Assessing Health Vital Signs

1. Assessing HealthVital Signs NURSING WEBشبكة التمريض HTTP://NURSINGWEB.WEEBLY.COM/

2. Vital signs: are body temperature, pulse, respiration, blood pressure and pain, pulse oximetry. • Signs should be looked at in total, are checked to monitor the functions of the body. • The signs reflect changes in function that otherwise might not be observed. • Monitoring a client’s V/S should not be automatic or routine procedure, it should be a thoughtful, scientific assessment. • When and how often to assess a specific client’s V/S are chiefly nursing judgments, depending on the client’s health status. • A nurse should measure V/S more often if the client’s health status requires it.

3. Frequency of vital signs: vital signs are assessed at least every 4 hours in hospitalized patients with elevated temperatures, with low or high blood pressures, with changes in pulse rate or rhythm or with respiratory difficulty as well as in patients who are taking medications that effect cardiovascular or respiratory function or who had a surgery.

4. Times to assess vital signs: ( Box 29-1 page 527) • On admission to a health care agency to obtain baseline data • When a client has a change in health status or report symptoms such as chest pain or feelings hot or faint. • Before and after surgery or an invasive procedure • Before and/or after the administration of a medication that could affect the respiratory or cardiovascular systems such as before giving digitalis preparation • Before and after any nursing interventions that could affect the vital signs such as ambulating a client who has been on bed rest.

6. Body Temperature Body temperature reflects the balance between the heat produced and the heat lost from the body, and is measured in heat units called degrees. There are two kinds of body temperature: Core temperature is the temperature of the deep tissues of the body such as abdominal cavity and pelvic cavity; it remains relatively constant. The surface temperature is the temperature of the skin, the subcutaneous tissue, and fat. It rises and falls in response to the environment. When the amount of heat produced by the body equals the amount of heat loss, the person is in heat balance.

7. A number of factors affect the body's heat production: • Basal metabolic rate "BMR" is the rate of energy utilization in the body required to maintain essential activities such as breathing. MR ↓ with age. • Muscle activity; including shivering , increases the metabolic rate. • Thyroxine output; increased thyroxine output increases the rate of cellular metabolism throughout the body. This effect is called chemical thermogenesis, the stimulation of heat production in the body through ↑ cellular metabolism.

8. Epinephrine, norepinephrine, and sympathetic stimulation/stress response. These hormones immediately increases the rate of cellular metabolism in many body tissues. Epinephrine and norepinephrine directly affect liver and muscle cells, thereby ↑ cellular metabolism. • Fever . Fever increases the cellular metabolism rate and thus increases the body's temperature further.

9. Heat is lost from the body through : Radiation; the transfer of heat from the surface of one object to the surface of another without contact between the two objects, mostly in the form infrared rays. Conduction; is the transfer of heat from one molecule to a molecule of lower temperature such as the body transfers heat to an ice pack causing the ice to melt. The amount of heat transferred depends on the temperature difference and the amount and duration of the contact.

10. Convection is the dispersion of heat by air currents. The body usually has a smallamount of warm air adjacent to it. This warm air rises and is replaced by cooler air. Vaporization; is continuous evaporation of moisture from the respiratory tract and from the mucosa of the mouth and from the skin. This continuous and unnoticed water loss is called Insensible water loss, and the accompanying heat loss is called insensible heat loss. Insensible heat loss accounts for about 10% of basal heat loss.

12. Regulation of body temperature The system that regulates body temperature has three main parts: sensors in the shell and in the core, an integrator in the hypothalamus, and an effector system that adjust the production and loss of heat. Most sensors or sensory receptors are in the skin. The skin sensors detect cold more efficiently than warmth.

15. When the skin becomes chilled over the entire body, three physiologic processes to ↑ the body temperature take place: • Shivering ↑ heat production. • Sweating is inhibited to ↓ heat loss. • Vasoconstriction ↓ heat loss.

16. When the sensors in the hypothalamus detected heat, they send out signals intended to reduce the temperature, that is , to decrease heat production and increase heat loss. In contrast, when the cold sensors are stimulated, signals are sent out to increase heat production and decrease heat loss. The signals from the cold sensitive receptors of the hypothalamus initiate effectors, such as vasoconstriction, shivering, and the release of epinephrine, which increase cellular metabolism and hence heat production.When the warmth sensitive receptors in the hypothalamus are stimulated, the effector system sends out signals that initiate sweating and peripheral vasodilation.

17. Factors affecting body temperature: • Age; the infant is greatly influenced by the temperature of the environment and must be protected from extreme changes. Children’s temperatures continue to be more variable than those of adults until puberty. • Diurnal variations; body temperatures normally change throughout the day, varying as much as 1.0C between the early morning and the late afternoon.

18. Exercise, hard work or strenuous exercise can increase body temperature. • Hormones; women tend to have more fluctuations in body temperature than men as a result of hormones changes

19. Stress; stimulation of the sympathetic nervous system can increase the production of epinephrine and norepinephrine thereby increasing metabolic activity and heat production. • Environment. Extremes in environmental temperature can affect a person’s temperature regulatory systems. If the temperature is assessed in a very warm room and the body temperature cannot be modified by convection, conduction, or radiation, the temperature will be elevated.

20. Alterations in body temperature There are two primary alterations in body temperature: pyrexia and hypothermia. Pyrexia A body temperature above the usual range is called pyrexia, hyperthermia, or fever. Hyperpyrexia; is a very high fever usually above 41 °C and survival is rare when the temperatureReaches 44 °C and death due to damaging effects on the respiratory center. The client who has a fever is referred to as febrile; the one who does not is afebrile.

21. The signs and symptoms of fever: loss of appetite, headache, hot, dry skin, flushed face, thirst and general malaise. Young children or other people with high fevers may experience periods of delirium or seizures.

22. Nursing Interventions for Client's with fever: Box 29-2 page 531 • Monitor vital signs • Assess skin color and temperature • Monitor WBC, HCT, and other laboratory reports for indications of infection or dehydration • Remove excess blanket when the client feels warm, but provide extra warmth when the client feels chilled. • Measure intake and output • Provide adequate nutrition and fluid • Reduce physical activity to limit heat production.

23. Administer antipyretic • Provide oral hygiene to keep the mucous membrane moist. • Provide a tepid sponge bath to increase heat loss through conduction. • Provide dry clothing and bed linens.

24. Hypothermia; isa core body temperature below the lower limit of normal. The three physiologic mechanisms of hypothermia are: • Excessive heat loss • Inadequate heat production to counteract heat loss • Impaired hypothalamic thermoregulation

25. The clinical signs of hypothermia: • Decreased body temperature, pulse, and respiration • Severe shivering • Feelings of cold and chills • Pale, cool skin • Hypotension • Decreased urinary output • Lack of muscle coordination • Disorientation • Drowsiness progressing to coma • Frostbite (nose, fingers, toes)

27. Nursing Interventions for Client's with Hypothermia • Provide a warm environment • Provide dry clothing • Apply warm blanket • Keep limbs close to body • Cover the client's scalp with a cap • Supply warm oral or intravenous fluids • Apply warming pads

28. Assessing Body Temperature The four most common sites for measuring body temperature are oral, rectal, axillary, and the tympanic membrane and the skin / temporal artery. Advantages and disadvantages of four sites for body temperature measurement –box 29-1

29. Orally Temperature - The nurse should wait 30minutes before taking the temperature orally to ensure that the temperature of the mouth is not affected by the temperature of the food, fluid, or warm smoke.

31. Rectally; are considered to be very accurate. Contra indication of rectal temperature • Clients with M.I (vagal stimulation) • Diarrhea • Rectal surgery • Clotting disorders • Hemorrhoids "pile“ • Immunosuppressed

33. Axillary; is the preferred site for measuring temperature newborn because it is accessible and safe. Tympanic membrane or nearby tissue in the ear canal because the membrane has an abundant arterial blood supply. - Risk for membrane injury or perforation.

35. Forehead using a chemical thermometer or a temporal artery thermometer are most useful for infants and children where a more invasive measurement is not necessary.

36. Temperature scales The body temperature is measure in degreed on two scales: Celsius (centigrade) and Fahrenheit. C= (Fahrenheit temperature – 32) * 5/9 F = (Celsius temperature * 9/5) +32

37. Pulse Pulse;is a wave of blood created by contraction of the left ventricle of the heart. Pulse wave represent the SV or the amount of blood that enters the arteries with each ventricular contraction. Compliance of the arteries is their ability to contract and expand. When person’s arteries lose their distensibility, as can happen in old age, greater pressure is required to pump the blood into the arteries.

38. Cardiac output :is the volume of blood pumped into the arteries by the heart and equals the result of the stroke volume times the heart rate per minute. A peripheral pulse : is a pulse located away from the heart such as in the foot, wrist neck. Apical pulse : is a central pulse; that is, located at the apex of the heart.

39. Factors affecting pulse • Age; as age increases, the pulse rate gradually decreases. • Gender. After puberty male’s pulse rate is slightly lower than the female’s. • Exercise; the pulse rate normally increase with activity • Fever; the pulse rate increases in response to the lowered blood pressure that results from peripheral vasodilatation associated with elevated temperature and because of the increased metabolic rate. • Medications; some medications decrease the pulse rate, and others increase it such as digitalis decrease the heart rate.

40. Hypovolemia; loss of blood from the vascular system normally increase pulse rate. • Stress; in response to stress, sympathetic nervous system stimulation increases the overall activity of the heart. • Position changes. when a person is sitting or standing, blood usually pools in dependent vessels of the venous system. • Pathology; certain diseases such as some heart conditions or those with impair oxygenation can alter the resting pulse rate.

41. Pulse Sites • Temporal; passes over the temporal bone of the head. The site is superior and lateral to the eye. • Carotid; at the side of the neck between the trachea and the sternocleiodomastoid muscle. • Apical; at the apex of the hearty. About 8cm to the left of the sternum and at the fourth and sixth intercostals space. • Brachial; at the inner aspect of the biceps muscle of the arm

42. Radial; on the thumb side of the inner aspect of the wrist • Femoral; alongside the inguinal ligaments • Popliteal; behind the knee • Posterior tibial; on the medial surface of the ankle • Pedal “dorsalis pedis”; over the bones of the feet

43. Pulse Sites

46. Assessing the Pulse A pulse is normally palpated by applying moderate pressure with the three middle fingers of the hand. A pulse is commonly assessed by palpation “feeling’ or auscultation “hearing”. Apical pulse; if the peripheral pulse is difficult to assess accurately because it is irregular. The apical pulse located at 5-6 intercostals rib.

47. A Doppler ultrasound stethoscope (DUS) is used for pulses that are difficult to assess The nurse should aware of the following: • Any medications that could affect the heart rate. • Whether the client has been physically active. • Whether the client should assume a particular position.

49. When assessing the pulse the nurse collect the following data: • Rate, an excessively fast heart rate over 100 BPM in an adult is called Tachycardia. A heart rate in an adult of less than 60BPM is called Bradycardia. 2. Rhythm is the pattern of the beats and the intervals between the beats. Equal time elapses between beats of a normal pulse.A pulse with an irregular rhythm is referred to as adysrhythmia or arrhythmia.

50. 3. Pulse volume, also called pulse strength or amplitude, refers to the force of blood with each beat. It can range from absent to bounding. 4. Elasticity of the arterial wall reflects its expansibility or its deformities. A healthy, normal artery feels straight, smooth, soft, and pliable. Elders often have inelastic arteries that feel twisted and irregular upon palpation.