PATIENT CARE VITAL SIGNS AND THE ELECTROCARDIGRAM

Why take vital signs?

• To establish a baseline to which additional assessments can be compared

• Reveals the first clue of adverse reactions associated with treatments and diagnostic procedures.

(Cardinal and Vital signs)

Vital signs

• Indicates someones homeostatis

Homeostasis

Constancy in the internal environment of the body, naturally maintained by adaptive responses that promote healthy survival

What are the Vital signs?

THERE ARE FIVE

1. Temperature (T)

2. Respiration (R)

3. Pulse oxygen (spo2)

4. Pulse (P)

5. Blood pressure (BP)

Body temperature

The degree of heat of the deep tissues of the human body

Thermo-regulation

The body’s maintenance of heat production and heat loss

What is the thermoregulation regulated by?

Regulated by the hypothalamus

• Initiate peripheral vasodilation and sweating (diaphoresis) to dissipate body heat

• Initiates shivering to generate heat and vasoconstriction to conserve heat

• What the body needs to do to get back on TRACK

Body Temp (Part two)

NOT ON BOARDS

1. Oral

2. Axillary

3. Tympanic

4. Temporal

5. Rectal

Oral temperature

• Obtained by placing a thermometer under the patient's tongue

• The thermometer has more aslender pointed up

Axillary temperature

• Obtained by placing the thermometer high between the upper arm and the torso

• Primary used on infants and children

Tympanic temperature

Obtained by placing a tympanic membrane thermometer in the ear

• Preferred used in infants and adults when oral temperatures are not achievable

• May be inaccurate sometimes

Rectal temperature

Obtained by placing the tip of the thermometer into the rectum

• Tip of thermometer is more rounded

• Most accurate

Temporal temperature

Obtained by the temporal artery (TA) FOREHEAD

• TA lies superficial in the temporal region of the skull

Body temp

Temperatures can range depending on the route used to measure

• Normal ranges for healthy adults and children are within (97.6-100 F) (36.5-37.8C)

Hyperthermia

Hyperthermia (Febrile or pyrexia)

• Abnormally high body temperature

• When body temperature increases, metabolic rate also increases, resulting in increased oxygen consumption and carbon dioxide production at the cellular level

• Cardiopulmonary system must work hard to meet the addition cellular demands by providing more oxygen

Symptoms of Hyperthermia

• Increased metabolism

• Increased pulse

• Increased respiration

• Achy

• Flushed/Dry skin

• Chills

• Loss of appetite

• Dizziness

• Comatose

WHY?

• pt may not be able to get in a certain position

• Change techq

• Blanket?

Hypothermia (more common)

• Low body temp

• May be present in pts exposed to cold environment temperatures and those with trauma to the hypothalamus

• Not very common

• Child neglect

• Child abuse

• Shaking them

Symptoms of hypothermia

• Less common

• Shivering

• Slurred speech or mumbling

• Weak pulse

• Clumsiness or lack of coordination

• Drowsiness or very low energy

• Confusion or memory loss

• Loss of Consciousness

• Bright red, cold skin (In infants)

• Decreased body temp

• Tissue metabolism

• Medically incluse due to open heart surgery

Body temp (3)

Temperatures outside of the normal range may be a result of

• Disease

• Infection

• Exercise

• Prolonged exposure to hear or cold

• hormonal change’s

Respiratory Rate

• Responsible for delivering oxygen from the environment to the tissues and eliminating carbon dioxide from the tissues to the environment

• The depth of breath determines tidal volume

• Respiration is often counted by observing the movement of the abdomen or the rise (Inspiration) and fall (expiration) of the chest

• COUNTING respiration for a minimum of ONE minute is important to obtain and accurate measurements

Respiration

Action of inhaling oxygen and exhaling carbon dioxide during breathing

Tidal Volume

The volume of air inhaled and exhaled during one respiratory cycle

Inhalation

Decreases the Diaphragm

Exhalation

Increases the diaphragm

Respiratory rate (Measurement)

Observe and record the rate, depth, and rhythm

• Recorded in number of breaths per min

• Assessing depth (Shallow, normal, deep), Rhythm (regular or irregular)

Normal Respiratory Rates

ADULT: 12-20 Breaths/min

CHILD: 20-30 breaths/min

Abnormal Respiratory Rate (Tachypnea)

It is a rapid rate of breathing

Greater than 20 breaths per min

• Over 20 breaths for adults is abnormal

• Over 30 breaths for a child

• IF NOT SPECIFIED, THINK ADULT

Signs/Causes of Tachypnea

Signs

• Panting

• Lightheadedness

• Chest Pain

• Rapid Breathing

• Fever

Causes

• Exercise

• Anxiety

• Infection

• Chest trauma

• CNS disease

• Fever

• Pain

• Heart failure

• Decreased oxygen in blood

Bradypnea

Abnormal slowness of breathing

• Less than 12 breaths per min

SO

• Less than 12 breaths for an adult

• Less than 20 for a child

Signs/Causes of Bradypnea

Signs

• Cyanosis

• Restlessness

• Apprehension

• Altered level of awareness

CAUSES (USUALLY THREE)

• Drug OD

• Hypothermia

• Injury

Dyspnea

Difficulty or labored breathing

Orthopnea

Difficulty breathing expect when sitting up or standing erect

Apnea

Cessation of spontaneous Ventilation

Pulse

Regular expansion of an artery caused by the ejection of blood into the arterial system by the contractions of the heart

Pulse (measurement)

Record the Rate, strength, and regularity

• recorded in beats per min

• Assessing rate (Fast or slow), Strength (Shallow, Normal, Deep), Regularity (regular or irregular)

Pulse sites

• Common sites.

- Radial artery, Brachial Artery, and Carotid artery

RADIAL ARTERY IS MOSTLY USED

• Least common sites

- Femoral, popliteal (Behind the knee), Apical (Apex of the heart) Sethscope

Normal Pulse Rates

ADULTS:60-100 Beats/min

CHILD: 70-120 Beats/min

Abnormal pulse (Tachycardia)

Rapidity of the heart action, usually defined as heart rate greater than 100 BPM

*Over 120 is ABOVE)

Symptoms/Causes of Tachycardia

Causes

• Exercise

• Anemia

• CHF (Congestive Heart Failure)

• Shock/Pain

• Anger

• Anxiety/Fear

• Fever

• Respiratory disorders

• Hypoxemia

• Medications

Symptoms

• SOB

• Lightheadedness

• Rapid pulse rate

• Heart palpation

• Chest Pain

• Fanting (Syncope)

Bradycardia

Slowness of the heartbeat as evidenced by slowing of the pulse rate to less than 60 BPM

• ADULT: Slower than 60

• CHILD: Slower than 70

Causes/Symptom’s of Bradycardia

Causes

• Heart tissue damage

• Pain

• Physically fit athletes

• Hypothermia

• Infection of the heart

• Hypothyroidism

• Sleep apnea

• Inflammatory disease

• Medications

Symptoms

• Near fainting or Fainting

• Dizziness or lightheadedness

• Fatigue

• SOB

• CP

• Confusion or memory problems

• Easily tiring during physical Activity

Pulse Oxygen (Pulse oximeter)

Photoelectric device used for determining the oxygen saturation level of the blood

• Normally pulse oxygen on a healthy person is 95-100 percent

• Anything less is considered to be abnormal

• Slow deep breaths might help

BP- Blood pressure

A measure of the force exerted by blood on the arterial walls during contraction and relaxation of the heart

• Recorded with systolic and diastolic measurements

• Measured in millimeters of mercury-mm HG

• Systolic: contraction of the left Ventricle

• Diastolic: relaxation of the heart

• REMEMBER SARA IS SUPERIOR TO DAN (DIASTOLIC)

Normal BP

Systolic: <120mm Hg

Diastolic: <80mm HG

ALL CAN VARY BASED ON THE PATIENT

Abnormal Blood Pressure (Prehypertension)

Consistent systolic pressure of 120-139 mmHg,

diastolic pressures between 80-89 mm HG

Hypertension

Persistently High arterial blood pressure

• May be silent (no symp)

• Extreme elevations can damage the brain within minutes, increases workload on the heart, and may affect the brain, kidneys, lungs, and other organ systems

• HAS TO BE 140-149, ANYTHING ABOVE 140/90 IS HBP

Hypotension

• abnormally low BP

• Dizziness, confusion, blurred vision

• Shock from trauma (Usually from loss of total blood volume), such as trauma, Vomiting, burns, severe bleeding, Heat exhaustion

• FINE UNTIL SYMPTOMS OCCUR

Orthostatic hypotension

A condition where your blood pressure suddenly drops when you stand up from a seated or lying position