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

2. www.lf1.cuni.cz → Pracoviště → Ústav teorie a praxe ošetřovatelství → 1 st year medical students / 1 st 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 Changes in consciousness QUALITATIVEQUANTITATIVE anxiety depression delirium somnolent sopor coma (shallow/deep)

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 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

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

9. 3. RESPIRATION 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)

10. 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)

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 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)

15. 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?

16. THANK YOU !