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Chapter 16 VITAL SIGNS

Chapter 16 VITAL SIGNS. Pam Diggens. 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.

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Chapter 16 VITAL SIGNS

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  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 Patient’s 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 person’s “normal” measurement.

  6. Remember, a baseline measurement may not always be the person’s “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 person’s temperature fluctuates throughout the day. This is known as the circadian rhythm. A person’s 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, women’s 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.

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

  23. 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)

  24. 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)

  25. 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.

  26. 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).

  27. PART 4: Respiration

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

  29. 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 body’s demand for oxygen, so the rate and depth of respirations likewise increases. • Respiration rate and rhythm can be altered by pain.

  30. 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)

  31. 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 patient’s condition. (Goldhill et al, 1999).. • Any abnormalities should be reported immediately, as the patient may be at risk of deteriorating.(Hogan, 2006)

  32. 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.

  33. 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. Susan’s condition could potentially deteriorate and she needs to be fully re-assessed.

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