chapter 4 vital signs. overview mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990,...
TRANSCRIPT
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CHAPTER 4
VITAL SIGNS
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Overview
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Vital signs (VS) are used to: Determine the general status of the patient
Establish a baseline Monitor response to therapy Observe for trends Determine the need for further evaluation or intervention
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Obtaining VS and Clinical Impression
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Four classic VS Temperature
Pulse
Respirations
Blood pressure
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Additional Observations4
Height and weight
LOC
Level and type of pain
General appearance
Pulse oximetry
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Frequency of VS Measurement
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Depends on patient’s condition Baseline measurement
On admission At beginning of each shift Before and after procedure Any time patient’s condition changes Based on protocol or physician's order As often as necessary for patient safety
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Trends in Vital Signs
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Isolated measurement provides limited information
Normal VS for a patient depend on: Age Presence of chronic disease Treatment protocols
Trend = baseline + measurements over time Multiple-day graph
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Trending
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Elsevier Inc.
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Comparing VS Information
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Shows change in patient’s condition:
Comparing changes in VS, signs, and symptoms
Establishing differential diagnosis
Determining if patient is improving or deteriorating
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Comparing VS Information (Cont.)
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Key to expert assessment: Constant awareness of change Look Listen Touch Reassess and analyze Trend, trend, trend
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Height and Weight
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Routinely measured Pt needs an admission weight
Document in kilograms (1 kg = 2.2 lb) Follow up every 24 to 48 hours Dehydration or fluid overload
Follow intake/output (I&O) Scales must be age appropriate and
regularly calibrated
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General Clinical Impression
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Gives clues to levels of distress and severity of illness
Information about personality, hygiene, culture, and reaction to illness
May dictate order of care, physical examination
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General Clinical Impression (Cont.)
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Cardiopulmonary distress suggested by:
Labored, rapid, irregular, or shallow breathing
Coughing, choking, and/or wheezing
Chest pain and/or cyanosis
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General Clinical Impression16
Anxiety may be suggested by:
Restlessness
Fidgeting
Tense look
Difficulty communicating
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General Clinical Impression (Cont.)
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Pain may be suggested by:
Drawn features
Moaning and guarding
Shallow breathing and/or refusal to take deep breath
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Head-to-toe inspection18
Hearing Smelling Seeing Touching Perception
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Pain Level and Type
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“Fifth vital sign” Pain intensity scales
Ranking of 1 to 10 Quantifies a subjective measure
Corresponding facial expressions and verbal description to assess pain level
Find associated symptoms as well as alleviating and aggravating factors
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Level of Consciousness
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Measure cerebral oxygenation
Evaluation of time, place, and person “Oriented × 3”
Deterioration from restlessness to coma Cerebral hypoxia Side effect to medications or drug
overdose
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LOC23
Status of sensorium Directs treatment plan Patient cooperation, coordination
Glasgow Coma Scale
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Temperature
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Normal: 98.6° F (37° C), range (97°-99.5° F)
Daily variations (1°-2° F)
Lowest in morning
Highest late afternoon
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Temperature26
Normal increase during exercise, ovulation, and first months of pregnancy
Balance of heat production and loss
Dissipation through sweating, peripheral vasodilation, and hyperventilation
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Fever
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Elevation of temperature (febrile) From normal activities (exercise) =
hyperthermia From disease (infection) = fever
Body temperature of >102° F usually indicates infection
Not all infections result in fever Immunocompromised patients may not
be able to generate fever despite infection
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Fever (Cont.)
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Increases O2 consumption and CO2 production
O2 consumption and CO2 production increase 10% for each 1 C elevation in body temperature
Patients with limited respiratory function may develop respiratory failure in response to fever
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Hypothermia
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Body temperature below normal Head injury Cold exposure
Compensatory mechanisms Shivering Peripheral vasoconstriction
Reduces O2 consumption and CO2 production Slow and shallow breathing
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Inducing mild therapeutic hypothermia in selected patients surviving out-of-hospital sudden cardiac arrest can significantly improve rates of long-term neurologically intact survival and may prove to be one of the most important clinical advancements in the science of resuscitation.
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Measuring Body Temperature
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Sites: Mouth, ear, axilla, rectum, forehead Axillary: Safe and accurate in infants
and small children1 F lower than oral, 2 F lower than rectal
Fahrenheit and Celsius conversion ° F = (° C × 9/5) + 32 ° C = (° F – 32) × 5/9
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Pulse
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Evaluate: Rate, rhythm, and strength
Normal rate: 60-100 beats/min for adults The younger the patient, the faster the rate
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Heart Rate - Tachycardia34
HR greater than 100 b/min
HR can increase from hypoxemia, pain, anxiety, stress, fever, drug reactions, MI, hypovolemia, or cardiac output defects.
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Heart Rate
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Bradycardia = <60 beats/min Diseased heart, athletes,
medication side effects, hypoxemia in infants, low CO
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Arrhythmia = Irregular rhythm
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Measurement of Pulse Rate
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Right radial artery = Most common site Index and middle fingers
Avoid thumb: examiner’s own pulsation
Central pulses if hypotension present Carotid, femoral
Pulse counted for a full minute If regular, counted for 15 sec × 4 or 30 sec × 2
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Taking a Pulse
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Pulse Rhythm and Pattern
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Regular, regularly irregular, irregularly irregular Irregularly irregular is unfavorable
finding Bigeminy = Rhythm coupled in pairs Trigeminy = Rhythm grouped in three
beats
Pulse deficit = Auscultated – Palpated
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Pulse Rhythm and Pattern (Cont.)
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Volume of the pulse Described as: bounding, full,
normal, weak, thready, absent
Pulsus paradoxus Strength decreases with inspiration Alternans = strong and weak
pulses
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Respiratory Rate and Pattern
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Sensitive Marker of Acute Respiratory Distress
Tachypnea = rate above normal
Atelectasis, hypoxemia, hypercapnia
Anxiety, pain, exertion, metabolic acidosis
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Respiratory Rate and Pattern
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Bradypnea = rate below normal
Uncommon
Head injury, hypothermia, side effect of medications (narcotics), drug overdose
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Measurement of Respiratory Rate
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Watching abdomen or chest wall movement Can be done as you assess radial pulse
When regular = Count for 30 sec × 2
Assess depth and pattern
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Blood Pressure
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Blood Pressure (BP)
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Force exerted against arterial walls
Systolic: peak force during ventricular contraction
Diastolic: force during ventricular relaxation
Normal: 120/80 mm Hg
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Blood Pressure
Pulse pressure = P systolic – P diastolic
Normal: 35-40 mm Hg
<30 mm Hg: poor peripheral perfusion
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Hypertension and Hypotension Hypertension
BP of >140/90 mm Hg Risk factor for heart,
vascular, renal disease
Major modifiable risk factor for stroke, CAD, CHF, peripheral vascular disease
Cause in most cases is unknown
Hypotension BP of <90/60 mm Hg
If symptomatic: dizziness, fainting
Causes: left ventricular failure, blood loss, peripheral vasodilation
Orthostatic hypotension: resulting from changes in posture
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Measurement of Blood Pressure
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Sphygmomanometer Occluding cuff, stethoscope, manometer
Continuous noninvasive arterial pressure
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Blood Pressure
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Errors in Blood Pressure Measurement Erroneously High
Too narrow a cuff Cuff applied too
tightly or too loosely Excessive pressure
in cuff during measurement
Incomplete deflation of cuff between measurements
Erroneously Low Too wide a cuff
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Blood Pressure
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Effects of the Respiratory Cycle on BP
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Systolic pressure decreases (2-4 mm Hg) with inspiration
Pulsus paradoxus: if BP drops >10 mm Hg Asthma, cardiac tamponade are two
common causes Pulsus paradoxus in asthma signifies
a more severe case