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VITAL SIGNS - Copy.pptx

  1. Vital Signs Presented by- Ms. Sayma Khan Nursing Tutor/CI ECON
  2. INTRODUCTION • Vital signs reflect the body’s physiological status and provide information critical to evaluating homeostatic balance. Includes- Temperature Pulse rate Respiration Blood pressure • Pain is often referred to as the 5th vital signs. • SPo2 is also referred as 6 th vital sign
  4. 1- TEMPERATURE • Temperature- Measurement of the balance between heat loss and heat production of the body. There are two types of temperature- • 1- Core temperature (inner body temperature) • 2- Surface temperature (skin temperature ) • Average Temperature - 98.6 f • Body temperature regulation- The hypothalamus, located between the cerebral hemispheres of the brain, control body temperature. The hypothalamus at tempts to maintain a comfortable temperature or “set point”. When the hypothalamus senses an increase in body temperature, it sends impulses out to reduce body temperature by sweating and vasodilation. If hypothalamus sense the body temperature is lower than set point. It send signals out to increase heat production by muscle shivering or heat conservation by vasoconstriction.
  5. Sites for measuring temperature- Oral – taken by mouth Rectal- taken by rectum Auxiliary- taken by armpit Tympanic- taken by ear
  6. Assessing temperature- Body temperature can be assessed with variety of devices- 1- glass thermometer / clinical thermometer- 2- electronic thermometer 3- tympanic membrane thermometer 4- disposable paper thermometer 5- temperature sensitive strips and chemical dot
  7. Factors affecting temperature -
  8. Temperature alterations- 1- 1- Hypothermia- temperature below the 95F caused by prolonged exposure to cold. 2-Hyperthermia- temperature above 104f caused by prolonged exposure to hot temperature, serious infection & brain damage. hyperthermia describes a group of illness that include  Heat cramps  Heat exhaustion  Heat rash  Heat stress  Heat stroke
  9. Fever- fever or pyrexia is defined as a rise in the body temperature above 99.6 degree F. the cause of fever are infections, disease, diseases such as leukaemia, embolism and thrombosis, heat stroke from exposure to hot environments, dehydration, Phases of fever- 1- onset or invasion- onset or invasion of fever is the period when the body temperature is rising and it may be a sudden or gradual process. 2- fastigium or stadium- fastigium of fever is the period when the body temperature has reached its maximum and remains fairly constant at a high level. 3- defervescence- or decline- decline of fever is the period when elevated temperature is returning to normal. The fever may subside suddenly or gradually. 4- crisis- crisis is a sudden return to normal temperature from a very high temperature within a few hours or days. a) true crisis- the temperature falls suddenly within few hours and touches normal, accompanied by a marked improvement In a client condition. b) false crisis- a sudden fall in temperature not accompanied by an improvement in the general condition is called false Crisis. It may be a danger signal and not a sign of improvement.
  10. Types of fever-  Constant fever or continious fever- it is one in which the temperature varies not more than 2 degrees between morning and evening and it does not reach normal for a period of days or weeks.  Remittent fever- remittent fever is a fever characterized by variations of more than two degrees between morning and evening but does not reach normal.  Intermittent or quotidian fever- the temperature rises from normal to subnormal intervals. The interval may vary from few hours to 3days. Usually the temperature is higher in the evening than in the morning.  Inverse fever- in this type the highest range of temperature is recorded in the morning hours and the lowest in the evening which is contrary to that found in the normal range of fever.  Hectic or swinging fever- when the difference between the high low points is very great, the fever is called hectic or swinging fever.  Relapsing fever- relapsing fever is one in which there are brief febrile periods followed by one or more days of normal temperature.
  11.  Irregular fever- when the fever is entirely irregular in its course, it can not be classified under any one of the fevers describe above and it is called irregular fever.  Rigor- rigor is a sudden severe attack of shivering in which the body temperature rises rapidly to a stage of hyperpyrexia as seen in malaria.  Low pyrexia- in low pyrexia the fever does not rise above 99 degree F to 100 degree F.  Moderate pyrexia- the body temperature remains between 100 degree F to 103 degree F.  High pyrexia- the temperature remains between 103 degree F to 105 degree F.  Hyperpyrexia- the temperature goes above 105 degree F.  Subnormal temperature- when the body temperature falls below normal, it is called subnormal temperature. The temperature may vary between 95 to 98 degree F
  12. Nursing management Assessment- *Obtain frequent core temperature reading during febrile episode. *Assess for contributing factors such as dehydration, infection or environmental temperature. *Obtain all vital signs. *Assess skin color and temperature, presence of thirst, anorexia, *Assess patient comfort and well being.
  13.  Interventions- Monitor temperature every two hourly. 2- Provide cold sponging with normal tap water 3- Instruct patient to increase caffine free oral fluids of choice. 4- Instruct patient to limit physical activity and increase frequency of rest periods over next two days. 5- Administer antipyretic as prescribed by physician. 6- To access resources to provide temporary air conditioning for home environment. 7- Reassess the condition of patient.
  14. Hot Applications- Hot applications is the application of a hot agent, warmer than skin either in moist or dry form on the surface of the body to relieve pain and congestion, to provide warmth, to promote healing to decrease muscle tone and to soften the exudates. Therapeutic Uses Of Hot Application- 1- Heat decreases pain 2- Heat decreases muscle tone 3- Heat promotes healing 4- Heat promotes suppuration 5- Heat relieves deep congestion 6- Heat soften the exudates 7- Heat provides warmth 8- Heat stimulates peristalsis. Contraindication Of Hot Application- Heat should not be applied on the client with high temperature. Heat should not be applied when there is an open wounds, bleeding may take place.
  15. Heat should not be applied in case of headache because vasodilaltion may increase discomfort. Heat should not be applied to very young and very old people because of the risk of the tissue burn Heat should not be applied in client with metabolic disorders because of increase hazards of tissue damage. Heat should not be applied on the client with paralysis, weak and debilitated clients because they have imparied perception and may not be able to response to hot applications resulting in burn. Heat is not used in malignancies, because heat increases the metabolism of both the normal and abnormal cells. Heat is not used for clients with impaired kidney, heart, and lung functions. Heat should not be applied to acutely inflammed areas i.e. tooth abscess. Cold Applications- cold application is the application of cold agent cooler than skin either in a moist or dry form, on the surface of the skin to reduce pain and body temperature, to anesthetize and area, to check haemorrhage, to control the growth of bacteria, to prevent gangrene, to prevent oedema and reduce inflammation.
  16. Therapeutic Uses Of Cold Application- 1- Cold relieves pain 2- Prevent gangrene 3- To reduce inflammation 4- Control haemorrhage 5- Check the growth of bacteria 6- Reduces the body temperature 7- Cold anesthetize an area. Contrainidications Of Cold Application- cold should not be applied on clients who are in a state of shock and collapse cold should not be applied when there is an oedema. cold should not be applied when there is an muscle spasm. cold should not be applied when the client is having shivering cold should not be applied when the client is having a very low temperature. cold should not be applied when there is decreases the sensation.
  17. Primary Physiological Effects-
  18. Pulse is an alternate expansion and recoil of an artery as the wave of blood is forced through it during the contraction of the left ventricle. The pulse can be felt by fingers on a point where an artery crosses a bone close to the surface of the skin. Average range of pulse- Adult- 60-100 b/m Children- 70- 130 b/min Infants- 140-160 b/min.  Pulse
  19. Characteristics of the pulse-  Rate- Rate is the number of pulse b/m. The normal rate in the resting adult is 60 – 100 b/m. A pulse rate over 100 b/m referred as “tachycardia”. A pulse rate below 60 b/m referred as “bradycardia.”  Rhythm- Rhythm refers to the regularity of beats. Normally the heart beats are spaced at equal intervals and they are said to be normal or “regular”. When the interval varies between the beats it should be “irregular”.  Volume- Volume refers to the fullness of the artery. It is the force of the blood felt at each beat. Volume depends upon the amount of blood in the arteries.  Tension- Tension is the degree of compressibility. It is said to be high tension when the artery is difficult to compress and low tension when it is easy to compress.
  20. There are following sites for measuring pulse rate.  Carotid  Temporal  Apical  Brachial  Radial  Femoral  Popliteal  Posterior tibial  Dorsal pedis
  21. Methods of taking pulse- 1- palpation 2- auscultation Equipment Stethoscope- Auscultation of the apical pulse requires a stethoscope. The stethoscope should have snugly fitting ear pieces and thick walled tubing about 12 inch long for optimal sound transmission. The stethoscope should have a bell and a diaphragm.
  22. Factors affecting pulse rate- 1- Age- The very young have a rapid pulse rate. The adult have a normal range. The very old have a relatively slow. at birth- 140-160b/m adult- 60- 100b/m old age- 60-80b/m 2- Sex- The female has a slightly more rapid pulse than the male. 3- Physique- The short person with small body build has a slightly more rapid pulse than the tall individual. 4- Exercise- Increase the muscular activity will increase the pulse rate. 5- Food- Indigestions of food causes a slight increase in the pulse rate for several hours.
  23. 6- Posture 7- Emotions 8- Application Of Heat 9- Pain 10- Increase Body Temperature 11- Disease Condition 12- Drugs.
  24. Respiration- Process of taking in oxygen and expelling carbon dioxide from the lungs and respiratory tract. Inhalation +exhalation = 1 breath Rate is breaths per minute. Normal range-  Adult- 14-24br/min  Child- 16- 0br/min  Infant- 0-50br/min
  25. Characteristic Of Respiration- 1- Rate- rate is the number of full respiration in a minute 2- Depth Of Respiration- a normal average man at rest inspires and exhales about 500cc of air with each respiration. If more than this quantity of air passes in and out of the lungs the respiration is said to be deep. 3- Rhythm- in a normal respiration, the rhythm is normal. Critically ill person nearing death are found to have a irregular respiration. Abnormalities of respirations- Apnea- absence of respirations (usually temporary) Tachypnea- rapid shallow respiratory rate above 25br/min Bradypnea- slow respiratory rate below 12 br/min Hyperapnoea- it is increases in the depth of respiration. .
  26. Orthopnoea- the client can only breath in an upright position. Dyspnoea- difficult or laboured breathing. Wheeze- the high pitched, musical whistling sound that occurs with partial obstruction of smaller bronchi. Sigh- a very deep inspiration followed by a prolonged expiration.
  27. Factors affecting respiration rate-  Age  Sex  Exercise or Physical Exertion  Stress  Drugs & Smoking  Posture  Emotions  Pain  Increase Body Temperature  Disease Condition
  28. Nursing care- To provide psychological support To maintain proper ventilation To provide comfortable position To administer oxygen To clearance of the air passage To motivate for breathing and coughing exercises To provide steam inhalation To ask patient to take small and frequent diet
  29. Blood pressure Measurement of the pressure that the body exerts on the walls of the arteries as blood pulsates through them. • Blood pressure reading is measured in mmHg (millimeters mercury ). • Normal range- • Systolic- 100- 140mmhg • Diastolic- 90-60mmhg • Average is 120/80mmhg
  30. Types of blood pressure-  Systolic- pressure that occurs when the heart is contracting. Systolic reading is the top number.  Diastolic- pressure that is present when the heart is at rest. Diastolic reading is the bottom number.
  31. • Sphygmomanometer- instrument used to measure blood pressure.
  32. Abnormalities of blood pressure 1. Hypertension - blood pressure more than 140/90mmhg. 2. Hypotension- blood pressure below the 90/60mmhg. Sites for measuring blood pressure-  Brachial- taken in upper arm.  Radial – taken on the lower arm.  Poplitial- taken on the thigh  Dorslis pedis- taken on the lower leg
  33. Factors Affecting Blood Pressure- Age Sex Body Build Race Climate Time Of The Day Exercise Pain Emotions Posture Disease Condition Drugs Increase Intracranial Pressure Haemorrhage
  34. Nursing Care- To identify the client To check the diagnosis To check the reason for taking blood pressure. To schedule the frequency of obtaining blood pressure To know the previous measurements and range of blood pressure. To know the physical and mental state of the client. To asses the arm on which blood pressure can be taken. To not to take BP if the arm has an intravenous infusion on it, the arm is injured or disease, the arm has a shunt or fistula for renal dialysis. To check defects in the B.P. Instrument. To recheck the BP for accurate findings.
  35. A tray containing-  A thermometer  Antiseptic solution bottle to keep thermometer in.  A sphygmomanometer  A stethoscope  A wrist watch  A paper bag- for collecting dry waste.  A kidney tray- for collecting wet waste.  A vital sheet- to record the vitals.  A cotton bowl- for cleaning purpose.  A blue ,black, red pen.
  36. Steps of procedure-  Wash hands.  Remove the thermometer from the anti septic solution and rinse in a cold water.  Shakes the thermometer if mercury level below the 35 degree.  Ask the patient to open mouth and place the thermometer.  Place the thermometer for 2 min and in axillary method for 5 min.  Count the pulse and respiration while thermometer is in place.  Place patient’s hand over his chest with wrist extended the palm downwards. Place the finger tips over pulse point.  Continue palpation of pulse to assess rhythm, volume ,tension, and irregularity.
  37.  If the respirations are normal count the number of respiration for 30 sec and multiply by two. If the breathing pattern is abnormal count for full one minute.  Remove the thermometer after two min. wipe the stem to bulb with a clean cotton swab using a rotating movement. Discard swab.  Read level of mercury  Return thermometer to bottle.  Open the sphygmomamometer and tie the cuff above the elbow.  Auscultate the sound using stethoscope  Wash hands.  Record the temperature, pulse, respiration and blood pressure.