ppt chapter 12

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 12

Vital Signs

Chapter 12

Vital Signs


• Body temperature

• Pulse

• Respiratory rate

• Blood pressure

• Pain

– Fifth vital sign

Vital SignsVital Signs


QuestionQuestion

•Is the following statement true or false?

Pain is considered as the fifth vital sign.


Answer Answer

True.

Pain is considered the fifth vital sign. The other vital signs include body temperature, pulse, respiratory rate, and blood pressure.


Assessing a Client’s Health StatusAssessing a Client’s Health Status


Body TemperatureBody Temperature

• Shell temperature: the warmth at the skin surface

• Core temperature: the warmth in deeper sites within the body like the brain and heart


Factors Affecting Body TemperatureFactors Affecting Body Temperature

• Food intake, age, gender

• Climate, exercise and activity

• Circadian rhythm

• Emotions

• Illness or injury

• Medications


Temperature MeasurementTemperature Measurement

• Fahrenheit scale: uses 32˚F as the temperature at which water freezes and 212˚F as the point at which it boils

• Centigrade scale: uses 0˚C as the temperature at which water freezes and 100˚C as the point at which it boils


Normal Body TemperatureNormal Body Temperature

• In normal, healthy adults, shell temperature generally ranges from 96.6˚F to 99.3˚F or 35.8˚C to 37.4˚C

• Chances of survival diminish if body temperatures exceed 110˚F (43.3˚C) or fall below 84˚F (28.8˚C)


Normal Body Temperature (cont’d)Normal Body Temperature (cont’d)

• Based on temperature, animals are either:

– Poikilothermic: temperature fluctuates depending on environmental temperature

– Homeothermic: structural and physiologic adaptations keep body temperature within a narrow stable range


Assessment SitesAssessment Sites• Accurate assessment site: Brain, heart,

lower third of the esophagus, and urinary bladder

• Practical and convenient assessment sites:

– Ear, temporal artery (on forehead or behind ear lobe), mouth, rectum, and axilla

– Ear, temporal artery provide the temperature closest to the core temperature


Clinical ThermometersClinical Thermometers

• Instruments used to measure body temperature

– Electronic

– Infrared

– Chemical

– Digital

– Glass


Types of Clinical ThermometersTypes of Clinical Thermometers

(Refer to Table 12-3 in the textbook.)


Electronic ThermometersElectronic Thermometers


Infrared Tympanic Thermometer Infrared Tympanic Thermometer


Chemical ThermometerChemical Thermometer


Automated Monitoring DevicesAutomated Monitoring Devices

• Equipment that allows for the simultaneous collection of multiple data

• Measure the temperature, blood pressure, pulse, heart rhythm, and pulse oximetry

• Portable to save time and money


Continuous Monitoring DevicesContinuous Monitoring Devices

• Used primarily in critical care areas

• Measure body temperature using internal thermistor probes within the esophagus of anesthetized clients, inside the bladder, or attached to a pulmonary artery catheter


Elevated Body TemperatureElevated Body Temperature

• Fever is a condition in which the body temperature exceeds 99.3˚F (37.4˚C)

• Pyrexia is a condition in which the temperature is warmer than the normal set point

• Hyperthermia is a condition in which core temperature is excessively high and the temperature exceeds 105.8˚F (40.6˚C)


Symptoms of FeverSymptoms of Fever

• Pinkish, red (flushed) skin that is warm to the touch

• Restlessness in some; excessive sleepiness in others

• Irritability; poor appetite

• Glassy eyes and sensitivity to light

• Increased perspiration

• Headache


Symptoms of Fever (cont’d)Symptoms of Fever (cont’d)

• Above-normal pulse and respiratory rates

• Disorientation and confusion (when the temperature is high)

• Convulsions in infants and children (when the temperature is high)

• Fever blisters about the nose or lips in clients who harbor the herpes simplex virus


Phases of FeverPhases of Fever

• Prodromal phase

• Onset or invasion phase

• Stationary phase

• Resolution or defervescence phase


Phases of Fever and Physiologic ChangesPhases of Fever and Physiologic Changes


QuestionQuestion


Fever is a condition where the body temperature exceeds 105.8˚F.


AnswerAnswer

False.

Fever is a condition where the body temperature exceeds 99.3˚F.


HypothermiaHypothermia

• Core body temperature less than 95˚F (35˚C)

• Mildly hypothermic: 95˚F to 93.2˚F (35˚C to 34˚C)

• Moderately hypothermic: 93˚F to 86˚F (33.8˚C to 30˚C)

• Severely hypothermic: below 86˚F (30˚C)


Symptoms of HypothermiaSymptoms of Hypothermia

• Shivering until body temperature is extremely low

• Pale, cool, and puffy skin

• Impaired muscle coordination

• Listlessness and irregular heart rhythm

• Slow pulse and respiratory rates

• Incoherent thinking and diminished pain sensation


PulsePulse

• Produced by the movement of blood during the heart’s contraction

• In most adults, the heart contracts 60 to 100 times per minute at rest

– Pulse rhythm

– Pulse volume

– Pulse rate


Pulse Assessment TechniquesPulse Assessment Techniques

• Primary pulse assessment site: radial artery located at inner (thumb) side of the wrist

• Alternate assessment techniques

– Counting the apical heart rate

– Obtaining an apical–radial rate

– Using a Doppler ultrasound device over a peripheral artery


Peripheral Pulse SitesPeripheral Pulse Sites


• Exchange of oxygen and carbon dioxide

• Respiratory rate is the number of ventilations per minute

• Cheyne-Stokes respiration: a breathing pattern in which the depth of respirations gradually increases, followed by a gradual decrease, and then a period when breathing stops briefly before resuming again

RespirationRespiration


• Rapid respiratory rate

– Tachypnea accompanies elevated temperature or diseases affecting cardiac and respiratory systems

• Slow respiratory rate

– Bradypnea can result from medications; observed in clients with neurologic disorders or hypothermia

Respiratory RateRespiratory Rate


• Hyperventilation

• Hypoventilation

• Dyspnea

• Orthopnea

• Apnea

• Stertorous breathing

• Stridor

Abnormal Breathing CharacteristicsAbnormal Breathing Characteristics


Blood PressureBlood Pressure

• Force that the blood exerts within the arteries

• Lower-than-normal volumes of circulating blood cause a decrease in blood pressure

• Excess volumes cause an increase in blood pressure

• Regular aerobic exercise increases tone of heart muscle and increases efficiency

• Cardiac output


Blood Pressure (cont’d)Blood Pressure (cont’d)

• Cardiac output is approximately 5 to 6 L in adults at rest

• Blood pressure measurements provide physiologic data about:

– Ability of arteries to stretch

– Volume of circulating blood

– Amount of resistance heart must overcome when it pumps blood


Factors Affecting Blood PressureFactors Affecting Blood Pressure

• Age

• Circadian rhythm

• Gender

• Exercise and activity

• Emotions and pain


Factors Affecting Blood Pressure (cont’d)

Factors Affecting Blood Pressure (cont’d)

• Lower blood pressure

– Lower when lying down than when sitting or standing

• Higher blood pressure

– When urinary bladder is full, when the legs are crossed, when the person is cold

– When drugs that stimulate the heart are taken


Pressure MeasurementsPressure Measurements

• Systolic pressure

• Diastolic pressure

• Blood pressure is expressed in millimeters of mercury (mm Hg) as a fraction; systolic pressure/diastolic pressure

• Pulse pressure: difference between systolic and diastolic blood pressure measurements


Assessment SitesAssessment Sites• Usually assessed over the brachial artery

• Lower arm and radial artery

• Measured over the popliteal artery behind the knee in case:

– Client’s arms are missing

– Both of a client’s breasts have been removed

– Client has had vascular surgery


Equipments for Measuring Blood Pressure

Equipments for Measuring Blood Pressure

• Sphygmomanometer

• Aneroid manometer

• Electronic oscillometric manometer

• Inflatable cuff

• Stethoscope


Aneroid and Electronic Oscillometric Manometer Aneroid and Electronic

Oscillometric Manometer


Measuring Blood PressureMeasuring Blood Pressure

• Phase I: first faint but clear tapping sound that follows a period of silence as pressure is released from the cuff

• Phase II: change from tapping sounds to swishing sounds

• Phase III: change to loud and distinct sounds—crisp knocking sounds


Measuring Blood Pressure (cont’d)Measuring Blood Pressure (cont’d)

• Phase IV: sounds muffled and has a blowing quality—first diastolic pressure measurement

• Phase V: point at which the last sound is heard—second diastolic pressure measurement


Characteristics of Korotkoff Sounds Characteristics of Korotkoff Sounds


QuestionQuestion


First diastolic pressure measurement is taken at phase III of Korotkoff sounds.


AnswerAnswer

False.

First diastolic pressure measurement is taken at phase IV of Korotkoff sounds.


Alternate Techniques for Assessing Blood PressureAlternate Techniques for Assessing Blood Pressure

• Palpation

• Using a Doppler stethoscope

• Automatic blood pressure monitoring

• Measuring thigh blood pressure


Abnormal Blood Pressure Measurements

Abnormal Blood Pressure Measurements

• Blood pressures above or below normal ranges indicate significant health problems

• Hypertension: high blood pressure

• Hypotension: low blood pressure

• Postural or orthostatic hypotension: sudden but temporary drop in blood pressure when rising from a reclining position


Abnormal Blood Pressure Measurements (cont’d)

Abnormal Blood Pressure Measurements (cont’d)

• Hypertension or high blood pressure is associated with:

– Anxiety

– Obesity

– Vascular diseases

– Stroke, heart failure

– Kidney diseases


Documenting Vital SignsDocumenting Vital Signs

• Once vital sign measurements are obtained:

– Document the data in medical record for analysis of patterns and trends

– Enter the data, along with any other subjective or objective information in narrative nursing notes


Nursing ImplicationsNursing Implications

• Vital sign assessment is the basis for identifying problems

• Nurses identify from the nursing diagnoses:

– Hyperthermia, hypothermia, ineffective thermoregulation, decreased cardiac output, risk for injury, or ineffective breathing pattern


Gerontologic ConsiderationsGerontologic Considerations

• Lower “normal” or baseline temperature

• Changes in thermoregulation system

• Delayed or diminished febrile response to illnesses

• Change in cognitive function, restlessness, or anxiety may be initial sign of illness


Gerontologic Considerations (cont’d)Gerontologic Considerations (cont’d)

• Susceptible to hypothermia and heat-related conditions; elevated blood pressure readings in clinical settings

• Blood pressure assessment in bilateral arms; document subsequent trends

• Older adults are more susceptible to arrhythmias and postural and postprandial hypotension


Gerontologic Considerations (cont’d)Gerontologic Considerations (cont’d)

• If older client is hypotensive, plan for limited activities during the hour following eating or for frequent smaller food consumption throughout the day

• More profound responses to cardiovascular medications than younger adults

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