Vital Signs Quick Assessment ! New Procedure 2022

VITAL SIGNS (CARDINAL SIGN)

          Nursing officer to know about normal parameter in clinical practice. In this article describes about vital signs and how to assessment quickly vital signs. Normal parameter is very important in hospital/home because you can save their life. This article help full for competitive exam as a best short notes 2022. All information given bellow about temperature,pulse,respiration,blood pressure and pain.

 

INFORMATION ABOUT VITAL SIGNS IN THIS ARTICLE:-

 

  • Definition of Vital Sings?

  • Types of Vital Sings?

1. Body temperature
2. Pulse rate
3. Respiration rate
4. Blood pressure
5. Pain

 

 

Definition of  Vital Sings:-

Five vital signs (Cardinal Sign) most important medical signs that indicate the status of the body’s vital functions.

Types of Vital Sings:-

1. Body temperature
2. Pulse rate
3. Respiration rate
4. Blood pressure
5. Pain

1. BODY TEMPERATURE VITAL SIGNS:-

A degree of heat maintained by body or it is the balance between heat production & heat loss.

    • THERMOGENESIS – Chemical regulation of heat production.

    • THERMOLYSIS – Physical regulation of heat loss.

    • Temperature /Heat regulation Centre — Hypothalamus.

TEMPERATURE-CHECK-UP
TEMPERATURE-CHECK-UP

A. THERMOGENESIS:

a) Oxidation of food
b) Specific dynamic action of food

c) Exercise
d) Strong emotion
e) Hormonal effect- Increase adrenal thyroid
f) Disease condition

B. THERMOLYSIS:

i. SKIN

a) Radiation (60%) – Transfer of heat from surface of one object to
another which is not in direct contact.
b) Evaporation (22%) – A process by which substance in liquid change
to vapor state.
c) Convection (15%) – Heat transfer by air circulation.
d) Conduction (3%) – Heat transfer from hot part to cold part.

ii. LUNG
iii. KIDNEY
iv. BOWELS

 

KEY POINT:-
Normal Body Temperature 98.6 °F (37 °C)
Circadian rhythm/ Diurnal variation Body Temperature normally changes 0.5- 1°C during 24-hour period.

Common site of Temperature:-

Axillary –       97.6P °F        = 36.4 °C
Oral –          98.6 °F          = 37 °C
Rectal –        99.6 °F         = 37.5 °C
By ear –
By skin –

The temperature is not taken rectally in cardiac client, who has undergone rectal surgery or diarrhea,fecal impaction or rectal bleeding or who is at risk for bleeding.

ASSESSMENT OF TEMPERATURE:.

  • Highest Temperature 4-6 PM in evening.

  • Lowest Temperature 4-6 AM in Morning.

  • After menstruation temperature decreases and after Ovulation temperature increases (0.5 -1°F) due to hormone progesterone.

  • Use Dorsal surface of your hand while taking temperature.

  • Most reliable method of temperature assessment -RECTUM.

  • Most common method of temperature assessment-ORAL.

 

For Vital Sign thermometer
For-Vital-Sign-thermometer

Glass thermometer: – (Mercury)

  • Highly heat sensitive.

  • Uniform expansion.

  • Economical & easily visible.

  • There is a constriction above the bulb which prevents mercury fall.

  • Before taking the temperature, clean the thermometer from bulb to stem & after stem to bulb (Less contaminated area to more contaminated area.)

Cleaning Before – Bulb to Stem.
Cleaning After – Stem to Bulb.

Disinfection of thermometer: –

No.

Disinfection

Strength

Time

1.

Dettol

1:40

5 Minute

2.

Savlon

1:20

5 Minute

3.

Lysol

1:40

3 Minute

Electronic Thermometer:-

It contains a battery power control unit and temperature sensitive probe. Non-breakable and short time for reading. Ideal for children.

Convert Formulas: –      C = (F-32) x 5/9

                                          F = (Cx9/5) + 32

 

2. PULSE RATE

PULSE-CHECK-UP

         

 

         Pulse Rate: The alternate expansion (rise) & recoil (fall) of an artery as the wave of blood is passed through it during left ventricular contraction.Your pulse is the rate at which your heart beats.Pulse is usually called your heart rate, which is the number of times your heart b/m. Rhythm and strength of the heartbeat can also be noted,blood vessel feels hard or soft.Normal pulse rate for adult – 60 to 100 b/m. Most common site use for pulse radial artety and blood pressure brachial artery used.

 

Commonest site:-

Temporal artery:- Over the temporal bone.

Carotid artery:- Side of neck. Used during cardiac arrest/shock in adult.

Brachial artery:- Above elbow in antecubital fossa.Used to measure Blood Pressure and during cardiac arrest in infants.

Radial artery:- Thumb side of forearm at wrist. Common site for pulse assessment.

Femoral artery:- Groin area. Used to determine circulation in the leg.

Popliteal artery:- Back of the knee in popliteal fossa.

Posterior tibial artery:- Behind/ below medial malleolus.

Dorsalis pedis:- Along top of foot.

Apical pulse:- Over the apex of heart.

Characteristic of Pulse:-

A. Rate:- Beats/minute

Before birth = 140 (120-160)
At birth = 130- 1500
Infant = 120 (115- 130)
Adult 70-80 (60- 100)
Old 60-70

B. Rhythm: The regularity of the beat.

  • Dysrhythmias: The variation or irregularity of the rhythm.
  • Intermittent pulse: The beat is missed at regular intervals.

  • Sinus arrhythmias: The condition in which the pulse rate is rapid inspiration & slow

    expiration.

  • Dicrotic pulse:– One heart beat & two arterial pulsation giving sensation of double beat.

  • Pulse deficit:– Difference between apical pulse and radial pulse.

C. Volume:- Fullness of artery.

a) Water hammer/ Corrigan’s/ collapsing pulse: The full volume pulse rapidly
collapsing E.g. Aortic regurgitation.
b) Bounding pulse: The full blood volume pulse. Stroke volume
c) Pulsus alternan: The rhythm is regular but volume has an alternative strong &
weak character. Ex. Heart block, Lt. V. failure.
d) Bigeminal pulse: The irregular rhythm in which every other beat comes early.
Ex. MI.

e) Thready/ weak/ wiry pulse:- The small weak pulse that feels like wire or
thread. Ex. Shock, Diarrhea, Vomiting.
f) Paradoxical pulse: The pulse feels weaker at inspiration Ex. Heart failure,
Cardiac damage.

D. Tension:- The degree of compressibility.

  • High tension is difficult to compress.

  • Low tension Easy to compress.

How to check your pulse:-

Palpation: Tip finger 1st & 2nd, Never use your thumb because there is an artery.
Auscultation: -For apical pulse- stethoscope.

Position:-

  • In Adult at 5th left intercostal space over midclavicular line (Mitral area).

  • In infants at 4th left intercostal space lateral to midclavicular line.

If regular pulse = 30 sec x 2
If irregular pulse = full one minute pulse.

 

3.RESPIRATION RATE

       Respiratory rate is the number of breaths you take per minute. The normal respiration rate for an adult at rest is 12 to 20 breaths per minute. A respiration rate under 12 or over 25 breaths per minute while resting is considered abnormal.

Respiration two types:-

External Respiration: The exchange of gases between lungs & blood.
Internal Respiration: – The exchange of gases between blood & Tissue.

Characteristic of the respiration:-

The number of respirations in one minute.
Birth-35 (30 -60/min.)
Infant-30 (20-40 /min.)
Adult- 16 (12-20/min.)
Old age- 10-24/min.

Respiratory center present in medulla oblongata.

1. Dyspnea: The difficult, labored, painful breathing.
2. Hyperventilation: Over expansion of lungs by rapid & deep breathing.
3. Hypoventilation:- Under expansion of the lung characterized by shallow breathing.
4. Hyperpnoea:- Deep breathing.
5. Eupnosa ;- Normal breathing.
6. Tachypnoea;- Respiration more than 24 respiration/min.
7. Bradypnoea:- Respiration less than 10 respiration/min.
8. Hypoxia: the lack of oxygen in tissue.
9. Hypoxaemia:- Lack of oxygen in blood.
10. Cyanasiss- The bluish skin discoloration due to lack of oxygen in tissue.
11. Apnoea- Complete cessation of respiration.
12. Cheyne stokes respiration:- Rhythmic waxing and waning of respiration, from very deep to very shallow breathing and temporary apnoea.
13. Orthopnoea: Ability to breath only in an upright sitting position or standing position.
14. Asphyxia; the state of suffocation.
15. Biot’s respiration: Shallow 2-3 respiration followed by irregular period of apnoea.
16. Kussmaul’s respiration:- Regular but increased rate and depth of respiration.
17. Sich:- Deep inspiration followed by prolonged expiration.

Abnormal Sounds:-

  • Stridor: The vibration, shrill, harsh sound due to upper airway obstruction.

    Ex.Laryngitis.

  • Wheezing:- High pitch, whistling sound. Lower airway obstruction.Ex. Asthma

  • Rahl/ Rale: The bubbling sound/ Rating sound due to mucus in air passage.Ex. Pneumonia.

*For each 19F (0.6C ) Temperature increase = 7 – 10 beats/minute (Pulse) increases.
*For each 19F (0.6C ) Temperature increase = 4 breath/minute respiration increases.
*For each 1°F Temperature increase = 7% oxygen consumption increases
*For each 1°C Temperature increase = 13% oxygen consumption increase

Respiration rate counted = 30 sec x 2
If Client very ill Respiration rate counted   = full one minute.

4.BLOOD PRESSURE

                 The pressure exerted by the blood against the wall of the artery as it flows through them. Blood pressure is the force of the blood pushing against the artery walls during contraction and relaxation of the heart. Each time the heart beats, it pumps blood into the arteries.

Types of B.P.:-

1. Systolic B.P:- The highest pressure against the wall of artery during ventricular systole. Normal Systolic B.P 120 mm of Hg.
2. Diastolic B.P. :- The lowest pressure of the blood against the wall of vessels when the heart is resting. (The pressure just before the contraction of the left ventricle.) Normal Diastolic B.P. 80 mm of Hg.

Normal Blood pressure = 120/80 mm of Hg. Or 16/11 KPa.

Assessment of BP:-

Avoid smoking for 30 minute before.

Rest for 5 minute.

Apply cup above antecubital fossa 2.5 cm(1 inch.

The first heard sound “Korotkoff sound” denotes systolic B.P.

When the sound ceases it shows diastolic B.P.

Cuff deflate rate 2-3 mm of Hg/second.

The B.P. in the leg:- Systolic pressure higher 20 -30 mm of Hg. Diastolic pressure is the same as the arm.

 

Artery use in B.P.measurement:-

Arm – Brachial artery

Thigh – Popliteal artery

Ankle joint – Posterior tibial artery

Pulse Pressure – Difference between Systolic blood pressure and Diastolic blood Pressure.

Normal Pulse pressure = 40 mm of Hg.

Blood Pressure Categorized:-

Blood Pressure

Systolic Pressure/Diastolic Pressure

Normal B.P.

120/80 mm of Hg

Prehypertension

120-139/80-89 mm of Hg

Hypertension stage 1st

>140/ >159 mm of Hg

Hypertension stage 2nd

>160/ >100 mm of Hg

Hypertensive crisis

>180/120 mm of Hg

Hypotension

<90/<60 mm of Hg

Primary Hypertension:- Unknown cause.
Secondary Hypertension:- Known Pathology.

Ratio of Systolic pressure, Diastolic pressure and Pulse pressure is 3:2:1

The instrument used to measure B.P. is the Sphygmomanometer.

 

Types of Sphygmomanometers:

1. Mercury
2. Aneroid
3. Digital
MABP Mean ( Arterial Blood Pressure)
MABP = (DP x 2 ) +SP/3 OR Diastolic pressure + 1/3 Pulse pressure
Normal value – 93 mm of Hg

5.Pain:-

  • Pain is a 5th vital Sign.

 

PAIN

PAIN ASSESSMENT

 

ASSESSMENT: To be done once in every shift and as and when required in case of presence of pain.

 

ASSESSMENT TOOL:

 

  • Numeric pain scale

    Numeric pain scale
    1.Numeric pain scale

     

Visual Analog Scale
Visual analogue scale

 

 

  • Visual analogue scale
  • Verbal pain scale

  • Wong Baker Faces pain rating scale

Wong baker pain scale

  • FLACC – Face, Legs, Activity, Cry, Consolability scale:-                                                                                   – measurement used to assess pain of infants to 7 years.

  • Children or individuals that are unable to communicate their pain.

  • NIPS- Neonatal infant pain scale.

  • Behavioral modified pain scale

 

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