Vital Signs RAMJ Feb. 2012

8/2/2019 Vital Signs RAMJ Feb. 2012

1/62

Faculty / Department to be placed here

Bahrain


N203: Vital Signs Assessment (1)Rolando A. Martinez Jr.

Nursing Lecturer

Royal College of Surgeons in Ireland

Medical University of Bahrain


2/62


Bahrain


Learning Outcome

By the end of this lecture you will be able to;

1. Discuss the importance of human Vital Signs (V/S).

2. Determine when to assess the V/S.

3. Describe factors that affect the vital signs andaccurate measurement of them.

4. Identify the variations in normal body temperature,

pulse,respirations, and blood pressure that occurfrom infancy to old age.

5. Compare methods of measuring body temperature.

RAMJ / SONM


3/62


Bahrain


Learning Outcome

6. Describe appropriate nursing care for alterations in

body temperature.

7. Identify nine sites used to assess the pulse and statethe reasons for their use.

8. List the characteristics that should be includedwhen assessing pulses.

9. Explain how to measure the apical pulse10. Describe the mechanics of breathing and the

mechanisms that control respirations.

RAMJ / SONM


4/62


Bahrain


Learning Outcome

11. Identify the components of a respiratory assessment.

12. Differentiate systolic from diastolic blood pressure.

13. Describe five phases ofKorotkoffs sounds.14. Describe methods and sites used to measure blood

pressure.

15. Discuss measurement of blood oxygenation using

pulse oximetry.16. Identify when it is appropriate to delegate

measurement of vital signs measurement.

RAMJ / SONM


5/62


Bahrain


Vital Signs

RAMJ / SONM

1. Temperature

2. Pulse

3. Respirations

4. Blood Pressure

5. Pulse Oximetry = Pulse + SaO2

6. Pain


6/62


Bahrain


Vital Signs Importance

1.Provides data that determine a patients health

status.2. It reflects changes in physiologic function.

3. Objectively monitor a persons response to any

given stimuli.

4. Serves as a basis for intervention.

RAMJ / SONM


7/62


Bahrain


When to Assess V/S?

On admission

Change in clients health status

Client reports symptoms such as chest pain,feeling hot, or faint

Pre and post surgery/invasive procedure

Pre and post medication administration thatcould affect CV system

Pre and post nursing intervention that couldaffect vital signs

RAMJ / SONM


8/62


Bahrain


Factors Affecting Body Temperature

RAMJ / SONM

Age

Diurnal variations

(circadian rhythm)

Exercise

Hormones

StressEnvironment


9/62


Bahrain


Factors Affecting Pulse

Age

Gender

Exercise Fever

Medications

Hypovolemia

Stress

Position changes

Pathology

RAMJ / SONM


10/62


Bahrain


Factors Affecting Respiration

Exercise

Stress Environmental

temperature

Medications

RAMJ / SONM


11/62


Bahrain


Factors Affecting Blood Pressure

RAMJ / SONM

AgeExercise

StressRaceGenderMedicationsObesityDiurnal variationsDisease process


12/62


Bahrain


(1) Assessment of Body Temperature

Body Temp: reflects balance between heatproduced & heat lost from body.

Measurement: Heat units: degrees (F/C)

Normal: 37C = 98.6F

C = (Fahrenheit temp 32) x 5/9

e.g.: 100F

C=(100-32) x 5/9 = (68) x 5/9 = 37.8

F = (Celsius temp x 9/5) + 32


13/62


Bahrain


Types of Body Temperature

Core Temperature:

Temp. of deep tissue of

body.

E.g.: abdominal, pelviccavity.

Remains relatively

constant.

Surface Temperature:

Temp. of the skin,

subcutaneous tissue &

fat. Raises & falls in

response to the

environment.


14/62


Bahrain


Estimated Variations in Normal Body Temp.

Kozier (2008.


15/62


Bahrain


Heat Balance Heat Produced by body = Amount of Heat

Lost

Kozier (2008. P.528)


16/62


Bahrain


Factors Affecting Heat Production

1. Basal Metabolic Rate (BMR):Rate of energy utilization.

2. Muscle Activity & shivering: Metabolic Rate (MR).

3. Thyroxin output: Thyroxin= Cellular MR.

4. Epinephrine, norepinephrine, & sympathetic

stimulation/stress response: Hormones Cellular

MR (affect liver & muscles).

5. Fever: CellularMR = Further body Temp.


17/62


Bahrain


Heat Loss

1. Radiation

2. Conduction

3. Convection

4. Vaporization:skin, oral mucosa & Respiratory

tract.

Insensible water & heat loss:continuous &unnoticed (10% of heat loss).

Body Temp. = vaporization.


18/62


Bahrain


Regulation of Body Temperature

Three main parts: sensors in skin & core Hypothalamusan effector system that adjusts production/loss of heat.

Cold sensitive Receptors:

Shivering: increases heat production

Sweating inhibited: reduce heat loss

Vasoconstriction: decreases heat loss

Release of epinephrine: increases Cellular MR

Warmth Sensitive Receptors:

Sweating, peripheral vasodilation, conscious responses

(fanning, taking off clothing).


19/62


Bahrain


Factor Affecting Body Temperature

1. Age2. Diurnal Variations (circadian Rhythms).

3. Exercise

4. Hormones5. Stress

6. Environment

Kozier (2008. P.529)


20/62


Bahrain


Alterations in Body Temperature

1. Hyperthermia:Pyrexia, hyperpyrexia

(Fever): above usual

range.

Febrile / Afebrile

2. Hypothermia: body

temp. below lower

normal limit.

Kozier (2008. P.529)


21/62


Bahrain


Types of Fever

Remittent FeverIntermittent fever

Adopted from: Al-Zayani. N. (2008). Vital signs: Body Temperature, N203-FN (1)-RCSI-Bahrain.

Constant FeverRelapsing Fever Fever Spike


22/62


Bahrain


Clinical Manifestations of Fever

Elevated Temp, But NotTrue Fever:

Heat Exhaustion:due to

excessive heat & dehydration

(38-39C).Pale, dizzy, fainting, N&V.

Heat Stroke: exercising inwarm weather (+41C).

Warm flushed skin,

delirious, unconscious, or

seizures. Kozier (2008. P.530)


23/62


Bahrain


Nursing Care: Fever

Kozier (2008. P.531)

Nursing Diagnosis:

Risk for

imbalanced body

Temp./At risk tomaintain body temp.

within normal range.

Hyperthermia/bodyTem. Elevated above

normal range.


24/62


Bahrain


Hypothermia Core Body Temp. below the lower limit of normal

temperature (


25/62


Bahrain


Nursing Care: Hypothermia

Kozier (2008. P.531)


26/62


Bahrain


Assessing Body Temperature

Oral

Axillary

Rectal

Infrared Tympanic

Temporal Artery

Refer: Kozier (2008). Table 29-1: Advantages &

disadvantages of sites for body temp. measurement (P.532).


27/62


Bahrain


WhichSite Would You Use to Measure Temperature

In The Following Cases?

1. Mr. Saleh came back from surgery with a nasal pack in both

nostrils after removal of a nasal polyp?

2. Mr. Saad is a 89 year old bedridden emaciated patient?

3. Ms. Jones is a 76 year old, confused patient?

4. After examination you found that Ms. Brown has impacted

stool in the rectum?

5. Mr. Saeed was been smoking 10 minutes ago?

6. Maria is a newborn girl who has just been brought into the

nursery from the labor ward?

Adopted from: Al-Zayani. N. (2008). Vital signs: Body Temperature, N203-FN (1)-RCSI-Bahrain.


28/62


Bahrain


References

Berman, A, Snyder. S. J, Kozier. B. & Erb. C. (2008)Kozier & Erbs Fundamentals of Nursing (8th ed).

Prentice Hall, New Jersey: USA. (Chapter: 29:

P.527-563).


29/62


Bahrain


1. Temperature

2. Pulse

3. Respirations

4. Blood Pressure

5. Pulse Oximetry = Pulse + SaO2

6. Pain


30/62


Bahrain


Importance of Vital Signs

1. Provides data that determine a patients

health status.

2. It reflects changes in physiologic function.

3. Objectively monitor a persons response to

any given stimuli.

4. Serves as a basis for intervention.


31/62


Bahrain


When or How often to Assess V/S?

1. Hospital policy (on admission)

2. Patients health status (stable vs.

unstable)

3. Pre and post

procedure/medication/intervention.


32/62


Bahrain


When to delegate

V/S Assessment?


33/62


Bahrain


Temperature Assessment


34/62


Bahrain


Learning Outcomes

Upon completion of this module, the student will be able to:

1. Discuss the thermo-regulation concept.

2. Identify the factors that affect body

temperature. 3. Compare methods of measuring body

temperature.

4. Enumerate appropriate nursing measures for

alterations in body temperature.


35/62


Bahrain


Temperature

Regulation Temperature - Hypothalamus unit measurement heat units

Conversion - C = (temp in F 32) 5/9

F = (Celsius temp x 9/5) + 32


36/62


Bahrain


100 F

C = (100 - 32) 5/9

C = (68) 5/9

C = 340 / 9

37.77 / 37.8 C

convert: 104 FC

C = (fahrenheit temp.32) 5/9


37/62


Bahrain


F = (celsius temp 9/5) + 32

37.8C

F

F = (37.8 x 9 / 5) + 32

F = (340.2 / 5) + 32

F = 68.04 + 32

100.04 / 100 F

convert: 40.0C

F


38/62


Bahrain


Types of Body Temperature

Core Temp: Surface Temp:

- A/P cavity temp. - S/S/F temp.

- constant - varies


39/62


Bahrain



40/62


Bahrain


Estimated Variations in Normal Body Temp.

Kozier (2008.


41/62


Bahrain


Heat Balance

Heat Produced bybody

Kozier (2008. P.528)

Amount of Heat Lost=


42/62


Bahrain


Heat Production

1. Basal Metabolic Rate (BMR)

2. Musclar activity / shivering

3. Thyroxin output

4. Epinephrine, norepinephrine & sympathetic

stimulation/stress response

5. Fever


43/62


Bahrain


Heat Loss

1. Radiation

2. Conduction

3. Convection

4. Vaporization


44/62


Bahrain


1. Radiation


45/62


Bahrain


2. Conduction


46/62


Bahrain


3. Convection


47/62


Bahrain


4. Vaporization


48/62


Bahrain



Systems that regulate body temp.

1. Sensors/Receptors

2. Integrator

3. Effector


49/62


Bahrain



COLD

sensitive receptors

Hypothalamus

initiate Effectors

-

WARM

sensitive receptors

Hypothalamus

initiate Effectors

- Sweating

- Vasodilatation

turns on the A/Cremoves clothing

takes bath

drinks water


50/62


Bahrain



1.

2.

3.

4.


51/62


Bahrain



5.

6.

7.

8.


52/62


Bahrain


Alterations in Body Temperature

FEVER BUT NOT TRUE


53/62


Bahrain


FEVER BUT NOT TRUE


54/62


Bahrain


Types of Thermometer


55/62


Bahrain


Sites for Assessing Body Temperature


56/62


Bahrain


Nursing Diagnosis:


57/62


Bahrain


Nursing Diagnosis:

1. Risk for imbalanced body Temp./At risk tomaintain body temp. within normal range.

2. Hyperthermia / Body tem. elevated above

normal range.


58/62


Bahrain



59/62


Bahrain


HYPOTHERMIA

Core body temp. below the normal temperaturelimit (


60/62


Bahrain



61/62


Bahrain


Which SITE would YOU use to m

easure


62/62

F l / D b l d h

Bahrain

F l / D b l d h

WhichSITE would YOU use to measureTemperature in the following cases?

1. Mr. Saleh came back from surgery with a nasal pack in both

nostrils after removal of a nasal polyp?

2. Mr. Saad is a 89 year old bedridden emaciated patient?

3. Ms. Jones is a 76 year old, confused patient?

4. After examination you found that Ms. Brown has impacted stoolin the rectum?

5. Mr. Saeed was been smoking 10 minutes ago?

6. Maria is a newborn girl who has just been brought into the nursery

from the labor ward?

Vital Signs RAMJ Feb. 2012

Documents

Transcript of Vital Signs RAMJ Feb. 2012