assessing-vital-signs.ppt
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ASSESSING VITAL SIGNSRLE 1a
VITAL SIGNSVITAL SIGNS
• Also known as Cardinal Signs
• Includes TEMPERATURE, PULSE, RESPIRATION, and BLOOD PRESSURE
• A person’s physiologic status is reflected by these indicators of body function
Vital Signs are commonly assessed:
1. Screenings at health fairs and clinics2. In the home3. Upon admission to a healthcare
setting4. When certain medications are given
Taylor’s p. 4
5. Before and after diagnostic and surgical procedures
6. Before and after certain nursing interventions
7. In emergency situations
Vital Signs are commonly assessed:
Purposes of assessing Vital Signs
1. To obtain baseline measurement of the patient’s vital signs
2. To assess patient’s response to treatment or medication
3. To monitor patient’s condition after invasive procedures
ASSESSING TEMPERATURE
TEMPERATURE •heat of the body measured indegrees
•Difference between production of heat and loss of heat
Taylor’s p. 8
PROCESS OF HEAT PRODUCTION DONE
THROUGH:1. Food Metabolism and Activity2. Increased thyroxin production3. Chemical thermogenesis
PROCESS OF HEAT LOSS IS DONE THROUGH:
1. Radiation – surface to surface by waves
2. Conduction – contact between 2 surfaces
3. Convection – mov’t by air currents or fluid
4. Evaporation – water to steam5. Elimination – urination, defecation
TYPES of TEMPERATURE
• Core Temperature measured thru tympanic and rectal routes
• Surface Temperaturemeasured thru oral and axillary routes
FACTORS AFFECTING BODY TEMPERATURE
1. Age2. Sex3. Exercise4. Time of day5. Emotions6. Environment7. Others; food, drugs
COMMON SITES FOR ASSESSING BODY
TEMPERATURE1. Oral – most frequently used, least
disruptive, most convenient CONTRAINDICATIONS:
Infants and very young children Patients with oral surgery Unconscious or irrational patients Seizure-prone patients Mouth breathers and pts. with oxygen
2. Rectal – most accurate route, but invasive and uncomfortable
to patientCONTRAINDICATIONS:
Rectal abnormalities Diarrhea Certain heart conditions Immunosuppressed
COMMON SITES FOR ASSESSING BODY
TEMPERATURE
3. Axillary – safer than the oral method, non-invasive, least accurate
4. Tympanic – accessible, less invasiveCONTRAINDICATIONS:
Presence of ear ache Significant ear drainage Scarred tympanic membrane Sleeping with the head turned on one side
COMMON SITES FOR ASSESSING BODY
TEMPERATURE
ROUTESPECIAL CONSIDERATIONS
ORAL•Done for 3 minutes•Upon intake of hot/cold fluids, wait 30 minutes
RECTAL
•Done for 2-3 minutes•Presence of fecal matter could result to a false reading•Lubricate tip prior to inserting
AXILLARY •Done for 10 minutes
TYMPANIC•Within two seconds•Up/back for adult•Down/back for pedia
ASSESSING TEMPERATURE (axillary route)
Taylor’s p.14
Unexpected Situations in assessing TEMPERATURE
• Temperature higher/lower than expected based on how skin feels
(re-assess with new thermometer) • Feeling lightheaded or passes out
during rectal temp assessment (remove thermometer
immediately, assess BP & HR, notify doctor, don’t take another rectal temp)
Taylor’s p. 16
Pyrexia Elevated BT
Hyperpyrexia BT above 41˚C
Intermittent fever BT alternates regularly between periods o fever, normal or subnormal temperature
Remittent fever Fluctuations of several degrees above normal, but not reaching normal between fluctuations
Constant fever Consistently elevated and fluctuates very little
Relapsing fever Returns to normal for at least a day then the fever occurs
Resolution of Pyrexia by crisis
Elevated BT returns to normal suddenly
ASSESSING PULSE
PULSE •A wave of blood being pumped into
the arterial circulation by the contraction of the left ventricle
•Throbbing sensation palpated over a peripheral artery
Taylor’
Taylor’s p. 16
ASSESSMENT PARAMETERS / CHARACTERISTICS OF PULSE1. Rate – number of beats per
minuteAGE GROUP PULSE RANGE
Newborn 80-180 bpm
Adults 60-100 bpm
Elderly 60-100 bpm
ASSESSMENT PARAMETERS / CHARACTERISTICS OF PULSE
2. Rhythm – pattern or regularity of beats and interval between each beat Term Meaning
Pulsus regularis Equal rhythm
Arrhythmia Irregular rhythm
Premature beat Beat that occurs between normal beats
Heart rhythm Time interval between each heartbeat
3. Volume/amplitude – amount of blood pumped with each heartbeat
Cardiac Output – 5-6 Liters of blood is forced out of the left
ventricle per minute
Pulse Deficit – difference between the apical and radial counts taken simultaneously
ASSESSMENT PARAMETERS / CHARACTERISTICS OF PULSE
ASSESSMENT PARAMETERS / CHARACTERISTICS OF PULSE
Amplitude
Interpretation
+4 Bounding:felt by exerting only light pressure over artery
+3 Normal
+2 weak
+1 Feeble/thready: difficult to feel & easily obliterated by pressure
0 absent
LOCATION OF PERIPHERAL PULSES
Taylor’s p. 5
1. Age2. Sex3. Exercise4. Emotions5. Prolonged heat application6. Body positions7. Pain8. Decreased BP9. Increased temperature10. Any conditions resulting to poor
oxygenation of blood ex. CHF
FACTORS AFFECTING PULSE RATE
ASSESSING A PULSETaylor’s p. 17
Respiration Pulmonary ventilation –(breathing)
movement of air in and out of the lungs Inspiration –(inhalation) act or breathing inExpiration –(exhalation) act of breathing outExternal respiration – exchange of O2 and CO2
between alveoli and blood
Internal respiration – exchange of O2 and CO2 between blood and tissue cells
ASSESSING RESPIRATION
1. Rate – number of breaths per minute
ASSESSMENT PARAMETERS / CHARACTERISTICS OF RESPIRATION
AGE GROUP RESPIRATORY RANGE
Newborn 30 – 60 bpm
Adults 12-20 bpm
ASSESSMENT PARAMETERS /
CHARACTERISTICS OF RESPIRATION2. Rhythm – regularity of respiration,
inhalation and exhalation are evenly spaced
Regular Effortless, quiet
Irregular Abnormal
3. Depth – assessed by watching the movement of the
chest
ASSESSMENT PARAMETERS /
CHARACTERISTICS OF RESPIRATION
2 TYPES OF BREATHING
1. Costal/thoracic breathing – involves external intercostal muscles and other accessory muscles
• Observed thru upward and outward movement of the chest
2. Diaphragmatic/abdominal breathing – involving the contraction and relaxation of diaphragm
• Observed by the movement of the abdomen
FACTORS AFFECTING RESPIRATION
1. Exercise2. Certain infections3. Age 4. Emotions5. Cardiac illness6. stress
TERMINOLOGIES REGARDING RESPIRATION
Eupnea Normal, effortless breathing
Tachypnea RR > 24 bpm
Bradypnea RR < 10 bpm
Apnea Absence of breathing
Hyperpnea Deeper respiration with normal rate
Cheyne stokes Resp. becomes faster and deeper then slower with alternate periods of
apnea(20-60sec) Biot’s Faster and deeper than normal with
abrupt pauses in between each breath
• Kussmaul’s Faster and deeper respi. without pauses in between panting
• Apneustic Prolonged grasping followed by extremely short insufficient
exhalation• Dyspnea difficulty of breathing• Orthopnea DOB unless sitting• Wheezing narrowing of airways, causing
whistling or sighing sounds
• Stridor high-pitched sounds heard on inspiration
TERMINOLOGIES REGARDING RESPIRATION
• Rales - sound caused by air passing thru fluid or mucus in
the airways usually heard on inhalation
• Rhonchi sound caused by air passing thru airways narrowed by fluids,
edema, muscle spasm usually heard during exhalation
TERMINOLOGIES REGARDING RESPIRATION
ASSESSING RESPIRATIONTaylor’s p. 20
BLOOD PRESSURE-Force of the blood against the
arterial walls-Measured in millimeters of mercury
(mmHg)Systole – the highest pressureDiastole – the lowest pressurePulse pressure – difference between the
systole and diastole
BLOOD PRESSUREBasic Terms:• Korotkoff’s sound• Hypertension – above 140/90 mmHg• Hypotension – below 90/60 mmHg • Orthostatic Hypotension –
decrease in Bp when changing position
Factors that control Blood Pressure
1. Cardiac Output – amount of blood ejected from the heart per contraction
2. Blood Volume – adult has about 5-6 liters of circulating blood
3. Elasticity of arterial walls – yields upon systole and retracts upon diastole
Factors affecting Blood pressure
1.Age2.Emotions3.Exercise4.Drugs5.Environment
To ensure accuracy in taking the BP, you must:
1.Let the patient rest for a minimum of 5 minutes for routine assessment
2. Should not have ingested caffeine or nicotine 30 minutes before
3.Delay assessing if patient is in pain,emotionally upset, have just exercised.
Assessing Blood PressureTaylor’s p. 23
