Chapter 29

Vital Signs

Vital SignsTemperature, pulse, respiratory rate, blood pressure

Pain

Oxygen saturation also frequently measured

Vital signs are used to:◦ Monitor patient’s condition

◦ Identify problems

◦ Evaluate response to intervention

Guidelines for Measuring Vital SignsEnsure that equipment is functional and is appropriate for the size and age of the patient.

Appropriately delegate measurement.

Be able to understand and interpret values.

Know the patient’s usual range of vital signs.

Determine the patient’s medical history, therapies, and prescribed medications.

Control or minimize environmental factors that affect vital signs.

Guidelines for Measuring Vital Signs(cont’d)Use an organized, systematic approach when taking vital signs.

Know the acceptable ranges for your patients before administering medications, and use vital sign measurements to determine indications for medication administration.

Communicate findings.

Accurately document findings.

Analyze the results of vital sign measurement.

Instruct the patient or family caregiver in vital sign assessment and the significance of findings.

Case StudyMs. Coburn is a 26-year-old schoolteacher. Her maternal grandparents immigrated to America from Brazil. She smokes one pack of cigarettes a day and has smoked since she was 16. She is 20 lbs overweight.

She made an appointment because she started to have headaches and frequently felt tired.

Body Temperature PhysiologyBody temperature:

◦ Heat produced

◦ Heat lost

Acceptable temperature range:◦ 98.6° F to 100.4° F or 36° C to 38° C

Temperature sites:◦ Oral, rectal, axillary, tympanic membrane, temporal artery, esophageal,

pulmonary artery

Body Temperature RegulationNeural and vascular

controlHeat production

Heat loss (radiation, conduction, convection,

evaporation)Skin temperature

regulation

Behavioral control Thermoregulation

Case Study (cont’d)Miguel is a 42-year-old Hispanic nurse who works at the clinic Ms. Coburn is visiting. He enjoys providing health-related teaching to the patients and has provided Mrs. Coburn care for 2 years.

During the visit, Miguel assesses Ms. Coburn’s symptoms. He asks her about her headache and fatigue, then takes her vital signs.

Her temperature is 98° Fahrenheit.

Factors Affecting Body Temperature

Age Exercise

Hormonal level Circadian rhythm

Environment Temperature alterations

Temperature Cycle

Temperature AlterationsPyrexia (fever): important defense mechanism◦ Pyrogens

◦ Febrile/afebrile

◦ Fever of unknown origin (FUO)

Hyperthermia◦ Malignant hyperthermia

Heatstroke (104° F or higher)

Heat exhaustion

Hypothermia ◦ Frostbite

Hypothalamic Temperature Control

Patterns of FeverSustained

Constant above 38° C (100.4° F) with little fluctuation

IntermittentFever spikes interspersed

with usual temperature levels

RemittentFever spikes and falls without

a return to normal temperature levels

RelapsingPeriods of febrile episodes and periods with acceptable

temperature values

Nursing Process and TemperatureAssessment

◦ Sites: advantages and disadvantages◦ Core and surface

◦ Thermometers◦ Electronic: oral, axillary, rectal, tympanic membrane, temporal artery

◦ Disposable: oral, axillary, rectal

◦ Fahrenheit or Celsius scale

Electronic Thermometer

Temporal Artery Thermometer

Chemical Dot Thermometer

Quick Quiz!1.You have delegated vital signs to assistive personnel. The assistant informs you that the patient has just finished a bowl of hot soup. The nurse’s most appropriate advice would be to

◦ A. Take a rectal temperature.

◦ B. Take the oral temperature as planned.

◦ C. Advise the patient to drink a glass of cold water.

◦ D. Wait 30 minutes and take an oral temperature.

Nursing Process: TemperatureDiagnosis

◦ Risk for imbalanced body temperature

◦ Hyperthermia

◦ Hypothermia

◦ Ineffective thermoregulation

Planning

Nursing Process: Temperature (cont’d)Implementation

◦ Health promotion◦ Consider activity, environment, and clothing.

◦ Acute care: treat pyrogen, antipyretics◦ Heatstroke

◦ Hypothermia

◦ Restorative and continuing care

Evaluation◦ Get patient’s perspective, compare actual with expected outcomes, and

determine whether goals were met.

Pulse Physiology and RegulationPulse = Palpable bounding of blood flow noted at various points on the body

◦ The indicator of circulatory status

Pulse rate = Number of pulsing sensations in 1 minute

Electrical impulses originate from the sinoatrial (SA) node.◦ Cardiac output, heart rate, stroke volume

Mechanical, neural, and chemical factors regulate ventricular contraction and stroke volume.

Assessment of PulseSites: temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, posterior tibial, and dorsalis pedis

Use of stethoscope

Character of pulse: rate, rhythm, strength, and equality

Nursing process and pulse determination

Parts of a Stethoscope

Use of a Stethoscope

Pulse CharacterRate

◦ Apical rate: ID S1 and S2, “lub”+“dub” = 1 heartbeat

◦ Lub-dubs per minute = Rate

◦ Bradycardia

◦ Tachycardia

◦ Pulse deficit = Difference between radial and apical pulse rates

Rhythm◦ Dysrhythmia: regularly or irregularly irregular

Strength: 4+, 3+, 2+ (normal), 1+, 0

Equality

Nursing Process and Pulse Determination

Activity intolerance

Anxiety Fear

Decreased cardiac output

Deficient/excess fluid volume

Impaired gas exchange

Hyperthermia Hypothermia Acute pain

Ineffective peripheral tissue perfusion

Quick Quiz!2. You notice that a teenager has an irregular pulse. The best action you should take includes

A. Reading the history and physical.

B. Assessing the apical pulse rate for 1 full minute.

C. Auscultating for strength and depth of pulse.

D. Asking whether the patient feels any palpitations or faintness of breath.

RespirationVentilation = Movement of gases into and out of the lung.

Diffusion= Movement of oxygen and carbon monoxide between alveoli and red blood cells.

Perfusion = Distribution of red blood cells to and from the pulmonary capillaries.

Physiological control; hypoxemia

Mechanics of breathing; eupnea

Movements During Breathing

Assessment of VentilationEasy to assess

◦ Respiratory rate: breaths/minute

◦ Ventilatory depth: deep, normal, shallow

◦ Ventilatory rhythm: regular/irregular

Diffusion and perfusion

Arterial oxygen saturation

Case Study (cont’d)Miguel continues to take Ms. Coburn’s vital signs.

Ms. Coburn’s respiratory rate is 14 breaths per minute, and her pulse is 86 beats per minute.

Factors Influencing Character of Respirations

Exercise Acute pain

Anxiety Smoking

Body position Medications

Neurological injury Hemoglobin function

Alterations in Breathing PatternBradypnea

Tachypnea

Hyperpnea

Apnea

Hyperventilation

Hypoventilation

Cheyne-Stokes respiration

Kussmaul’s respiration

Biot’s respiration

Assessment of Diffusion and PerfusionMeasurement of arterial oxygen saturation (SaO2), the percent of hemoglobin that is bound with oxygen in the arteries

◦ Usually 95% to 100%

◦ Pulse oximeter◦ Probes: digit, earlobe, disposable

Pulse Oximeter

Nursing Process and Respiratory Vital SignsNursing diagnosis

◦ Activity intolerance

◦ Ineffective airway clearance

◦ Anxiety

◦ Ineffective breathing pattern

◦ Impaired gas exchange

◦ Acute pain

◦ Ineffective peripheral tissue perfusion

◦ Dysfunctional ventilatory weaning response

Planning, interventions, evaluation

Quick Quiz!3. A postoperative patient is breathing rapidly. You should immediately

A. Call the physician.

B. Count the respirations.

C. Assess the oxygen saturation.

D. Ask the patient if he feels uncomfortable.

Arterial Blood Pressure 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

Pulse pressure = Difference between systolic and diastolic pressures

Physiology of Arterial Blood Pressure

Factors affecting arterial blood pressure:

Cardiac output

Peripheral resistance

Blood volume

Viscosity

Elasticity

Factors Influencing Blood Pressure

Age Stress

Ethnicity Gender

Factors Influencing Blood Pressure(cont’d)

Daily variation Medications

Activity, weight Smoking

Case Study (cont’d)Ms. Coburn’s blood pressure is 164/98 mm Hg. Ms. Coburn asks whether this means she is healthy.

Blood Pressure Cuff Size Guidelines

Hypertension versus Hypotension

Hypertension

More common than hypotension

Thickening of walls

Loss of elasticity

Family history

Risk factors

Hypotension

Systolic <90 mm Hg

Dilation of arteries

Loss of blood volume

Decrease of blood flow to vital organs

Orthostatic/postural

Case Study (cont’d)Miguel responds, “Ms. Coburn, your blood pressure is pretty high right now. After you see the nurse practitioner today, I am going to take your blood pressure again.

We are also going to talk about the changes you can begin to make to help you be healthier and feel better.”

Measurement of Blood PressureEquipment

Auscultation

Children

Ultrasonic stethoscope

Palpation

Lower extremity

Electronic blood pressure

Sphygmomanometer

Alternate Methods of Measuring Blood Pressure

Patient Conditions Not Appropriate for Electronic Blood Pressure Measurement

Irregular heart rate

Peripheral vascular obstruction (e.g., clots, narrowed vessels)

Shivering

Seizures

Excessive tremors

Inability to cooperate

Blood pressure less than 90 mm Hg systolic

Patient Measurement of BPBenefits

◦ Detection of new problems (prehypertension)

◦ Patients with hypertension can provide to their health care provider info about patterns of BP.

◦ Self-monitoring helps adherence to therapy.

Disadvantages◦ Improper use risks inaccurate readings.

◦ Unnecessary alarming of patient

◦ Patients may inappropriately adjust medications.

Nursing Process and Blood Pressure DeterminationAssessment of blood pressure and pulse evaluates the general state of cardiovascular health.

Hypertension, hypotension, orthostatic hypotension, and narrow/wide pulse pressures are defining characteristics of certain nursing diagnoses.

Case Study (cont’d)After caring for Ms. Coburn, Miguel sees the need to educate Ms. Coburn about the different types of vital signs.

Miguel determines that the priority is to focus on hypertension and ways to prevent or control elevated BP. He states, “We need to watch your blood pressure closely over the next few weeks. In the meantime, remember, you decided that you are going to walk for at least 15 minutes 3 days a week; you are also going to try to eat foods with less salt and think about not smoking anymore.

Quick Quiz!4. When assessing the blood pressure of a school-aged child, using an adult cuff of normal size will affect the reading and produce a value that is

A. Accurate.

B. Indistinct.

C. Falsely low.

D. Falsely high.

Health Promotion and Vital SignsMonitor vital signs.

Include age-related factors.

Include environmental and activity factors.

Case Study (cont’d)Ms. Coburn has purchased an electronic blood pressure device for home use.

What evaluation strategies would you suggest for Miguel to use with Ms. Coburn?

Recording Vital SignsRecord values on electronic or paper graphic.

Record in nurses’ notes any accompanying or precipitating symptoms.

Document interventions initiated on the basis of vital sign measurement.

If a vital sign is outside anticipated outcomes, write a variance note to explain, along with the nursing course of action.

In the nurse’s variance note, address possible causes of a fever.

Safety Guidelines for SkillsCleaning devices between patients decreases the risk for infection.

Rotating sites during repeated measurements of BP and pulse oximetry decreases the risk for skin breakdown.

Analyze trends for vital signs, and report abnormal findings.

Determine the appropriate frequency of measuring vital signs based on the patient’s condition.