Vital signs
By : Dr. Suad .J.mohmed
Terminologies ;
Vital signs ; is an indicators or signs checked to monitor the function of
the body it includes ; temperature ,pulse , respiration & blood pressure,
recently some agency designed pain as a fifth vital to be assessed .
Bradypnea; quick , shallow braeths
Febrile ; the client who has a fever.
Hyperpyrexia, A very high fever such as 41
co
Tidal volume ; a normal inspiration & expiration an adult takes in about
500 mL of air .
Pyrexia ; a body temperature above the usual range (fever)
Pulse deficit ;the deference between radial pulse and apical pulse.
Intermittent , a body temp, alternate at regular intervals between
periods of fever and periods of normal or subnormal temp, ex. With
malaria disease.
Time to assess Vital signs ;
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On admission to a health care agency.
When a client has feel hot or faint.
Before & after an invasive procedure.
As a routine nursing care .
After certain cardiac drugs.
BODY Temperature;
Body Temperature; it reflects the balance between the
heat produced and the heat lost from the body ,it measured in a
heat units called degrees.
Kinds of body temperature;
1- CORE Temp, is the temp. Of the deep tissue of the body , such
as abdomen cavity and pelvic cavity , it remain constant.
2- The Surface temp, is the temp. Of the skin , the subcutaneous
tissue , and fat .it rises and falls in response to the
environment.
Factors affecting body s heat production ;
Heat Production;
- Basal metabolic rate.
- Muscular activity .
- Thyroxine and
epinephrine
(stimulating affects on
metabolic rate).
- Temp, effects on cells.
Heat Loss
-
Radiation
Conduction
Convection
Evaporation(vaporiza
tion)
Regulation of body temperature;
1- Sensors in the shell &in the core.
2- An integrator in the hypothalamus.
3- An effectors system which , adjust production and heat loss.
BODY Temperature affecting factors ;
1- Age , the infant is greatly influenced by temp, of
environment.
2- Time of the day ,body temp, changes throughout the day ,
between the 1.O ,CO in early morning
3- Exercise; hard work can increase body temp.
4- Hormones, women usually experience more hormone
fluctuations than men.
5- Stress ; stimulation of sympathetic nervous system can
increase the heat production .
6- Environment, extremes in environmental temp,can affect a
person s temp .
Alteration in body Temperature;
Pyrexia , a very high fever , such as 41OC TEMPERATURE.
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Types of fever ;
Intermittent fever.
Remittent fever , such as with cold or influenza .A body with a
wide range of fluctuation during 24 h a day and may above
normal.
Relapsing fever ; short febrile periods of few days of interspersed
with periods of 1-2 days of normal temp,
Constant fever ; the body temp, fluctuate minimally but always
remains normal , as in typhoid fever.
Clinical Manifestation of fever;
 Onset of cold or chill ;
- Increased heart rate
- Increased respiratory rate
- Cold skin &cyanotic nail beds
 COURSE OF PLAEAU PHASE ;
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ABSENCE OF CHILLS
INCREASED THIRST
Drowsiness
Mild or severe dehydration
Malaise ,weakness ,& aching muscle
Hypothermia ;
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Is a core body temp, below the lower limit of normal .
Clinical Manifestation (hypothermia);
Decreased body temp, pulse ,and respiration
Feeling of cold & chill
Pale ,cool, waxy skin
Hypotension
Decreased urinary output
Disorientation progressing to coma.
Nursing intervention for clients with
fever.
 Monitor vital signs
 Assess skin color & temp.
 Monitor W B C count , hematocrit , & other
laboratory report.
 Remove excess blankets when the client feels
warm.
 Provide adequate nutrition & fluids (e.g 2,000 –
3000 ml) per day to met the body requirement &
prevent dehydration.
 Measure intake & output.
 Administer antipyretics &provide oral hygiene.
Nursing intervention for clients with hypothermia;
 Provide a warm environment
 Provide dry clothing &warm blanket
 Apply warming pads
 Supply warm oral or intravenous fluids
Identifying nursing Diagnosis , outcomes .
Imbalance Body Temperature.
Nursing
Out come
Indicators
diagnosis /
definition
Risk for
Adequate
Moist mucous
imbalanced
water in the
membranes.
body
intracellular
temperature
&extracellular
of the body
Pulse;
Pulse , is a wave of blood created by contraction of the left
ventricles of the heart.
Factors affecting the pulse;
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Age , as age increase , the pulse rate gradually decrease.
Gender , after puberty , the average males pulse rate lower than
Exercise.
Medication , some medication decrease the pulse such as
(digitalis).
 Fever or hypothermia & stress.
Nursing Diagnosis;
Ineffective Peripheral Tissue Perfusion.
Outcome definition
Maintain adequate tissue perfusion.
Respiration;
Respiration , is act of breathing , inhalation or inspiration ,
which refers to the intake of air into the lungs and exhale out .
Ventilation ;it refers to the movement of air in and out of the
lungs.
Types of breathing ;
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Costal (thoracic ) breathing, involves the external intercostals
muscles.
Diaphragmatic (abdominal ) breathing, it involves movement of
the abdomen.
Mechanics & Regulation of breathing;
*respiratory center in the medulla oblongata and Pons .
*Chemoreceptors , located peripherally in the aortic bodies &
carotid.
Factors affecting Respiration;
Exercise , stress , increased environmental temp., increased
altitudes.
Nursing Diagnosis
Ineffective breathing pattern
Out come ; maintain normal respiration.
Blood Pressure;
Arterial blood pressure ,is a measure of the pressure exerted by
the blood as it flows through the arteries , as it moves in waves.
Systolic pressure , is the pressure of the blood as a result of
contraction of the ventricles , which present the height of the blood.
Diastolic pressure ,the pressure when the left ventricle is relaxed
presenting the lowest pressure.
Peripheral vascular resistance
, is the capillaries diameter or the
capacity of the arterioles presents the peripheral vascular resistance.
Blood viscosity , is the blood thickening , that is when proportion
of RBC to blood plasma is high, which referred as (hematocrit)
Factors affecting Blood /pressure;
 Age the pressure rises with age , reaching the peak on
puperity.
 Exercise & physical activity, increases cardiac output and
thus increasing B/P.
 STRESS,
 Medication & disease process.
CLassificaton of BLood Pressure;
Systolic ,mm HG
Normal
<120
Prehypertension,
120- 139
Hypertension,1
140-159
Hypertension,2
>160
diastolic , mmHg
<80
80 -89
90-99
>100
`Alteration in Blood Pressure;
Hypertension ; blood pressure that is persistently above
normal .
Hypotension ;is a blood pressure below normal , that is
between 85-and 110 mm hg in an adult.
Orthostatic hypotension ;is a blood pressure that falls
when the clients sits or stands .
Shock ;is a state of generalized inadequate circulation, which
causes decreased perfusion of the body tissue with blood and
produces a wide range of systemic effects.
Physiology of Shock ;
Circulatory inadequate as results of three basic factors;
 The heart (pump).
 The blood volume.
 The vascular bed .
Classification of shock ;
 Hypovolemic shock ;due to reduction the circulatory blood volume
ex, haemorrhage , burns trauma .
 Cardio genic shock; In which the circulatory failure due to faulty
pumping of the heart as a result of MI (myocardial infariction) .
 Vaso vagal shock ; threr is a diffuse vasodilation and an increase in
size of the vascular beds.
 Neurogenic shock ; involves loss of sympathetic control , this
producing vasodilation .
 Psychogenic shoch , such as sudden fright of pain .
 Septic shock ;such as in strangulating hernia and intestinal
infection , or of certain drugs as penicillin injection.
Signs & symptoms ;
The patient presents;
*anxious ,tired expression , skin feels cool , pale and mottled
which showed a decreased in capillary blood flow.
* IN neurogenic shock pulse rate normal , low blood pressure.
*Restlessness then become apathy and sleepy.
*Nausea and vomiting due to hypovolaemia and excessive thirst.
Management of Shock ;
The faster the shock treated the greater
chance to prevent complication.
The main aim of treatment of shock is;
Improving and maintaining tissue perfusion.
This can be achieved by the following measures;
 Maintenance of respiratory function , adequate O2 supply
 Maintenance of adequate blood pressure ,by proper poisoning the
patient (legs upper level than the head).
 Fluid replacement , quantity of fluid replaced urgency.
Reference:
Taylor,C.""Fundamentals of NURSING, Art &Science of Nursing Care"" .Sixth
ed , LIPPINCOTT ,Philadelphia ,2005 ,Page -315.