Vital Signs Taking - Presentation Transcript

1. Assessing Vital Signs Dr. Lorena C. Balacanao

2. Introduction
* Assessing vital signs or cardinal sign is a routine medical procedur
e. And somehow determines the internal functions of the body
* Vital signs composes of the following:
o Body temperature
o Pulse
o Respiration and
o Blood pressure
3. Body Temperature
4.
* Body temperature
o It is a balance between the internal and external environment
of the body, or
o It is the balance between the heat produced by the body and th
e heat lost from the body.
o It is measured in heat units, called degrees
5. Two types of Body temperature
* CORE Temperature- it is the temperature of the deep tissues of the b
ody, such as the cranium, thorax, abdominal cavity and pelvic cavity.
* It remains relatively constant (37 °C/ 98 °F)
* An accurate measurement is usually done using a pulmonary catheter.
6.
* SURFACE temperature- is the temperature of the skin, the subcutaneou
s tissues and fat
* It constantly rises and falls in relation to the environment
* It varies from 20 °C (68 °F) to 40 °C (104 °F)
7. Sites commonly used in taking BT
* Oral- most common
* Axilla mostly used in infants and children
* Rectal- second choice
* Tympanic membrane- most favorable site
8. Factors that affect heat production
* 1. BMR- is the rate of energy utilization in the body required to ma
intain essential activities such as breathing, walking, speaking and others.
* Metabolic rate decreases with age
* 2. Muscle Activity- such as shivering increases metabolic rate
* Example: walking, jogging etc
9.
* 3. Thyroxine output- increase in thyroxine hormone, increases the ra
te of cellular metabolism throughout the body.
* This is called Chemical thermogenesis, the stimulation of heat produ
ction in the body through increase cellular metabolism.
* 4. Sympathetic stimulation- the release of epinephrine and nor epine
phrine thus increase the rate of cellular metabolism
* 5. Fever- it increases metabolic rate and thus increases the body te
mperature
10. Heat loss
* 1. Radiation is the transfer of heat from the surface of one object
to the surface of another without contact between the two objects
* 2. Conduction is the transfer of heat from one molecule to another.
E.g. the body is immersed in ice water
11.
* 3. Convection is the dispersion of heat by air currents
* 4. Evaporation is the continuous evaporation of moisture from the re
spiratory tract and from the mucosa of the mouth as well as from the skin.
12. Regulation of body temperature
* System that regulates body temperature
 * 1. Sensors in the skin and in the core
* 2. An integrator in the hypothalamus and
* 3. A system that adjusts the production and loss of heat.
* NOTE: the skin has a more receptor for colds than warmth, it therefo
re detect cold more efficiently that warmth
13. Factors affecting Body temperature
* 1. Age infants greatly influenced by the temperature, children more
labile than adult and elderly are extremely sensitive to environmental change du
e to decreased thermoregulatory control
* 2. Diurnal variations (circadian rhythms) Body temperature normally
change throughout the day, varying as much as 1.0 °C between early morning and lat
e afternoon
14.
* The point of highest body temperature is usually reached between 8pm
and 12 midnight and the lowest point is reached during sleep between 4 a.m. and
6 a.m.
* 3. Exercise
* 4. Hormones women usually experience more hormone fluctuations than m
en, progesterone secretion in women raises body temperature.
* 5. Stress- epinephrine and nor epinephrine increases metabolic activ
ity and heat production
15. Alteration in Body temperature
* Pyrexia, hyperpyrexia or fever- increase body temperature
o febrile with fever
o Afebrile without fever
+ Types of fever
+ Intermittent-alternate body temperature (time)
+ Remittent- wide range of temperature fluctuation
+ Relapsing- short febrile periods few days then normal
+ Constant- continuous
* Hypothermia- decrease in core temperature below the low limit of nor
mal
16. Types of Thermometer
* 1 . Mercury in glass
o Oral thermometer have a long, slender tips
o Rectal thermometer have a short, rounded tips
* 2. Electronic thermometer
o Digital thermometer
* 3. Chemical thermometer
* 4 . Temperature sensitive strip
* 5. Infrared thermometer
o Tympanic thermometer
17. Oral thermometer (Glass)
18. Digital Thermometer
19. Taking axillary Temperature
20. Digital thermometer is commonly used in infants and children, insert it at
the axillary region
21. closed the arm and wait for timer to bustle
22. Remember when taking BT in infants and children make sure that the patient
is not in distress mood because any change in the activity will directly affect
the BT reading.
23. Taking Oral temperature
24. The Oral Cavity
25. Parts: Oral Vestibule and Oral Cavity Proper
26. Floor of the mouth
27. Insert the tip at the sublingual fossa
28. Positioned the thermometer
29. Let stay for 1 to 2 minutes, tell the patient to close the mouth
30. Temperature conversion
* °C = (Fahrenheit 32 ) x 5/9
 o Convert 100 °F
* °F = (Celsius x 9/5) + 32
o Convert 40 °C
o Normal/ Average temperature is between 36-37.9 °C or 96.8 100.3 °F
31. Pulse Rate
32. Pulse
* Is a wave of blood created by contraction of left ventricle of the h
eart
* Generally, the pulse wave represents the stroke volume output and th
e compliance of arteries.
* Stroke volume output is the amount of blood that enters the arteries
with each ventricular contraction.
* Compliance its the ability of the arteries to contract andexpand.
33.
* When adult is resting, the heart pumps 4 to 6 liters of blood per mi
nute. This volume is called cardiac output,
* The cardiac output (CO) is the result of the stroke volume (SV) time
s the heart rate (HR) per minute
* CO= SV x HR
* Note: in healthy person the pulse reflects the heartbeat
34.
* Peripheral pulse- is a pulse located in the periphery of the body.
* Apical pulse- is a central pulse located at the apex of the heart.
35. Pulse site
* 1. Temporal- it is where the temporal artery located, between the up
per, lateral part of the eye and upper medial part of the ear
* 2. Carotid- at the side of the neck, at the carotid triangle. Locate
d between the Anterior/front of SCM and below the angle of the mandible
* 3. Apical- at the apex of the heart.
o In adult this is located on the left side of the chest, no mor
e than 8 cm (3 in) to the left sternum under the
36. Carotid pulse
37.
o 4 th , 5 th or 6 th intercostal space.
o In Children 7 to 9 years old, the apical pulse is located betw
een the 4 th and 5 th intercostal space.
o In Young Children below 4 years old , it is located at the lef
t side of midclavicular line and
o In Children between 4 and 6 years old it is at the midclavicul
ar line.
38.
* 4. Brachial- at the anterior part of the arm in children and at the
ante-cubital space (elbow crease) in adult.
* 5. Radial located at the wrist (anterior part), along with the thumb
. It is where the radial artery is located
* 6. Femoral at the inguinal ligament, the femoral artery is located.
39. Radial and Brachial pulse
40.
* 7. Popliteal- at the popliteal region, located at the back of the kn
ee
* 8. Posterior Tibial- at the medial aspect of the ankle, it is where
the posterior tibial artery is located
* 9. Dorsalis pedis- where the dorsalis pedis artery passes over the b
ones of the foot, at the space between the big toe and the 2 nd toe.
41. Posterior tibial & Dorsalis pedis Pulse
42. Pulse site Reasons for Use Radial Readily accessible & routinely used Temp
oral Used when radial pulse is not accessible Carotid Used for infants, in cases
of cardiac arrest and to determine the circulation to the brain Apical Routinel
y used in infants and children up to 3 years of age, Used to determine the discr
epancies with radial pulse, and Used in conjunction with some medication Brachia
l Used to measure blood pressure, used for cardiac arrest for infants Femoral Us
ed in cases of cardiac arrest, for infants and children, determine circulation i
n the leg Popliteal Used to determine the circulation in the lower leg and leg b
lood pressure Posterior tibial Used to determine the circulation in the foot Ped
al Used to determine circulation in the foot
43. Assessing the Pulse
* 1. A pulse is commonly assessed by palpation or auscultation.
* 2. 3 middle fingers are used for palpating all pulse site, except fo
r apical pulse.
* 3. Stethoscope is used in assessing apical pulse and fetal heart ton
es.
* 4. Doppler ultrasound is used for pulses that is to difficult to ass
ess.
44.
* 5. The pulse is normally palpated by applying are moderate pressure
with the three fingers of the hand.
* 6. The pads of the most distal aspect of the fingers are the most se
nsitive areas of detecting the pulse.
45.
* 7. When assessing the pulse, there is a need to take note of the fol
lowing
* 1. rate
* 2. rhythm
* 3. volume
* 4. arterial wall elasticity
* 5. presence or absence of bilateral equality.
46. Kozier Barbara, et.al. Fundamentals of Nursing , 5 th ed. (US Addison-Wesl
ey Publishing Company, Inc. 1995) p. 438 Age Average Range Newborn to 1 month 13
0 80-180 1 year 120 80-140 2 years 110 80- 130 6 years 100 75- 120 10 years 70 5
0-90 Adult 80 60- 100 Pulse rate/ Minute Variations in Pulse Rate
47.
* Rate - referred to tachycardia - (over 100 beats/ minute) bradycardi
a (60 beats/minute or less)
* Rhythm - is the patterns of beat and the interval between the beats.
* Dysrhythmia or arrhythmia is an example of irregular rhythm.
48.
* Volume - is the pulse strength or the amplitude, refers to the force
of blood with each beat. E.g. bounding/full; weak/feeble/thready pulse
Kozier Barbara, et.al. Fundamentals of Nursing , 5 th ed. (US Addison-Wesl
ey Publishing Company, Inc. 1995) p. 440 Scale Description of pulse 0 Absent 1
o Thready or weak; difficult to feel
2 Normal, detected readily, obliterated by strong pressure 3 Bounding; dif
ficult to obliterate
49. Elasticity of the arterial wall
* It reflects the expansibility of the arterial wall.
* A healthy, normal artery feel straight, smooth, soft and pliable
* While, elderly people often have inelastic arteries that feels twist
ed or tortuous and irregular upon palpation
50. Factors affecting pulse rate
* 1. Age
* 2. Sex- after puberty the man s pulse rate is slightly lower than the
female
* 3. Exercise
* 4. Fever- pulse rate increases when metabolic rate increases
* 5. Medications
* 6. Hemorrhage- loss of blood increase pulse rate
* 7. Stress
51. Respiration
 52.
* Is the act of breathing; it includes the intake of oxygen and the ou
tput of carbon dioxide
* Types
* 1. External respiration- the interchange of O2 and CO2 between the a
lveoli and the pulmonary blood
* 2. Internal respiration- takes place throughout the body; it is the
interchange of gases between the circulating blood and the cells of the body tis
sues
53. Terminologies
* Inhalation or inspiration- the act of intake of air into the lungs
* Exhalation or expiration- the act of breathing out of gases from the
lungs to the environment
* Ventilation- movement of air in and out the lungs
* Hyperventilation- refers to very deep and rapid ventilation
* Hypoventilation- refers to very shallow respiration
54. Types of breathing
* 1. Costal or thoracic breathing
* 2. Diaphragmatic or abdominal breathing
55. Costal breathing
* It involves the external intercostal muscle and other intercostal mu
scle. It can be observed by the movement of the chest upward and outward or down
ward
56. Diaphragmatic breathing
* It involves the contraction and relaxation of the diaphragm, it is o
bserved by the movement of the abdomen
57. Control Centers for Respiration
* 1. Medulla oblongata and Pons
* 2. Chemoreceptors located centrally in the medulla and peripherally
in the carotid and aortic bodies
* NOTE: These centers and receptors respond to changes in the concentr
ation of O2, CO2 and Hydrogen in arterial blood.
* Increased CO2 concentration in the blood triggers chemoreceptors thu
s stimulates respiration
58. Assessing Respiration
* 1. The client normal breathing pattern is assessed therefore the cli
ent should be at resting mode.
* 2. Identify behavior/ activities of the patient as well as medicatio
n or therapies because these will affect the respiration taking.
* 3. Identify if there are any health problems such as heart problems
and others
59. Kozier Barbara, et.al. Fundamentals of Nursing , 5 th ed. (US Addison-Wesl
ey Publishing Company, Inc. 1995) p. 448 Age Average Range Newborn 35 30-80 1 ye
ar 30 20-40 2 years 25 20-30 8 years 20 15-25 16 years 18 15-20 Adult 16 12-20 R
espiratory rate/ Minute Variations in Respiratory rate
60. Respiratory rate
* is normally described in breaths per minute
* Types:
* Eupnea- Normal Breathing
* Bradypnea- Abnormally slow
* Tachypnea or polypnea- Abnormally fast
* Apnea- cessation of breathing
61. Respiratory depths
* is established by watching the movement of the chest.
* It is generally describe as normal, deep or shallow, deep respiratio
n are those in which a large volume of air is inhaled and exhaled. Shallow respi
ration involve the exchange of small volume of air
* NOTE: in normal inspiration and expiration, an adult takes in about
500ml of air. This volume is called Tidal volume
62. Respiratory rhythm/ pattern
 * It refers to regularity of expiration and inspiration
* Types
* Regular
* Irregular
o Dsypnea- difficulty in breathing
o Orthopnea- ability to breath in an upright position
63. BLOOD PRESSURE
64. Heart Sound
* 1. First Sound-occurs at the beginning of ventricular systole. It is
caused by the closure of the tricuspid and mitral valves
* 2. Second Sound- marks the beginning of ventricular diastole and is
caused by the closure of aortic and pulmonary valves.
65. Arterial blood Pressure
* is a measure of the pressure exerted by the blood as it flows throug
h the arteries.
* Two blood pressure measurements
* 1. Systolic pressure- is the maximum pressure developed on the eject
ion of blood from the left ventricle into the arteries
* 2. Diastolic Pressure-is the lowest pressure and is a measure of the
peripheral resistance.
66. In measuring the BP
* By means of auscultation- the systolic pressure is taken at the poin
t when beats becomes audible. As the mercury continues to fall, the sound of the
beats becomes louder, then gradually diminishes until a point is reached at whi
ch there is a sudden, marked diminution in intensity.
* The average BP is about 120/80 at 20 yrs old and at the age of 60 is
160/90
67. Aneroid manometer with stethoscope
68. Part of the sphygmomanometer
69. Taking BP
* It is measured with a blood pressure cuff, a sphygmomanometer and a
stethoscope
* The BP cuff has a bladder than can be inflated with air, it is cover
ed with cloth and has two tubes attached to it (sometimes it s three), one tube is
connected to the rubber bulb.
* To introduce air turn the valve clockwise and to release air turn it
counterclockwise, the second tube to the sphygmomanometer and the third to stet
hoscope
70. Auscultatory method of obtaining BP
* First the health care provider must determine the Korotkoff s sound- t
his is a series of sounds heard during BP assessment.
* Phases of Korotkoff s sound
* Phase 1- The first faint clear tapping sound is heard. This sound gr
adually becomes strong and deep
* Phase 2- This is the period during deflation when the sounds have a
swishing quality.
71.
* Phase 3- The period during which the sounds are forceful and powerfu
l
* Phase 4- The time when the sounds begins to decrease in intensity, a
nd has a less bounding force
* Phase 5- The pressure level wherein the sound disappear.
72. Reading Blood Pressure
* The first sound heard is the systolic pressure and the last sound he
ard is the diastolic pressure
73. Mercury manometer and cuff Aneroid manometer and cuff
74. 2 types of sphygmomanometer
* Aneroid and mercury manometer
* Aneroid is a calibrated dial with a needle that points to the calibr
ations while the other is a calibrated cylinder filled with mercury.
 75. Other types
* Electric sphygmomanometer
* Doppler stethoscope
76. Variations in BP cuff
* If the bladder is too narrow, the obtained BP reading is erroneously
elevated; if it is too wide the reading will be erroneously low
* The width should be 40% of the circumference or 20% wider than the d
iameter of the midpoint of the limb on which it is used
* The length of the bladder should be sufficiently long almost to enci
rcle the limb and to cover at least 2/3 of its circumference
77. Variations in BP by Age Kozier Barbara, et.al. Fundamentals of Nursing , 5
th ed. (US Addison-Wesley Publishing Company, Inc. 1995) p. 452 Age Mean BP (mm
Hg) Newborn 73/55 1 year 90/55 6 years 95/57 10 years 102/62 14 years 120/80 Ad
ult 120/80 Elderly (over 70 years) Diastolic pressure may increase
78. The End