of artery
during cuff inflation
If using a mercury manometer, the
manometer should be vertical and at eye
level.
This position prevents distortion and
promotes accurate reading of mercury.

66. Assessment cont..
Palpate brachial artery with finger tips
Close valve on pressure bulb and inflate cuff
until the pulse disappears.
Slowly release the valve and note when the
pulse reappears

67. Assessment cont..
Fully deflate the cuff and wait for 1 to 2
minutes to prevent false high readings.
Place stethoscope ear piece in ears.
Palpate the brachial artery and place the
stethoscope diaphragm or bell over the
site

68. Assessment cont..
Close bulb, Inflate cuff to 30 mm Hg above
reading where the brachial pulses
disappeared to ensure accurate assessment
of Bp.
Slowly release the valve to allow the
pressure to drop about 2to3 mmHg.

69. Assessment cont..
Identify manometer reading when the first
clear korotkoff sound is heard.
It indicates the systolic pressure.
Continue to deflate and note the reading
when the sound muffles or dampens and
when it disappears.

70. Assessment cont..
Deflate cuff completely and remove from the
patient’s arm
Record the blood pressure
Assist patient to comfortable position and
inform the patient the findings

71. Position of the Patient
Sitting position
Arm and back are
supported.
Feet should be
resting firmly on the
floor
Feet not dangling.
 

72. Position of the arm
Raise patient arm so that the brachial artery is roughly
at the same height as the heart. If the arm is held too
high, the reading will be artifactually lowered, and vice
versa.

73. Technique of BP
measurement
Listen for auditory
vibrations from
artery "bump,
bump, bump"
(Korotkoff)

74. In order to measure the BP
Systolic blood
pressure is the
pressure at which
you can first hear
the pulse.

75. In order to measure the BP
Diastolic blood pressure is the last pressure at
which you can still hear the pulse

76. In order to measure the BP
Avoid moving your
hands or the head
of the stethescope
while you are taking
readings as this
may produce noise
that can obscure the
Sounds of Koratkoff.

77. Remember the following for
accuracy of your readings
If the BP is surprisingly high or low, repeat the
measurement towards the end of your exam
(Repeated blood pressure measurement
can be uncomfortable).

78. What Abnormal Results
Mean

79. Blood pressure
The minimal SBP
required to maintain
perfusion varies
with the individual.
Interpretation of low
values must take
into account the
clinical situation.

80. Blood pressure for adult
Physician will want
to see multiple
blood pressure
measurements over
several days or
weeks before
making a diagnosis
of hypertension and
initiating treatment.

81. What Abnormal Results Mean
Pre-high blood
pressure: systolic
pressure
consistently 120 to
139, or diastolic 80
to 89
Stage 1 high blood
pressure: systolic
pressure
consistently 140 to
159, or diastolic 90
to 99

82. What Abnormal Results
Mean
Stage 2 high blood
pressure: systolic
pressure
consistently 160 or
over, or diastolic
100 or over

83. What Abnormal Results
Mean
Hypotension (blood pressure below normal):
may be indicated by a systolic pressure
lower than 90, or a pressure 25 mmHg lower
than usual

84. Hypertension
High blood pressure greater
than 139-89..

85. Blood pressure may be affected
by many different conditions

86. Blood pressure may be affected
by many different conditions
Cardiovascular
disorders
Neurological
conditions
Kidney and
urological disorders

87. Orthostatic Hypotention

88. Remember the following for
accuracy of your readings
Orthostatic
(postural)
measurements of
pulse and blood
pressure are part of
the assessment for
hypovolemia.

89. Remember the following for
accuracy of your readings
First measuring BP
when the patient is
supine and then
repeating them
after they have
stood for 2
minutes, which
allows for
equilibration.

90. Oxygen Saturation
Vital signs

91. Oxygen Saturation
Over the past
decade, Oxygen
Saturation
measurement of gas
exchange and red
blood cell oxygen
carrying capacity has
become available in
all hospitals and
many clinics.

92. Oxygen Saturation
Oxygen
Saturation provide
important
information about
cardio-pulmonary
dysfunction and is
considered by
many to be a fifth
vital sign.

93. References
Bickley, L.S (2016). Bates’ guide to physical
examination and history taking. (12th Ed.)
Philadelphia: Lippincott Williams & Wilkins.
Jensen, S. (2014). Pocket Guide for Nursing Health
Assessment: A best practice approach (2nd Ed).
Philadelphia William and Wilkins.
Kozier, B. (2016). KOZIER & ERB`S Fundamentals of
nursing: concepts, process, and practice
(10thEd.). New Jersey: Prentice Hall
Lewis, S.L., et al., (2016). Medical Surgical Nursing-
Assessment and Management of Clinical Problems
(10th Ed.). Mosby. Inc., St. Louis.
.