Vital signs. Chapter 27. Ra'eda Almashagba 1

Transcription

1 Vital signs Chapter 27 Ra'eda Almashagba 1

2 Vital sign Vital sign are: a body temperature pulse respiration and blood pressure May add pulse oximetery and pain Monitoring a client vital sign should note be an automatic or routine procedure, it should be thoughtful and scientific assessment. Ra'eda Almashagba 2

3 Times to assess vital signs On admission to a health care agency to obtain baseline data. When a client has a change in health status or reports symptoms such as chest pain or feeling hot or faint. Before and after surgery or an invasive procedure. Before and/or after the administration of a medication that could affect the respiratory or cardiovascular systems, e.g., before giving digitalis. Before and after any nursing intervention that could affect the vital signs (e.g. ambulating a client who has been on bed rest). Measure vital signs more often if the client s health status requires it. Ra'eda Almashagba 3

4 Body temperature Body temperature reflect the balance between the heat produced and the heat lost from the body. Tow kind of body temperature: core temperature : is the temperature of the deep tissue of the body (such as abdominal cavity and pelvic cavity.it remain relatively constant ). surface temperature : is the temperature of the skin,the subcutaneous tissue and the fat. Heat balance: when the amount of heat produced by body equal the amount of heat lost. Ra'eda Almashagba 4

5 Heat Balance The state a person is in when the amount of heat produced by the body exactly equals the amount of heat loss. Heat Production Basal Metabolism Muscular activity (shivering) Thryoxine and epinephrine (stimulating effects on metabolic rate) Fever Heat Loss Radiation Conduction/Convection Evaporation (vaporization) Ra'eda Almashagba 5

6 Heat is lost from the body through radiation: is the transferee of heat from the service of one object to another object without contact between the tow object. conduction :is the transfer from one molecule to molecule of lower temperature, contact between material, when body put on cold water. convection :is the dispersion of heat by air current. vaporization: : is the continuous evaporation of moisture from respiratory tract and from the mucosa of mouth and from the skin. Ra'eda Almashagba 6

7 Regulation of body temperature sensors in the shell and the core in skin.the skin has more receptor for cold than warmth When the skin become chilled: shivering increase heat production Swatting is inhibited to decrees heat loss Vasoconstriction decreased heat loss the hypothalamus integrator effectors system that adjust the production and loss of heat Ra'eda Almashagba 7

8 Factor affecting body temperature age : The infant is greatly influenced by the temperature of the environment and must be protected from extreme changes. Children s temperature continue to be more labile than those of adults until puberty. Elderly people are at risk of hypothermia for variety of reasons. Such as lack of central heating, inadequate diet, loss of subcutaneous fat, lack of activity, and reduced thermoregulatory efficiency. Ra'eda Almashagba 8

9 Factor affecting body temperature continuo exercise : Hard work or strenuous exercise can increase body temperature. diurnal variation : This refers to the sleep wake rhythm of the body, a pattern that varies slightly from person to person. Body temperature normally changes throughout the day, varying as much as 1.0C between the early morning and the late afternoon Ra'eda Almashagba 9

10 Factor affecting body temperature continuo hormone: Women usually experience more hormone fluctuations than men do. Progesterone secretion at the time of ovulation raises body temperature above basal temperature. stress : Stimulation of the SNS can increase the production of epinephrine and norepinephrine, thereby increasing metabolic activity and heat production. Environment. Extremes in environmental temperatures can affect a person s temperature regulatory systems. Ra'eda Almashagba 10

11 Alteration in body temperature Pyrexia: a body temperature above the usual range is called pyrexia, hyperthermia or fever. Avery high fever such as 41C is called hyperpyrexia febrile: client who has a fever a febrile a person who has not fever Hypothermia: Excessive heat loss. Inadequate heat production by body cells. Increasing impairment of hypothalamic thermoregulation. Ra'eda Almashagba 11

12 Clinical Signs of Fever Onset (Cold or chill stage): chills feeling of coldness cold skin (due to vasoconstriction) and shivering. Course. Defervescence (fever abatement): excessive sweating and a hot flushed skin due to sudden vasodilation. Ra'eda Almashagba 12

13 Nursing Interventions for Clients with fever Monitor vital signs. Assess skin color and temperature. Monitor white blood cell count, hematocrit value, and other pertinent laboratory records. Remove excess blankets when the client feels warm, but provide extra warmth when the client feels chilled. Provide adequate food and fluids to meet the increased metabolic demands and prevent dehydration, if health permits. Clients who sweat profusely can become dehydrated. Ra'eda Almashagba 13

14 Nursing Interventions for Clients with fever continuo Measure intake and output. Maintain prescribed intravenous fluids. Reduce physical activity to limit heat producing, especially the flush stage. Administer antipyretics as ordered. Provide oral hygiene to keep the mucous membranes moist. They can become dry and cracked because of excessive fluid loss. Provide a tepid sponge bath to increase heat loss through conduction. Provide dry clothing and bed linens to increase heat loss through conduction. Ra'eda Almashagba 14

15 Four most common sites fore measuring body temperature: Oral Rectal Auxiliary and tympanic membrane: Ra'eda Almashagba 15

16 Oral: This is the most accessible and convenient However, because of the mercury in glass thermometer, this is contraindicated for children under 6 years and clients who are confused or who have convulsive disorder. Rectal: This is considered the most accurate However, it is inconvenient and more unpleasant for client It is contraindicated for clients who are undergoing rectal surgery or have diarrhea or diseases of the rectum. Ra'eda Almashagba 16

17 Auxiliary: This is the safest and most noninvasive. It is the preferred site for measuring temperature in newborns because there was no possibility of rectal perforation. tympanic membrane: This is readily accessible and reflects the core temperature. The tympanic has an abundant arterial blood supply, primarily from branches of the external carotid artery. The noninvasive infrared thermometers are now used for this purpose. Ra'eda Almashagba 17

18 Temperature Scales Celsius = (Fahrenheit (F) temperature 32) X 5/9. Fahrenheit= (Celsius temperature X 9/5) Ra'eda Almashagba 18

19 Type of thermometer 1- Electronic thermometer. 2- Chemical disposable thermometer. 3- Temperature sensitive tape. 4- Mercury in glass thermometer:- can be hazardous due to exposure to mercury which is toxic to human. oral thermometer may have long short slander or rounded tip. A rounded thermometer can be used as rectal as well as other site. Ra'eda Almashagba 19

20 Pulse This is a wave of blood created by contraction of the left ventricle of the heart. The heart is a pulsating pump, and the blood enters the arteries with each heartbeat, causing pressure pulses or pulse waves. Generally, the pulse wave represents the stroke volume and the compliance of the arteries. Ra'eda Almashagba 20

21 Stroke volume is the amount of blood that enters the arteries with each contraction in a healthy adult. Compliance of the arteries is their ability to contract and expand. When a person s arteries lose their dispensability, greater pressure is required to pump the blood into the arteries. Peripheral pulse is the pulse located in the periphery of the body, for example in the foot, hand and neck. Apical pulse is a central pulse. It is located at the apex of the heart. Ra'eda Almashagba 21

22 Factor affecting the pulse Age Sex As age increases, the pulse rate gradually decreases. After puberty, the average male s pulse rate is slightly lower than the female s. Exercise Fever Pulse rate normally increases with activity. The pulse rate increases in response to the lowered blood pressure that results from peripheral vasodilation associated with elevated body temperature, and because of the increased metabolic rate. Ra'eda Almashagba 22

23 Factor affecting the pulse continuo Medications Some medications decrease the pulse rate, and others increase it. Hemorrhage Loss of blood from the vascular system normally increases pulse rate. Stress In response to stress, sympathetic nervous stimulation increases the overall activity of the heart. Stress increases the rate as well as the force of the heartbeat. Position changes When a person assumes a sitting or standing position, blood usually pools in dependent vessels of the venous system. Pooling results in a transient decrease in the venous blood return to the heart and a subsequent reduction in blood pressure reduction in blood pressure and increase in the heart rate. Ra'eda Almashagba 23

24 Rate Characteristics of Normal Pulse This is the number of pulse beats per minute (70 80 beats/min in the adult). An excessively fast heart rate (100 beats/min) is referred to as tachycardia. A heart rate in the adult of 60 beats/minute or less is called bradycardia. Pulse rhythm This is the pattern of the beats and the intervals between the beats. Equal time elapses between beats of a normal pulse. A pulse with an irregular rhythm is referred to as a dysrhythmia or arrhythmia. It may consist of random, irregular beats or a predictable pattern of irregular beats. Ra'eda Almashagba 24

25 Characteristics of Normal Pulse continuo Pulse volume This is also called the pulse strength or amplitude. It refers to the force of blood with each beat. It can range from absent to bounding. A normal pulse can be felt with moderate pressure of the fingers and can be obliterated with greater pressure. A forceful or full blood volume that is obliterated only with difficulty is called a full or bounding pulse. A pulse that is readily obliterated with pressure from the fingers is referred to as weak, feeble, or thready. A pulse volume is usually measured on a scale 0 to 3. Ra'eda Almashagba 25

26 Pulse Sites Temporal, Carotid Apical Brachial Radial Femoral, Popliteal, Poserior tibial Pedal (dorsalis pedis), Ra'eda Almashagba 26

27 Respirations Respiration is the act of breathing external respiration: interaction of oxygen and carbon dioxide between the alveoli of the lung and the pulmonary blood Internal respiration: is the exchange between oxygen and carbon dioxide between the circulating blood and the cells of the body tissue Inhalation or inspiration: intake of air into the lung Exhalation or expiration: movement of the gas from the lung to the atmosphere Ventilation: movement of air in and out the lung Ra'eda Almashagba 27

28 Type of breathing: costal (thoracic breathing ): involve the external intercostals muscle and the other accessory muscle such as sternocledomastoied. it observe by the movement by the chest upward and downward. Diaphragmatic breathing: involve the contraction and relaxation of the diaphragm. it observed by the movement of the abdomen. Ra'eda Almashagba 28

29 Assessing Respirations Resting respirations should be assessed when the client is at rest. Respiration may also need to be assessed after exercise to identify the client s tolerance to activity. Before assessing a client s respirations, a nurse should be aware of: The client s normal breathing pattern. The influence of the client s health problems on respirations. Any medications or therapies that might affect respirations. The relationship of the client s respirations to cardiovascular function. Ra'eda Almashagba 29

30 Characteristics of Normal Respiration Respiratory rate This is described in breaths per minute. A healthy adult normally takes between 15 and 20 breaths per minute. Breathing that is normal in rate is eupnea. Abnormally slow respirations are referred to as bradypnea, and abnormally fast respirations are called tachypnea or polypnea. Ra'eda Almashagba 30

31 Factor influence respiratory rate: exercise stress increased environmental temperature lowered oxygen concentration Factor decrease respiratory rate decrease environmental temperature certain medication(narcotic) increased intracranial pressure Ra'eda Almashagba 31

32 Characteristics of Normal Respiration continuo Depth This can be established by watching the movement of the chest. It is generally described as normal, deep, or shallow. Respiratory rhythm or pattern This refers to the regularity of the expirations and the inspirations. Normally, respirations are evenly spaced. Respiratory rhythm can be described as regular or irregular. Ra'eda Almashagba 32

33 Characteristics of Normal Respiration continuo Respiratory quality or character This refers to those aspects of breathing that are different from normal, effortless breathing. It includes: Amount of effort a client must exert to breathe. Usually, breathing does not require noticeable effort. The sound of breathing.normal breathing is silent, but a number of abnormal sounds such as a wheeze are obvious to the nurse s ear. Ra'eda Almashagba 33

34 BLOOD PRESSURE Ra'eda Almashagba 34

35 BLOOD PRESSURE This is the force exerted by the blood against a vessel wall. Arterial blood pressure is a measure of the pressure exerted by the blood as it flows through the arties. There are two blood pressure measures: Systolic pressure. This is the pressure of the blood because of contraction of the ventricles, which is the height of the blood wave. Diastolic pressure. This is the pressure when the ventricles are at rest. It is the lower pressure present at all times within the arteries. Pulse pressure is the difference between the diastolic and systolic pressures. Ra'eda Almashagba 35

36 Blood pressure is measured in millimeters of mercury (mm Hg) and recorded as a fraction. The systolic pressure is written over the diastolic pressure. The average blood pressure of a healthy adult is 120/80 mm Hg. A number of conditions are reflected by changes in blood pressure. The most common is hypertension, an abnormally high blood pressure. Hypotension is an abnormally low blood pressure below 100min Hg systolic. Ra'eda Almashagba 36

37 Physiology of Arterial Blood Pressure Pumping action of the heart Cardiac output is the volume of blood pumped into the arteries by the heart. When the pumping action of the heart is weak, less blood is pumped into arteries, and the blood pressure decreases. When the heart s pumping action is strong and the volume of blood pumped into the circulation increases, the blood pressure increases. Cardiac output increases with fever and exercise. Ra'eda Almashagba 37

38 Physiology of Arterial Blood Pressure continuo Peripheral Vascular Resistance This can increase blood pressure. The diastolic pressure is especially affected. The following are factors that create resistance in the arterial system: Size of the arterioles and capillaries. Compliance of the arteries. Viscosity of the blood. Ra'eda Almashagba 38

39 Physiology of Arterial Blood Pressure continuo Size of the arterioles and capillaries. This determines in great part the peripheral resistance to the blood in the body pressure, whereas decreased vasoconstriction lowers the blood pressure. Compliance of the arteries. The arteries contain smooth muscles that permit them to contract, thus decreasing their compliance (distensibility). The major factor reducing arterial compliance is pathologic change affecting the arterial walls. The elastic and muscular tissues of the arteries are replaced with fibrous tissues. The condition, most common in middle-aged and elderly adults, is known as arteriosclerosis. Ra'eda Almashagba 39

40 Physiology of Arterial Blood Pressure continuo Viscosity of the blood. Blood volume. When the blood volume decreases, the blood pressure decreases. Conversely, when the volume increase, the blood pressure increases. Blood viscosity. This is a physical property that results from friction of molecules in a fluid. The blood pressure is higher when the blood is highly viscous. that is, when the proportion of RBC s to the blood plasma is high. This ratio is referred to as the hematocrit is more than 60 to 65% Ra'eda Almashagba 40

41 Factors Affecting Blood Pressure Age. Newborn have a mean systolic pressure of 78mmHg. The pressure rises with age. The pressure rises with age, reaching a peak at the onset of puberty, and then tends to decline somewhat. Exercise. Physical activity increase both the cardiac output and hence the blood pressure. Thus, a rest of 20 to 30 minutes is indicated before the blood pressure can be readily assessed. Stress. Stimulation of the sympathetic nervous system increase cardiac output and vasoconstriction of the arterioles. thus increasing the blood pressure. Ra'eda Almashagba 41

42 Factors Affecting Blood Pressure continuo Race. African American males over 35 years have higher blood pressure than European American males of the same age. Obesity. Sex. Pressure is generally higher in some overweight and obese people than in people of normal weight. After puberty, females usually have lower blood pressures than males of the same age this difference is thought to be due to hormonal variations After menopause, women generally have higher blood pressures than before. Ra'eda Almashagba 42

43 Factors Affecting Blood Pressure continuo Medications. Many medications may increase or decrease the blood pressure nurses should be aware of the specific medications a client is receiving and consider their possible impact when interpreting blood pressure readings. Diurnal variations. Pressure is usually lowest early in the morning, when the metabolic rate is lowest then rises throughout the day and peaks in the late afternoon or early evening. Disease process. Any conditions affecting the cardiac output, viscosity, and or compliance of the arteries have a direct effect on the blood pressure. Ra'eda Almashagba 43

44 Hypertension blood pressure above the normal value. Usually asymptomatic and contributing factor to myocardial infarction. Primary hypertension: elevated blood pressure of unknown cause. Secondary hypertension: elevated blood pressure of known causes Ra'eda Almashagba 44

45 Factor associated with hypertension include thickening of arterial wall. inelasticity of the arteries. lifestyle factor as cigarette smoking heavy alcohol. Obesity. lack of physical exercise. high blood cholesterol level. continued exposure to stress. Ra'eda Almashagba 45

46 Hypotension It is a blood pressure that is below normal may caused by analgesia, bleeding, sever burn and dehydration Orthostatic hypotension: is the blood Pressure that falls when the client's Site or stand, (change their position suddenly). Ra'eda Almashagba 46

47 Common Errors in Blood Pressure Assessment Bladder cuff too narrow. Bladder cuff too wide. Arm unsupported. Insufficient rest before the assessment. repeating assessment too quickly. Cuff wrapped too loosely or unevenly. Deflating cuff too quickly. Deflating cuff too slowly. Failure to use the same. arm consistently Arm above level of the heart. Assessing immediately after a meal or while client smokes. Failure to identify auscultatory gap pressure. Ra'eda Almashagba 47

48 Oxygen saturation A pulse oxymetr is a non invasive device that measure a client's arterial blood saturation sensor attached to the client finger, toe, nose, earlobe, or forehead can detect hypoxemia before clinical signs and symptom. Ra'eda Almashagba 48

49 A pulse oxymetr Ra'eda Almashagba 49

50 Factors affecting oxygen saturation reading A client could be severely anemic and have inadequate oxygen to supply the tissues, but the pulse oximeter would return a normal value. Circulation: The oximeter will not return an accurate reading if the area under the sensor has impaired circulation. Activity: Shivering or excessive movement of the senor site may interfere with accurate readings. Ra'eda Almashagba 50

51 Ra'eda Almashagba 51