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Chapter 16 VITAL SIGNS

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Chapter 16 VITAL SIGNS Pam Diggens Introduction This chapter is concerned with taking patients vital signs as well as factors that may affect them. – PowerPoint PPT presentation

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Title: Chapter 16 VITAL SIGNS


1
Chapter 16VITAL SIGNS
  • Pam Diggens

2
Introduction
  • This chapter is concerned with taking patients
    vital signs as well as factors that may affect
    them.
  • Part 1 Taking Patients Vital Signs
  • Part 2 Temperature
  • Part 3 Pulse Rate
  • Part 4 - Respirations

3
  • PART 1 Taking Patients Vital Signs

4
Taking Patients Vital Signs
  • Q. There are various reasons for taking
    patients temperature, pulse and respirations
    (TPR) can you identify any?
  • Remember, it is important to ensure you have
    gained patients consent prior to taking their
    vital signs (Nursing and Midwifery Council (NMC),
    2004).

5
Reasons for Taking Patients Vital Signs
  • On admission, to provide a baseline which can be
    compared with subsequent measurements, thereby
    providing objective data and trends.
  • To monitor effects of any treatment or
    medication.
  • To give an indication of patients general
    condition, and help to identify changes or
    deterioration. Patients conditions may change
    rapidly or slowly over time.
  • (Perry and Potter, 2002
  • Remember, a baseline measurement may not always
    be the persons normal measurement.

6
  • Remember, a baseline measurement may not always
    be the persons normal measurement.
  • A series of measurements is more useful than a
    one off measurement, as it enables a trend to be
    recorded. A trend is useful to help identify and
    monitor potential problems. Wherever possible,
    compare different vital sign trends as these can
    also provide additional information.
  • Look at the following patients charts, which
    show their vital sign measurements over a period
    of time and trends of data.

7
Evidence-Based Practice
  • Monitoring vital signs is often viewed as one
    of the more mundane aspects of nursing care, and
    is frequently devolved to healthcare assistances
    and nursing students. However, their immense
    value in patient care should not be overlooked
  • (Davidson Barber, 2004, pp42)

8
Trends

9
Normal Adult Range for Vital Signs
  • Q. Do you know the normal ranges for
    temperature, pulse and respirations in adults?
  • It is important to familiarise yourself with
    these if your client base are adults, as this
    will assist you to identify abnormal measurements
    as well as recognise when you need to report them
    to senior/qualified staff.

10
  • Patients vital signs may fluctuate. It is
    important to acknowledge that these normal ranges
    should act as a guide and that any factors that
    may affect individuals temperature, pulse and
    respiration rates need to be taken into account.
    It is also essential to taken into account that
    the normal range may vary in certain patients
    due to a chronic condition.

11
  • PART 2 Temperature

12
Factors that Affect Temperature
  • Q. Before looking at the next slide, can you
    identify any factors that might affect our body
    temperature?

13
  • There are several factors that can affect daily
    fluctuation of body temperature, which are
    circadian rhythm, age, exercise, food/drink
    intake, hormones, drugs/medication, stress,
    ovulation, stress and environmental extremes in
    temperature.

14
  • 1. CIRCADIAN RHYTHM
  • Generally, in health, a persons temperature
    fluctuates throughout the day. This is known as
    the circadian rhythm. A persons temperature
    often rises during the evening and is lower
    during the early hours of the morning.
  • 2. AGE
  • As people age they become more sensitive to
    extremely hot or cold environments, which can
    affect body temperature. (Perry and Potter, 2002).

15
  • 3. HORMONES
  • Hormones can affect our body temperature. During
    ovulation, for example, womens temperatures can
    be raised. (Perry and Potter, 2002).
  • 4. EXERCISE
  • Exercise increases heat production, which results
    in an increased body temperature.
  • 5. MEDICATION
  • Medication such as paracetamol can reduce body
    temperature.
  • 6. STRESS
  • Stress can have an impact on our nervous, immune
    and endocrine systems and hence body temperature.
    (Perry and Potter, 2002).

16
  • 7. FOOD AND DRINK
  • Hot and cold food and drink may affect our
    temperature.
  • 8. CLIMATES
  • Environmental climates where individuals are
    exposed to extreme temperature conditions may
    result in them developing heat stroke or
    hypothermia. Infants/children and elderly people
    may be more susceptible to changes of climate.
    (Perry and Potter, 2002).

17
  • Q. In your learning groups, consider how the
    following two patients temperatures might be
    affected.
  • 1) An elderly patient who has been sitting near
    an open window on a cold winters day.
  • 2) A young adult patient admitted with a chest
    infection.

18
  • Q. Consider what type of thermometer and site
    you would use to obtain a temperature measurement
    in each of these three situations.
  • 1) An unconscious adult admitted with
    hypothermia.
  • 2) A breathless patient with a respiratory
    problem.
  • 3) A patient with an ear infection.

19
  • PART 3 Pulse Rate

20
Palpable Pulse Sites
  • Although the most common site used for taking
    patients vital signs is the radial (Massey,
    2006), there are other sites at which a pulse can
    be palpated.
  • Q. Can you name any and identify their location
    on the body?
  • Look at the next slide consider in what
    situation you might need to palpate a pulse at
    any of these sites.

21
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Posterior Tibia
22
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23
Factors that Affect Pulse Rate
  • Q. Before you look at the next slide can you
    identify any factors that can affect our pulse
    rate?

24
Factors that Affect Pulse Rate
  • There are various physical, neural and chemical
    factors that affect the heart rate and,
    consequently, the pulse rate. (Marieb, 2004)
  • Some of the physiological factors that can
    affect pulse rate include age, gender, exercise,
    and temperature. (Perry and Potter, 2002
    Marieb,2004)
  • As we get older our heart rate and, hence, pulse
    decreases (Marieb, 2004)

25
  • Generally, male pulse rates are lower than
    female. (Jarvis, 2004)
  • Exercise causes the sympathetic nervous system
    to increase the heart rate, which subsequently
    increases the pulse rate. (Marieb,2004)
  • Temperature can affect the pulse rate in cold
    conditions heart and pulse rate are decreased.
    (Marieb,2004)

26
Practical Tips
  • When feeling for the pulse, you need to be aware
    of certain characteristics, such as rate,
    strength and rhythm.
  • Make sure you count for one full minute
    (Castledine, 2006), as this will ensure that any
    irregular rhythms are detected.
  • Tachycardia is a term used when the heart rate
    and pulse rates are greater than 100 beats per
    minute (bpm). Conversely, a rate slower that 60
    bpm is referred to as bradycardia (Marieb,2004).
  • It can take time to develop skills needed to
    determine pulse strength. If you are in any
    doubt, always get your mentor or a qualified
    member of staff to check.

27
  • Be aware that some individuals may be extremely
    fit and as a result may have resting pulse rates
    slower than 60 bpm. In particular, trained
    athletes can have resting rates of 40 bpm.
    (Marieb,2004)
  • In some situations you may see or have to
    palpate pulses simultaneously, bilaterally (both
    sides). You must never palpate both carotid
    pulses at the same time as this can occlude blood
    flow to the brain causing the patient to black
    out. (Bickley and Szilaygi, 2003).

28
  • PART 4 Respiration

29
Factors that Affect Respirations
  • Q. Before you look at the next slide can you
    identify any factors that can affect our
    respiration?

30
Factors that Affect Respirations
  • There are a variety of factors that can affect
    respirations. These include exercise, pain,
    smoking, certain medications and body position.
  • Exercise increases the bodys demand for oxygen,
    so the rate and depth of respirations likewise
    increases.
  • Respiration rate and rhythm can be altered by
    pain.

31
  • Changes in the pulmonary system may occur due
    to smoking, causing respiratory rate to be
    increased.
  • Certain medication used in general anaesthetics
    may cause the respiratory rate and depth to be
    decreased.
  • Patients who are slumped in their beds/chairs or
    lying flat have restricted lung movement and
    expansion. (Perry and Potter, 2002)

32
Evidence-Based Practice
  • A change in respiration rate, in conjunction
    with changes in heart rate, can often be an early
    indicator that there is a deterioration in the
    patients condition. (Goldhill et al, 1999)..
  • Any abnormalities should be reported
    immediately, as the patient may be at risk of
    deteriorating.(Hogan, 2006)

33
  • Q. Look at the next slide which has Susan Jones
    chart, showing her vital sign measurements over
    the past 13 hours. What do you see?
  • Consider what action you would take in this
    situation.

34
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35
Answer
  • Susan Jones chart shows the measurements
    recorded for her vital signs over the past 13
    hours. This collection of vital signs enables
    trends to become visible. Observing her chart,
    you can see that her pulse rate has increased to
    110 beats per minute (bpm), which is above the
    normal range. A rate greater than 100 bpm is
    known as tachycardia. Her respiration rate has
    also increased to 30 breaths per minute (bpm) and
    is termed tachypnoea.
  • Unless anyone has already done so, you would
    need to report this to a qualified nurse or
    senior member of staff as a matter of urgency.
    Susans condition could potentially deteriorate
    and she needs to be fully re-assessed.
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