Checking PATIENT VITAL SIGNS

SESSION 2A: CHECKING PATIENT’S VITAL SIGNS.

At the end of this session learner is expected to be able to:

• Define common terms used in checking patients vital signs
• Identify reasons for checking patients vital signs
• Outline factors influencing vital signs
• Identify common anatomical site for checking vital signs
• Demonstrate the procedure of checking patients vital signs

Learning Tasks

Vital signs are cardinal signs or physiological parameters that reflect key body processes

• The vital signs include temperature, pulse, respiration and blood pressure

Temperature

Temperature: Is the state of hotness or coldness of a substance as measured by a themometer Body temperature: Is the measure of warmth or coldness of the body resulting from body metabolism.

• It is the balance between heat production and heat lost.
• Normal body temperature range from 36.5OC- 37.5OC depend on the site taken

Common Terms Used in Checking Vital Signs

Thermometer

Thermometer: Is an instrument used to measure the degree of heat or cold Clinical Thermometer: Is a thermometer used to measure body temperature (Example of thermometers used in clinical settings are mercury and digital thermometers) Fever: Is abnormal elevation of body temperature.

• Pyrexia: Is elevated body temperature ranging from 38 0C
• Hyperpyrexia: Is an extremely elevated body temperature ranging from 41oC and above

Hypothermia: Is abnormal body temperature below 36 OC Constant Fever: The patient’s body temperature is constantly high throughout a period of some days. The fluctuation between morning and evening temperature doesn’t exceed1OC.

Intermittent Fever: The patient’s body temperature swings from normal or subnormal to high fever regularly.

Common Terms Used in Checking Vital Signs cont…

Checking PATIENT VITAL SIGNS

Remittent Fever: The patient’s body temperature may fall by more than 1OC in the morning and rise again later in the day. The characteristics fact is that the temperature does not reach the normal within twenty four hours.

Inverse Fever: The patient’s body temperature is high in the morning and low in the evening.

Irregular Fever: The patient’s body temperature rises and falls without definite pattern.

Relapsing Fever: The patient’s high body temperature falls to normal and remains normal for a day or two and then it rises again Common Terms Used in Checking Vital Signs cont…

Pulse

Pulse: Pulse is a wave of contraction felt in the arterial walls when the left ventricle contract or is the vibration produced by heart beat waves of blood through the arteries Pulse Rate: (heart rate) Tells how often a person’s heart beats or Is the frequency of heart beats per minute, normal adult pulse rate ranges from 60-80 beats/minute (average beats per minute is 72), Newborn 120 beats/minutes, 4-8 years child ranges from 90-100beats/minutes Bradycardia: Is the term describing adult pulse rate below 60 beats/minutes Tachycardia: Is the term describing adult pulse rate above 100 beats/minutes The Rate: This is the speed at which the heart is beating.

The Rhythm: Is the regularity of the heart; a normal pulse has beats of uniform force and separated by equal intervals.

The Volume: Is the strength of the beats, it indicates the power of the heart and the amount of the Common Terms Used in Checking Vital Signs cont…

Respiration

• Respiration: Is the process of breathing in oxygen and exhaling out carbon dioxide
• External respiration is the exchange of gases between lungs and atmosphere
• Internal respiration is the exchange of gases between blood and cells

Dyspnea: Is a condition where the person experience difficult in breathing Wheezing: Is production of whistling sound during difficult breathing as occurs in asthmatic patients Apnoea: Is term describing a temporary cessation in breathing Orthopnoea: This is inability to breath easily and freely unless patient is in a sitting – up position Croup: Is noisy or harsh- sounding sort of breathing due to laryngeal obstruction (common causes of the obstruction are oedema or spasm or could both) Common Terms Used in Checking Vital Signs cont…

Blood pressure

Blood pressure: Is the force exerted by the blood against the arterial walls. Normally is recorded as systolic/diastolic in millimeters of mercury (mmHg) Systolic pressure: Is force exerted when the left ventricle contracts and pushes blood out of the heart through the Aorta. It ranges from 110 -140 mmHg for adult.

Diastolic pressure: Is the force of the blood against the arterial walls when the heart is at rest between beats. It ranges from 60-90mmHg for adult Pulse pressure: Is the difference between systolic pressure and diastolic pressure Hypertension: Is when the systolic blood pressure is over 160mmHg or/and diastolic pressure is over 100mmHg Hypotension: Is when the systolic blood pressure is bellow 100mmHg or/and diastolic blood pressure is bellow 60mmHg.

Common Terms Used in Checking Vital Signs cont…

To identify any abnormalities /changes in body functions

To evaluate patient condition during admission, before discharging, before and after any invasive medical /surgical procedure or treatment To assist physician to make a change in medications Reason for Checking Patient’s Vital Signs

Factor affecting body temperature (causes of variation in normal body temperature)

Time of the day: Temperature tend to be a bit higher during late afternoon and a bit lower early in the morning Menstrual cycle and pregnancy: Temperature is lower before ovulation, higher during ovulation, lower 1 – 2 days before menstruation and a bit higher during pregnancy Muscle action: During physical exercise temperature is a bit higher Age: Temperature fluctuate during infancy due to immature heat regulating center, lower during old age due to malfunction of heat regulating center and loss of fat tissue Clothing: Heavy clothing may increase temperature Certain medication: Barbiturates lower the temperature Loss of sweat regulating center (glands): There will be failure of regulation of heat during higher atmospheric temperature

Factors Influencing Vital Signs

Factors contributing to variation in normal pulse rate

Position of the patient: – Pulse rate is more rapid when patient is standing or walking, slower when patient is lying or resting Sex: – Pulse rate is slightly higher in female than in men Age: – Pulse rate is more rapid during infancy and young children than in adult patient Exercise of any type: – Increases the pulse rate Emotions: – Strong emotions increases the rate of pulse Factors Influencing Vital Signs cont…

Average normal range of pulse rate

• Newborn – 120 – 140 beats per minute
• 12 months: 110 – 120 beats per minute
• 2 – 2 years: about 100 beats per minute
• 5 – 12 years: about 90 beats per minute
• Adult: about 60 – 80 beats per minute
• Old age tends to become slower

Factors Influencing Vital Signs cont…

Characteristics of pulse

• Rate – Frequency of beats per specified time period
• Rhythm – Regularity of heart beats

Volume – Strength of the beat

Tension – Softness or hardness felt on the vessel, normally should feel soft and flexible under nurse’s fingers, not hard and twisting Factors Influencing Vital Signs cont…

Factors contributing to variation in normal respiration

• Causes of normal increase of respiration
• Exercises
• State of excitement
• Fear, worries and anger
• Causes of normal decrease of respiration
• Sleeping
• Resting
• Having a calm emotion

Factors Influencing Vital Signs cont…

Factors influencing blood pressure in a healthy person

Age – low at birth, increases as the person grows Body structure – Overweight people tend to have higher blood pressure than those with normal weight Sex – Women have lower blood pressure than men Rest and exercise – Physical activities increases blood pressure, blood pressure becomes low at rest Emotions – Anger, fear, worries and exercises can cause rise in blood pressure Posture – blood pressure may be low when a patient is lying than when standing Factors Influencing Vital Signs cont…

Factors responsible for maintaining blood pressure

• Cardiac output – blood pressure decreases when pumping action of the heart is weak

Blood volume – blood pressure becomes low when circulating blood volume is low Blood viscosity – The more viscous the blood the more force is needed to pump the blood into arteries thus high blood pressure Peripheral resistance – constricted blood vessels needs greater force to pump blood into vessels leading to raised blood pressure Elasticity of the blood vessel wall – Decrease in elasticity of the vessels wall causes an increase in blood pressure Factors Influencing Vital Signs cont…

Temperature

• In the axilla
• In the mouth – under the tongue
• In the groin
• In rectum
• Pulse
• Radial artery
• Facial artery
• Temporal artery
• Brachial artery
• Femoral artery
• Apex of the heart

Common Anatomical Site for Checking Vital Signs

Pulse points

Checking body temperature by Axilla or Groin

• Assessment:
• Make sure the patient has not taken bath recently
• Assess if the patient is very thin or having discharging lesions in the groin or axilla
• Equipment:
• A clean tray containing:
• A rack with thermometers
• Galipot with cotton wool swabs
• Kidney dish for used swabs
• A small bottle with spirit
• Temperature charts
• Watch with second hand or pulsometer
• Pen for recording the findings

Procedure of Checking Vital Signs

Steps for checking body temperature by Axilla or Groin

Inform patient or relative about the procedure, perform quick assessment to make sure the patient is ready for the procedure Wash hands and prepare the equipment Ensure that the skin surface of the axilla (arm pit) or groin is dry Wipe the thermometer with cotton wool from the bulb to the stem Take and read the thermometer to make sure that mercury level is below 35°C Place the thermometer in the axilla or groin with the bulb totally surrounded Ask or assist the patient to place his arm across the chest with fingers on the opposite shoulder Leave the thermometer in place for 5 to 10 minutes, making sure the clothes do not interfere with the thermometer Procedure of Checking Vital Signs cont…

Checking PATIENT VITAL SIGNS

If the temperature is taken from the groin, ask or assist the patient to cross one thigh over the other and leave it in place for 5 to 10minutes Take the thermometer out of axilla or groin; wipe it with cotton wool swab starting from the stem to the bulb. Avoid contaminating your fingers Discard the used swab into the kidney dish Hold the thermometer at eye-level and rotate slowly until the column of mercury is seen clearly Read mercury level accurately

• Place the thermometer in the container for used thermometers
• Record the temperature accurately on the patient’s chart
• Thank the patient and leave him comfortable
• Clear up equipments and wash hands
• Report or take immediate action on the abnormalities noted

Procedure of Checking Vital Signs cont…

Checking Pulse

• Assessment:
• The patient’s level of activity prior to performing the procedure
• The patient’s temperature
• Equipment:
• Observation chart
• Watch with second hand or pulsometer
• Pen for recording the findings

Procedure of Checking Vital Signs cont…

Steps for checking Pulse rate

• Explain to the patient about the procedure
• Perform hand washing
• Assist the patient to the comfortable position – lying or sitting
• Place two or three finger tips on the radial artery at the inside of the patient’s wrist
• Look at your watch and count the pulse beats for the whole minutes. If pulse is normal

Count for the whole minute to get the beats per minute) Continue placing the finger tips on the artery and evaluate the strength and regularity of the beats Record the findings on the patient’s chart and communicate to the ward in charge. This will include –beats per minute, strength ( strong, weak, or thread) and rhythm whether regular or irregular Inform patient findings

• Thank the patient and perform hand washing

Procedure of Checking Vital Signs cont…

Checking Respiration Rate

• Assessment:
• Is the patient experiencing respiratory distress after exercise period?
• Equipment:
• Watch with second hand or pulsometer
• Patient’s chart
• Pen for recording the findings

Procedure of Checking Vital Signs cont…

Steps for checking respiration

With your fingers still resting on the patient’s wrist after checking pulse, observe the patient’s chest for inspiration and expiration movements Count the respirations for full minute to get the rate per minute Assess the respiratory qualities such as wheezing, stridor, deep or shallow breathing.

• Remove the fingers and record the findings on patient’s chart
• Inform patient about the procedure

Procedure of Checking Vital Signs cont…

Checking blood pressure

• Assessment:
• History of elevated blood pressure
• If the client is on antihypertensive therapy
• If he has been exposed to physical exercises within the last 10 minutes
• Equipment:
• Sphygmomanometer (Aneroid, Mercury and electronic manometers)
• Stethoscope
• Patient’s chart
• Pen for recording the findings

Procedure of Checking Vital Signs cont…

Steps for checking blood presure

• Explain the procedure to the patient
• Wash hands and dry
• Prepare the equipment, check if they are in good working condition.
• Position the client in sitting or lying
• Expose the left arm as necessary
• Apply the calf on the client’s bare arm, above the antecubital space
• Palpate the brachial artery and place the stethoscope over the pulse point

Position the sphygmomanometer so that the gauge is visible for reading Put the stethoscope in your ears, close the valve on the bulb of sphygmomanometer, pump the mercury until it rises to 40 mmHg above the anticipated systolic pressure Procedure of Checking Vital Signs cont…

Checking PATIENT VITAL SIGNS

Release the valve slowly while listening the pulse beats. Note the number on the gauge at which you hear the first beat is the systolic pressure Continue deflating the cuff slowly and listening the muffling sound and note both the points of muffling and the number at which the beats disappears, this is a diastolic pressure Remove cuff from the client’s arm, and position him comfortably Record findings on client’s chart

• Inform patient findings
• Thank patient and wash hands

Procedure of Checking Vital Signs cont…

Vital signs are cardinal signs which indicate how the body is carrying out the important processes

• Everything goes wrong in the body can be reviewed in the vital signs
• Factor that affect vital signs may include age, activities, time of the day and position
• It is important to inform the patient the findings in order to alley her anxiety

SUMMARY

What are the four vital signs?

• What are the common sites used to check temperature?
• What will you observe on pulse?
• What are factors responsible for maintaining blood pressure

Evaluation

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Kozier, B., Erb, G., Blais, K., & Wilkinson, J. M. (1995). Fundamental of nursing: Concepts process and practice (5th ed.). Oakland, CA: Wesley.

KMTC-VVOB. (2009). Skills lab project: Nursing procedure manual. Kenya.Lynn, P. (2011). Taylor’s clinical nursing skills: A nursing process approach (3rd ed.).New York: Lippincott Williams & Wilkins.

MOHSW. (2008). Basic nursing procedures: A manual for nursing practice in Tanzania(3rd ed.). NCP: KIUTA.

Moshi, N., & Karungura, J. (2005). Basic nursing procedures. KCMC NursingProfession.Paulinus, S. (2004). Basic nursing care (2nd ed.). Tanzania: Ndanda-Peramiho:Benedictine.

Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). USA: Mosby.Rider Ellis, J. (1992). Basic nursing skills (5th ed.). New York: Lippincott Williams &Wilkins Thomas, C. (1993). Taber’s cyclopedic medical dictionary. Philadelphia: F. A. Davis.

References