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    Vital Signs: Jeffrey Evangelista, RN, MAN

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    Hikari 光 Shidou
    This document discusses vital signs, which are important indicators of physiological status. It defines the four main vital signs - temperature, pulse, respiration, and blood pressure. For each vital sign, it describes normal ranges and factors that can influence them. It provides details on how each vital sign is assessed, including important parameters like rate, rhythm, depth. Common abnormalities for each vital sign are also outlined. Equipment used for assessing blood pressure is explained.

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    Vital Signs: Jeffrey Evangelista, RN, MAN

    Uploaded by

    Hikari 光 Shidou
    35 views52 pages
    This document discusses vital signs, which are important indicators of physiological status. It defines the four main vital signs - temperature, pulse, respiration, and blood pressure. For each vital sign, it describes normal ranges and factors that can influence them. It provides details on how each vital sign is assessed, including important parameters like rate, rhythm, depth. Common abnormalities for each vital sign are also outlined. Equipment used for assessing blood pressure is explained.

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    This document discusses vital signs, which are important indicators of physiological status. It defines the four main vital signs - temperature, pulse, respiration, and blood pressure. For each vital sign, it describes normal ranges and factors that can influence them. It provides details on how each vital sign is assessed, including important parameters like rate, rhythm, depth. Common abnormalities for each vital sign are also outlined. Equipment used for assessing blood pressure is explained.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    35 views52 pages

    Vital Signs: Jeffrey Evangelista, RN, MAN

    Uploaded by

    Hikari 光 Shidou
    This document discusses vital signs, which are important indicators of physiological status. It defines the four main vital signs - temperature, pulse, respiration, and blood pressure. For each vital sign, it describes normal ranges and factors that can influence them. It provides details on how each vital sign is assessed, including important parameters like rate, rhythm, depth. Common abnormalities for each vital sign are also outlined. Equipment used for assessing blood pressure is explained.

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    © All Rights Reserved
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    of 52

    VITAL SIGNS

    Jeffrey Evangelista, RN, MAN


    VITAL SIGNS (VS)
    • Also referred as the “CARDINAL SIGNS”
    • Important indicators of the body’s physiologic status
    • Reflect the function of the internal organs
    • NORMAL VITAL SIGNS are specific to individual
    • Performed and recorded at periodic intervals rather than
    one time assessment.
    • Generally include:
    Temperature (T)
    Pulse (P)
    Respiration (R)
    Blood Pressure (BP)
    Time to Assess Vital Signs

    • Upon admission to a health care agency


    • Has a change in health status
    • According to nursing or medical order
    • Before and after surgery or invasive procedure
    • Before and/or after administration of medication
    • Before and after nursing intervention
    Factors/ Variables Influencing VS:
    • Time of the day
    • Time of the month
    • Exercise
    • Age
    • Sex
    • Weight
    • Metabolic conditions
    • General health status
    • Pain
    • Drug Intake
    BODY
    TEMPERATURE
    BODY TEMPERATURE

    • Is the balance between the heat produced by the body


    and the heat lost from the body.

    • It is measured in heat units called degrees.


    • 36.5‫ﹾ‬C – 37.5‫ﹾ‬C : normal body temperature
    Two Kinds of Body Temperature
    1. CORE TEMPERATURE
    • Temperature of the deep tissues of the body
    • Ex : Thorax, abdominal cavity and pelvic cavity
    • Remains relatively constant (37 ‫ﹾ‬C/ 98.6 ‫ﹾ‬F)

    2. SURFACE TEMPERATURE
    • Temperature of the skin, subcutaneous tissue and fat
    • Rises and falls in response to the environment
    • Vary from 20‫ﹾ‬C – 40 C/ 68 ‫ﹾ‬F- 104 ‫ﹾ‬F
    Alterations in Body Temperature
    • PYREXIA
    Body temperature above usual range; more commonly
    referred as fever/ febrile
    • HYPERPYREXIA/ HYPERTHERMIA
    An extremely high fever 41‫ﹾ‬C/ 105.8 ‫ﹾ‬F

    Four common Types of fever:


    1. Intermittent Fever
    2. Remittent Fever
    3. Relapsing Fever
    4. Continuous Fever
    INTERMITTENT FEVER
    • Temperature is present only for some hours in a day and
    remains to normal for the remaining hours.

    REMITTENT FEVER
    • Temperature remains above normal throughout the day.
    • Fluctuates more than 2 degree Celsius in 24 hours.
    RELAPSING FEVER
    • Periods of pyrexia that alternate with normal temperatures, periods
    may last for a day or more

    CONTINOUS FEVER
    • Temperature remains above normal throughout the day
    • Does not fluctuate more than 1 degree celsius in 24 hours
    Alterations in Body Temperature
    • HYPOTHERMIA
    Body temperature below the lower limit of normal

    2 TYPES OF HYPOTHERMIA:
    1. Accidental Hypothermia – result of exposure to a cold
    environment or from immersion in cold water.

    2. Induced Hypothermia- deliberate lowering of the body


    temperature to the need for oxygen by the body tissues.
    PULSE
    PULSE

    • Is a wave of blood created by contraction of the Left


    Ventricle of the heart.

    • Rate of the heart is expressed in beats per minute (bpm)

    • Normal PR of healthy adult : 60 – 100 bpm


    Parameters in Assessing Pulse

    • Rate
    • Rhythm
    • Volume
    • Arterial Wall Elasticity
    • Presence or Absence of bilateral equality
    PULSE RATE
    • The number of beats per minute.
    • Normal range : 60- 100 bpm for adult

    • BRADYCARDIA – 60 bpm or less


    • TACHYCARDIA – over 100bpm
    PULSE RHYTHM

    • The pattern of the beats and the intervals between beats.


    • The equal time elapses between beats of normal pulse.
    • Should be constant and regular

    • DYSRRHYTHMIA / ARRYTHMIA
    • Random or irregular beats or a predictable pattern of irregular
    beats.
    PULSE VOLUME

    • Also called pulse strength or amplitude


    • The force of blood with each beat.
    • Usually same with each beat.
    • Absent to Bounding
    Scale for Measuring Pulse Volume

    • SCALE 0 - Absent, not discernible


    • SCALE 1 - Thready or weak, difficult to feel
    • SCALE 2 - Normal, detected readily, obliterated by
    strong pressure
    • SCALE 3 -Bounding, difficult to obliterate
    ELASTICITY OF ARTERIAL WALL

    • Expansibility or its deformities

    • Healthy, normal artery feels straight, smooth, soft


    and pliable

    • May NOT affect the PR, rhythm or volume


    PULSE BILATERAL EQUALITY

    • Assessing the corresponding pulse on the other side of the


    body.

    • If the right and left pulses are same they are BILATERALLY
    EQUAL
    FACTORS AFFECTING PR
    • AGE - as age increases, the PR gradually decreases
    • SEX - after puberty, the average male PR is slightly
    lower than female
    • EXERCISE - increases with activity
    • FEVER - increases in response to lowered blood
    pressure that results peripheral vasodilation associated
    with elevated body temperature.
    • MEDICATIONS- some medications decrease and others
    increase it.
    FACTORS AFFECTING PR

    • HEMORRHAGE- loss of blood from the vascular


    system increases PR

    • POSITION CHANGES – when sitting or standing ,


    blood usually pools in dependent vessels of the
    venous system.
    RESPIRATION
    RESPIRATION

    • The act of breathing.

    • Supply the body with oxygen for metabolic activity


    and to remove carbon dioxide
    TYPES OF RESPIRATION
    • EXTERNAL RESPIRATION
    - Interchange of oxygen and carbon dioxide between the
    alveoli of the lungs and pulmonary blood.

    • INTERNAL RESPIRATION
    - Interchange of the same gases between the circulating blood
    and the cells of the body tissues
    • INHALATION / INSPIRATION
    - refers to the intake of air into the lungs.
    • EXHALATION / EXPIRATION
    - refers to the breathing out or the movement of
    gases from the lungs to the atmosphere

    • VENTILATION
    -Used to refer to the movement of air in and out of
    the lungs
    PARAMETERS OF RESPIRATION

    • Respiratory Rate
    • Depth
    • Rhythm
    • Character
    RESPIRATORY RATE (RR)
    • Normally described in cycles per minute (cpm)
    • Normal RR for adult : 12- 20 cpm

    • EUPNEA – normal respiration that is quiet, rhythmic,


    and effortless
    • TACHYPNEA / POLYPNEA – rapid respiration, quick,
    shallow breaths, greater than 20 cpm
    • BRADYPNEA – abnormally slow breathing, less than
    12cpm
    RESPIRATORY DEPTH
    • DEEP RESPIRATIONS – large volume of air is inhaled /
    exhaled , inflating most of the lungs

    • SHALLOW RESPIRATIONS – exchange of a small


    volume of air and often the minimal use of the lungs

    • HYPERVENTILATION- increase in the amount of air in


    the lungs, prolonged deep breaths, maybe associated with
    anxiety.
    • HYPOVENTILATION- reduction in the amount of air in
    the lungs; shallow respirations
    RESPIRATORY RHYTHM
    • Refers to the regularity of the expirations and the
    inspirations.
    • Can be regular or irregular

    • CHEYNE- STOKE BREATHING – rhythmic waxing and


    waning of respirations, from very deep to very shallow
    breathing, and temporary apnea. (Cardiac Failure, increase
    ICP or brain damage)
    RESPIRATORY CHARACTER
    • Refers to those aspects of breathing that are different
    from normal, effortless breathing.

    A. BREATH SOUNDS
    B. EASE OR EFFORT
    BREATH SOUNDS
    AUDIBLE WITHOUT AMPLIFICATION:
    • STRIDOR - shrill, harsh sound heard during inspiration
    with laryngeal obstruction
    • STERTOR – snoring or sonorous respiration due to
    partial obstruction of the upper airway
    • WHEEZE – continuous high pitched musical squeak or
    whistling sound on expiration and sometimes on
    inspiration due to narrowed airway
    • BUBBLING- gurgling sounds heard as air passes
    through moist secretions in respiratory tract
    BREATH SOUNDS
    AUDIBLE BY STHETHOSCOPE:
    • CRACKLES – (formerly called rales) dry or wet crackling
    sounds simulated by rolling a lock of hair near the ear.

    • GURGLES- (formerly called rhonchi) coarse, dry,


    wheezy, whistling sound more audible during
    expiration as air moves through narrowed bronchi

    • PLEURAL FRICTION RUB – coarse, leathery or grating


    sound by rubbing together of inflamed pleura.
    RESPIRATOR EASE/ EFFORT
    • DYSPNEA – difficult and labored breathing during which
    individual has a persistent need of air and feels distressed.

    • ORTHOPNEA- ability to breathe only in upright sitting or


    standing positions.
    BLOOD
    PRESSURE
    BLOOD PRESSURE (BP)
    • Refers to the force the blood exerts against a vessel wall.
    TWO BLOOD PRESSURE MEASURES :

    • SYSTOLIC PRESSURE – pressure of blood as a result of


    contraction of the ventricles.
    • DIASTOLIC PRESSURE- lower pressure as a result of
    ventricular relaxation.

    PULSE PRESSURE – difference between the systolic and


    the diastolic pressure
    BLOOD PRESSURE (BP)

    • Measured in millimeters of mercury (mmHg)


    • Recorded as fraction
    • Systolic pressure is written over the diastolic pressure.
    • Ave BP of normal adult: 120/80 mmHg
    BLOOD PRESSURE (BP)

    • HYPERTENSION – most common, an abnormally high


    blood pressure over 140mmHg systolic and / 90mmHg
    diastolic

    • HYPOTENSION- is an abnormally low blood pressure


    below 100mmHg systolic.
    SELECTED CONDITIONS
    AFFECTING BLOOD PRESSURE

    CONDITIONS EFFECT CAUSE


    Fever Increase Increase Metabolic Rate
    Stress Increase Increase cardiac output
    Arteriosclerosis Increase Decrease artery compliance
    Obesity Increase Increase peripheral
    resistance
    Hemorrhage Decrease Decreases blood volume
    Low Hematocrit Decrease Decrease blood viscosity
    External Heat Decrease Increase vasodilation and
    thus decreases PVR
    Exposure to cold Increase Cause vasoconstriction and
    thus increase PVR
    FACTORS THAT INFLUENCE
    BLOOD PRESSURE
    • Age
    • Exercise
    • Stress
    • Obesity
    • Sex
    • Medications
    ASSESING BLOOD PRESSURE

    • EQUIPMENTS:

    • Blood Pressure cuff


    • Sphygmomanometer
    • Stethoscope
    BLOOD PRESSURE CUFF

    • an airtight, flat rubber bladder that can be inflated


    with air.
    • The “bladder” is usually covered with cloth and has
    two tubes attached to it.
    • One tube connects to a rubber bulb that has a valve to
    maintain or to release air from the cuff.
    • The second tube is attached to a manometer (registers
    pressure reading)
    SPHYGMOMANOMETER
    • Indicates the pressure of the air within the bladder.

    TWO TYPES OF SPHYGMOMANOMETER:


    1. ANEROID MANOMETER – register blood pressure way
    of a circular calibrated dial and needle
    2. MERCURY MANOMETER- registers blood pressure on
    a mercury filled calibrated cylinder.
    Meniscus – convex curve uppermost portion of the
    mercury. Reading obtained by viewing
    meniscus at eye level
    STETHOSCOPE
    • Used to listen to the sounds over the artery as pressure is
    released from the cuff.

    • Includes an amplifying mechanism (diaphragm) and


    earpieces connected by a rubber tubing

    TWO TYPES OF DIAPHRAGM:

    • BELL SHAPED DIAPHRAGMS


    • FLAT DISK SHAPE
    STETHOSCOPE
    Methods of Assessing BP
    • DIRECT MEASUREMENT (INVASIVE MONITORING)
    -Involves insertion of a catheter into the brachial, radial or
    femoral artery.
    - With correct placement, pressure reading is HIGHLY
    ACCURATE
    • NON- INVASIVE MEASUREMENT
    • Ausculatatory Method
    • most commonly used
    • Required equipment: Sphygmomanometer, Cuff and
    Stethoscope
    • Palpatory Method
    KOROTKOFF’S SOUND
    • A series of sounds heard when assessing BP

    • PHASE 1 – first faint clear tapping sounds. Gradually


    become more intense. To ensure that they are not
    extraneous sounds, the examiner should identify at
    least two consecutive tapping sounds. (SYSTOLIC
    PRESSURE)

    • PHASE 2- deflation when the sounds have a swishing


    quality
    KOROTKOFF’S SOUND

    • PHASE 3 – The sounds are crispier and more intense

    • PHASE 4- Sounds become muffled and have a soft,


    blowing quality. First diastolic pressure

    • PHASE 5- Pressure level when sounds disappear.


    Second diastolic pressure
    Common Errors in Assessing BP
    ERRORS EFFECT
    Bladder cuff too narrow Erroneously High
    Bladder cuff too wide Erroneously Low
    Arm unsupported Erroneously High
    Insufficient rest before the assessment Erroneously High
    Repeating assessment too quickly Erroneously High systolic or low diastolic
    Cuff wrapped too loosely or unevenly Erroneously High
    Deflating cuff too quickly Erroneously Low systolic and high diastolic
    Deflating cuff too slowly Erroneously High diastolic reading
    Failure to use the same arm consistently Inconsistent measures
    Arm above level of the heart Erroneously Low
    Assessing immediately after a meal or Erroneously High
    while client smokes or has pain
    Failure to identify auscultatory gap Erroneously Low systolic and low diastolic
    readings
    THANK YOU!

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