VITAL SIGNS

Module C

What are Vital Signs?

• Temperature

• Pulse

• Respirations

• Blood Pressure

• Pain (considered the 5th vital sign)

When to measure vital signs?

• On admission to health care facility• In a hospital on regular hosp schedule or as

MD ordered (q8hours, q4 hours, etc)• Before and after procedures (surgery,

invasive diagnostic procedures)• Before, during, and after blood transfusions• When patient’s general condition changes

(nursing judgment)

GUIDELINES FOR ASSESSMENT

• Taken by nurse giving care• Equipment should be in good

condition• Know baseline VS and normal

range for pt and age group• Know pt’s medical history• Minimize environmental factors

GUIDELINES CONTINUED

• Be organized in approach• Increase frequency of VS as

condition worsens• Compare VS readings with the

whole picture• Record accurately• Describe any abnormal VS

VS MUST BE ACCURATE

• Both measuring and recording

• VS vary according to pt’s illness/condition

• Compare results with pt’s normal

• Results are used to determine treatments, medications, diagnostic work, etc

REPORTING ABNORMAL VS

• WHEN—grossly abnormal, return to normal, noted change for that pt

• WHY—indicates change in metabolism or physiological function within the body

• WHO—student reports to instructor, then TL, RN, Dr (follow chain of command)

• HOW—orally to appropriate person, then document on chart

Body Temperature

• Difference between heat produced by body processes and the heat lost to the external environment

• Range 96.8 – 100.4 F (36 – 38 degree C)

• Average for healthy young adults 98.6F or 37degrees C

• No single temp is normal for all people

HEAT IS PRODUCED BY:

• Metabolism

• Increased muscle activity

• Vasoconstriction

• External sources

HEAT IS LOST BY:

• Vasodilation

• Convection

• Radiation

• Conduction

• Evaporization

TEMP or FEVER?

• TEMPERATURE—the measurement of heat in the body

• FEVER—the measurement of heat in the body that is above normal for the individual

TYPES OF THERMOMETERS

READING A THERMOMETER

Normal Range Throughout Life Cycle

• Adults- 96.8- 100.4 degree F

• Adult Avg 98.6 F Oral• Adult Avg 99.5 F

Rectal• Adult Avg 97.7 F Ax

• Newborn range – 95.9- 99.5F

• Infants and children – same as adults

• Elderly – Avg 96.8F

Frequently used terms:

• Pyrexia or fever

• Febrile

• Hyperthermia

• Hypothermia

• Afebrile

FEVER—A DEFENSE MECHANISM

• Indicator of disease in body

• Pathogens release toxins

• Toxins affect hypothalamus

• Temperature is increased

• Rest decreases metabolism and heat production by the body

PATTERNS OF FEVER

• SUSTAINED- remains above normal with little change

• RELAPSING – periods of febrile episodes interspersed with acceptable temp values

• INTERMITTENT—varies from normal to above normal to below normal (may have a fairly predictable pattern)

• REMITTENT—fever spikes and falls w/o a return to normal temp values

Factors Affecting Body Temp

• Age ( newborn- temp control mechanism immature, elderly- sensitive to temp changes)

• Exercise• Hormonal level• Circadian rhythm (temp

normally changes 0.9 to 1.8 degree F /24hr Lowest 1-4AM Max-6PM )

• Stress • Environment

ORAL TEMPERATURE

• Accessible

• Dependable

• Accurate

• Convenient

RECTAL TEMPERATURE

• Most reliable

• MUST hold thermometer in place

AXILLARY TEMPERATURE

• Safe

• Non-invasive

• Least accurate

TYMPANIC TEMPERATURE

• Non-invasive• Safe• Accurate • Disadvantages

– Excessive cerumen

– Improper technique

AXILLARY TEMPERATUREIMPORTANT POINTS

• AXILLA MUST HAVE ADEQUATE TISSUE & BE FREE OF PERSPIRATION

• Not good method for persons with elevated temp

• Used when cannot get oral or tympanic

• Leave in place 10 minutes

ORAL TEMPERATURES

• Wait 15-30 minutes after eating, drinking, chewing gum or smoking

• If mouth breather-do not take orally

• Leave in place 2 – 4 minutes with glass thermometer

TYMPANIC TEMPERATURES

• Oral & tympanic readings will be same/ similar

• Must direct probe toward TM (eardrum)

• Follow instructions • Keep plugged in and on

charger when not in use• Usually preferred method• Adults –pull pinna of ear

up & back• Children under 3y/o-pull

pinna of ear down & back

RECTAL TEMPERATURES• MOST accurate• MUST hold thermometer in

place• Very high temp• Unconscious• Do not take rectal temp on

clients with heart conditions• Leave in place 2-3 min with

glass thermometer• Lubricate thermometer• DO Not take hand from

thermometer while rectal in progress

NURSING DIAGNOSIS

Hyperthermia> 100.4F

Hypothermia <96.8F

Risk for altered body temperature

Ineffective Thermoregulation

Temperature Conversion

• Temperature can be measured in Fahrenheit (F) or centigrade or Celsius (c)

• To convert F to c, subtract 32 from F reading and multiply times 5/9. Ex. (104 F – 32) x 5/9 = 40 degree c

• To convert c to F, multiply the c reading by 9/5 and add 32 to the product. Example (40 x 9/5) + 32 =104 F

Pulse

• Pulse- is the palpable bounding of the blood noted at various points on the body. It is an indicator of circulatory status.

TERMS RELATED TO PULSE

• Pulse—Rate, Rhythm, Quality

• Pulse Deficit

• Auscultate

• Palpate

• Tachycardia, Bradycardia

Pulse Sites

• Temporal• Carotid• Apical• Brachial• Dorsalsis Pedis

(Pedal)• Radial and Apical are

most common pulse sites used!

• Radial• Ulnar• Femoral• Popliteal• Posterior Tibial

PULSE RANGESAGE RANGE

ELDERLY (65+) 60-100

AVERAGE ADULT 60-100 (50 or below if extremely athletic)

NEWBORN

0-24 HOURS

120-160

INFANT

1 MONTH – 1 YEAR

100-120

CHILDREN (varies with age)

TECHNIQUE• Feel over BONY area• DO NOT use thumb• Use 2-3 fingers• DO NOT squeeze• Count 30 seconds if regular

x 2 • Note Rate, Rhythm, Quality• If irregular, count for 1 full

minute or take apical pulse for 1 minute.

APICAL-RADIAL PULSE• Requires 2 nurses• 1 nurse counts apical

heart rate • 1 nurse counts radial

pulse• BOTH count during

the same 60 seconds• 1 nurse acts as

timekeeper for both nurses

PULSE DEFICIT

• Count apical-radial pulse

• The difference is the PULSE DEFICIT

• Apical pulse will always be the same or higher than the radial pulse if both are counted correctly

• If the radial pulse is higher, one or both nurses counted incorrectly

Factors Affecting Pulse Rates

• Exercise

• Temperature

• Emotions

• Drugs

• Hemorrhage

• Postural Changes

• Pulmonary Conditions

Variations of Pulse Rates

• Tachycardia – Abnormally elevated pulse rate. (above 100 beats/ min)

• Bradycardia – Abnormally slow pulse rate (less than 60 beats / min)

Pulse Rhythm

• Regular – A regular interval of time occurs between each heartbeat or pulse felt.

• Irregular – Interval interrupted by early, late, or missed beat.

Strength and Quality of Pulse

• Pulse strength may be described as weak, strong, bounding, or thready.

• PULSE GRADING (0-4 rating scale)• 0 – absent, not palpable• 1+ - diminished, barely palpable• 2+- easily palpable, normal pulse• 3+ - full, increased strength • 4+ - bounding, cannot be obliterated

Respirations

• Mechanism the body uses to exchange gases between the atmosphere, blood, and the cells. Involves three processes:

• Ventilation

• Diffusion

• Perfusion

PROCESS OF RESPIRATION

• EXTERNAL RESPIRATION– Inhaled air enters lungs, at alveoli O2 crosses over

to bloodstream– CO2 and other wastes cross over from

bloodstream to alveoli and are exhaled

• INTERNAL RESPIRATION– O2 carried in bloodstream crosses over to body

cells– CO2 and other wastes from body cells cross over

to the bloodstream

RESPIRATION

• Chest Cavity—airtight vacuum with negative pressure

• INSPIRATION—diaphragm contracts and pulls down, ribs move up, lungs fill with air

• EXPIRATION—diaphragm relaxes and moves up, ribs move down, lungs expel air

NORMAL RESPIRATION RANGE

AGE RANGE

ELDERLY (65+) 12-20

AVERAGE ADULT 12-20

NEWBORN

0-24 HOURS

30-60

INFANT

1 MONTH – 6 Months

30-50

CHILDREN (varies with age)

COUNTING RESPIRATIONS

• Count pulse first, then count respirations while holding wrist

• Note rate, rhythm, quality, and character

• Observe a full inspiration and expiration

• Respiratory rates below 12 or greater than 20 require further assessment.

Counting Respirations cont.

• If respirations regular, count respirations for 30 seconds and multiply times 2.

• If irregular, less than 12 or greater than 20, count for 1 full minute.

• Quality of respirations- assess movement of chest or abdominal wall- deep, normal, shallow

• Deep- full expansion of lungs• Normal- normal• Shallow- limited expansion of lungs

Factors Influencing Characteristics of Respirations

• Exercise• Acute Pain• Anxiety• Smoking• Body position

• Medications• Neurological injury• Age• Environmental Temp• Hemoglobin Function

Blood Pressure

• Force exerted on the walls of the artery. Created by the pulsing blood under pressure of the heart.

• Systolic- Peak and maximum pressure of ejection of blood from the heart into the aorta. This is the top number.

• Diastolic- The minimal pressure remaining the heart when the heart relaxes. This is the bottom number.

• Recorded as a ratio Ex. 120/80 • Pulse pressure- Difference between the systolic and

diastolic. ( 120/80 – Pulse pressure 40)

EQUIPMENT FOR BP

“DOPPLER” OR ELECTRONIC BP READINGS

ALTERNATIVE SITES

MEASURING BP

MEASURING BLOOD PRESSURE

• Cuff must be appropriate size

• Cuff should be snug, not loose

• Do not put stethoscope under cuff ( place cuff 1-2 inches above elbow)

• Make mental note of systolic and diastolic numbers

MEASURING BP CONT’D

• If unsure of reading, wait 30 seconds and recheck-if unsure, have someone else check with you

• Loosen cuff even if to be checked q 15 minutes

• Make sure all air is out cuff before applying

MEASURING BP

• False high if cuff too small, false low if cuff is too loose

• Auscultatory gap-temporary disappearance of sound between first sound and next sound.

• Don’t take BP on arm with IV, sling, surgery, mastectomy, renal dialysis shunt, etc.

MEASURING BP CONT’D

• Pt should be sitting or lying with arm at the level of the heart

• Distinguish Korotkoff sounds (sounds heard when taking BP) from artifact

ASSESSMENT OF BP IN BOTH ARMS

• Heart disease• 1st time BP• 5-10 mm Hg

difference-use reading that is highest

• Difference of 10mm Hg should be reported

HOW and WHY BP TAKEN BY PALPATION

• HOW-apply cuff over brachial artery

• Pump up to 20-30 points above last systolic reading

• Feel with 2 fingers for systolic pressure; will not feel diastolic pressure

• WHY- unable to hear weak BPs

FACTORS AFFECTING BP

• Exercise-increases• Arteriosclerosis (loss

of vessel elasticity) & Atherosclerosis (build up of plaque)-increases

• Transfusions- increases

• Emotions -increases

FACTORS CONT’D

• Drugs• Medications• Diurnal variations

FACTORS CONT’D

• PAIN-increases• Hemorrhage –decrease• Sex/Gender• RACE-Blacks more prone

increase• Age• Heredity-increased chance

if immediate family history

Alterations in Blood Pressure

• Hypertension – most common alteration in BP. Most often asymptomatic. Characterized by persistently elevated BP. Noted when diastolic is greater than 90 mm/Hg and systolic is greater than 140mm/Hg. Optimal BP for 18 y/o and older is less than 120/80mm/Hg.

Alterations In BP cont

• Hypotension- When systolic blood pressure falls to 90 or below.

• Orthostatic (Postural) Hypotension- Occurs when a normotensive person develops symptoms and low blood pressure when rising to an upright position.

Common Mistakes in Blood Pressure Assessments

• Cuff too wide or too narrow

• Cuff wrapped too loose or unevenly

• Inflating cuff too slowly

• Deflating cuff too slowly or too quickly

• Arm above or below heart level or not supported

• Repeating assessment too quickly

• Inaccurate inflation level

• Poorly fitting stethoscope

• Impairment of examiners hearing

Documentation of Vital Signs

• Graphic sheets

• Flow sheets

• Nurses notes

• Computerized

Pain – Fifth Vital Sign

• Process of measuring pain: • Verbal and nonverbal• Characteristic of pain- onset, duration, location,

quality, intensity, variations• Factors affecting pain – culture, developmental

stage, gender, anxiety, previous experience• Pain scale- numerical (0-10), verbal (descriptive),

visual analog( faces pain rating scale)