Vital Signs. Shurouq Qadose 17/2/2008. Vital signs are temperature, pulse, respiration, blood pressure and pain. A change in vital signs may indicate a change in health.
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Vital signs are temperature, pulse, respiration, blood pressure and pain. A change in vital signs may indicate a change in health.
Frequency of vital signs: vital signs are assessed at least every 4 hours in hospitalized patients with elevated temperatures, with low or high blood pressures, with changes in pulse rate or rhythm or with respiratory difficulty as well as in patients who are taking medications that effect cardiovascular or respiratory function or who had a surgery.
Body temperature reflects the balance between the heat produced and the heat lost from the body, and is measured in heat units called degrees. There are two kinds of body temperature:
Core temperature is the temperature of the deep tissues of the body such as abdominal cavity and pelvic cavity; it remains relatively constant. The surface temperature is the temperature of the skin, the subcutaneous tissue, and fat. It rises and falls in response to the environment. When the amount of heat produced by the body equals the amount of heat loss, the person is in heat balance.
Radiation; the transfer of heat from the surface of one object to the surface of another without contact between the two objects, mostly in the form infrared rays.
Conduction; is the transfer of heat from one molecule to a molecule of lower temperature such as the body transfers heat to an ice pack causing the ice to melt.
Vaporization; the conversion of a liquid to vapor such as body fluid in the form of perspiration and insensible loss is vaporized from the skin.
Convection is the dispersion of heat by air currents. The body usually has a smallamount of warm air adjacent to it. This warm air rises and is replaced by cooler air.
Stress; the body respond to both emotional and physical stress as a threat increasing the production of epinephrine and nor epinephrine as a result the metabolic rate increases raising the body temperature
There are two primary alterations in body temperature: pyrexia and hypothermia.
A body temperature above the usual range is called pyrexia, hyperthermia, or fever.
Hyperpyrexia; is a very high fever usually above 41 °C and survival is rare when the temperatureReaches 44 °C and death due to damaging effects on the respiratory center.
The client who has a fever is referred to as febrile; the one who does not is afebrile.
The signs and symptoms of fever: loss of appetite, headache, hot, dry skin, flushed face, thirst and general malaise. Young children or other people with high fevers may experience periods of delirium or seizures.
Hypothermia; isa core body temperature below the lower limit of normal. The three physiologic mechanisms of hypothermia are:
The four most common sites for measuring body temperature are oral, rectal, axillary, and the tympanic membrane and the skin.
Orally: It reflects changing body temperature more quickly than the rectal method. Oral thermometers may have long, short, or rounded tips
Contra indication of rectal temperature
Axillary; is the preferred site for measuring temperature newborn because it is accessible and offers no possibility rectal perforation.
Contraindication of axillary temperature
Tympanic membrane; nearby tissue in the ear canal because the membrane has an abundant arterial blood supply.
Temporal artery thermometer are most useful for infants and children where a more invasive measurement is not necessary.
The body temperature is measure in degreed on two scales: Celsius (centigrade) and Fahrenheit.
C= (Fahrenheit temperature – 32) * 5/9
F = (Celsius temperature * 9/5) +32
Pulse; is a wave of blood created by contraction of the left ventricle of the heart.
Cardiac output; is the volume of blood pumped into the arteries by the heart and equals the result of the stroke volume times the heart rate.
A peripheral pulse; is a pulse located away from the heart such as in the foot, wrist neck.
Apical pulse; is a central pulse; that is, located at the apex of the heart.
Hypovolemia; loss of blood from the vascular system normally increase pulse rate. Stress; in response to stress, sympathetic nervous system stimulation increases the overall activity of the heart.
A pulse is normally palpated by applying moderate pressure with the three middle fingers of the hand. A pulse is commonly assessed by palpation “feeling’ or auscultation “hearing”.
Apical pulse; if the peripheral pulse is difficult to assess accurately because it is irregular. The apical pulse located at 5-6 intercostals rib.
A Doppler ultrasound stethoscope (DUS) is used for pulses that are difficult to assess.
The nurse should aware of the following:
1. Rate, an excessively fast heart rate over 100 BPM in an adult is called Tachycardia. A heart rate in an adult of less than 60BPM is called Bradycardia.
2. Rhythm is the pattern of the beats and the intervals between the beats. A pulse with an irregular rhythm is referred to as a dysrhythmia or arrhythmia.
3. Volume is called pulse strength or amplitude, refers to the force of blood with each beat. It can range from absent to bounding.
4. Elasticity of the arterial wall reflects its expansibility or its deformities. A healthy, normal artery feels straight, smooth, soft, and pliable. Elders often have inelastic arteries that feel twisted and irregular upon palpation.
It may need to be assessed for clients with certain cardiovascular disorders. Normally the apical pulse and radial are identical.
Pulse deficit; the discrepancy between the radial pulse and apical pulse.
During inhalation, the diaphragm contracts the ribs move upward and outward, and the sternum moves outward, thus enlarging the thorax and permitting the lungs to expand.
During exhalation. The diaphragm relaxes, the ribs move downward and inward, and the sternum moves inward, thus decreasing the size of the thorax as the lungs are compressed.
Respiration is controlled by (a) respiratory centers in the medulla oblongata and the pons of the brain and (b) by chemo receptors located centrally in the medulla and peripherally in the carotid and aortic bodies.
External respiration; the interchange of oxygen and carbon dioxidebetween the alveoli of the lungs and the pulmonary blood. Internal respiration; the interchange of these same gases between the circulating blood and the cells of the body tissues.
The respiratory rate is normally described in breaths per minute, normal in depth and rate called eupnea. Bradypnea; abnormally slow respirations. Tachypnea; abnormally fast respirations. Apnea; the absence of breathing.
Factors increase the rate:
Respiration depth; is generally described as normal, deep, or shallow. Deep respirations; large volume of air is inhaled and exhaled, inflated most of the lungs.
Shallow breathing involve the exchange of a small volume of air and often the minimal use of a lung tissue
Hyperventilation; refers to very deep, rapid respiration.
Hypoventilation; refers to very shallow respirations
Respiratory rhythm refers to the regularity of the expirations and the inspirations .An respiratory rhythm can be described as regular or irregular.
- Cheyne-stokes breathing, from very deep to very shallow breathing and temporary apnea.
Kussmaul …….. Increased rate and depth of respiration above 20bpm
Respiratory quality, usually breathing does not require noticeable effort. Dyspnea, difficult and labored breathing. Orthopnea, ability to breath only in upright sitting or standing positions.
- Stridor, harsh sound heard during inspiration with laryngeal obstruction
- Stertor, snoring respiration usually due to a partial obstruction of the upper airway.
- Wheeze, continuous, high pitched musical sound occurring on expiration when air moves through narrowed or partially obstructed air way.
- Hemoptysis, the presence of blood in the sputum
- Productive cough, a cough accompanied by expectorated secretions
- Nonproductive cough, a dry, harsh cough without secretions
Blood pressure is referred to the force of the blood against arterial walls. Maximum blood pressure is exerted on the walls of arteries when the left ventricles of the heart pushes blood through the aortic valve into the aortas during contraction, the highest pressure thus called systolic pressure.
Diastolic pressure is the pressure when the ventricles are at rest. Diastolic pressure, then, is the lower pressure present at all times within the arteries. The differences between the two called the pulse pressure
Peripheral vascular resistance; peripheral vascular can increase blood pressure. The diastolic pressure especially is affected. Some factors that create resistance in the arterial system are the capacity of the arterioles, the compliance of the arteries, and the viscosity of the blood
Blood volume; when the blood volume decreases as a result of hemorrhage, the blood pressure decreases because of the decreased fluid in the arteries.
Stress; stimulation of the nervous system increases cardiac output and vasoconstriction of the arterioles, however severe pain can decrease blood pressure greatly by inhibiting the vasomotor center and provide vasodilatation
Hypertension; an abnormally high blood pressure, over 140mm Hg systolic and 90 mm Hg diastolic.
Factors associated with hypertension
Hypotension; blood pressure below normal that is systolic reading between 85-110mm Hg. It occurs as a result of peripheral vasodilatation in which blood leaves the central body organs especially the brain and moves to the periphery
Factors associated with hypotension
It is important to monitor hypotensive clients carefully to prevent falls. When assessing the orthostatic hypotension:
After one minute in the upright position, check the pulse and blood pressure in the same site as previously
Assessing the blood pressure on a client’s thigh is indicated in these situations:
Blood pressure is not measured on a particular clients’ limb in the following situations:
1) Avoid having blood [pressure in injured or an area with cast
2) The client has had removal of axilla lymph node on that site
3) The client has intravenous line in that limb
4) The client has an arteriovenous fistula for dialysis in that limb
A pulse oximeter; is a non invasive device that measures a client's arterial blood oxygen saturation by means of a sensor attached to the client's finger, toe, nose, earlobe, or forehead. The pulse oximeter can detect hypoxemia before clinical signs and symptoms such as dusky skin color and dusky nailbed color.