Post on 18-Jan-2018
description
transcript
1Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
Chapter 4Vital Signs
2Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
3Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
4Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
5Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
Learning Objectives (cont’d)
Describe how fever affects the following: Oxygen consumption and carbon dioxide
production Respiratory rate Pulse
6Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
7Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
8Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
9Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
10Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
11Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
12Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
Comparing VS Information
Change in patient’s condition Comparing changes in VS, signs and
symptoms Establishing differential diagnosis
13Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
Comparing VS Information (cont’d)
Key to expert assessment: Constant awareness of change Look Listen Touch Reassess and analyze Trend, trend, trend
14Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
15Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
16Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
17Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
18Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
19Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
20Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
21Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
22Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
23Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
24Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
Fever
Elevation of temperature From normal activities (exercise) =
hyperthermia From disease (infection) = fever
Immunocompetent patients may not be able to generate fever despite infection
25Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
26Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
27Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
28Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
29Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
30Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
31Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
32Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
33Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
34Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
35Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
36Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
37Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
38Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
39Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
40Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
Hypertension and Hypotension (cont’d)
Hypotension: <90/60 If symptomatic: dizziness, fainting Causes: left ventricular failure, blood loss,
peripheral vasodilation Orthostatic hypotension: postural
41Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
42Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
43Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
44Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
45Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
46Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
47Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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
48Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
49Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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