chapter 4 vital signs. overview mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990,...

CHAPTER 4

VITAL SIGNS

Overview

Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc.

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Vital signs (VS) are used to: Determine the general status of the patient

Establish a baseline Monitor response to therapy Observe for trends Determine the need for further evaluation or intervention

Obtaining VS and Clinical Impression


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Four classic VS Temperature

Pulse

Respirations

Blood pressure

Additional Observations4

Height and weight

LOC

Level and type of pain

General appearance

Pulse oximetry

Frequency of VS Measurement


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Depends on patient’s condition Baseline measurement

On admission At beginning of each shift Before and after procedure Any time patient’s condition changes Based on protocol or physician's order As often as necessary for patient safety

Trends in Vital Signs


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Isolated measurement provides limited information

Normal VS for a patient depend on: Age Presence of chronic disease Treatment protocols

Trend = baseline + measurements over time Multiple-day graph

Trending

Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of

Elsevier Inc.

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Comparing VS Information


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Shows change in patient’s condition:

Comparing changes in VS, signs, and symptoms

Establishing differential diagnosis

Determining if patient is improving or deteriorating

Comparing VS Information (Cont.)


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Key to expert assessment: Constant awareness of change Look Listen Touch Reassess and analyze Trend, trend, trend


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Height and Weight


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Routinely measured Pt needs an admission weight

Document in kilograms (1 kg = 2.2 lb) Follow up every 24 to 48 hours Dehydration or fluid overload

Follow intake/output (I&O) Scales must be age appropriate and

regularly calibrated

General Clinical Impression


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Gives clues to levels of distress and severity of illness

Information about personality, hygiene, culture, and reaction to illness

May dictate order of care, physical examination

General Clinical Impression (Cont.)


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Cardiopulmonary distress suggested by:

Labored, rapid, irregular, or shallow breathing

Coughing, choking, and/or wheezing

Chest pain and/or cyanosis

General Clinical Impression16

Anxiety may be suggested by:

Restlessness

Fidgeting

Tense look

Difficulty communicating

General Clinical Impression (Cont.)


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Pain may be suggested by:

Drawn features

Moaning and guarding

Shallow breathing and/or refusal to take deep breath

Head-to-toe inspection18

Hearing Smelling Seeing Touching Perception


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Pain Level and Type


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“Fifth vital sign” Pain intensity scales

Ranking of 1 to 10 Quantifies a subjective measure

Corresponding facial expressions and verbal description to assess pain level

Find associated symptoms as well as alleviating and aggravating factors

Level of Consciousness


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Measure cerebral oxygenation

Evaluation of time, place, and person “Oriented × 3”

Deterioration from restlessness to coma Cerebral hypoxia Side effect to medications or drug

overdose

LOC23

Status of sensorium Directs treatment plan Patient cooperation, coordination

Glasgow Coma Scale

Temperature


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Normal: 98.6° F (37° C), range (97°-99.5° F)

Daily variations (1°-2° F)

Lowest in morning

Highest late afternoon

Temperature26

Normal increase during exercise, ovulation, and first months of pregnancy

Balance of heat production and loss

Dissipation through sweating, peripheral vasodilation, and hyperventilation

Fever


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Elevation of temperature (febrile) From normal activities (exercise) =

hyperthermia From disease (infection) = fever

Body temperature of >102° F usually indicates infection

Not all infections result in fever Immunocompromised patients may not

be able to generate fever despite infection

Fever (Cont.)


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Increases O2 consumption and CO2 production

O2 consumption and CO2 production increase 10% for each 1 C elevation in body temperature

Patients with limited respiratory function may develop respiratory failure in response to fever

Hypothermia


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Body temperature below normal Head injury Cold exposure

Compensatory mechanisms Shivering Peripheral vasoconstriction

Reduces O2 consumption and CO2 production Slow and shallow breathing

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Inducing mild therapeutic hypothermia in selected patients surviving out-of-hospital sudden cardiac arrest can significantly improve rates of long-term neurologically intact survival and may prove to be one of the most important clinical advancements in the science of resuscitation.

Measuring Body Temperature


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Sites: Mouth, ear, axilla, rectum, forehead Axillary: Safe and accurate in infants

and small children1 F lower than oral, 2 F lower than rectal

Fahrenheit and Celsius conversion ° F = (° C × 9/5) + 32 ° C = (° F – 32) × 5/9

Pulse


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Evaluate: Rate, rhythm, and strength

Normal rate: 60-100 beats/min for adults The younger the patient, the faster the rate

Heart Rate - Tachycardia34

HR greater than 100 b/min

HR can increase from hypoxemia, pain, anxiety, stress, fever, drug reactions, MI, hypovolemia, or cardiac output defects.

Heart Rate


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Bradycardia = <60 beats/min Diseased heart, athletes,

medication side effects, hypoxemia in infants, low CO

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Arrhythmia = Irregular rhythm


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Measurement of Pulse Rate


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Right radial artery = Most common site Index and middle fingers

Avoid thumb: examiner’s own pulsation

Central pulses if hypotension present Carotid, femoral

Pulse counted for a full minute If regular, counted for 15 sec × 4 or 30 sec × 2

Taking a Pulse


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Pulse Rhythm and Pattern


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Regular, regularly irregular, irregularly irregular Irregularly irregular is unfavorable

finding Bigeminy = Rhythm coupled in pairs Trigeminy = Rhythm grouped in three

beats

Pulse deficit = Auscultated – Palpated

Pulse Rhythm and Pattern (Cont.)


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Volume of the pulse Described as: bounding, full,

normal, weak, thready, absent

Pulsus paradoxus Strength decreases with inspiration Alternans = strong and weak

pulses

Respiratory Rate and Pattern


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Sensitive Marker of Acute Respiratory Distress

Tachypnea = rate above normal

Atelectasis, hypoxemia, hypercapnia

Anxiety, pain, exertion, metabolic acidosis

Respiratory Rate and Pattern

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Bradypnea = rate below normal

Uncommon

Head injury, hypothermia, side effect of medications (narcotics), drug overdose


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Measurement of Respiratory Rate


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Watching abdomen or chest wall movement Can be done as you assess radial pulse

When regular = Count for 30 sec × 2

Assess depth and pattern

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Blood Pressure

Blood Pressure (BP)


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Force exerted against arterial walls

Systolic: peak force during ventricular contraction

Diastolic: force during ventricular relaxation

Normal: 120/80 mm Hg

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Blood Pressure

Pulse pressure = P systolic – P diastolic

Normal: 35-40 mm Hg

<30 mm Hg: poor peripheral perfusion


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Hypertension and Hypotension Hypertension

BP of >140/90 mm Hg Risk factor for heart,

vascular, renal disease

Major modifiable risk factor for stroke, CAD, CHF, peripheral vascular disease

Cause in most cases is unknown

Hypotension BP of <90/60 mm Hg

If symptomatic: dizziness, fainting

Causes: left ventricular failure, blood loss, peripheral vasodilation

Orthostatic hypotension: resulting from changes in posture

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Measurement of Blood Pressure


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Sphygmomanometer Occluding cuff, stethoscope, manometer

Continuous noninvasive arterial pressure

Blood Pressure


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Errors in Blood Pressure Measurement Erroneously High

Too narrow a cuff Cuff applied too

tightly or too loosely Excessive pressure

in cuff during measurement

Incomplete deflation of cuff between measurements

Erroneously Low Too wide a cuff

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Blood Pressure


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Effects of the Respiratory Cycle on BP


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Systolic pressure decreases (2-4 mm Hg) with inspiration

Pulsus paradoxus: if BP drops >10 mm Hg Asthma, cardiac tamponade are two

common causes Pulsus paradoxus in asthma signifies

a more severe case

chapter 4 vital signs. overview mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990,...

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