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ASSESS MENT OF VITAL SIGNS

ASSESS MENT OF VITAL SIGNS. Marie B ártová, BSN Institute of Nursing Theory and Practice 1 st Faculty of Medicine, Charles University. www.lf1.cuni.cz → P racovi ště → Ústav teorie a praxe ošetřovatelství → 1 st year medical students / 1 st Aid. CONTENTS. Consciousness

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ASSESS MENT OF VITAL SIGNS

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  1. ASSESSMENT OF VITAL SIGNS Marie Bártová, BSN Institute of Nursing Theory and Practice 1st Faculty of Medicine, Charles University

  2. www.lf1.cuni.cz → Pracoviště → Ústav teorie a praxe ošetřovatelství → 1st year medical students / 1st Aid

  3. CONTENTS Consciousness Body temperature Respiration Blood pressure Pulse

  4. 1. CONSCIOUSNESS Human ability to be aware of own thoughts, emotions, surroundings → adequate responses GLASGOW COMA SCALE (GCS) Patient’s response to: - verbal stimulation - painful stimulation - movement Scale 3 – 15

  5. CONSCIOUSNESS

  6. 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

  7. BODY TEMPERATURE

  8. 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 inchildren/adults - RECTAL fast thermometer, used in infants/confused patients/receiving O2 th. axillo – rectal difference 0,5 °C - VAGINAL used in gynecology

  9. NORMAL RESPIRATIONS Effortless Regular Smooth AVERAGE RESPIRATIONS Infant to 2 years 24–34/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 ) Kussmaul’s breathing(deep) 3. RESPIRATION

  10. 4. BLOOD PRESSURE (BP) The pressure of blood in the arterial wall Factorsaffecting 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)

  11. BLOOD PRESSURE (BP) BP reading: - systolic pressure (ventricle contraction) - diastolic pressure (ventricle at rest) BP readings record: BP 120/80 Equipment: - sphygmomanometer - stethoscope

  12. BLOOD PRESSURE (BP) Places for measuring: - upper arm (brachial artery) - calf / thigh (popliteal artery) Measuring techniques: - auscultation (sphygmomanometer+stethoscope)- palpation (sphygmomanometer) - invasive methods (CVP)

  13. 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

  14. 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) PULSE

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

  16. THANK YOU !

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