L/ Hanaa Eisa 2015 - 2016.

L/ Hanaa Eisa

2015 - 2016

1. Learning outcome

2. Definition of vital signs.

3. Guide line to measured vital signs.

4. When to take vital signs and how.

Course outline

After completing this unit the learner should be able to

1. Define terms used in this unit. Vital signs, Temperature

Pyrexia ,Hyperpyrexia ,Hypothermia, Pulse ,Bradycardia

Tachycardia ,Dysrhythmia, Stethoscope , Blood pressure,

Hypertension, Hypotension , Pulse pressure ,Systolic,

,Diastolic, Apnea , Bradypnea, Tachypnea , Expiration,

Inspiration

Learning outcome

2) Describe nursing responsibilities in assessing vital

signs

3) Recall the normal ranges for each vital signs

4) List sites for assessing vital signs

5) Tell information to patients regarding vital signs

Learning outcome cont’d

What are the Vital signs? Vital signs are physical signs that indicate an individual

is alive. Vital signs are quick & efficient way of monitoring a

condition or identifying the presence of problems. are they:

1. Temperature.2. Pulse .3. Respiration. 4. Blood pressures. 5. (Pulse-oximeter) oxygen saturation

Normal vital signs change with:

1. Age.2. Sex.3. Weight.4. Exercise tolerance5. And condition.

Factor that influence vital signs

1) The nurse caring for the client measures his vital signs.

2) Equipment is functional & appropriate.

3) The nurse knows the normal range for all vital signs.

4) The nurse uses organized, systematic approach when

taking vital signs (first temperature then pulse then

RR & BP)

Guidelines for measuring vital signs

5) The nurse must be able to do all of the following:

a) Measure vital signs correctly.

b) Understand and interpret the values.

c) Communicate findings appropriately.

d) Begin interventions as needed.

Guidelines for measuring vital signs

1) On the clients admission to a health care agency to obtain baseline data.

2) When a client has a change in health status.

3) Before & after surgery

4) Before & after administration of certain medications5) Before & after nursing intervention that could affect

the VS.

When To Measure Vital Signs

What is temperature

• Temperature is the hotness or coldness of a substance.

• Temperature is measured by Thermometer

• In heat unit called degrees (Centigrade or Fahrenheit) scales.

Thermometer

1. Mercury-in-glass.

2. Electronic thermometers.

3. Sensitive tape.

4. Tympanic.

Types of thermometer

What is body temperature?

Body Temperature : reflects the balance between the heat produce and the heat lost from the body.

Types of Body Temperature There are two types of body temperature:1) Core body temperature Temperature of the deep tissues of the body assessed

by using a thermometer.

2) Surface body Temperature Temperature of the skin assessed by touching the skin

Factor affecting body temperature

1) Age2) Diurnal variations3) Exercise4) Hormones5) Stress6) environment

Pyrexia or Febrile, Hyperthermia, hypothermiao Normal range 36-37 º Co Hypothermia less than 36 º C.

o Pyrexia From 38 to 40 º C.

o Hyperpyrexia Avery high fever, such as 41 º C (105 F)

Terms used to describe alteration in body temperature

1) Fahrenheit to Centigrade º C = (F-32) X 5/9e.g. when F reading 100 º F º C = (100 – 32) X 5/9=37.7

2) Celsius to Fahrenheit º F = (9/5 X C) + 32e.g. When C reading 40: º F = (9/5 X 40) + 32 = 104

For examples1. Temp. 98.6 F, is

equal to…..a. 37C.b. 37.5C.c. 36.8C.d. 37.3 C

Converting temperature Reading

1) Oral: which is the most convenient & accessible

2) Rectal : which is the most accurate & reliable

3) Axillary : which is the most safe & noninvasive

4) Tympanic membrane.

Sites to Assess body temperature

Oral temperature can be affected by number of variables.

If a client has been taking cold or hot food , liquids or

smoking, The nurse should wait 30 minutes before

taking the temperature

Variables affect Oral temperature

Oral Rectal Axillary Tympanic

37.0 C 37.5 C 36.5 C 34.5

In the table below you will find the average normal

temperature for healthy adults at various sites

Normal Temperature at various sites

Pulse

What is the pulse? Is the wave of blood created by contraction of the left

ventricle of the heart.

The pulse is the palpable bounding of blood flow noted at various points in the body

Assessing the pulse

What is the pulse Rate?

The pulse rate is an indirect measurement of cardiac

output, which is the volume of blood pumped by the

heart during one minute.

cardiac output = stroke volume X heart rate (HR) E.g.

65 X 70 = 4.55L/m

In an adult the heart normally pumps 5000 to 6000ml of

blood per minute throughout the circulation.

Pulse rate

• The normal pulse for healthy adults ranges from

• 60 to 100 beats per minute.(b/m)

Factors Affecting the Pulse

1) Age (decrease with age )2) Gender ( after puberty male pulse than female.3) Exercise with activity.4) Pathology (e.g. fever)5) Medication(some decrease it some increase it6) Hypovolemia (loss of blood )7) Stress8) Position change.

The pulse may be measure in nine sites as the following:1.  Temporal 2. Carotide 3. Apical4. Brachial5. Radial6. Femoral7.  Popliteal8. Posterior tibial9.  dorsales pedis

Pulse sites

Assessing the pulse

• A pulse is commonly assessed by palpation

(feeling) or auscultation (hearing).• The middle three fingertips are used for

all pulse sites except the apex of the heart (stethoscope is used) applying moderate pressure

Assessing the Pulse

When assessing the pulse, the nurse collect the following

data: Rate, volume (strength) rhythm , equality ,arterial wall

elasticity, If the rate is particularly slow or fast it is probably best to measure for a full 60 seconds in order to minimize the error.

Abnormal Pulse rate

• Tachycardia:– The pulse is faster than 100 b/m.– It may result from shock, hemorrhage, exercise, fever,

acute pain, and drugs.• Bradycardia:– The pulse is slower than 60 beats per minute.– It may result from unrelieved severe pain, drugs,

resting, and heart block.

Assessing apical pulsePoint of maximum impulse is at fifth intercostals space.

Apical Pulse : Apical pulse represents the actual beating of the heart.

1. Rate:• Before measuring a pulse rate, the nurse should know

the baseline heart rate for comparison.• Pulse rates vary depending on age, level of activity and

variety of factors.• To obtain a baseline pulse, the client should be at rest

during measurement of the pulse. It may be necessary to wait 5-10 minutes after activity before measuring the pulse. Check the pulse rate as the client assumes sitting, standing & lying positions

Character of the pulse

2) Regularity or RhythmSuccessive heartbeats normally occur at a regular interval.

If an interval is interrupted by an early beat or if a beat is late or missed, the individual has an abnormal rhythm (dysrhythmia)

3) Equalityo Pulses on both sides of the peripheral vascular system

should be assessed.o The nurse assesses both the radial pulses to compare

the characteristics of each.

Character of the pulse

4) Pulse volume (Strength) a. The strength of a pulse reflects the volume of

blood ejected against the arterial wall with each heart contraction.

b. A normal pulse is full, easily palpable .c. A weak pulse is difficult to palpate and easy for

the assessor to lose during palpation

Character of the pulse cont’d

Respiration is act of breathing.

Human survival depends on

the ability of oxygen (O2) to reach

body cells and for carbon dioxide

(CO2) to be removed from the cells.

Respiration involves two different processes:

Respiration

1) External Respiration : Refers to the inter change of oxygen and carbon dioxide between the alveoli of the lunge and pulmonary blood.

(At Alveoli , blood take oxygen and release carbon dioxide)

2) Internal Respiration: take place throughout the body

Inter change of oxygen &carbon dioxide between the circulating blood and the cell of the body tissues.

At the tissue. Blood takes carbon dioxide and release oxygen to the tissue.

Respiration cont’d

Types of breathing

There are basically two types costal & abdominal breathing :1) Costal (thoracic) breathing involve the external

intercostals muscle & other accessory muscles e.g. sternocleidomastoid muscles, can observed by movement of the chest upward &downward.2) Abdominal breathing By contrast, diaphragmatic

breathing involves the contraction &relaxation of diaphragm observed by movement of the abdomin, upward &downward

Abnormal Respiratory Rate

• Respiration rates over

20 or under 10 breaths

per minute (when at

rest) may be considered

abnormal

over 20 breaths

under 10 breaths

1) Tachypnea It is respiratory rate greater than 20c/m

in adults .

2) Bradypnea It’s respiratory rates less than 10 c/m

3) Apnea Is the absence of breathing.

4) Dyspnea It is difficulty in breathing .

Abnormal Respiratory Rate

1. A skillful nurse does not let a client know that respirations are being assessed.

2. A nurse assesses respiration when a client is at rest.3. The nurse observes a full inspiration & expiration

when counting a respiration.4. Assessment is best done immediately after measuring

pulse rate with the nurse’s hand still on the client’s wrist.

5. Assess also fore respiratory status including:o The rate ,Depth ,Rhythm of breathing & ventilatory

movements

Assessment of respiration

o Normal breathing is regular & uninterrupted.

o Regular interval occurs at each respiratory cycle.

o Infants tend to breathe less regularly.

o The young child may breath slowly for a few seconds &

then suddenly breathes more rapidly.

Rhythm

Factor affecting respiration

1) Factors increase RT:a. Exerciseb. Stress

2) Factors decrease RTc. Decreased environmental temperatured. Certain medication (narcotics e.g. morphine),e. Increase intracranial pressure

1) Rate:o Tachypnea –quick , shallow breathso Bradypnea- abnormally slow breathingo Apnea- cessation of breathing

2) Volume:o Hyperventilation- over expansion of the

lungs (rapid &deep breath)o Hypoventilation- under expansion of the

lungs (shallow respiration)

Breathing Patterns

3) Rhythm:

o From very deep to very shallow breathing

&temporary apnea

4) Ease or effort:

oDyspnea – difficult & labored breathing

oOrthopnea- ability to breathe only in upright

sitting or standing position.

Breathing Patterns

What is Blood Pressure?

Is a measure of the pressure exerted by the blood as it flows through the arteries. There are two blood pressure measures1) The systolic pressure which is the pressure of the

blood as a result of contraction of the ventricles, that is the pressure of the height of blood wave,

2) The Diastolic pressure which is the pressure when the ventricles are at rest. that is the pressure of the lower of blood wave,

• The difference between the diastolic & the systolic pressures is called the pulse pressure.

• standard unit is millimeters of mercury (mm/hg)

Factors Affecting Blood Pressure

• Age ,exercise ,Stress ,Race , genderMedications , Diurnal

variation, Obesity

• Diurnal variations, Disease process

What is Blood Pressure?

Abnormalities in blood pressure Hypertension

• The diagnosis of hypertension in adults is made

when an average of two or more diastolic readings

on at least two subsequent visits is 90 mm/hg or

higher or when an average of two or more systolic

readings on at least two visits is higher than 140

mm/hg.

2.Hypotension

• Hypotension: is Blood pressure that is below

normal(systolic between 85-110mmHg)

• Although some adults have a low Blood pressure

normally, for the majority of people, low BP is an

abnormal finding associated with illness

Types of manometers :

1) Mercury

2) Aneroid

3 (Electronic

Types of sphygmomanometer

They are three

A. Small cuff for a child

B. Normal adult sized cuff

C. Large cuff called leg cuff.

Manometer cuff sizes

1) The nurse is responsible for recording all vital signs accurately and in a timely manner.

2) When a change or abnormality is assessed, the nurse reports the problem to the physician and the nurse on the next shift.

3) The nurse decides when an abnormality has been assessed or reports.

4) Special graphic flow sheets exist for recording vital signs

Reporting and recording

5) In addition to the actual vital sign values, the nurse records in the nurse’s notes any accompanying or precipitating symptoms chest pain or dizziness with abnormal BP

6) The nurse documents any interventions initiated as result of vital sign measurement such as administration of tepid sponging or any anti-hypertensive medications.

Reporting and recording

Vital signs according to age

• Table below shows the variations of vital signs

according to age, you can see that pulse and

respiration are decreasing when becoming older and

older, while blood pressure is increasing with aging.

AGE b/min R/min B/P

NEW BORN 80-180 30-80 73/55 mmHg

1-3 YEAR 80-140 20-40 90/55 mmHg

6-8 YEARS 75-120 15-25 95/75 mmHg

TEENS 60-100 15-20 120/80 mmHg

ADULT 60-100 12-20 120/80 mmHg

Vital signs according to age

What Abnormal Results Mean

1. Normal blood pressure: 100/60 and 139/89.2. Hypotension : Blood pressure below normal : may be indicated by a

systolic pressure lower than 90, or a pressure 25 mmHg lower than usual

3. Hypertension:High blood pressure, greater than 139-89..

What is abnormal results mean

Oxygen Saturation

Considered by many to be a fifth vital sign. It means the amount of oxygen bound to hemoglobin in the blood, expressed as a percentage Normal saturation is 96%-100%.

• Mild hypoxia : 91%– 95%• Significant or moderate hypoxia : 86%– 90%• Severe hypoxia : 85% or lessNote:Oxygen Saturation Measured by pulse oximeter

Review Questions

Choose the correct answer1- The nurse measures the vital signs in all the

following situations except:a. Before and after meal b. Before and after surgical procedure c. Before and after giving medication d. Before and after invasive diagnostic procedure

2. The most preferable site for taking pulse is: e. Carotid f. Radial g. Temporal h. Femoral

3. For infant or a young child the best site to assess pulse is:a. Radial b. Femoral c. Apical d. Carotid

How much time the nurse must wait to take a temperature for a patient who drank cold water? e. 10 minutes f. 20 minutes g. 30 minutesh. 40 minutes

5. The common site for measuring temperature is: a. Oral b. Axilla c. Rectum d. Tympanic membrane

6. The human respiration involves the following process: a. External respiration b. Internal respiration c. A and bd. None of above

7. Breathing is a…..a. Passive process b. Active process c. Passive and Active process d. None of above

8. The pulse pressure is: e. Deference between systolic and diastolic blood pressure f. Difference between blood pressure and breathing g. Difference between blood pressure and pulse h. None of the above

9. The normal value of pulse pressure is …..a. 40mmHg b. 60mmHg c. 80mmHg d. 100mmHg