Vital Signs
Published on Nov 22, 2015
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PRESENTATION OUTLINE
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WHAT ARE VITAL SIGNS?
- AKA cardinal signs
- includes blood pressure, pulse, respiration, temperature, and pain
- clearest indicator of overall health status
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- forms baseline assessment data necessary for an ongoing evaluation of a client's condition, thus allowing deviations to be easily identified
So when do we take vital signs?
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- usually q 4h, q 6h, q8h
- In acute situtations, may be assessed q 5min, q 15 min, q1-2h
- upon admittance, pre/post surgery, before certain medications
- whenever physical distress is noted
Photo by David Jackmanson
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- as per doctor order
- before, after, or during medications that affect body system function
- before, after, or during nursing interventions that affect vital signs
- before and after a day/weekend pass
last one: e.g blood administration
WHENEVER YOU THINK IT IS APPROPRIATE TO DO SO!
Age
HOW DOES AGE PLAY A FACTOR?
AGE INFLUENCES BODY TEMPERATURE. BODY TEMPERATURE VARIES IN NEWBORNS AND THE ELDERLY DUE TO THERMOREGULATION DEFIENCIES IN BOTH AGE GROUPS. IN NEWBORNS THEIR THERMOREGULATORY MECHANISMS ARE IMMATURE. SO BABIES TEMPERATURES CHANGE WITH THEIR ENVIRONMENT. WITH THE ELDERLY, THEIR THERMOREGULATION IS INEFFECTIVE DUE TO THE AGING PROCESS. ALSO WITH AGING, PULSE RATE AND RATE OF RESPIRATIONS DECREASE. ON THE OTHER SIDE, BLOOD PRESSURE INCREASES WITH AGE.
Photo by Libertinus
Gender
WHAT MAY BE SOME DIFFERENCES?
WOMEN EXPERIENCE GREATER TEMPERATURE FLUCTUATIONS, PROBABLY DUE TO HORMONAL CHANGES, AND TEMPERATURE CHANGES ALSO OCCUR DURING THE MENSTRUAL CYCLE. AND DURING MENOPAUSE BRINGS INTENSE BODY HEAT AND SWEATING.
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Race and Heredity
WHY ARE THESE IMPORTANT TO CONSIDER?
SOME STUDIES SHOW THAT AFRICAN AMERICANS/Aboriginal ARE MORE PRONE TO HIGH BLOOD PRESSURE.
Photo by Finn Frode (DK)
Medications
How do these affect vital signs?
SOME MEDICATIONS CAN DIRECTLY OR INDIRECTLY ALTER THE PULSE, RESPIRATIONS AND BLOOD PRESSURE, FOR EXAMPLE NAROCOTIC RESPIRATIONS CAN DEPRESS THE RATE AND DEPTH OF RESPIRATIONS AND LOWER THE BLOOD PRESSURE, WHILE MEDS LIKE DIGITALIS DECREASES THE PULSE RATE.
and think about--have they taken their BP meds yet?
and think about--have they taken their BP meds yet?
Photo by Damian Gadal
Pain
WHAT IS THE LINK BETWEEN PAIN AND VITAL SIGNS?
ACUTE PAIN INCREASES THE HEART RATE, RESPIRATORY RATE AND BLOOD PRESSURE, (SYMPATHETIC) WHILE CHRONIC PAIN DECREASES THE PULSE RATE.(PARASYMPTHETIC)
and of course we know if there is a physical reason or ill ness that can be causing it, bleeding, shock, MI etc...
and of course we know if there is a physical reason or ill ness that can be causing it, bleeding, shock, MI etc...
Photo by Joaquin Villaverde Photography
Exercise
exercise can increase body temperature- in a marathon some may go up as high as 40
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Circadian Rhythm
temperature normally changes 0.5 to 1.0 degrees during a 24 hour period. The temperature is usually the lowest between 0100-0400. Maximum temp is at 1800.
Photo by garryknight
Infection
A client who has an infectious process caused by bacteria, virus, fungi and/or other microrganisms which release pyrogens which increase temperature= FEVER (usually not harmful if it stays below 39 degrees
Others:
EXPOSURE TO EXTREMELY HOT OR COLD TEMPERATURES CAN ALTER BODY TEMPERATURE.Ex being in a very hot room without taking coat off, or going outside in the very cold without wearing the proper clothing
stress:PHYSICAL AND EMOTIONAL STRESS INCREASE BODY TEMPERATURE.
Others:
EXPOSURE TO EXTREMELY HOT OR COLD TEMPERATURES CAN ALTER BODY TEMPERATURE.Ex being in a very hot room without taking coat off, or going outside in the very cold without wearing the proper clothing
stress:PHYSICAL AND EMOTIONAL STRESS INCREASE BODY TEMPERATURE.
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FACTORS AFFECTING PULSE RATE
Photo by JD Hancock
Postural Changes
standing or sitting-increase P, decreases BP
lying down-decreases P, increases BP
lying down-decreases P, increases BP
Photo by Mirko Isaia
Pulmonary Conditions
increases P
age-AS THE ADULT AGES , LUNG ELASTICITY DECREASES THUS LUNG CAPACITY DECREASES. TO COMPENSATE, RESPIRATIONS INCREASE.
Others:
neurological injury hemoglobin function
stress/anxiety
altitudeTHE OXYGEN CONTENT OF THE AIR DECREASES AS THE ALTITUDE INCREASES.LESS OXYGEN CONTENT, INCREASED RR.
gender:MEN HAVE A LARGER LUNG CAPACITY, AND A LOWER RR
hx of cardiovascular disease
hx of diabetes mellitus
Rapid IV infusion of fluids or blood products
obesity
increased cholesterol intake
age-AS THE ADULT AGES , LUNG ELASTICITY DECREASES THUS LUNG CAPACITY DECREASES. TO COMPENSATE, RESPIRATIONS INCREASE.
Others:
neurological injury hemoglobin function
stress/anxiety
altitudeTHE OXYGEN CONTENT OF THE AIR DECREASES AS THE ALTITUDE INCREASES.LESS OXYGEN CONTENT, INCREASED RR.
gender:MEN HAVE A LARGER LUNG CAPACITY, AND A LOWER RR
hx of cardiovascular disease
hx of diabetes mellitus
Rapid IV infusion of fluids or blood products
obesity
increased cholesterol intake
Photo by Cea.
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- ensure functioning equipment
- know the client's normal ranges
- be aware of the client's medical history, therapies,medications
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- if you delegate vital sign measurement.....
- because physical and emotional stress can alter vital signs--help client to relax
- use a consistent system for obtaining vital signs
#3:FOR EXAMPLE TAKE RESPIRATIONS AFTER TAKING PULSE WHILE YOUR FINGERS ARE STILL IN PLACE AT PULSE SITE.
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- unusual/abnormal finding? repeat
- abnormal finding? stay calm and professional
- inform the nurse in charge or doctor of abnormal findings when necessary
IF YOU ARE NOT , THIS CAN UPSET THE CLIENT. If the client asks why you are taking another reading, calmly explain that you have obtained a slightly high or low measurement and just want to check it again. Even getting another nurse to read it is a very good idea.
They do mention in your textbook about delegating vita sign measurement to others----Ex: LPN’s. However if we do delegate we must remember that we are responsible for the correspnding actions
They do mention in your textbook about delegating vita sign measurement to others----Ex: LPN’s. However if we do delegate we must remember that we are responsible for the correspnding actions
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Temperature
Body temperature is the difference between the amount of heat produced by the body processes and the amount of heat lost to its external environment
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Sites for Temperature Reading
- oral: the most common, easy access, and client comfort
- rectal: most reliable
- tympanic: accurate for core temp
- axillary: noninvasive, can be ued for newborns and the unconscious
rectal: explain procedure for positioning. lubricate probe 2.5-3.5 cm-for adult, 1.2-2.5 cm for infant or child-do not press ejection button!!!!Insert 3.5 cm for adults
axillary: explain procedure.
tympanic (ear) --pull pinna backward, up and out for adults, pinna down and back for children younger than 3. point specula towards nose
axillary: explain procedure.
tympanic (ear) --pull pinna backward, up and out for adults, pinna down and back for children younger than 3. point specula towards nose
TYPES OF THERMOMETERS
Chemical strips- 30-6 page 538 (used mostly for children., single use, removed after 60 seconds. Used in oral and axillary temps. usually for screening--not considered reliable.
Temporal artery thermometer--page 538 fig 30-5
Temporal artery thermometer--page 538 fig 30-5
Photo by Leo Reynolds
GLASS MERCURY THERMOMETER
: ONLY HANDLE AT THE SEALED END BECAUSE THE MERCURY BULB COULD INFLUENCE YOUR READING. USE YOUR WRIST TO SHAKE MERCURY BELOW 35.6, AND PLACE UNDER TONGUE TO LEFT OR RIGHT AND TELL CLIENT TO HOLD IN MOUTH-TIGHTLY CLOSED- FOR 3-5 MIN. However now not used due to safety issues
FOR THE AXILLA, IT IS UNDER THE ARMPIT WITH ARM ACROSS THE CHEST FOR 6-8MIN. FOR THE RECTAL, IT GOES IN ONE INCH INTO ADULTS AND ONE HALF INCH IN INFANTS AND CHILDREN. DISPOSABLE SHEATHS ARE USED. THIS TAKES ABOUT 3MIN.
FOR THE AXILLA, IT IS UNDER THE ARMPIT WITH ARM ACROSS THE CHEST FOR 6-8MIN. FOR THE RECTAL, IT GOES IN ONE INCH INTO ADULTS AND ONE HALF INCH IN INFANTS AND CHILDREN. DISPOSABLE SHEATHS ARE USED. THIS TAKES ABOUT 3MIN.
TYMPANIC ELECTRONIC THERMOMETER
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ELECTRONIC ORAL/RECTAL THERMOMETER
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WATCH FOR CLIENTS THAT HAVE DRUNK HOT OR COLD LIQUIDS JUST PRIOR TO HAVING THEIR TEMPERATURE TAKEN. IF SO WAIT ABOUT 15 MINUTES BEFORE TAKING TEMPERATURE.
ORAL ROUTE SHOULD NOT BE USED IF THE CLIENT HAS HAD ORAL SURGERY, TRAUMA OR SHAKING CHILLS. ALSO SHOULD NOT BE USED IN INFANTS, THE CONFUSED OR UNCONSCIOUS CLIENT OR ONE WITH A FREQUENT COUGH.
ORAL ROUTE SHOULD NOT BE USED IF THE CLIENT HAS HAD ORAL SURGERY, TRAUMA OR SHAKING CHILLS. ALSO SHOULD NOT BE USED IN INFANTS, THE CONFUSED OR UNCONSCIOUS CLIENT OR ONE WITH A FREQUENT COUGH.
Scales of Temperature:
- celcius
-fahrenheit
F=(9/5 xC)+32
C=(F-32)x 5/9
Photo by sameold2010
Normal Readings for Temperature
Normal temp for adults-36-38,
Box 30-1 page 527, The normal temperature inside your infant/child’s body is around 37 degrees Celsius (but it can be up to 38 degrees). There is a fever when the body temperature is more than 38 degrees Celsius.
newborn/child 35.5-37.5
Box 30-1 page 527, The normal temperature inside your infant/child’s body is around 37 degrees Celsius (but it can be up to 38 degrees). There is a fever when the body temperature is more than 38 degrees Celsius.
newborn/child 35.5-37.5
PULSE
When the left ventricle of the heart contracts, a wave of blood surges through the systemic arteries-this wave is called the pulse.
Photo by Charlotte Astrid
RHYTHM
(equal interval between beats)--if not dysrhythmia
Strength
Strength (strong, weak)
bounding, strong, weak, thready (a scarcely perceptible and commonly rapid pulse that feels like a fine mobile thread under a palpating finger) or absent.
bounding, strong, weak, thready (a scarcely perceptible and commonly rapid pulse that feels like a fine mobile thread under a palpating finger) or absent.
Photo by Official U.S. Navy Imagery
Normal Readings for Pulse Rate
box 30-1 page 527, 30-3 page 547
60-100 adults
60-100 adults
Respirations
A term used to cover both the exchange of oxygen and carbon dioxide that takes place in the lungs (external respiration), and the exchange of these gases that takes place in the tissues (between the blood and body cells).(internal respiration).
We assess the external respiration.
Involves two movements-
Inspiration= breathing in
Expiration= breathing out
We assess the external respiration.
Involves two movements-
Inspiration= breathing in
Expiration= breathing out
DEPTH
the degree of movement in the patient’s chest wall. Deep, normal, or shallow.
Photo by Stuck in Customs
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: RESPIRATIONS ARE USUALLY AUTOMATIC, QUIET AND EFFORTLESS
best time to measure respirations is right after pulse with hands still on pulse site as we don't want patients to know we are measuring it....
if regular-then take for 30 seconds and multiply by 2--if not measure for full minute
best time to measure respirations is right after pulse with hands still on pulse site as we don't want patients to know we are measuring it....
if regular-then take for 30 seconds and multiply by 2--if not measure for full minute
Photo by Thomas Hawk
NORMAL READINGS FOR RESPIRATORY RATE
box 30-1 page 527 (says 10-12)
12-20 for adults
Table 30-5 pg 553 for all ages
12-20 for adults
Table 30-5 pg 553 for all ages
ARTERIAL OXYGEN SATURATION LEVELS
Measurement of oxygen saturation of a patient’s hemoglobin
go over norms
PVD, pharmacological vasoconstrictors, low cardiac output, hypotension, tight probe
no moisture, nail polish, fake nails
go over norms
PVD, pharmacological vasoconstrictors, low cardiac output, hypotension, tight probe
no moisture, nail polish, fake nails
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BLOOD PRESSURE
Blood pressure is a measurement of the pressure of the blood in the arteries when the ventricles are contracted (systolic blood pressure) and of the pressure of the blood in the arteries when the ventricles are relaxed (diastolic blood pressure).
BP=systolic/diastolic
BP=systolic/diastolic
Photo by Rosmarie Voegtli
NORMAL READINGS FOR BLOOD PRESSURE
30-1 page 527
BP measurement is not a routine part of assessment in children younger than 3 years.
Table 30-7 page 558
BP measurement is not a routine part of assessment in children younger than 3 years.
Table 30-7 page 558
HYPERTENSION VS HYPOTENSION
be aware of possible signs and symptoms of high blood pressure (headache, flushing of face, nosebleed, fatigue in elderly patients)
be aware of possible signs of low blood pressure (dizziness, mental confusion, restlessness, pale or cyanotic skin and mucous membranes, and cool and mottled skin over the extremities).
be aware of possible signs of low blood pressure (dizziness, mental confusion, restlessness, pale or cyanotic skin and mucous membranes, and cool and mottled skin over the extremities).
BLOOD PRESSURE EQUIPMENT
automatic blood pressure devices
SPHYGMANOMETER
sphygmomanometer= is a pressure manometer with an occlusive cloth cuff that encloses an inflatable ribber bladder. a pressure bulb with a release valve inflates the bladder.
The Manometer
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STETHOSCOPE
page 511 figure 30-7
GENERAL GUIDELINES
avoid extremity with an IV line, arteriovenous shunt(AV shunt= a U-shaped plastic tube inserted between an artery and a vein; usually to allow repeated access to the arterial system for hemodialysis), presence of trauma, side of mastectomy, or side of paralysis after a CVA
the bladder enclosed by the blood pressure cuff should be 80% of the limb circumference in length and the cuff should be 40% of the limb circumference in width.
cuff goes 2.5 cm above site
60 minutes with out caffeine and tobacco, exercise 30 min. Let them rest for at least 5 minutes before taking.
if sitting legs should not be crossed with feet touching the floor. (the unsupported limb can increase diastolic BP. Leg crossing can elevate both)
Table 30-9 page 565
the bladder enclosed by the blood pressure cuff should be 80% of the limb circumference in length and the cuff should be 40% of the limb circumference in width.
cuff goes 2.5 cm above site
60 minutes with out caffeine and tobacco, exercise 30 min. Let them rest for at least 5 minutes before taking.
if sitting legs should not be crossed with feet touching the floor. (the unsupported limb can increase diastolic BP. Leg crossing can elevate both)
Table 30-9 page 565
AUSCULTATING
in the auscultatory method, the examiner listens with a stethoscope, for a series of sounds created as blood flows through an artery after it had been occluded with a cuff and when the cuff pressure is gradually released.
the pattern of sounds =korotoff sounds
Although there are five—it is very often very hard to differentiate between each one—we just want you to focus on the first sound you hear and when you hear no more sounds
first korotoff sound= your first number or the systolic pressure.
the fifth korotoff sound or the point of silence is second number or diastolic pressure.
the pattern of sounds =korotoff sounds
Although there are five—it is very often very hard to differentiate between each one—we just want you to focus on the first sound you hear and when you hear no more sounds
first korotoff sound= your first number or the systolic pressure.
the fifth korotoff sound or the point of silence is second number or diastolic pressure.
Lying and Standing BP
obtain blood pressure after patient lying in bed for five minutes
get patient to stand
take BP after patient standing for 2 minutes
greater than 20mmhg drop in systolic BP or greater than 10mmHg drop in diastolic--positive for orthostatic hypotension.
talk about the study done at the hospital--need risk for fall bracelet, write on carded, falling star, notify physician, take lying standing BP prior to medication administration.
get patient to stand
take BP after patient standing for 2 minutes
greater than 20mmhg drop in systolic BP or greater than 10mmHg drop in diastolic--positive for orthostatic hypotension.
talk about the study done at the hospital--need risk for fall bracelet, write on carded, falling star, notify physician, take lying standing BP prior to medication administration.
Lying and Standing BP
obtain blood pressure after patient lying in bed for five minutes
get patient to stand
take BP after patient standing for 2 minutes
greater than 20mmhg drop in systolic BP or greater than 10mmHg drop in diastolic--positive for orthostatic hypotension.
talk about the study done at the hospital--need risk for fall bracelet, write on carded, falling star, notify physician, take lying standing BP prior to medication administration.
Other sites for blood pressure:
a)must be wide and long enough for larger area of thigh. lying down is best. 2.5cm above popliteal site with bladder over the posterior aspect of thigh.Procedure is identical after this
b)automatic blood pressure devices fig 30-17 page 531
get patient to stand
take BP after patient standing for 2 minutes
greater than 20mmhg drop in systolic BP or greater than 10mmHg drop in diastolic--positive for orthostatic hypotension.
talk about the study done at the hospital--need risk for fall bracelet, write on carded, falling star, notify physician, take lying standing BP prior to medication administration.
Other sites for blood pressure:
a)must be wide and long enough for larger area of thigh. lying down is best. 2.5cm above popliteal site with bladder over the posterior aspect of thigh.Procedure is identical after this
b)automatic blood pressure devices fig 30-17 page 531
Pulse Pressure
The difference between systolic and diastolic pressure. A potential indicator of CV disease.
Normal is approx 30-50mmHg
Why is this important?
Normal is approx 30-50mmHg
Why is this important?
PAIN
Photo by Felix42 contra la censura
P=PROVOCATIVE OR PALLIATIVE
Provocative or Palliative? *What brings it on?What were you doing? What makes it worse/better?
Q= QUALITY OR QUANTITY
Quality or Quantity? *How does it look, feel, sound? How intense/severe?
R= REGION OR RADIATION
Region or Radiation? *Where is it? Spread anywhere?
S= SEVERITY SCALE
Severity Scale? * How bad? 1-10? Getting better, worse, same?
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T- TIMING
Timing? * Onset? Duration? How often?
U= UNDERSTAND PATIENT'S PERCEPTION
Understand patient’s perception. * What does he/she think it means?
