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Vital Signs
Rashid Hussain
Nursing Instructor RMISON
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Objectives
Define Vital Signs. Identify the reasons/situations necessary to
take vital signs.
Enlist the components of vital signs.
Explain each component in detail. Temperature Pulse Respiration Blood pressure
Discuss the normal & abnormal values of vitalsigns
Describe the factors affecting vital signs.
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History of nurses taking vital signs
No reference to any form of
vital sign monitoring by nurses
pre 1893
Concept ofnurses taking vitalsigns evolved - 1893 to 1950
Codified into nursing text of the
1950s
Zeitz & McCutcheon (2003)
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Vital Signs
Vital from Latin word vita, which meansLife
Sign means indicator.
So vital signs are the indicators of Life. Vital signs are physical signs that indicate an
individual is alive, such as Heart beat (Pulse),Breathing rate (Respiration), Temperature,
Blood pressure and recently oxygensaturation.
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Vital Signs
These signs may be
observed, measured,
and monitored to
assess an individual'slevel of physical
functioning.
Used to determine
response to treatment
Normal vital signs
change with age, sex,
weight, exercise
tolerance, andcondition.
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Vital Signs
Prior to measuring
vital signs, the patient
should have had the
opportunity to sit for
approximately five
minutes.
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When to take vital signs
On a clients admission
According to the physicians order or the institutionspolicy or standard of practice
When assessing the client during home health visit
Before & after a surgical or invasive diagnostic
procedure Before & after the administration of meds or therapy
that affect cardiovascular, respiratory & temperature
control functions. E.g. Blood Transfusion
When the clients general physical condition changesLOC, pain
Before, after & during nursing interventions
influencing vital signs
When client reports symptoms of physical distress
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Observation Before diving in, take a
minute or so to look atthe patient in their
entirety.
Does the patient seem
anxious, in pain,upset?
What about their dress
and hygiene? Remember, the exam
begins as soon as you
lay eyes on the patient.
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Health Assessment
A nursing assessment consist of collection of
subjective and objective data, which includes
health history, measurement of vital signs and
physical examination:
A bodily assessment from head to toe or
systemic examination by using the techniques
of Inspection, Auscultation, Palpation andPercussion.
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Methods of Physical Examination
Inspection The visual examination of thebody using the eyes and a lighted instrument
if needed. The sense of smell may also be
used.
Auscultation The process of listening tosounds that are produced in the body.
Direct auscultation uses the ear alone,
Indirect auscultation involves the use of a
stethoscope to amplify the sounds from within
the body, like a heartbeat.
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Methods of P.E conti
Palpation The examination of the bodyusing the sense of touch. There are two types:
light and deep.
Percussion An assessment method inwhich the surface of the body is struck with
the fingertips to obtain sounds that can be
heard or vibrations that can be felt. It can
determine the position, size, and consistencyof an internal organ.
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Vital Signs
The vital signs are body temperature, pulse,respirations blood pressure and recently the
pulse oximetry and the pain are also included
in the list of vital signs.
Temperature
Pulse
Respiration
Blood pressure
Oxygen saturation
Pain
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Temperature
Is a state of hotness and coldness of the body.
BODY TEMPERATURE is the balancebetween the heat produced by the body and
the heat lost from the body. The temperature of the body is measured by
thermometer in units called degrees.
Centigrade (C) or Fahrenheit (F)
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Neural control Hypothalamus acts as thermostat
Vascular control
Vasoconstriction ---hypothalamus directsthe body to decrease heat loss and
increase heat production
If cold, vasoconstriction will conserveheatshivering will occur
Regulation of Temperature
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Vasodilatation If body temp is above normal, the
hypothalamus will direct the body to
decrease heat production;Perspiration and increased respiratory rate
Body heat production
Bodys cells produce heat from foodreleasing energy.
Kilocalorie= energy value;
BMR= rate of energy used in the body to
maintain essential activities
Regulation of temperature
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Conduction
Transfer of heat from a warm to cool surface
by direct contact
Convection
Transfer of heat through currents of air orwater
Radiation
Loss of heat through electromagnetic wavesfrom surfaces that are warmer than the
surrounding air
Evaporation
Water to vapor lost from skin or breathing
Heat lost from the body through
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Types of Thermometers
Glass Thermometer
Oral Thermometer
Rectal Thermometer Electronic Thermometer
Digital Thermometer
Disposable Thermometer
Tympanic Thermometer
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A small hollow glass tube that contains
mercury in a bulb at one end. When heated
the mercury rises in the tube.
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Reading a Glass-Thermometer
The scale is marked from 94
to 108
The long lines represent one degree
The short lines represent two tenths of a
degree Only every other degree is marked with a
number
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o Battery operated
o Have an oral probe and a rectal probe
o Disposable probe cover is placed on the probe
o The temperature is recorded in about 30
seconds
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Use a disposable sheath
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o Measures the temperature in the tympanic membrane (eardrum)
o Fast and accurate - 1 to 3 seconds
INFANTS PULLTHE EAR
STRAIGHT BACK
ADULTS ANDCHILDREN OVER
ONE YEAR
PULL THE EAR UPAND BACK
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Sites of taking Temperature
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Sites of taking TemperatureSites Things to consider Duration of Placement
Oral
Posterior sublingual pocket
under tongue (close to carotidartery)
No hot or cold drinks or smoking 20
min prior to temp. Must be awake
& alert.Not for small children (bite down)
Leave in place 3 min
Axillary
Bulb in center of axilla
Lower arm position across
chest
Non invasive good for children.
Less accurate (no major bld vessels
nearby)
Leave in place 5-10 min.
Measures 0.5 C lower than
oral temp.
Rectal
Side lying with upper leg flexed,
insert lubricated bulb (1-11/2
inch adult) (1/2 inch infant)
When unsafe or inaccurate by
mouth (unconscious, disoriented or
irrational)
Side lying position leg flexed
Leave in place 2-3 min.
Measures 0.5 C higher
than oral
Ear
Close to hypothalamus
sensitive to core temp. changes
Adult - Pull pinna up & back
Child pull pinna down & back
Rapid measurement
Easy accessibility
Cerumen impaction distorts reading
Otitis media can distort reading
2-3 seconds
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Factors Affecting Temperature
Exercise Illness
Age
Time of day Medications
Infection Emotions
Hydration
Clothing Environmental
temperature/air
movement
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Alterations in body temperature:
o Pyrexia/Hyperthermia/Fever a bodytemperature above the normal range. >100 F
o Hyperpyrexia a very high fever. 104 F and
above.o Hypothermia Body temp below 95 F
o Febrile referred to a client who has a fever
o Afebrile referred to a client who has nofever
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4 Common types of fever:
o Constant Fever When the fever dose not
fluctuate more than about two degree Fahrenheitduring 24 hours, but at no time touches the normal.
o Intermittent When the temperature is onlypresent for several hours in 24 hours and touches
the normal for few hours. E.g. Malaria.o Remittent When the daily fluctuation of temp is
more than two F and never touches the normal. In
this fever the evening temp is usually higher than
morning one. E.g. Typhoid fever
o Rigor Feversever attack of shivering. 3 stages.
o Shivering stage
o Hot stage
o Cold stage
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Clinical signs of fever
o Onset (cold or chill stage)
o Increased heart rate
o Increased respiratory rate and depth
o Shivering due to increased skeletal muscle
tension and contractionso Pallid, cold skin due to vasoconstriction
o Complaints of feeling cold
o Cyanotic nail beds due to vasoconstriction
o Gooseflesh appearance of the skin due to
contraction of the arrectores pilorum muscles
o Cessation of sweating
o Rise in body temperature
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Clinical signs of hypothermia
o
Decreased body temperatureo Severe shivering (initially), feelings of cold
and chills
o Pale, cool, waxy skin
o Hypotension
o Decreased urinary output
o Lack of muscle coordination
o Disorientation
o Drowsiness progressing to coma
C ti d d F h h it C i
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Centigrade and Fahrenheit ConversionFormulas
Centigrade to Fahrenheit conversion:Multiply the centigrade reading by 9/5 and
add 32:
F = (C 9/5) + 32
Fahrenheit to centigrade conversion:
Deduct 32 from the Fahrenheit reading andmultiply by 5/9:
C = (F 32) 5/9
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Contraindications for oral tempsoAn infant or young child ( under age 6)
o An unconscious patient
o A patient that has had oral surgery or an injury
to the face, neck, nose, or mouth
o A person receiving oxygeno A patient with a nasogastric tube in place
o A patient who is confused or restless
o A patient who is paralyzed on one side of thebody
o Has a history of seizures
o A patient who breathes through the mouth
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Assignment:
Sign & Symptoms ofHyperpyrexia and
Hypothermia.
Nursing care of a patientwith high grade fever.
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What is Pulse
Pulse is a wave of expansion felt in thearteries when the heart pumps blood in the
vessels, that though always full or distensible.
It can be felt in any artery near the surface of
the body with the fingers pads. OR The pulse is caused by the stroke volume
ejection and distension of the walls of the
aorta.
The bounding of blood flow in an artery is
palpable at various points in the body (pulse
points).
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Terms related to Pulse
Peripheral pulse located in the periphery of the
body (ex. foot, hand, neck).
Apical pulse central pulse; located at the apexof the heart.
Compliance of the arteries the ability of thearteries to contract and expand.
Stroke volume output the amount of bloodthat enters the arteries with each ventricular
contractions. Cardiac output the volume of blood pumped
into the arteries by the heart. It is the result of the
stroke volume (SV) x the heart rate (HR) per
minute.
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Pulse Assessment
Pulse Points
Temporal: Over the temporal bone, superior and lateral to eye
Carotid: Bilateral, under the lower jaw in neck along medial
edge of sternocleidomastoid muscle
Apical: Left midclavicular line at fourth to fifth intercostal
space Brachial:
Inner aspect between groove of biceps and tricepsmuscles at antecubital fossa.
Radial: Inner aspect of forearm on thumb side of wrist
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Pulse Points conti
Ulnar: Outer aspect of forearm on finger side of wrist
Femoral: In groin, below inguinal ligament (midpoint between
symphysis pubis and antero-superior iliac spine)
Popliteal: Behind knee, at center in popliteal fossa
PosteriorTibial: Inner aspect of ankle between Achilles tendon and
tibia (below medial malleolus) DorsalisPadis:
Over in step, midpoint between extension tendonsof great and second toe
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Factors that increase pulse
Exercise Strong emotions fear, anger, laughter,
excitement
Infection Fever
Pain
Shock
Hemorrhage, Hypovolemia
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Factors that decrease pulse
Sleep/rest Old age
Heart Diseases e.g. Heart block
Depression Drugs digitalis, morphine
Athletes in good physical condition may
have a lower pulse, probably
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Pulse counting
Regular Pulse Rhythm
Count for 30 seconds,
then multiply by 2(a rate of 35 beats in 30
seconds equals a pulse
rate of 70 beats/minute)
Irregular Pulse Rhythm
Count for one full minute
May use stethoscope tolisten for apical pulse and
count for a full minute
Normal pulse rate for adults is 60 to 100
beats/min & is regular in rhythm..
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Assess: rate, rhythm, strength
Rate N 60-100, average 80 bpm
Tachycardia greater than 100 bpm
Bradycardia less than 60 bpm
Rhythm the pattern of the beats (regular or irregular)
Strength or size or amplitude, the volume of bld pushedagainst the wall of an artery during the ventricular contraction
weak or thready (lacks fullness)
Full, bounding (volume higher than normal)
Imperceptible (cannot be felt or heard)
0----------------- 1+ -----------------2+--------------- 3+ ----------------4+
Absent Weak NORMAL Full Bounding
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What is Respiration?
Respiration is the act of breathing; it includesthe intake of oxygen and the output of carbon
dioxide from the body.
Inhalation/Inspiration refers to the intake ofair into the lungs.
Exhalation/Expiration refers to the
breathing out or the movement of gases fromthe lungs to the atmosphere.
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Respiration conti
Ventilation another word that is used torefer to the movement of air in and out of the
lungs.
External respiration refers to the
interchange of oxygen and carbon dioxidebetween the alveoli of the lungs and the
pulmonary blood.
Internal respiration takes place throughoutthe body; the interchange of same gasesbetween the circulating blood and the cells of
the body tissues.
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Assessing Respiration
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Assessing Respiration
Rate # of breathing cycles/minute (inhale/exhale-1cycle)
N 12-20 breaths/min adult - Eupnea normal rate & depth
breathingAbnormal increase tachypnea
Abnormal decrease bradypnea
Absence of breathing apnea
Depth Amt. of air inhaled/exhalednormal (deep & even movements of chest)
shallow (rise & fall of chest is minimal)
SOB shortness of breath (shallow & rapid)
Rhythm Regularity of inhalation/exhalation
Normal (very little variation in length of pauses b/w I&E
Character Digressions from normal effortless breathing
Dyspnea difficult or labored breathing
Cheyne-Stokes alternating periods of apnea and
hyperventilation, gradual increase & decrease in rate & depth of
M j F t I fl i
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Major Factors InfluencingRespiratory Rate
Exercise (increases metabolism) increaseRR
Stress (readies the body for fight or flight) increase RR
Environment (increase temperature)increase RR
Increased altitude (lower oxygen
concentration) increase RR Certain medications (ex. narcotics,
analgesic) decrease RR
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Breathing Patterns:
Rate: Eupnea normal respiration that is quiet,
rhythmic, and effortless
Tachypnea rapid respiration marked byquick, shallow breaths
Bradypnea abnormally slow breathing
Apnea cessation of breathing
B thi P tt ti
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Breathing Patterns: conti
Volume: Hyperventilation an increase in the
amount of air in the lungs, characterized by
prolonged and deep breaths; may be
associated with anxiety.
Hypoventilation a reduction in theamount of air in the lungs; characterized by
shallow respirations
Breathing Patterns: conti
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Breathing Patterns: conti
Rhythm:
Cheyne-stoke breathing rhythmic waxingand waning of respirations, from very deep
to very shallow breathing and temporary
apnea; often with associated with cardiac
failure, increased ICP, or brain damage
Effort
o Dyspnea difficulty in breathing, in which
an individual has a persistent, unsatisfiedneed for air and feel distressed
o Orthopnea ability to breath only in uprightsitting or standing positions
BLOOD PRESSURE
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BLOOD PRESSURE
Blood pressure is the force or pressure of the
blood exerted on the walls of the arteries at
which the blood is pushed out of heart. OR
Arterial blood pressure is a measure of thepressure exerted by the blood as it flows
through the arteries. It is measured in
millimetres of mercury (mmHg).
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Blood Pressure conti
Blood pressure consist of:
Systolic Pressure
Diastolic Pressure
Systolic pressure the pressure of the blood as
a result of contraction of the ventricles, that is thehigh pressure of the blood wave
Diastolic pressure the pressure when theventricles are at rest; it is the lower pressure
Pulse pressure Difference b/w systolic &diastolic pressure. Normal pulse pressure 30 to
40 mm Hg
E i d Bl d P
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Equipments used to assess Blood Pressure
Stethoscope; is used to auscultate andassess body sounds including the apical
pulse and the blood pressure
Sphygmomanometer; is used to assess
blood pressure consist of cuff, good
selection of the cuff in order to obtainaccurate blood pressure.
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F Aff i Bl d P
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Factors Affecting Blood Pressure
Age BP increases as person grows older. BP
continuous to increase with aging. Gender women usually have lower BP than
men. BP rises in women after menopause.
Blood volume Severe bleeding lowers blood
volume, therefore BP lowers. Rapidadministration of IV fluids increases the bloodvolume, therefore the BP rises.
Stress HR and BP increases as part of the
bodys response to stress. Pain generally increases BP. However, severe
pain can cause shock. BP is seriously low in thestate of shock.
F t Aff ti g B P
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Factors Affecting B.P
Exercise increases HR and BP; so BP
should not be measured right after exercise. Weight BP is higher in overweight persons.
BP lowers with weight loss.
Race black persons generally have higherBP than white persons.
Diet a high-sodium diet increases theamount of water in the body. Extra fluid
volume increases BP. Medications drugs can be given to raise or
lower BP. Other drugs have side effects of
high or low BP.
Factors Affecting B P
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Factors Affecting B.P
Position BP is lower when lying down and higher
in standing position. (orthostatic hypotension).
Alcohol excessive alcohol intake can raise BP.
Smoking increases BP. Nicotine in cigarettes
causes blood vessels to narrow. Diurnal variations BP s usually lowest early in
the morning, when the metabolic rate is lowest; then
rises throughout the day and peaks in the late
afternoon or early evening.
Disease process any condition affecting the
cardiac output, blood viscosity, and/or compliance of
the arteries has a direct effect on the BP.
H t i
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HypertensionAn abnormally high blood pressure, over 140
mmHg systolic and 90 mmHg diastolic.
Factors associated with hypertension
Thickening of the arterial walls, which reduces the
size of the arterial lumen
Elasticity of the arteries
Lifestyle as cigarette smoking
Obesity Lack of physical exercise
High blood cholesterol level
Continued exposure to stress
Hypotension
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Hypotension
Blood pressure below normal, when the systolic
reading less than110 mmHg. It occurs as a resultof peripheral vasodilatation in which blood leaves
the central body organs especially the brain and
moves to the periphery.
Factors associated with hypotension
Analgesics
Bleeding Severe burn
Dehydration.
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Oxygen Saturation
Oxygen is carried in the blood attached to
haemoglobin molecules. Oxygen saturation is
a measure of how much oxygen the blood is
carrying as a percentage of the maximum itcould carry.
Oxygen Saturation provide important
information about cardio-pulmonarydysfunction and is considered by many to be
a fifth vital sign.
Pulse Oximetery
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Pulse Oximetery
Pulse Oximeter is a non invasive device thatmeasures a client's arterial blood oxygen
saturation by means of a sensor attached to
the client's finger, toe, nose, earlobe, orforehead.
The pulse oximeter can detect hypoxemia
before clinical signs and symptoms such as
dusky skin color and dusky nail bed color.
Normal SpO2- 92% to 100%
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Measurement of Height and Weight
Height Height is expressed in inches (in), feet (ft),
centimeters (cm), or meters (m).
A scale for measuring height is usuallyattached to a standing weight scale.
Infants length is measured from vertex(top) of head to soles of feet while infant islying with knees extended.
M t f H i ht d W i ht
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Measurement of Height and Weight
Weight Measurement of weight is expressed in
ounces (oz), pounds (lb), grams (g), or
kilograms (kg).
Daily weights should be obtained at the
same time of the day, on the same scale,
with the client wearing the same type of
clothing.
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M f H i h d W i h
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Measurement of Height and Weight
Nursing Considerations
Accurate recordings are necessary for drug
dosage calculations and evaluation of
effectiveness of drug, fluid, and nutritional
therapy.
Intake and output records provideinformation on fluid balance and kidney
function.
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