VITAL SIGNS.pdf

K
Khyber medical university Peshawar Pakistan Professor en Khyber medical university Peshawar Pakistan
VITAL SIGNS
By : Ibne Amin
Institute of Nursing Sciences,
Khyber Medical University , Peshawar
OBJECTIVES
1. Define Vital Signs.
2. Define terms related to Vital sign.
3. Describe the physiological concept of temperature, respiration
and blood pressure.
4. Describe the principles and mechanisms for normal
thermoregulation in the body.
5. Identify ways that affect heat production and heat loss in the
body.
6. Define types of body temperature according to its
characteristics.
7. Identify the sign and symptoms of fever.
OBJECTIVES
8. Discuss the normal ranges for temperature, pulse,
respiration and blood pressure.
9. List the factors affecting temperature,pulse,
respiration.
10. Describe the characteristics of pulse and respiration.
11. List factors responsible for maintaining normal blood
pressure.
12. Describe various methods and sites used to measure
T.P & B.P.
13. Recognize the signs of alert while taking TPR and B.P.
INTRODUCTION
Vital sign are the indicator of the body’s physiologic
status and response to physical environment and
psychological stressor.
The vital sign or the cardinal sign are temperature,
pulse, respiration, and blood pressure. The findings are
governed by the vital organs.
DEFINITION
Vital sign are called cardinal signs because of their
importance. These are the indicator of health status, as
these indicate the effectiveness of circulatory,
respiratory, neural, & endocrine body functions.
1. Temperature
2. Pulse
3. Respiration
4. Blood pressure
5. oxygen saturation
6. Pupillary reaction / pain
WHEN TO TAKE VITAL SIGNS
• Upon admission.
• On a routine basis.
• Before and after invasive procedure.
• Before and after administration of medication.
• Any deterioration of patient’s general condition.
• Before and after nursing intervention that may
influence vital sign.
• Prior to medical emergency
TEMPERATURE
Body Temperature: it is the hotness or coldness of the body.
OR
It is balance between the heat produced by the body and
heat lost from the body.
Heat produced – Heat lost = Body temperature
Types: There are two kinds of temperature..
1. Core Temperature
2. Surface Temperature
TEMPERATURE
Core Temperature: is the temperature of the deep
tissues of the body. It remains constant and varies very
little as + 1 F except when a person has a fever. We
measure it with a thermometer.
Surface Temperature: by contrast the temperature of
the surface or skin, fluctuate (rises or fall) in response
to the environment.
Normal body temperature: is not an exact point on a
scale but a range of temperatures. When measured
orally for an adult, on an average it is between 36-38 C
(96.8 – 100 F)
Regulation of Body Temperature
The system that regulates body temperature has 3 main parts:
1. Sensors in the periphery and in the core,
2. An integrator in the hypothalamus, and
3. An effector system that adjusts the production and loss of
heat.
Most sensors or sensory receptors are in the skin. The skin has more
receptors for cold than warmth. Therefore, skin sensors detect cold more
efficiently than warmth.
When the skin becomes chilled over the entire body, three physiological processes to
increase the body temperature take place:
1. Shivering increases heat production.
2. Sweating is inhibitedto decrease heat loss.
3. Vasoconstrictiondecreases heat loss.
Regulation of Body Temperature
Body temperature is regulated by balancing the amount of
heat the body produces with the amount of heat the body
loses. Body heat is produced as a by-product of
metabolism, which is the sum of all biochemical and
physiological processes that take place in the body.
The hypothalamus, a gland located in the brain, acts as a
thermoregulator. It is able to adjust body temperature that
results in either increasing or decreasing heat production
throughout the day.
• Regulation of Body Temperature
• The anterior Hypothalamus promotes heat loss
through vasodilatation and sweating
• The posterior Hypothalamus promotes: – Heat
conservation by vasoconstriction – Heat production
And maintains the core temperature
THERMOREGULATION
Thermoregulation: Balance between heat production
and heat loss. When the amount of heat produced by
the body exactly equals the amount of heat lost, the
person is in heat balance.
1. Heat production
2. Heat loss
Heat production in the body is called thermogenesis.
Heat loss to the environment is called thermolysis.
1. HEAT PRODUCTION
1. Heat production:
Basal metabolic rate: Basal metabolic rate (BMR) is the
total number of calories that your body needs to
perform basic, life-sustaining functions like breathing
and circulation etc.
Muscle activity: Body cells are constantly producing
and breaking down ATP (Adenosine triphosphate) and
these chemical reactions produce heat during.
1. HEAT PRODUCTION
• Thyroxin: Thyroid hormones stimulate diverse
metabolic activities most tissues, leading to an
increase in basal metabolic rate
• Epinephrine, nor epinephrine and sympathetic
stimulation:
Epinephrine and nor epinephrine are released by the
adrenal medulla and nervous systemrespectively. They are
the flight/fight hormones that are released when the body
is under extreme stress.During stress,much of the body's
energy is used to combat imminent danger.
2. HEAT LOSS
• Radiation: The emission of energy as
electromagnetic waves from the body.
• Conduction: It is the transfer of heat from one
surface to the other through direct contact. Heat is
transferred via solid material
• Convection: Convection is the dispersion of heat by air
currents
• Conversion/Vaporization: Evaporation is the
continuous evaporation of moisture from the respiratory
tract and from the mucosa of the mouth as well as from
the skin.
Normal range of body temperature
(Adults)
FACTORS AFFECTING BODY TEMPERATURE:
• Age Infants greatlyinfluenced bythe temperature,childrenmore labile than adult and elderly
are extremelysensitiveto environmental change due to decreased thermoregulatorycontrol
• Diurnal variation Bodytemperature normallychange throughout the day,varyingas
much as 1.0 °C between early morningand late afternoon The point of highest bodytemperature
is usuallyreached between 8pm and 12 midnight and the lowest point is reached duringsleep
between 4 a.m. and 6 a.m.
• Exercise
• Hormones Women usually experience morehormonefluctuations than men, progesterone
secretion in women raises body temperature.
• Stress Epinephrine and nor epinephrine increases metabolic activity and heat production
• Environment
FACTORS AFFECTING BODY
TEMPERATURE:
ALTERATION IN BODY TEMPERATURE
ALTERATION IN BODY TEMPERATURE
The normal range for adults is considered to be between
36°C and 37.5°C (96.8°Fto 99.5°F).
There are two primary alterations in body temperature:
1. Pyrexia or Hyperthermia
2. Hypothermia.
1. Pyrexia
A body temperature above the usual range is called pyrexia,
hyperthermia, or (in lay terms) fever. A very high fever, such
as 41°C (105.8°F), is called hyperpyrexia.
Febrile:The client who has a fever is referred to as febrile.
Afebrile:The one who does not, is called afebrile.
Pyrexia
1. Low Pyrexia: The fever does not rise more than 99
to 100 F
2. Moderate Pyrexia: Body temperature remain between
100-103degree F
3. High Pyrexia: Body temperature remain between
103- 105 degree F
4. Hyperpyrexia: Temperature above 105 degree F
Pyrexia (Conti…)
4 Common Types Of Fever
1. Intermittent fever: The body temperature alternates at
regular intervals between periods of fever and periods of
normal or subnormal temperature e.g. Malaria
2. Remittent fever: A wide range of temperature fluctuation
(more than 2 0c) occurs over the 24 hr period, all of which are
above normal e.g. a cold or influenza
3. Relapsing fever: Short febrile periods of a few days are
interspersed with periods of 1 or 2 days of normal
temperature e.g.
4. Constant fever: The body temperature fluctuates minimally
but always remains above normal e.g. typhoid fever
VITAL SIGNS.pdf
Pyrexia (Conti…)
Fever Spikes: A temperature that rises to fever level
rapidly following a normal temperature and then
returns to normal within a few hours is called a fever
spike. Bacterial blood infections often cause fever
spikes.
Inverse Fever: The highest range of temperature is
recorded in morning hours and lowest in the evening.
Hectic Or Swinging Fever: When difference between
high and low temperature is very great.
ALTERATION IN BODY TEMPERATURE
In some conditions, an elevated temperature is not a true
fever. Two examples are heat exhaustion and heat stroke.
Heat exhaustion: is a result of excessive heat and
dehydration. Signs of heat exhaustion include paleness,
dizziness, nausea, vomiting, fainting, and a moderately
increased temperature (38.3°C to 38.9°C [101°F to 102°F]).
Heat stroke: Persons experiencing heat stroke generally
have been exercising in hot weather, have warm, flushed
skin, and often do not sweat. They usually have a
temperature of 41.1°C (106°F) or higher, and may be
delirious, unconscious, or having seizures
Stages / Phases of Fever
Onset
Invasion, onset of Fever, Period of rising
Also called Cold or Chilled Phase
Course
Stadium, fever has reached its peak level and
remains constant
Also called Plateau Phase
ABATEMEN
T
Defervescence, elevated temperature declines
Also called as Flush Phase
Clinical Manifestation of Fever
ONSET (COLD OR CHILL PHASE)
Increased heart rate, Increased respiratory rate and depth, Shivering
Pallid, cold skin ,Complaints of feeling cold , Cyanotic nail beds
“Gooseflesh” appearance of the skin ,Cessation of sweating
COURSE (PLATEAU PHASE)
Absence of chills ,Skin that feels warm , Photosensitivity , Glassy-eyed
appearance , Increased pulse and respiratory rates , Increased thirst
Mild to severe dehydration , Drowsiness, restlessness, delirium, or
convulsions ,Herpetic lesions of the mouth , Loss of appetite (if the
fever is prolonged) ,Malaise, weakness, and aching muscles
DEFERVESCENCE (FEVER ABATEMENT/FLUSH PHASE)
Skin that appears flushed and feels warm , Sweating , Decreased
shivering , Possible dehydration
Hypothermia
Hypothermia is a core body temperature below the lower
limit of normal i.e. 95 F or 35 C. The three physiological
mechanisms of hypothermia are
(a) Excessive heat loss,
(b) Inadequate heat production to counteract heat loss,
(c) Impaired hypothalamic thermoregulation
If skin and underlying tissues are damaged by freezing cold, this
results in frostbite. Frostbite most commonly occurs in hands,
feet, nose, and ears in which ice crystal forms inside the cell and
damage it.
Clinical Manifestation of Hypothermia
• Decreased body temperature, pulse, and respirations
• Severe shivering (initially)
• Feelings of cold and chills
• Pale, cool, waxy skin
• Frostbite (discolored, blistered nose, fingers, toes)
• Hypotension
• Decreased urinary output
• Lack of muscle coordination, Disorientation, drowsiness
progressing to coma
Types of Hypothermia
1. Induced hypothermia: is the deliberate lowering of
the body temperature to decrease the need for oxygen
by the body tissues such as during certain surgeries.
2. Accidental hypothermia: can occur as a result of
(a) exposure to a cold environment,
(b) immersion in cold water, and
(c) lack of adequate clothing, shelter, or heat.
In older adults, the problem can be compounded by a
decreased metabolic rate and the use of sedative
medications.
Sites to Measure Temperature
❑Oral
❑Rectal
❑Axillary
❑Tympanic membrane
❑Temporal artery
Condition of resident determines which is the best site for measuring body
temperature.
Advantages and Disadvantages of Sites for Body
Temperature Measurement
Types Of Thermometer
Thermometer
Thermometer
Two parts of thermometer-bulb and stem
• Blub is fragile part, containing mercury, sensitive to
temperature.
• Stem is hollow tube in which mercury can rise.
There are two scales, Fahrenheit and Celsius
Mercury, a liquid metal, with silvery appearance is used in
thermometers, because it is very sensitive to a small changes in
temperature, expansion of mercury is uniform, easily visible.
Temperature: Safety Precautions
• Hold rectal and axillary thermometers in place
• Stay with resident when taking temperature
• Prior to use, shake liquid in glass down
• Shake thermometer away from resident and hard
objects
• Wipe from end to tip of thermometer prior to
reading
• Delay taking oral temperature for 10 - 15 minutes
if resident has been smoking, eating or drinking
hot/cold liquids
Conti…
• Oral – most common, most convenient
• Rectal – registers one degree Fahrenheit higher than
oral, most accurate
• Axillary – least accurate; registers one degree
Fahrenheit lower than oral
• Tympanic – probe inserted into the ear canal
PULSE
The pulse is an index of the heart’s rate and rhythm.
Pulse provides valuable data about person’s
cardiovascular status.
DEFINITIONS- “The pulse is a wave of blood created by
contraction of the left ventricle of the heart.”
Physiology of Pulse
Blood flows through the body in a continues circuit.
Electrical impulses originating from the SA node travel
through heart muscle to stimulate cardiac contraction.
Approximately 60 to 70 ml (stroke volume) of blood
enters the aorta with each ventricular contraction.
With each stroke volume ejection, the wall distends,
creating a pulse wave that travels rapidly toward the
distal ends of the arteries.
When a pulse wave reaches a peripheral artery, it can be
felt by palpating the artery lightly against underlying bone
or muscles.
Regulation of Pulse
Pulse is regulated by the AutonomicNervous System through the
Sino-atrial node.( Often called pace-maker.)
• Para sympathetic stimulation decreases the heart rate
• Sympathetic stimulates increase the heart rate.
The quantity of blood forced out of the left ventricle during each
contraction is called stroke volume.(70 ml for an average adult).
Cardiac output = Stroke volume × Pulse rate =70ml × 80 BPM
=5600 ml =5.6 L/min
The number of pulsing sensation occurring in 1minute is the pulse rate.
The volume of blood pumped by the heart during 1 minute is the Cardiacoutput.
Pulse rate X Stroke Volume = Cardiacout put
70 beats per minute X 70 ml / beat = 4.9 L/min
60 beats per minute X 85 ml / beat = 5.1 L/min
Pulse assessment:
A pulse is commonly assessed by palpation (feeling) or
auscultation using stethoscope.A pulse is normally palpated by
applying moderate pressure with the three middle fingers of the
hand. The pads on distal aspects of the finger are the most
sensitive areas for detecting a pulse with gentle pressure. A
stethoscopeis used for assessing apical pulse. While palpating a
pulse a nurse should assess the followings…….
❑ Pulse Rate
❑ Pulse Rhythm
❑ Pulse Volume
❑ Character
❑ Bilateral Equality
Conti..
Pulse Rate :- It is stated as number of pulses or beats
per minute. Count the pulses for not less than half
minute. BPM
• Normal 60-100 b/min (80/min)
• Adult PR > 100 BPM is called tachycardia
• Adult PR < 60 BPM is called bradycardia
Conti..
Pulse Volume, or force, refers to the strength of the pulse
when the heart contracts. The pulse volume is also called
the pulse strength or quality, refers to the force of blood
with each beat
It can be range from absent to bounding.
• Bounding- Strong full force pulse.
• Thready / weak- Difficult to palpate, a pulse of
diminished strength.
• Absent- No palpable pulse.
Volume is influenced by the forcefulness of the heartbeat, the
condition of the arterial walls, and hydration or dehydration.
Conti …
Pulse Rhythm refers to the regularity, or equal spacing,
of all the beats of the pulse. Normally, the intervals
between each heartbeat are of the same duration.
A pulse with an irregular rhythm is known as a
dysrhythmia or arrhythmia.
• Equal time elapses between beat of a normal pulse;
this steady beat is called Pulsus regularis.
• A pulse with an irregular rhythm is referred to an
Arrhythmia.
Conti…
Bilateral Equality or Symmetry of Pulse
When assessing peripheral pulse to determine the
adequacy of blood flow to a particular area of the body.
To check the blood flow of bilateral is important.
Types of Pulse
1. Peripheral pulse is a pulse located away from the
heart, for example, in the foot or wrist. Assessed via
fingers
2. The apical pulse, in contrast, is a central pulse; that
is, it is located at the apex of the heart. It is also
referred to as the point of maximal impulse (PMI).
Assessed or taken via stethoscope
Pulse Sites
1. Radial – base of thumb
2. Temporal – side of forehead
3. Carotid – side of neck
4. Brachial – inner aspect of elbow
5. Femoral – inner aspect of upper thigh
6. Popliteal - behind knee
7. Dorsalis pedis – top of foot
8. Posterior tibial
9. Apical pulse – over apex of heart
– taken with stethoscope
– left side of chest
Pulse Sites
Reason For Using Specific Pulse Site
Variations in Pulse by Age
Factors Affecting Pulse
• Age
• Sex
• Exercise or Physical training
• Body fluids
• Position
• Drugs
• Illness
• Emotions
• Temperature
Factors Affecting Pulse
Age
As age increases, the pulse rate gradually decreases
overall. See Table 29–2 for specific variations in pulse
rates from birth to adulthood.
Sex
After puberty, the average male’s pulse rate is slightly
lower than the female’s.
Exercise
The pulse rate normally increases with activity. The rate
of increase in the professional athlete is often less than in
the average person because of greater cardiac size,
strength, and efficiency.
Factors Affecting Pulse
Hypovolemia/dehydration. Loss of blood from the
vascular system increases pulse rate. In adults, the
loss of circulating volume results in an adjustment
of the heart rate to increase blood pressure as the
body compensates for the lost blood volume.
Stress. In response to stress, sympathetic nervous
stimulation increases the overall activity of the
heart. Stress increases the rate as well as the force
of the heartbeat. Fear and anxiety as well as the
perception of severe pain stimulate the sympathetic
system
Factors Affecting Pulse
Fever
The pulse rate increases (a) in response to the lowered
blood pressure that results from peripheral vasodilation
associated with elevated body temperature and (b)
because of the increased metabolic rate.
Medications.
Some medications decrease the pulse rate, and others
increase it. For example, cardiotonics (e.g., digitalis
preparations) decrease the heart rate, whereas
epinephrine increases it.
Factors Affecting Pulse
Position. When a person is sitting or standing, blood
usually pools in dependent vessels of the venous
system. Pooling results in a transient decrease in the
venous blood return to the heart and a subsequent
reduction in blood pressure and increase in heart rate.
Pathology. Certain diseases such as some heart
conditions or those that impair oxygenation can alter
the resting pulse rate.
Respiration:
Respiration: Respiration is the mechanism the body
uses to exchange gases between the atmosphere and
the blood and the blood and the cell. Respiration
involves the following processes....
Ventilation; the movement of gases between in and
out of the lungs (inspiration and expiration).
Diffusion; the movement of oxygen and carbon dioxide
between the alveoli and the red blood cells.
Perfusion; the distribution of red blood cells to and
from the capillaries.
Physiological control:
The respiratory center (medulla oblangata) in the brain stem
regulates the involuntary (adults normally breathe in a
smooth, uninterrupted pattern, 12- 20 times / min) control of
respiration.
Ventilation is regulated by CO2, O2, and hydrogen ion
concentration (PH) in the arterial blood.
The most important factor in the control of ventilation is the
level of CO2 in the arterial blood.
An elevation in the Co2 level causes the respiratory control
system in the brain to increase the rate and depth of
breathing.
The increased ventilatory effort removes excess CO2 by
increasing exhalation.
Mechanism of breathing:
1. Inspiration/inhalation( active process)
2. Expiration / exhalation ( passive process)
3. Pause
Mechanism of breathing
1. Inspiration:
During this phase the respiratory center sends impulses
along the phrenic nerve, causing the diaphragm to
contract.
Abdominal organs move downward and forward,
increasing the length of the chest cavity to move air into
the lungs.
The diaphragm moves approximately 1 cm, and the ribs
retract upward from the body’s midline approximately 1.2
- 2.5 cm.
During a normal, relaxed breath, a person inhales 500ml
of air. This amount is referred as Tidal volume.
Mechanism of breathing
2. Expiration / Exhalation:
During expiration the diaphragm relaxes and the abdominal
organs return to their original position.
The thorax decreases in size, and thus the lungs are
compressed.
The ribs move downward and inward
The sternum moves inward
3. Pause: the relaxation time between inspiration and
expiration.
The normal (breath) rate and depth of ventilation is called Eupnoea,
interrupted by sigh.
Types of breathing
1. Costal (thoracic)
Observed by the movement of the chest up ward and
downward.
Commonly used for adults
2. Diaphragmatic (abdominal)
Involves the contraction and relaxation of the
diaphragm, observed by the movement of abdomen.
Commonly used for children.
Factors affecting respiration:
• Body position
• Exercise
• Acute pain
• Medications
• Smoking
• Hemoglobin function
• Anxiety
• Abdominal trauma
• Neurological Injury
BEAMS-HAAN
Characteristics of the respiration:
When the respiration rate is taken, several
characteristics should be noted:
• Rate,
• Rhythm,
• Depth, and
• The quality or characteristics of breathing.
Characteristics of the respiration:
Respiratory Rate: It is the number of respirations per
minute. The normal respiration rate for healthy adults
at rest is 12 to 20 cycles per minute. Children have a
more rapid rate of breathing than adults. Respiratory
Rate Ranges of Various Age Groups
Newborn 30–50
1–2 years old 20–30
3–8 years old 18–26
9–11 years old 16–22
12–Adult 12–20
Characteristics of the respiration:
Respiratory Rate:
❑Tachypnea—quick, shallow breaths
❑Bradypnea—abnormally slow breathing
❑Apnea—cessation of breathing
Characteristics of the respiration:
Respiratory Rhythm: It refers to the regular and equal
spacing of breaths. In a regular respiratory rhythm, the
cycles of inspiration and expiration have about the
same rate and depth. With irregular breathing patterns,
the depth and amount of air inhaled and exhaled and
the rate of respirations per minute will vary.
Characteristics of the respiration:
Respiratory Depth: The depth of respiration is the
volume of air that is inhaled and exhaled. It is described
as either “shallow” or “deep.” Rapid but shallow
respirations occur in some disease conditions, such as
high fever, shock, and severe pain.
Hyperventilation refers to deep and rapid respirations,
and hypoventilation refers to shallow and slow
respirations.
Characteristics of the respiration:
Respiratory Quality: Respiratory quality or character
refers to breathing patterns — both normal and
abnormal. Labored breathing refers to respirations that
require greater effort from the patient.
Dyspnea—difficult and labored breathing during which the individual
has a persistent, unsatisfied need for air and feels distressed
Orthopnea—ability to breathe only in upright sitting or standing
positions
Breath Sounds: Normal respirations do not usually
have any noticeable sounds. However, certain diseases
and illnesses can cause irregular respiration sounds.
Characteristics Of The Respiration:
• Abnormal breath sounds that are audible without
amplification include the following:
• Stridor: A shrill, harsh sound, heard more clearly during
inspiration but that can occur during expiration. This sound
may occur when there is airway blockage, such as in
children with croup and patients with laryngeal
obstruction. –
• Stertor (stertorous breathing): Noisy sounds during
inspiration, sounds similar to those heard in snoring.
• Crackles (also called rales): Crackling sounds resembling
crushing tissue paper, caused by fluid accumulation in the
airways.
Characteristics Of The Respiration:
• Rhonchi — Rattling, whistling, low-pitched sounds made in
the throat. Rhonchi can be heard in patients with
pneumonia, chronic bronchitis, cystic fibrosis, or COPD.
• Wheezes — Sounds similar to rhonchi but more high
pitched, made when airways become obstructed or
severely narrowed, as in asthma or COPD.
• Cheyne-Stokes breathing — Irregular breathing that may
be slow and shallow at first, then faster and deeper, and
that may stop for a few seconds before beginning the
pattern again. This type of breathing may be seen in certain
patients with traumatic brain injury, strokes, and brain
tumors.
Assessment of respiration Respiratory rate
• Eupnoea ( 12 – 20/ min)
• Ventilatory depth: The depth of respiration is
assessed by observing movement of chest wall
A deep respiration involves a full expansion of the lungs
with full exhalation.
• Ventilatory depth: Diaphragmatic breathing results
from the contraction and relaxation of the diaphragm
and is best observed by watching abdominal
movements.
Conti…
Ventilatory diffusion and perfusion:
The respiratory process of diffusion and perfusion can
be evaluated by measuring the oxygen saturation of the
blood.
• Color of skin
• Capillary refill
Alterations In Respirations
Apnea: Absence of breathing.
Eupnea: Normal breathing
Orthopnea: Only able to breathe comfortable in upright position
(such as sitting in chair), unable to breath laying down.
Dyspnea: Subjective sensation related by patient as to breathing
difficulty.
Paroxysmal nocturnal dyspnea attacksof severe shortness of
breath that wakes a person from sleep
Hyperpnea: Increased depth of breathing
Tachypnea: Increased frequency without blood gas abnormality
Bradypnea: is a respiratory rate that is lower than normal for
age.
Alterations in respiration
• Hyperventilation: Increased rate or depth, or
combination of both.
• Hypoventilation: Decreased rate or depth, or some
combination of both.
• Kussmaul's Respiration: is a deep and labored
breathing pattern often associated with severe
metabolic acidosis, particularly diabetic ketoacidosis
(DKA) but also kidney failure.
Blood Pressure
BLOOD PRESSURE
Blood pressure (BP) is one of the most important vital signs
because it aids in diagnosis and treatment,especially for
cardiovascular health. Blood pressure readings are almost
always taken at every medical visit, even if it is the only vital
sign obtained.
Definition: Blood pressure is the amount of force
exerted on the arterial walls while the heart is pumping
blood— specifically, when the ventricles contract.
Blood Pressure
Blood pressure is measured by gauging the force of this
pressure through two specific readings: Systolic and
Diastolic.
Systolic blood pressure is the highest pressure that
occurs as the left ventricle of the heart is contracting.
Diastolic blood pressure is the lowest pressure level
that occurs when the heart is relaxed and the ventricle
is at rest and refilling with blood.
Blood Pressure
Blood pressureis read in millimeters (mm) of mercury
(Hg), or “mmHg”. Blood pressure is recorded using just
the systolic (highest pressure)reading over the diastolic
(lowest pressure),similar to writing a fraction.
For example, 120/80 would indicate a systolic pressure of
120 (mmHg) and a diastolic reading of 80 (mmHg).
Conti..
Pulse pressure: PP is the difference between the systolic
and diastolic readings and calculated by subtracting the
diastolic reading from the systolicreading. If the blood
pressure is 120/80,the pulse pressure is 40.
In general, a pulse pressure that is greater than 40 mmHg is
considered widened, and one that is less than 30 mmHg is
considered to be narrowed.
.
Conti..
Pulse pressure
A widened pulse pressure may be an indicator for
cardiovascular disease and anemia
A narrowed pulse pressure may be an indicator for
congestive heart failure (CHF), stroke, or shock.
Although pulse pressure is useful in predicting
cardiovascular risk in patients, it should not be used
alone and depends on various other factors, such as
the patient’s BP and age.
Physiology and Regulation:
There are two basic mechanisms for regulating blood
pressure:
(1) short-term mechanisms, which regulate blood
vessel diameter, heart rate and contractility
(2) long-term mechanisms, which regulate blood
volume
VITAL SIGNS.pdf
VITAL SIGNS.pdf
Conti..
2. Long-term mechanisms, which regulate blood
volume Kidneys regulate arterial blood pressure by
Direct renal mechanism
Indirect renal (renin-angiotensin-aldosterone)
mechanism
VITAL SIGNS.pdf
Physiology of arterial blood pressure
A person’s blood pressure reflects the interrelation ship
of followings…..
1. Cardiac out put
2. Peripheral Vascular Resistance
3. Blood volume
4. Blood viscosity
5. Artery elasticity
Blood Pressure Guidelines
Blood Pressure Guidelines
Factors affecting blood pressure
• Race
• Exercise
• Age
• Diurnal variation
• Stress
• Gender
• Medications
Blood Pressure Assessment
Equipment used are
blood pressure cuff, a sphygmomanometer,and a stethoscope.
Types of sphygmomanometers:
• Mercury
• Aneroid
• Electronic
1. Direct (invasive, arterial blood pressure monitoring)
2. Indirect
I. Auscultatory method
II. Palpatory method
Blood Pressure Assessment
1.Direct method- A monitor is used for this method. This is
a continuous method which measures mean pressures. A
needle or catheter is inserted into the brachial, radial or
femoral artery and a monitor displays arterial pressure in
wave form.
Direct (invasive) blood pressure monitoring is
recommended in sick and compromised patients, those
who are at risk of developing major blood loss during
surgery or for whom abnormal blood gases are anticipated
(patients with respiratory disease or undergoing
thoracotomies).
Blood Pressure Assessment
2. Indirect method- Taking blood pressure by using
sphygmomanometer.
Palpatory method
In the palpatory method of blood pressure
determination, instead of listening for the blood flow
sounds, the nurse uses light to moderate pressure to
palpate the pulsations of the artery as the pressure in
the cuff is released. The pressure is read from the
sphygmomanometer when the first pulsation is felt
Conti..
The auscultatory method is most commonly used in
hospitals, clinics, and homes. External pressure is applied to
a superficial artery and the nurse reads the pressure from
the sphygmomanometer while listening with a stethoscope.
When carried out correctly,the auscultatory method is
relatively accurate.
When taking a blood pressure using a stethoscope, the
nurse identifies phases in the series of sounds called
Korotkoff’s sounds. The systolic pressure is the point where
the first tapping sound is heard while the diastolic pressure
is the point where the sounds become inaudible .
BP Assessment sites:
1. Upper arm
2. Thigh
3. Leg
4. Forearm
Upper arm (using brachial artery (commonest)
Thigh around popliteal artery
Fore -arm using radial artery
Leg using posterior tibial or dorsal pedis
Alteration in Blood Pressure
1.Hypertension
2.Hypotension:
3. Orthostatic Hypotension or Postural Hypotension
Alteration In Blood Pressure
1. Hypertension:
It is an often a symptomaticdisorder characterized by
persistently elevated blood pressure. The diagnosis of
hypertension is made when an average of two or more
diastolic readings on at least two visits is 90 mm Hg or
higher. Or
when the average of multiple systolic blood pressures on
two or more subsequent visits is consistentlyhigher than
135 mm Hg.
Alteration in Blood Pressure
2. Hypotension: is generally considered present when
the systolic blood pressure falls 90 mm Hg or below.
3. Orthostatic Hypotension or Postural Hypotension:
It occurs, when a normotensive person develops
symptoms of and low blood pressure when rising to an
upright position. Or change his position from lying to
sitting and to standing position.
REFERENCES
kozier & Erb’s Fundamental of Nursing ,8th edition
( Audrey Berman ,Shirlee J. Synder).
Fundamentals of Nursing: Standards & Practice, 2nd Edition
( Sue C. DeLaune Patricia K. Ladner.)
www.slideshare.com
www.google.com
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VITAL SIGNS.pdf

  • 1. VITAL SIGNS By : Ibne Amin Institute of Nursing Sciences, Khyber Medical University , Peshawar
  • 2. OBJECTIVES 1. Define Vital Signs. 2. Define terms related to Vital sign. 3. Describe the physiological concept of temperature, respiration and blood pressure. 4. Describe the principles and mechanisms for normal thermoregulation in the body. 5. Identify ways that affect heat production and heat loss in the body. 6. Define types of body temperature according to its characteristics. 7. Identify the sign and symptoms of fever.
  • 3. OBJECTIVES 8. Discuss the normal ranges for temperature, pulse, respiration and blood pressure. 9. List the factors affecting temperature,pulse, respiration. 10. Describe the characteristics of pulse and respiration. 11. List factors responsible for maintaining normal blood pressure. 12. Describe various methods and sites used to measure T.P & B.P. 13. Recognize the signs of alert while taking TPR and B.P.
  • 4. INTRODUCTION Vital sign are the indicator of the body’s physiologic status and response to physical environment and psychological stressor. The vital sign or the cardinal sign are temperature, pulse, respiration, and blood pressure. The findings are governed by the vital organs.
  • 5. DEFINITION Vital sign are called cardinal signs because of their importance. These are the indicator of health status, as these indicate the effectiveness of circulatory, respiratory, neural, & endocrine body functions. 1. Temperature 2. Pulse 3. Respiration 4. Blood pressure 5. oxygen saturation 6. Pupillary reaction / pain
  • 6. WHEN TO TAKE VITAL SIGNS • Upon admission. • On a routine basis. • Before and after invasive procedure. • Before and after administration of medication. • Any deterioration of patient’s general condition. • Before and after nursing intervention that may influence vital sign. • Prior to medical emergency
  • 7. TEMPERATURE Body Temperature: it is the hotness or coldness of the body. OR It is balance between the heat produced by the body and heat lost from the body. Heat produced – Heat lost = Body temperature Types: There are two kinds of temperature.. 1. Core Temperature 2. Surface Temperature
  • 8. TEMPERATURE Core Temperature: is the temperature of the deep tissues of the body. It remains constant and varies very little as + 1 F except when a person has a fever. We measure it with a thermometer. Surface Temperature: by contrast the temperature of the surface or skin, fluctuate (rises or fall) in response to the environment. Normal body temperature: is not an exact point on a scale but a range of temperatures. When measured orally for an adult, on an average it is between 36-38 C (96.8 – 100 F)
  • 9. Regulation of Body Temperature The system that regulates body temperature has 3 main parts: 1. Sensors in the periphery and in the core, 2. An integrator in the hypothalamus, and 3. An effector system that adjusts the production and loss of heat. Most sensors or sensory receptors are in the skin. The skin has more receptors for cold than warmth. Therefore, skin sensors detect cold more efficiently than warmth. When the skin becomes chilled over the entire body, three physiological processes to increase the body temperature take place: 1. Shivering increases heat production. 2. Sweating is inhibitedto decrease heat loss. 3. Vasoconstrictiondecreases heat loss.
  • 10. Regulation of Body Temperature Body temperature is regulated by balancing the amount of heat the body produces with the amount of heat the body loses. Body heat is produced as a by-product of metabolism, which is the sum of all biochemical and physiological processes that take place in the body. The hypothalamus, a gland located in the brain, acts as a thermoregulator. It is able to adjust body temperature that results in either increasing or decreasing heat production throughout the day.
  • 11. • Regulation of Body Temperature • The anterior Hypothalamus promotes heat loss through vasodilatation and sweating • The posterior Hypothalamus promotes: – Heat conservation by vasoconstriction – Heat production And maintains the core temperature
  • 12. THERMOREGULATION Thermoregulation: Balance between heat production and heat loss. When the amount of heat produced by the body exactly equals the amount of heat lost, the person is in heat balance. 1. Heat production 2. Heat loss Heat production in the body is called thermogenesis. Heat loss to the environment is called thermolysis.
  • 13. 1. HEAT PRODUCTION 1. Heat production: Basal metabolic rate: Basal metabolic rate (BMR) is the total number of calories that your body needs to perform basic, life-sustaining functions like breathing and circulation etc. Muscle activity: Body cells are constantly producing and breaking down ATP (Adenosine triphosphate) and these chemical reactions produce heat during.
  • 14. 1. HEAT PRODUCTION • Thyroxin: Thyroid hormones stimulate diverse metabolic activities most tissues, leading to an increase in basal metabolic rate • Epinephrine, nor epinephrine and sympathetic stimulation: Epinephrine and nor epinephrine are released by the adrenal medulla and nervous systemrespectively. They are the flight/fight hormones that are released when the body is under extreme stress.During stress,much of the body's energy is used to combat imminent danger.
  • 15. 2. HEAT LOSS • Radiation: The emission of energy as electromagnetic waves from the body. • Conduction: It is the transfer of heat from one surface to the other through direct contact. Heat is transferred via solid material • Convection: Convection is the dispersion of heat by air currents • Conversion/Vaporization: Evaporation is the continuous evaporation of moisture from the respiratory tract and from the mucosa of the mouth as well as from the skin.
  • 16. Normal range of body temperature (Adults)
  • 17. FACTORS AFFECTING BODY TEMPERATURE: • Age Infants greatlyinfluenced bythe temperature,childrenmore labile than adult and elderly are extremelysensitiveto environmental change due to decreased thermoregulatorycontrol • Diurnal variation Bodytemperature normallychange throughout the day,varyingas much as 1.0 °C between early morningand late afternoon The point of highest bodytemperature is usuallyreached between 8pm and 12 midnight and the lowest point is reached duringsleep between 4 a.m. and 6 a.m. • Exercise • Hormones Women usually experience morehormonefluctuations than men, progesterone secretion in women raises body temperature. • Stress Epinephrine and nor epinephrine increases metabolic activity and heat production • Environment
  • 19. ALTERATION IN BODY TEMPERATURE
  • 20. ALTERATION IN BODY TEMPERATURE The normal range for adults is considered to be between 36°C and 37.5°C (96.8°Fto 99.5°F). There are two primary alterations in body temperature: 1. Pyrexia or Hyperthermia 2. Hypothermia. 1. Pyrexia A body temperature above the usual range is called pyrexia, hyperthermia, or (in lay terms) fever. A very high fever, such as 41°C (105.8°F), is called hyperpyrexia. Febrile:The client who has a fever is referred to as febrile. Afebrile:The one who does not, is called afebrile.
  • 21. Pyrexia 1. Low Pyrexia: The fever does not rise more than 99 to 100 F 2. Moderate Pyrexia: Body temperature remain between 100-103degree F 3. High Pyrexia: Body temperature remain between 103- 105 degree F 4. Hyperpyrexia: Temperature above 105 degree F
  • 22. Pyrexia (Conti…) 4 Common Types Of Fever 1. Intermittent fever: The body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperature e.g. Malaria 2. Remittent fever: A wide range of temperature fluctuation (more than 2 0c) occurs over the 24 hr period, all of which are above normal e.g. a cold or influenza 3. Relapsing fever: Short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature e.g. 4. Constant fever: The body temperature fluctuates minimally but always remains above normal e.g. typhoid fever
  • 24. Pyrexia (Conti…) Fever Spikes: A temperature that rises to fever level rapidly following a normal temperature and then returns to normal within a few hours is called a fever spike. Bacterial blood infections often cause fever spikes. Inverse Fever: The highest range of temperature is recorded in morning hours and lowest in the evening. Hectic Or Swinging Fever: When difference between high and low temperature is very great.
  • 25. ALTERATION IN BODY TEMPERATURE In some conditions, an elevated temperature is not a true fever. Two examples are heat exhaustion and heat stroke. Heat exhaustion: is a result of excessive heat and dehydration. Signs of heat exhaustion include paleness, dizziness, nausea, vomiting, fainting, and a moderately increased temperature (38.3°C to 38.9°C [101°F to 102°F]). Heat stroke: Persons experiencing heat stroke generally have been exercising in hot weather, have warm, flushed skin, and often do not sweat. They usually have a temperature of 41.1°C (106°F) or higher, and may be delirious, unconscious, or having seizures
  • 26. Stages / Phases of Fever Onset Invasion, onset of Fever, Period of rising Also called Cold or Chilled Phase Course Stadium, fever has reached its peak level and remains constant Also called Plateau Phase ABATEMEN T Defervescence, elevated temperature declines Also called as Flush Phase
  • 27. Clinical Manifestation of Fever ONSET (COLD OR CHILL PHASE) Increased heart rate, Increased respiratory rate and depth, Shivering Pallid, cold skin ,Complaints of feeling cold , Cyanotic nail beds “Gooseflesh” appearance of the skin ,Cessation of sweating COURSE (PLATEAU PHASE) Absence of chills ,Skin that feels warm , Photosensitivity , Glassy-eyed appearance , Increased pulse and respiratory rates , Increased thirst Mild to severe dehydration , Drowsiness, restlessness, delirium, or convulsions ,Herpetic lesions of the mouth , Loss of appetite (if the fever is prolonged) ,Malaise, weakness, and aching muscles DEFERVESCENCE (FEVER ABATEMENT/FLUSH PHASE) Skin that appears flushed and feels warm , Sweating , Decreased shivering , Possible dehydration
  • 28. Hypothermia Hypothermia is a core body temperature below the lower limit of normal i.e. 95 F or 35 C. The three physiological mechanisms of hypothermia are (a) Excessive heat loss, (b) Inadequate heat production to counteract heat loss, (c) Impaired hypothalamic thermoregulation If skin and underlying tissues are damaged by freezing cold, this results in frostbite. Frostbite most commonly occurs in hands, feet, nose, and ears in which ice crystal forms inside the cell and damage it.
  • 29. Clinical Manifestation of Hypothermia • Decreased body temperature, pulse, and respirations • Severe shivering (initially) • Feelings of cold and chills • Pale, cool, waxy skin • Frostbite (discolored, blistered nose, fingers, toes) • Hypotension • Decreased urinary output • Lack of muscle coordination, Disorientation, drowsiness progressing to coma
  • 30. Types of Hypothermia 1. Induced hypothermia: is the deliberate lowering of the body temperature to decrease the need for oxygen by the body tissues such as during certain surgeries. 2. Accidental hypothermia: can occur as a result of (a) exposure to a cold environment, (b) immersion in cold water, and (c) lack of adequate clothing, shelter, or heat. In older adults, the problem can be compounded by a decreased metabolic rate and the use of sedative medications.
  • 31. Sites to Measure Temperature ❑Oral ❑Rectal ❑Axillary ❑Tympanic membrane ❑Temporal artery Condition of resident determines which is the best site for measuring body temperature.
  • 32. Advantages and Disadvantages of Sites for Body Temperature Measurement
  • 35. Thermometer Two parts of thermometer-bulb and stem • Blub is fragile part, containing mercury, sensitive to temperature. • Stem is hollow tube in which mercury can rise. There are two scales, Fahrenheit and Celsius Mercury, a liquid metal, with silvery appearance is used in thermometers, because it is very sensitive to a small changes in temperature, expansion of mercury is uniform, easily visible.
  • 36. Temperature: Safety Precautions • Hold rectal and axillary thermometers in place • Stay with resident when taking temperature • Prior to use, shake liquid in glass down • Shake thermometer away from resident and hard objects • Wipe from end to tip of thermometer prior to reading • Delay taking oral temperature for 10 - 15 minutes if resident has been smoking, eating or drinking hot/cold liquids
  • 37. Conti… • Oral – most common, most convenient • Rectal – registers one degree Fahrenheit higher than oral, most accurate • Axillary – least accurate; registers one degree Fahrenheit lower than oral • Tympanic – probe inserted into the ear canal
  • 38. PULSE The pulse is an index of the heart’s rate and rhythm. Pulse provides valuable data about person’s cardiovascular status. DEFINITIONS- “The pulse is a wave of blood created by contraction of the left ventricle of the heart.”
  • 39. Physiology of Pulse Blood flows through the body in a continues circuit. Electrical impulses originating from the SA node travel through heart muscle to stimulate cardiac contraction. Approximately 60 to 70 ml (stroke volume) of blood enters the aorta with each ventricular contraction. With each stroke volume ejection, the wall distends, creating a pulse wave that travels rapidly toward the distal ends of the arteries. When a pulse wave reaches a peripheral artery, it can be felt by palpating the artery lightly against underlying bone or muscles.
  • 40. Regulation of Pulse Pulse is regulated by the AutonomicNervous System through the Sino-atrial node.( Often called pace-maker.) • Para sympathetic stimulation decreases the heart rate • Sympathetic stimulates increase the heart rate. The quantity of blood forced out of the left ventricle during each contraction is called stroke volume.(70 ml for an average adult). Cardiac output = Stroke volume × Pulse rate =70ml × 80 BPM =5600 ml =5.6 L/min The number of pulsing sensation occurring in 1minute is the pulse rate. The volume of blood pumped by the heart during 1 minute is the Cardiacoutput. Pulse rate X Stroke Volume = Cardiacout put 70 beats per minute X 70 ml / beat = 4.9 L/min 60 beats per minute X 85 ml / beat = 5.1 L/min
  • 41. Pulse assessment: A pulse is commonly assessed by palpation (feeling) or auscultation using stethoscope.A pulse is normally palpated by applying moderate pressure with the three middle fingers of the hand. The pads on distal aspects of the finger are the most sensitive areas for detecting a pulse with gentle pressure. A stethoscopeis used for assessing apical pulse. While palpating a pulse a nurse should assess the followings……. ❑ Pulse Rate ❑ Pulse Rhythm ❑ Pulse Volume ❑ Character ❑ Bilateral Equality
  • 42. Conti.. Pulse Rate :- It is stated as number of pulses or beats per minute. Count the pulses for not less than half minute. BPM • Normal 60-100 b/min (80/min) • Adult PR > 100 BPM is called tachycardia • Adult PR < 60 BPM is called bradycardia
  • 43. Conti.. Pulse Volume, or force, refers to the strength of the pulse when the heart contracts. The pulse volume is also called the pulse strength or quality, refers to the force of blood with each beat It can be range from absent to bounding. • Bounding- Strong full force pulse. • Thready / weak- Difficult to palpate, a pulse of diminished strength. • Absent- No palpable pulse. Volume is influenced by the forcefulness of the heartbeat, the condition of the arterial walls, and hydration or dehydration.
  • 44. Conti … Pulse Rhythm refers to the regularity, or equal spacing, of all the beats of the pulse. Normally, the intervals between each heartbeat are of the same duration. A pulse with an irregular rhythm is known as a dysrhythmia or arrhythmia. • Equal time elapses between beat of a normal pulse; this steady beat is called Pulsus regularis. • A pulse with an irregular rhythm is referred to an Arrhythmia.
  • 45. Conti… Bilateral Equality or Symmetry of Pulse When assessing peripheral pulse to determine the adequacy of blood flow to a particular area of the body. To check the blood flow of bilateral is important.
  • 46. Types of Pulse 1. Peripheral pulse is a pulse located away from the heart, for example, in the foot or wrist. Assessed via fingers 2. The apical pulse, in contrast, is a central pulse; that is, it is located at the apex of the heart. It is also referred to as the point of maximal impulse (PMI). Assessed or taken via stethoscope
  • 48. 1. Radial – base of thumb 2. Temporal – side of forehead 3. Carotid – side of neck 4. Brachial – inner aspect of elbow 5. Femoral – inner aspect of upper thigh 6. Popliteal - behind knee 7. Dorsalis pedis – top of foot 8. Posterior tibial 9. Apical pulse – over apex of heart – taken with stethoscope – left side of chest Pulse Sites
  • 49. Reason For Using Specific Pulse Site
  • 51. Factors Affecting Pulse • Age • Sex • Exercise or Physical training • Body fluids • Position • Drugs • Illness • Emotions • Temperature
  • 52. Factors Affecting Pulse Age As age increases, the pulse rate gradually decreases overall. See Table 29–2 for specific variations in pulse rates from birth to adulthood. Sex After puberty, the average male’s pulse rate is slightly lower than the female’s. Exercise The pulse rate normally increases with activity. The rate of increase in the professional athlete is often less than in the average person because of greater cardiac size, strength, and efficiency.
  • 53. Factors Affecting Pulse Hypovolemia/dehydration. Loss of blood from the vascular system increases pulse rate. In adults, the loss of circulating volume results in an adjustment of the heart rate to increase blood pressure as the body compensates for the lost blood volume. Stress. In response to stress, sympathetic nervous stimulation increases the overall activity of the heart. Stress increases the rate as well as the force of the heartbeat. Fear and anxiety as well as the perception of severe pain stimulate the sympathetic system
  • 54. Factors Affecting Pulse Fever The pulse rate increases (a) in response to the lowered blood pressure that results from peripheral vasodilation associated with elevated body temperature and (b) because of the increased metabolic rate. Medications. Some medications decrease the pulse rate, and others increase it. For example, cardiotonics (e.g., digitalis preparations) decrease the heart rate, whereas epinephrine increases it.
  • 55. Factors Affecting Pulse Position. When a person is sitting or standing, blood usually pools in dependent vessels of the venous system. Pooling results in a transient decrease in the venous blood return to the heart and a subsequent reduction in blood pressure and increase in heart rate. Pathology. Certain diseases such as some heart conditions or those that impair oxygenation can alter the resting pulse rate.
  • 56. Respiration: Respiration: Respiration is the mechanism the body uses to exchange gases between the atmosphere and the blood and the blood and the cell. Respiration involves the following processes.... Ventilation; the movement of gases between in and out of the lungs (inspiration and expiration). Diffusion; the movement of oxygen and carbon dioxide between the alveoli and the red blood cells. Perfusion; the distribution of red blood cells to and from the capillaries.
  • 57. Physiological control: The respiratory center (medulla oblangata) in the brain stem regulates the involuntary (adults normally breathe in a smooth, uninterrupted pattern, 12- 20 times / min) control of respiration. Ventilation is regulated by CO2, O2, and hydrogen ion concentration (PH) in the arterial blood. The most important factor in the control of ventilation is the level of CO2 in the arterial blood. An elevation in the Co2 level causes the respiratory control system in the brain to increase the rate and depth of breathing. The increased ventilatory effort removes excess CO2 by increasing exhalation.
  • 58. Mechanism of breathing: 1. Inspiration/inhalation( active process) 2. Expiration / exhalation ( passive process) 3. Pause
  • 59. Mechanism of breathing 1. Inspiration: During this phase the respiratory center sends impulses along the phrenic nerve, causing the diaphragm to contract. Abdominal organs move downward and forward, increasing the length of the chest cavity to move air into the lungs. The diaphragm moves approximately 1 cm, and the ribs retract upward from the body’s midline approximately 1.2 - 2.5 cm. During a normal, relaxed breath, a person inhales 500ml of air. This amount is referred as Tidal volume.
  • 60. Mechanism of breathing 2. Expiration / Exhalation: During expiration the diaphragm relaxes and the abdominal organs return to their original position. The thorax decreases in size, and thus the lungs are compressed. The ribs move downward and inward The sternum moves inward 3. Pause: the relaxation time between inspiration and expiration. The normal (breath) rate and depth of ventilation is called Eupnoea, interrupted by sigh.
  • 61. Types of breathing 1. Costal (thoracic) Observed by the movement of the chest up ward and downward. Commonly used for adults 2. Diaphragmatic (abdominal) Involves the contraction and relaxation of the diaphragm, observed by the movement of abdomen. Commonly used for children.
  • 62. Factors affecting respiration: • Body position • Exercise • Acute pain • Medications • Smoking • Hemoglobin function • Anxiety • Abdominal trauma • Neurological Injury BEAMS-HAAN
  • 63. Characteristics of the respiration: When the respiration rate is taken, several characteristics should be noted: • Rate, • Rhythm, • Depth, and • The quality or characteristics of breathing.
  • 64. Characteristics of the respiration: Respiratory Rate: It is the number of respirations per minute. The normal respiration rate for healthy adults at rest is 12 to 20 cycles per minute. Children have a more rapid rate of breathing than adults. Respiratory Rate Ranges of Various Age Groups Newborn 30–50 1–2 years old 20–30 3–8 years old 18–26 9–11 years old 16–22 12–Adult 12–20
  • 65. Characteristics of the respiration: Respiratory Rate: ❑Tachypnea—quick, shallow breaths ❑Bradypnea—abnormally slow breathing ❑Apnea—cessation of breathing
  • 66. Characteristics of the respiration: Respiratory Rhythm: It refers to the regular and equal spacing of breaths. In a regular respiratory rhythm, the cycles of inspiration and expiration have about the same rate and depth. With irregular breathing patterns, the depth and amount of air inhaled and exhaled and the rate of respirations per minute will vary.
  • 67. Characteristics of the respiration: Respiratory Depth: The depth of respiration is the volume of air that is inhaled and exhaled. It is described as either “shallow” or “deep.” Rapid but shallow respirations occur in some disease conditions, such as high fever, shock, and severe pain. Hyperventilation refers to deep and rapid respirations, and hypoventilation refers to shallow and slow respirations.
  • 68. Characteristics of the respiration: Respiratory Quality: Respiratory quality or character refers to breathing patterns — both normal and abnormal. Labored breathing refers to respirations that require greater effort from the patient. Dyspnea—difficult and labored breathing during which the individual has a persistent, unsatisfied need for air and feels distressed Orthopnea—ability to breathe only in upright sitting or standing positions Breath Sounds: Normal respirations do not usually have any noticeable sounds. However, certain diseases and illnesses can cause irregular respiration sounds.
  • 69. Characteristics Of The Respiration: • Abnormal breath sounds that are audible without amplification include the following: • Stridor: A shrill, harsh sound, heard more clearly during inspiration but that can occur during expiration. This sound may occur when there is airway blockage, such as in children with croup and patients with laryngeal obstruction. – • Stertor (stertorous breathing): Noisy sounds during inspiration, sounds similar to those heard in snoring. • Crackles (also called rales): Crackling sounds resembling crushing tissue paper, caused by fluid accumulation in the airways.
  • 70. Characteristics Of The Respiration: • Rhonchi — Rattling, whistling, low-pitched sounds made in the throat. Rhonchi can be heard in patients with pneumonia, chronic bronchitis, cystic fibrosis, or COPD. • Wheezes — Sounds similar to rhonchi but more high pitched, made when airways become obstructed or severely narrowed, as in asthma or COPD. • Cheyne-Stokes breathing — Irregular breathing that may be slow and shallow at first, then faster and deeper, and that may stop for a few seconds before beginning the pattern again. This type of breathing may be seen in certain patients with traumatic brain injury, strokes, and brain tumors.
  • 71. Assessment of respiration Respiratory rate • Eupnoea ( 12 – 20/ min) • Ventilatory depth: The depth of respiration is assessed by observing movement of chest wall A deep respiration involves a full expansion of the lungs with full exhalation. • Ventilatory depth: Diaphragmatic breathing results from the contraction and relaxation of the diaphragm and is best observed by watching abdominal movements.
  • 72. Conti… Ventilatory diffusion and perfusion: The respiratory process of diffusion and perfusion can be evaluated by measuring the oxygen saturation of the blood. • Color of skin • Capillary refill
  • 73. Alterations In Respirations Apnea: Absence of breathing. Eupnea: Normal breathing Orthopnea: Only able to breathe comfortable in upright position (such as sitting in chair), unable to breath laying down. Dyspnea: Subjective sensation related by patient as to breathing difficulty. Paroxysmal nocturnal dyspnea attacksof severe shortness of breath that wakes a person from sleep Hyperpnea: Increased depth of breathing Tachypnea: Increased frequency without blood gas abnormality Bradypnea: is a respiratory rate that is lower than normal for age.
  • 74. Alterations in respiration • Hyperventilation: Increased rate or depth, or combination of both. • Hypoventilation: Decreased rate or depth, or some combination of both. • Kussmaul's Respiration: is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure.
  • 75. Blood Pressure BLOOD PRESSURE Blood pressure (BP) is one of the most important vital signs because it aids in diagnosis and treatment,especially for cardiovascular health. Blood pressure readings are almost always taken at every medical visit, even if it is the only vital sign obtained. Definition: Blood pressure is the amount of force exerted on the arterial walls while the heart is pumping blood— specifically, when the ventricles contract.
  • 76. Blood Pressure Blood pressure is measured by gauging the force of this pressure through two specific readings: Systolic and Diastolic. Systolic blood pressure is the highest pressure that occurs as the left ventricle of the heart is contracting. Diastolic blood pressure is the lowest pressure level that occurs when the heart is relaxed and the ventricle is at rest and refilling with blood.
  • 77. Blood Pressure Blood pressureis read in millimeters (mm) of mercury (Hg), or “mmHg”. Blood pressure is recorded using just the systolic (highest pressure)reading over the diastolic (lowest pressure),similar to writing a fraction. For example, 120/80 would indicate a systolic pressure of 120 (mmHg) and a diastolic reading of 80 (mmHg).
  • 78. Conti.. Pulse pressure: PP is the difference between the systolic and diastolic readings and calculated by subtracting the diastolic reading from the systolicreading. If the blood pressure is 120/80,the pulse pressure is 40. In general, a pulse pressure that is greater than 40 mmHg is considered widened, and one that is less than 30 mmHg is considered to be narrowed. .
  • 79. Conti.. Pulse pressure A widened pulse pressure may be an indicator for cardiovascular disease and anemia A narrowed pulse pressure may be an indicator for congestive heart failure (CHF), stroke, or shock. Although pulse pressure is useful in predicting cardiovascular risk in patients, it should not be used alone and depends on various other factors, such as the patient’s BP and age.
  • 80. Physiology and Regulation: There are two basic mechanisms for regulating blood pressure: (1) short-term mechanisms, which regulate blood vessel diameter, heart rate and contractility (2) long-term mechanisms, which regulate blood volume
  • 83. Conti.. 2. Long-term mechanisms, which regulate blood volume Kidneys regulate arterial blood pressure by Direct renal mechanism Indirect renal (renin-angiotensin-aldosterone) mechanism
  • 85. Physiology of arterial blood pressure A person’s blood pressure reflects the interrelation ship of followings….. 1. Cardiac out put 2. Peripheral Vascular Resistance 3. Blood volume 4. Blood viscosity 5. Artery elasticity
  • 88. Factors affecting blood pressure • Race • Exercise • Age • Diurnal variation • Stress • Gender • Medications
  • 89. Blood Pressure Assessment Equipment used are blood pressure cuff, a sphygmomanometer,and a stethoscope. Types of sphygmomanometers: • Mercury • Aneroid • Electronic 1. Direct (invasive, arterial blood pressure monitoring) 2. Indirect I. Auscultatory method II. Palpatory method
  • 90. Blood Pressure Assessment 1.Direct method- A monitor is used for this method. This is a continuous method which measures mean pressures. A needle or catheter is inserted into the brachial, radial or femoral artery and a monitor displays arterial pressure in wave form. Direct (invasive) blood pressure monitoring is recommended in sick and compromised patients, those who are at risk of developing major blood loss during surgery or for whom abnormal blood gases are anticipated (patients with respiratory disease or undergoing thoracotomies).
  • 91. Blood Pressure Assessment 2. Indirect method- Taking blood pressure by using sphygmomanometer. Palpatory method In the palpatory method of blood pressure determination, instead of listening for the blood flow sounds, the nurse uses light to moderate pressure to palpate the pulsations of the artery as the pressure in the cuff is released. The pressure is read from the sphygmomanometer when the first pulsation is felt
  • 92. Conti.. The auscultatory method is most commonly used in hospitals, clinics, and homes. External pressure is applied to a superficial artery and the nurse reads the pressure from the sphygmomanometer while listening with a stethoscope. When carried out correctly,the auscultatory method is relatively accurate. When taking a blood pressure using a stethoscope, the nurse identifies phases in the series of sounds called Korotkoff’s sounds. The systolic pressure is the point where the first tapping sound is heard while the diastolic pressure is the point where the sounds become inaudible .
  • 93. BP Assessment sites: 1. Upper arm 2. Thigh 3. Leg 4. Forearm Upper arm (using brachial artery (commonest) Thigh around popliteal artery Fore -arm using radial artery Leg using posterior tibial or dorsal pedis
  • 94. Alteration in Blood Pressure 1.Hypertension 2.Hypotension: 3. Orthostatic Hypotension or Postural Hypotension
  • 95. Alteration In Blood Pressure 1. Hypertension: It is an often a symptomaticdisorder characterized by persistently elevated blood pressure. The diagnosis of hypertension is made when an average of two or more diastolic readings on at least two visits is 90 mm Hg or higher. Or when the average of multiple systolic blood pressures on two or more subsequent visits is consistentlyhigher than 135 mm Hg.
  • 96. Alteration in Blood Pressure 2. Hypotension: is generally considered present when the systolic blood pressure falls 90 mm Hg or below. 3. Orthostatic Hypotension or Postural Hypotension: It occurs, when a normotensive person develops symptoms of and low blood pressure when rising to an upright position. Or change his position from lying to sitting and to standing position.
  • 97. REFERENCES kozier & Erb’s Fundamental of Nursing ,8th edition ( Audrey Berman ,Shirlee J. Synder). Fundamentals of Nursing: Standards & Practice, 2nd Edition ( Sue C. DeLaune Patricia K. Ladner.) www.slideshare.com www.google.com 97