Transcript Vital Signsx

Vital Signs
NUR 116

What is a sign? How is it different from a symptom?

What does “vital” mean?
The four vital signs

Temperature

Pulse

Respiratory Rate

Blood pressure

“pain is the fifth vital sign”

Oxygen saturation
Why monitor vital signs?

First part of assessing patient condition

Identify problems

Evaluate response to intervention
Guidelines for measuring vital signs

Ensure that equipment is functional and is appropriate for size and age of patent

Delegate measurements appropriately

Be able to understand and interpret values

Know the patient’s usual range of vital signs

Determine the patient’s medical history, therapies, and medications

Control or minimize environmental factors that affect VS

Use organized, systematic approach

Communicate and document findings

Analyze results

Educate patients and families in technique and significance
When do we measure VS?

On admission to facility

When assessing client during home visits

In hospital on routine schedule

Before and after surgery or diagnostic procedure

Before, during, and after blood transfusion

Before, during and after medications or therapies that might affect values

Change in client’s general condition

Before and after nursing interventions that might affect values

When client reports non specific symptoms of distress
Temperature

Body heat produced – body heat lost to environment= body temperature

Core temp remains constant but surface temp can fluctuate according to
environment

Sites: oral, rectal, axillary, tympanic membrane, temporal artery, esophagus,
pulmonary artery, bladder

Acceptable range: 96.8-100.4 F
(36-38 C)
Factors affecting body temperature
AGE
EXERCISE
HORMONE LEVEL
CIRCADIAN RHYTHM
TEMPERATURE
ALTERATIONS
ENVIRONMENT
Temperature Alterations



Fever (pyrexia)

Pyrogens trigger immune response, affects hypothalamic set point

FUO fever of unknown origin
Hyperthermia

Body is unable to promote heat loss or reduce heat production

Malignant hyperthermia
Heatstroke


Heat Exhaustion


Hot, dry skin, temp >104, nausea, muscle cramps, giddiness, confusion, unconscious
Profuse diaphoresis, caused by environmental heat exposure
Hypothermia

Heat loss due to prolonged exposure to cold. <93.2 F ; special thermometer required
Temperature Regulation
Heat production
Heat loss

By product of metabolism

Radiation

Activity increases metabolic rate

Conduction

Basal metabolic rate

Convection

Voluntary muscle movement

Evaporation

Shivering

Non shivering thermogenesis
Pulse

Pulse: the palpable bounding of blood flow at various points in the body

Indicator of circulatory status

Pulse rate: number of pulsing sensations felt in one minute

Cardiac contraction…aortic walls distend…pulse wave travels to distal arteries

Felt by palpating artery lightly against underlying bone or muscle

Inversely proportional to blood pressure

Not necessarily the same as “heart rate”

Regular count for 30 seconds x 2, irregular count for 60 seconds
Assessment of pulse
Sites
Character

Temporal

Rate

Carotid

Rhythm

Apical


Brachial
Equality

Radial

Strength

Ulnar

Femoral

Popliteal

Post tibial

Dorsalis pedis

0 absent

1 thready

2 weak

3 full, normal

4 bounding
Peripheral pulse assessment (radial)

Supine or sitting

Forearm straight alongside body, or across lower chest or abdomen. If sitting,
bend elbow 90 degrees and support lower arm.

Place tips of your first two or middle three fingers over groove along radial
(thumb side) of client’s inner wrist.

Lightly compress, obliterate pulse initially then relax pressure so pulse is
easily palpable

When regular pulse is felt, look at watch’s second hand and begin count
Assessing apical pulse

5th intercostal space, Left midclavicular line
Factors affecting pulse
EXERCISE
FEVER
EMOTIONS
PAIN
DRUGS
POSTURAL CHANGES
PULMONARY CONDITIONS
BLOOD PRESSURE/BLOOD VOLUME
TERMS TO KNOW

PULSE DEFICIT

BRADYCARDIA

TACHYCARDIA

DYSRHYTHMIA

SEE TABLE 24-1 (Taylor) FOR ACCEPTABLE RANGES ACROSS LIFESPAN.

ADULT NORMAL IS 60-100 BPM
RESPIRATIONS

VENTOLATION/DIFFUSION/PERFUSION

VENTOLATION IS ASSESSED BY MEASURING RESPIRATORY RATE, DEPTH, AND
RHYTHM.

DIFFUSION AND PERFUSION IS ASSESSED BY MEASURING OXYGEN SATURATION.
RESPIRATION

INSPIRATION : DIAPHRAGM CONTRACTS, RIBS RETRACT, ABD ORGANS MOVE

NORMAL, RELAXED BREATH INHALES 500 ML OF AIR

EXPIRATION: DIAPHRAGM RELAXES, LUNG AND CHEST WALL RETURN TO
RELAXED POSITION

SIGHS EVERY 5 OR SO BREATHS: EXPANDS SMALL AIRWAYS AND ALVEOLI

BRAIN STEM REGULATES RHYTHM AND DEPTH BASED ON OXYGEN, CARBON
DIOXIDE, ACID LEVELS IN BLOOD
Assessing respirations

Easiest to assess, but most haphazardly measured

Do not estimate

Do not let client know you are assessing respirations

Include rate, depth, rhythm

One inspiration + one expiration = 1

Visualize and palpate (hand on upper abdomen)

Auscultate with stethoscope x 30 seconds, mult x 2
Factors influencing respirations
EXERCISE
PAIN
ANXIETY
SMOKING
MEDICATIONS
NEUROLOGICAL INJURY
HEMOGLOBIN FUNCTION
BODY POSTION
ALTERATIONS IN BREATHING PATTERNS

BRADYPNEA

TACHYPNEA

HYPERPNEA

APNEA

HYPERVENTILATION

HYPOVENTILATION

CHEYNE-STOKES RESPIRATION

KUSSMAUL’S RESPIRATION

BIOT’S RESPIRATION

SEE TABLE 24-1 (Taylor) FOR ACCPTABLE RANGES ACROSS LIFESPAN. NORMAL ADULT
RATE IS 12-20 BREATHS PER MINUTE
ASSESSMENT OF DIFFUSION AND
PERFUSION

SaO2 (oxygen saturation or O2 sats) percentage of hemoglobin that is
bound (saturated) with oxygen molecules in the arteries

Measured with pulse oximeter: emits light wavelengths that oxygenated and
deoxygenated hemoglobin molecules absorb differently

Probe or sensor goes on finger or earlobe

Usual range is 95-100%

Document with rate, depth, rhythm of resp.
Blood Pressure


BP: the force exerted on the walls of an artery by pulsing blood under
pressure from the heart.

Systolic : maximum peak pressure during ventricular contraction

Diastolic: minimal pressure during ventricular relaxation

Systolic/diastolic= blood pressure
Pulse pressure: difference between systolic and diastolic pressure

Systolic-diastolic= pulse pressure
Physiology of arterial blood pressure

Cardiac output

Peripheral resistance

Blood volume

Viscosity

Elasticity
Measuring Blood Pressure

Expressed as millimeters of mercury (mm Hg)

Non invasive or invasive (direct measure using a thin probe in artery)

Sphygmomanometer and stethoscope

Cuff, bulb, gauge

Place diaphragm of stethoscope over artery (brachial or popliteal)

Inflate cuff to 30 mm Hg above palpated systolic pressure

Slowly release valve on gauge

First heard clear sound: systolic

Point at which sound disappears: diastolic

Difference of 5-10 mm Hg between extremities may be normal
Korotkoff phases
Factors Influencing Blood Pressure
AGE
STRESS
ETHNICITY
GENDER
MEDICATIONS
ACTIVITY/WEIGHT
SMOKING
DAILY VARIATION
HYPERTENSION

NORMAL ADULT RANGE IS <120/ <80

PREHYPERTENSION 120-139/ 80-89 (EITHER READING, TWO OR MORE
READINGS OVER SUBSEQUENT VISITS)

HYPERTENSION >140/ >90 (EITHER READING, TWO OR MORE READINGS)

HYPERTENSION IS OFTEN ASYMPTOMATIC

BLOOD FLOW TO HEART, BRAIN, KIDNEYS IS DECREASED
HYPOTENSION

SYSTOLIC PRESSURE >90

DILATION OF ARTERIES, LOSS OF BLOOD VOLUME, FAILURE OF HEART MUSCLE
TO PUMP ADEQUATELY

ORTHOSTATIC (POSTURAL) HYPOTENSION

DEHYDRATION, ANEMIA, BLOOD LOSS, EXTENDED BED REST, MEDS

OBTAIN BP AND PULSE 1-3 MINUTES AFTER CLIENT CHANGES POSITION
ERRORS IN BP MEASUREMENT
False high
False low

Cuff too narrow or short

Cuff too wide

Cuff wrapped too tightly

Arm above heart level

Arm below heart level

Stethoscope applied too firmly

Deflating cuff too slowly

Arm not supported
When electronic measurement is not
appropriate

Irregular heart rate

Peripheral vascular obstruction (clots, narrow vessels)

Shivering

Excessive tremors

Inability to cooperate

Blood pressure less than 90 systolic
Lifespan Considerations

Use appropriate size equipment for infants and children

Apical site for pulse measurement in infants

Know typical ranges for age

Loss of subcutaneous fat in older adults means temperatures in the low end of
normal range, and greater risk for hypothermia

Older adults’ heart rate takes longer to rise in response to stress and longer
to return to normal

Lift breast tissue in older women to assess apical pulse

Kyphosis, scoliosis, rigid rib cage make resp assessment difficult in older
adults
Documenting Vital Signs

Graphics or vital signs flow sheet

Watch for trends

Record in nurse’s notes any accompanying or precipitating symptoms: dizzy,
diaphoretic, chest pain, shortness of breath

Document any interventions initiated as a result of VS measurement

May address possible causes of alterations but be careful of documenting
“cause and effect”
“Pain is the 5th Vital Sign”

Pain is subjective and defined by the patient

“pain is whatever the patient says it is”

0-10 scale

Recorded with vital signs on flow chart
or description of pain behaviors