You are on page 1of 30

Vital Signs

Monitor functions of the body Should be a thoughtful, scientific assessment

Copyright 2008 by Pearson Education, Inc.

When to Assess Vital Signs


On admission Change in clients health status Client reports symptoms such as chest pain, feeling hot, or faint Pre and post surgery/invasive procedure Pre and post medication administration that could affect CV system Pre and post nursing intervention that could affect vital signs
Copyright 2008 by Pearson Education, Inc.

BODY TEMPERATURE
The balance between heat loss and heat production
Core
From inside the body

Surface
From outside the body

Factors affecting HEAT PRODUCTION


Basal metabolism Hormones
Thyroxine Epinephrine/norepinephrine Estrogen/Progesterone

Sympathetic stimulation to stress Muscle activity Disease producing fever

Mechanisms of HEAT LOSS


Radiation
Transfer of heat without direct contact

Conduction
From one molecule to another of lower temp.

Convection
Dispersion of heat by AIR CURRENT

Evaporation
Vaporization of moisture Insensible fluid loss

Factors affecting Body temp


Age
Infant and Elderly

Circadian Rhythm
4-6 PM HIGHEST. 4-6 AM LOWEST

Exercise Hormones Environment

Alteration in Body Temp.


Afebrile Pyrexia or Hyperthermia Hyperpyrexia (41OC) Hypothermia Febrile
Intermittent Remittent Relapsing Constant

ADVANTAGE ORAL Accessible and convenient

DISADVANTAGE May brake if bitten Smoking and food may alter the result Could injure the mouth following surgery

RECTAL

Inconvenient and Reliable measurement uncomfortable Could injure the rectum Not recommended for pt with brain and heart disorder. Safe and Noninvasive Needs long time to measure

AXILLARY

TYMPANIC

Reliable. Very fast. Accessible

Not recommended for pt with ear problems.

Nursing Care for Fever


Monitor vital signs Assess skin color and temperature Monitor laboratory results for signs of dehydration or infection Remove excess blankets when the client feels warm Provide adequate nutrition and fluid Measure intake and output Reduce physical activity Administer antipyretic as ordered Provide oral hygiene Provide a tepid sponge bath Provide dry clothing and bed linens

Copyright 2008 by Pearson Education, Inc.

Nursing Care for Hypothermia


Provide warm environment Provide dry clothing Apply warm blankets Keep limbs close to body Cover the clients scalp Supply warm oral or intravenous fluids Apply warming pads

Copyright 2008 by Pearson Education, Inc.

Conversion
Celsius to Fahrenheit.
C= (Fahrenheit 32) 5/9 Ex: 100OF C= (100-32) x 5/9 = (68) x 5/9 = 37.8OC

Fahrenheit to Celsius F= (Celsius x 9/5) +32


Ex: 40OC F= (40 x 9/5) + 32 F= (72 + 32) =104OF

PULSE
Wave of blood due to heart contraction Compliance- elasticity of the blood vessel

Factors Affecting Pulse


Age Gender Exercise Fever Medications Hypovolemia Stress Position changes Pathology

Copyright 2008 by Pearson Education, Inc.

Characteristics of the Pulse


Rate Rhythm Volume Bilateral equality

Copyright 2008 by Pearson Education, Inc.

Pulse Rate and Rhythm


Rate
Beats per minute Tachycardia Bradycardia

Rhythm
Equality of beats and intervals between beats Dysrhythmias Arrhythmia

Copyright 2008 by Pearson Education, Inc.

Characteristics of the Pulse


Volume
Strength or amplitude Absent to bounding

Presence or absence of bilateral equality


Compare corresponding artery

Copyright 2008 by Pearson Education, Inc.

Measuring Apical Pulse

Copyright 2008 by Pearson Education, Inc.

Inhalation
Diaphragm contracts (flattens) Ribs move upward and outward Sternum moves outward Enlarging the size of the thorax

Copyright 2008 by Pearson Education, Inc.

Exhalation
Diaphragm relaxes Ribs move downward and inward Sternum moves inward Decreasing the size of the thorax

Copyright 2008 by Pearson Education, Inc.

Respiratory Control Mechanisms


Respiratory centers
Medulla oblongata Pons

Chemoreceptors
Medulla Carotid and aortic bodies

Both respond to O2, CO2, H+ in arterial blood

Copyright 2008 by Pearson Education, Inc.

Components of Respiratory Assessment


Rate Depth Rhythm Quality Effectiveness

Copyright 2008 by Pearson Education, Inc.

Respiratory Rate and Depth


Rate
Breaths per minute Apnea Bradypnea Tachypnea

Depth
Normal Deep Shallow

Copyright 2008 by Pearson Education, Inc.

Components of Respiratory Assessment


Rhythm
Regular Irregular

Effectiveness
Uptake and transport of O2 Transport and elimination of CO2

Quality
Effort Sounds

Copyright 2008 by Pearson Education, Inc.

Breathing Pattern
Rate
Eupnea Tachypnea Bradypnea

Volume
Hyperventilation Hypoventilation

Ease or Comfort
Dyspnea Orthopnea

Systolic and Diastolic Blood Pressure


Systolic
Contraction of the ventricles

Diastolic
Ventricles are at rest Lower pressure present at all times

Measured in mm Hg Recorded as a fraction, e.g. 120/80 Systolic = 120 and Diastolic = 80

Pulse Pressure = difference between systolic and diastolic pressures


Copyright 2008 by Pearson Education, Inc.

Korotkoffs Sounds

Copyright 2008 by Pearson Education, Inc.

Korotkoffs Sounds
Phase 1
First faint, clear tapping or thumping sounds Systolic pressure

Phase 2
Muffled, whooshing, or swishing sound

Copyright 2008 by Pearson Education, Inc.

Korotkoffs Sounds
Phase 3
Blood flows freely Crisper and more intense sound Thumping quality but softer than in phase 1

Phase 4
Muffled and have a soft, blowing sound

Phase 5
Pressure level when the last sound is heard Period of silence Diastolic pressure

Copyright 2008 by Pearson Education, Inc.

You might also like