Assessing General Status and Vital Signs

• The client’s vital signs are the body’s indicators for health.

  • Usually when a vital sign (or signs) is abnormal, something is wrong in at least one of the body systems.
  • Provides data that reflects the status of the several body systems.
• Vital Signs:

  • Pulse
  • Respirations
  • Blood pressure
  • Temperature
  • Pain – fifth vital sign
• Measure the temperature first, followed by pulse, respirations, and blood pressure.
• TEMPERATURE

  • For the body to function on a cellular level, a core body temperature between 36.5 C to 37.7 C (96 F to 99.9 F) must be maintained.
  • It can be taken in different anatomic sites and none are completely accurate.
• Factors causing normal variations in body temperature:

  • Exercise
  • Stress
  • Ovulation
  • Body temp is lowest early in the morning (4:00 to 6:00 am) and highest at night (8:00 pm to midnight)
• Hypothermia

  • body temp lower than 36.5 C or 96 F
  • (seen in prolonged exposure to cold, hypoglycemia, hypothyroidism, or starvation).
• Hyperthermia

  • higher than 38.0 C or 100F
  • (seen in viral or bacterial infxn, malignancies, trauma, and various blood, endocrine, and immune disorders.
• Older adult temperature:

  range from95.0°F to 97.5°F. Therefore, the older client may not have an obviously elevated temperature with an infection or be considered hypothermic below 96°F.
• PULSE

  • A shock wave is produced when the heart contracts and forcefully pumps blood out of the ventricles into the aorta.
  • The shock waves travel along the fibers of the arteries and are commonly called the arterial peripheral pulse.
• Types of Pulses

  • Carotid
  • Brachial
  • Apical/ Central Pulse
  • Radial Pulse
  • Femoral
  • Popliteal
  • Posterior Tibial
  • Pedal pulse (dorsalis pedis)
• PULSE ASSESSMENT •

  • 1. Rate -number of beats/minute
  • 60 -100-normal
  • Pregnant -90 but not greater than 100
  • Less than 60 -bradycardia (near death, late sign of shock, elderly)
  • Tachycardia
  • Greater than 100
  • 1st Manifestation - exercise, bleeding, anxiety, constipation/diarrhea, anger
• PULSE ASSESSMENT

  2. Rhythm

  • pattern of beats/ regularity of beats |
  • Regular or Irregular/ Arrythmia / Dysrhytmia (skip beats, smoking)
  • Note: for cardiac patient & initial Assessment: • take PR for 1 full minute; for normal client & successive taking of PR -15 seconds x 4
  • 3. Amplitude/ Volume/Depth -Strength of heart contraction ; force of blood with each beat; For peripheral pulse only
• Grading of Pulse Strength

  • 0 - absent; dead
  • 1 - weak; thready; feeble (EASY TO OBLITERATE)
  • 2 - normal pulse; pulse can be easily taken (OBLITERATE WITH MODERATE PRESSURE)
  • 3 - full, increased pulse
  • 4 - bounding, strong/ bounding ((UNABLE TO OBLITERATE OR REQUIRES FIRM PRESSURE)
• PULSE ASSESSMENT

  Equality- both pulses/ present on both sides of the body
• PULSE ASSESSMENT

  Elasticity-reflects expansibility or its deformities - Normal-smooth, straight, soft, and pliable
• PULSE DEFICIT

  • difference between apical and radial pulse taken simultaneously
  • taken by two nurses or 1 nurse only
  • normal pulse deficit = 0
  • if w/ deficit -bleeding or obstruction
• BLOOD PRESSURE

  • force or pressure exerted on arterial wall every contraction of the heart
• FACTORS AFFECTING BP

  • Age
  • Stress
  • Exercise
  • Race
  • Obesity
  • Gender = Females – lower after puberty but higher after menopause
  • Medications
  • Diurnal variations – lower in am and higher in the afternoon
  • • Disease process
• 2 COMPONENTS OF BP

  • Systole - heart contraction
  • Diastole - heart relaxation
  • Normotensive - systole of less than 120 mm Hg and diastole of less than 80 mm Hg.
  • Hypotensive – Systole less than 90 mmHg; diastole less than 60 mmHg
  • Hypertensive – Systole greater than 140 mmHg; diastole less than 60 mmHg
• PULSE PRESSURE

  • difference between systolic and diastolic pressure
  • Normal PP: 30-40 mm HG
• PULSE PRESSURE

  
• Identifying Korotkoff’s Sounds

  • P1 - sharp tapping sound—SYSTOLE
  • P2 - muffled, swooshing, or swishing
  • P3 - thumping but softer than P1
  • P4 - muffled, soft blowing
  • P5 - last sound to be heard followed by silence- DIASTOLE
• Errors in BP Taking

  • Arm unsupported
  • Insufficient rest before assessment
  • Assessing immediately after smoking, in pain, or meal
  • Failure to use the same arm consistently inconsistent measurements
  • Failure to identify auscultatory gap systolic and low diastolic
  • Repeating Assessment too quickly- low diastolic and high systolic
• Assessing Orthostatic Hypotension

  • results from peripheral vasodilation causing blood to leave central/organs such as the brain, and heart towards the periphery
  • Place client in supine position for 2-3mins
  • Take BP & RR
  • Assist client to sit or stand
  • After 1 min, take BP or PR
  • PR increase of 40 beats/min & drop of 30mmHg in BP results to abnormal orthostatic vital signs
• RESPIRATION

  • the act of breathing (automatic/effortless)
  • controlled by:
  • (a) respiratory centers in the medulla oblongata and pons
  • (b) chemoreceptors located centrally in the medulla and peripherally in the carotid and aortic bodies
• TYPES OF BREATHING

  • Costal/thoracic -uses external intercostals muscles and other accessory muscles such as sternocleidomastoid muscles; can be observed by upward and outward movement of the chest
  • Diaphragmatic/abdominal - involves the contraction and relaxation of the diaphragm observed by movement of the abdomen
  • Pursed Lip Breathing -inhale and exhale in pursed lip; prolongs EXPIRATION to expel excess CO2 in the lungs; for patient with COPD
• ASSESSMENT OF RESPIRATION

  1. Rate- number of respiration per minute

  
• TERMINOLOGIES (RESPIRATION)

  • EUPNEA -normal breathing
  • TACHYPNEA - quick, swallow breaths
  • BRADYPNEA -slow breathing
  • APNEA - absence of breathing
  • Note: for bradypnea —never give narcotic analgesics- cause CNS and respiratory depression
• ASSESSMENT OF RESPIRATION

  2. Rhythm- regularity or pattern of Respiration
• HYPERVENTILATION

  • overexpansion of the lungs characterized by rapid and deep breaths (air hunger)
• HYPOVENTILATION

  • under expansion of the lungs characterized by shallow, slow respirations.
• Kussmaul Respiration

  • rapid breathing, a type of hyperventilation
• Cheyne Stokes Respiration-

  • rhythmic waxing & waning of respiration from very deep to very swallow and temporary apnea
• Biot’s Respiration

  • period of Normal breathing (3-4 breaths) followed by a varying period of apnea (10 sec-1minute)
• Apneustic Respiration-

  • prolonged in halation followed by short exhalation
  • CNS problem, asthma
• ASSESSMENT OF RESPIRATION

  3. Character/ Quality-aspects of breathing that are different from normal, effortless breathing
• DYSPNEA

  • difficulty breathing
  • Mngt: Semi fowler’s or High Fowler’s
• Orthopnea

  • DOB when lying; common inpatients with asthma and emphysema;
  • Mngt: Orthopneic Position
• Breath Sounds

  • Stridor - shrill harsh sound heard during Inspiration caused by laryngeal spasm, edema, or obstruction
• Breath Sound

  • Wheeze - musical, squeaky, whistling sound caused by narrowing of bronchioles during EXPIRATION initially