Post on 26-Dec-2015
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)