ASSESSMENT OF VITAL SIGNS

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ASSESSMENT OF VITAL SIGNS

• Marie Bártová, BSN
• Institute of Nursing Theory and Practice
• 1st Faculty of Medicine, Charles University

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• www.lf1.cuni.cz
• ? Pracovište
• ? Ústav teorie a praxe ošetrovatelství
• ? 1st year medical students / 1st Aid

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CONTENTS

• Consciousness
• Body temperature
• Respiration
• Blood pressure
• Pulse

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1. CONSCIOUSNESS

• Human ability to be aware of own thoughts,
• emotions, surroundings ? adequate responses
• GLASGOW COMA SCALE (GCS)
• Patients response to
• - verbal stimulation
• - painful stimulation
• - movement
• Scale 3 15

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CONSCIOUSNESS
Changes in consciousness Changes in consciousness
QUALITATIVE QUANTITATIVE
anxiety depression delirium somnolent sopor coma (shallow/deep)
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2. BODY TEMPERATURE

• Balance between heat produced and heat lost by
  the body
• Heat regulating centre hypothalamus
• Heat production caused by increasing cell
  metabolism
• Heat losses (cool off process)
• - perspiration
• - respiration
• - radiation
• Types of thermometers
• - mercury-in-glass
• - electronic
• - chemical

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BODY TEMPERATURE
BODY TEMPERATURE SYMPTOMS
Hypothermia ? 36 C Skin paleness Tiredness
Normal 36 36,9 C Lowest 5 6am Highest 4 6pm
Pyrexia / slight fever 37,0 37,9 C Perspiration Skin redness Headache
Fever ? 38 C Presence of infection ? body defence General weakness Tachycardia / hyperpnea Skin paleness/redness Shivers Perspiration
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BODY TEMPERATURE

• ROUTES FOR MEASURING THE BODY TEMPERATURE
• - ORAL
• best site for measuring in the clinical
  settings
• triangle shaped thermometer
• axillo oral difference 0,3 C
• - AXILLARY
• more likely to be affected by the environmental
  temperature,
• used in children/adults
• - RECTAL
• fast thermometer, used in infants/confused
  patients/receiving O2 th.
• axillo rectal difference 0,5 C
• - VAGINAL
• used in gynecology

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3. RESPIRATION

• NORMAL RESPIRATIONS
• Effortless
• Regular
• Smooth
• AVERAGE RESPIRATIONS
• Infant to 2 years 2434/min
• To puberty 20-26/min
• Adults 12-18/min

• RESPIRATORY RATE
• Normal 12 20 / min
• Bradypnea ? 10 / min
• Tachypnea ? 25 / min
• Apnea
• RESPIRATORY RHYTHM
• Normal
• Dyspnea (exertion/rest)
• Cheynes-Stokes respiration (irregular
  deep/slow/shallow )
• Kussmauls breathing (deep)

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4. BLOOD PRESSURE (BP)

• The pressure of blood in the arterial wall
• Factors affecting BP
• - blood volume
• - strength of contraction
• - elasticity of artery wall
• Assessment
• - Normal 120-140/60-80 mmHg
• - Hypertension ? 150/90 mmHg
• - Hypotension ?100 mmHg
• Measurements stated in terms of millimetres of
  mercury (mmHg)

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BLOOD PRESSURE (BP)

• BP reading
• - systolic pressure (ventricle contraction)
• - diastolic pressure (ventricle at rest)
• BP readings record BP 120/80
• Equipment
• - sphygmomanometer
• - stethoscope

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BLOOD PRESSURE (BP)

• Places for measuring
• - upper arm (brachial artery)
• - calf / thigh (popliteal artery)
• Measuring techniques
• - auscultation
• (sphygmomanometerstethoscope) - palpation
  
• (sphygmomanometer)
• - invasive methods (CVP)

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5. PULSE

• Expansion of an artery with each hart beat
• Measuring techniques / places of assessing
• - PALPATION
• a. carotis
• a. brachialis, radialis
• a. femoralis, poplitea etc.
• - AUSCULTATION
• stethoscope

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PULSE

• PULSE RATE
• Normal 60 90 / min
• Bradycardia ? 50 / min
• Tachycardia ? 100 / min
• Asystolia

• PULSE RHYTHM
• Regular
• Irregular arrythmia
• PULSE QUALITY
• Strong (fever)
• Weak (shock/heart failure)

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REPETITION

1. What do you evaluate in Glasgow Coma Scale?
2. What is the normal body temperature?
3. Name 3 symptoms of fever.
4. What is the most commonly used route for
   measuring the body temperature in infant?
5. Could you define the term for the high
   respiratory rate?
6. What is the limit for hypertension?
7. Name 2 methods of BP measurement?
8. Name 2 arteries where the pulse is most commonly
   felt?
9. Could you specify the normal pulse rate?
10. What is the point at which the beat stops during
    the BP measurement called?

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THANK YOU !