1 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 4...

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Chapter 4Vital Signs

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Learning Objectives

After reading this chapter you will be able to: Identify the four classic vital signs and the

value of monitoring their trends Recognize clinical significance of bedside

clinical findings including abnormal sensorium and pain level

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Learning Objectives

Describe normal values of the following vital signs and common causes of deviation from normal in the adult: Pulse rate Respiratory rate Blood pressure Body temperature

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Learning Objectives (cont’d)

Describe the following issues related to body temperature measurement: Types of devices commonly used Factors affecting the accuracy of devices Common sites and temperature ranges of

those sites for measurement

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Learning Objectives (cont’d)

Describe how fever affects the following: Oxygen consumption and carbon dioxide

production Respiratory rate Pulse

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Learning Objectives (cont’d)

Define the following terms: fever, tachycardia, bradycardia, bradypnea, pulsus paradoxus, pulsus alternans, tachypnea, systolic blood pressure, diastolic blood pressure, hypertension, hypotension, pulse pressure, postural hypotension

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Learning Objectives (cont’d)

Describe technique, palpation sites, and characteristics to evaluate for the pulse

Describe techniques for determining respiratory rate and blood pressure

Explain how hypotension affects perfusion and tissue oxygen delivery

Identify factors that cause erroneously elevated blood pressure measurements

Describe the mechanism by which pulsus paradoxus is produced

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Overview

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

Four classic VS Temperature, pulse, respirations, blood

pressure Additional observations

Height, weight, LOC, level and type of pain, general appearance

Pulse oximetry

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Frequency of VS Measurement

Depends on patient’s condition Baseline measurement

On admission At beginning of each shift Before procedure Any time patient’s condition changes

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Trends in Vital Signs

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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Comparing VS Information

Change in patient’s condition Comparing changes in VS, signs and

symptoms Establishing differential diagnosis

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Comparing VS Information (cont’d)

Key to expert assessment: Constant awareness of change Look Listen Touch Reassess and analyze Trend, trend, trend

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Height and Weight

Routinely measured If hospitalized = 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

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’d)

Cardiopulmonary distress suggested by: Labored, rapid, irregular, or shallow breathing Coughing, choking, wheezing, chest pain,

cyanosis Anxiety may be suggested by:

Restlessness, fidgeting, tense look, difficulty communicating

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General Clinical Impression (cont’d)

Pain may be suggested by: Drawn features, moaning, shallow breathing,

guarding, refusal to take deep breath Head-to-toe inspection

Hearing, smelling, seeing, touching, perception

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Pain Level and Type

“Fifth vital sign” Pain intensity scales (1 to 10) to quantify

a subjective measure Corresponding facial expressions and

verbal description to assess pain level Find associated symptoms, alleviating and

aggravating factors

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Level of Consciousness Measure cerebral oxygenation Evaluation of time, place, and person

“Oriented x 3” Deterioration from restlessness to coma

Cerebral hypoxia Side effect to medications or drug overdose

Status of sensorium directs treatment plan Patient cooperation, coordination

Glasgow Coma Scale

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Temperature Normal: 98.6° F (37° C), range (97° to

99.5° F), daily variations (1° to 2° F) Lowest in morning; highest late afternoon Normal increase during exercise,

ovulation, first months of pregnancy Balance of heat production and loss Dissipation through sweating, peripheral

vasodilation, hyperventilation

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Fever

Elevation of temperature From normal activities (exercise) =

hyperthermia From disease (infection) = fever

Immunocompetent patients may not be able to generate fever despite infection

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Fever (cont’d)

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 Body temperature below normal

Head injury, cold exposure Shivering and peripheral vasoconstriction

are compensatory mechanisms Reduced O2 consumption and CO2

production Slow and shallow breathing

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Measurement of Body Temperature

Mouth, ear, axilla, rectum Rectal temperature: body core temperature Rectal in comatose patients Axillary: safe and accurate in infants and small

children• 1 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 Evaluate rate, rhythm, and strength Normal rate: 60-100 beats/min adult

The younger the patient, the faster the rate Tachycardia = >100 beats/min

Anxiety, hypoxemia, exercise, fever, anemia Bradycardia = <60 beats/min

Diseased heart, athletes, medication side effects

Arrhythmia = irregular rhythm

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Measurement of Pulse Rate

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 x 4 or 30 sec x 2

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Pulse Rhythm and Pattern

Regular, regularly irregular, irregularly irregular Irregularly irregular is unfavorable finding

Bigeminy is a rhythm coupled in pairs Pulse deficit = auscultated – palpated

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Pulse Rhythm and Pattern (cont’d)

Volume of the pulse 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

Respiratory rate is a sensitive marker of acute respiratory distress

Tachypnea = rate above normal Atelectasis, hypoxemia, hypercapnea Anxiety, pain, exertion, metabolic acidosis

Bradypnea = rate below normal Uncommon Head injury, hypothermia, side effect of

medications (narcotics), drug overdose

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Measurement of Respiratory Rate

Watching abdomen or chest wall movement As you assess radial pulse

When regular = count for 30 sec x 2 Assess depth and pattern

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Blood Pressure Force exerted against arterial walls

Systolic: peak force during ventricular contraction

Diastolic: force during ventricular relaxation Normal: 120/80 mm Hg 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: >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

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Hypertension and Hypotension (cont’d)

Hypotension: <90/60 If symptomatic: dizziness, fainting Causes: left ventricular failure, blood loss,

peripheral vasodilation Orthostatic hypotension: postural

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Measurement of Blood Pressure Sphygmomanometer

Occluding cuff, stethoscope, manometer Indirect measure of pressure required to

collapse an artery Length of the bladder should cover:

80% distance around arm in an adult 100% distance around arm in a child Too wide a bladder: underestimate pressure Too narrow/short: overestimate pressure

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Auscultatory Blood Pressure Measurement

Korotkoff sounds: blood flow in arteries resumes Five phases (I – V) 1st sound (phase I) = systolic pressure Disappearance of sounds (phase V) = diastolic

pressure If discrepancy between muffling (phase IV) and

disappearance (phase V): record both pressures

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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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Effects of the Respiratory Cycle on BP

Systolic pressure decreases (2-4 mm Hg) with inspiration

If it drops >10 mm Hg: pulsus paradoxus Asthma, cardiac tamponade are two common

causes Pulsus paradoxus in asthma signifies a more

severe case