vital signs 2008

Ray Andrew S. del Rosario, RNCollege of Nursing and Health SciencesAquinas University of Legazpi

reflects changes in body functions that otherwise might not be observed

TemperaturePulseRespirationBlood pressurePain

When to Assess Vital SignsUpon admission to any healthcare agencyBased on agency institutional policy and proceduresAny time there is a change in the patient’s conditionBefore and after surgical or invasive diagnostic

proceduresBefore and after activity that may increase riskBefore administering medications that affect

cardiovascular or respiratory functioning

Special Nursing Interventions:Wash hands before and after a

procedure to maintain asepsisGather equipment needed including

watch with a second hand to maximize time and reduce effort

Greet client and introduce oneself to promote client’s sense of well-being

Special Nursing Interventions:Inform client what you will do to elicit

cooperation and allay anxietyCheck for proper lighting and diminish noise

when necessary to obtain accurate baseline dataAssist to a comfortable resting position, for a

child, have the parent remain close by and position the child comfortably in the parent’s arm to ensure comfort

Record/document appropriately and transfer readings to TPR sheet


BODY TEMPERATURE

Body Temperaturethe balance between the heat produced by the

body and the heat lost from the bodyTypes:

Core Temperature – temperature of the deep tissues of the body measured by taking oral and rectal temperature

Surface Temperature – temperature of the skin, subcutaneous tissue and fat measured by taking axillary temperature

Maintenance of Body TemperatureThermoregulatory center in the hypothalamus regulates temperature

Center receives messages from cold and warm thermal receptors in the body

Center initiates responses to produce or conserve body heat or increase heat loss

Heat ProductionPrimary source is metabolismHormones, muscle movements, and

exercise increase metabolismEpinephrine and norepinephrine are

released and alter metabolismEnergy production decreases and

heat production increases

Factors affecting Heat ProductionBasal metabolic rate (BMR)Muscle activityThyroxine outputEpinephrine, norepinephrine and sympathetic stimulation

Increased temperature of the body cells (fever)

Sources of Heat LossSkin (primary source)Evaporation of sweatWarming and humidifying inspired air

Eliminating urine and feces

Processes involved in Heat LossRadiation

transfer of heat loss from the surface of one object to the surface of another without contact between two objects

Convectiondissipation of heat by air currents

Evaporation continuous vaporization of moisture from the skin, oral

mucous, respiratory tract; insensible heat lossConduction

Transfer of heat from one surface to another transfer of heat from one surface to another, which requires

temperature difference between two surfaces

Factors affecting TEMPERATUREAgeDiurnal variationsExerciseHormonesStress

TYPES of FEVER (pyrexia):Intermittent

temperature fluctuates between periods of fever and periods of normal/subnormal temperature

Remittenttemperature fluctuates within a wide range over the 24

hour period but remains above normal rangeRelapsing

temperature is elevated for few days, alternated with 1 or 2 days of normal temperature

Constantbody temperature is consistently high

Decline of FEVER (pyrexia):Crisis/flush/defervescent stage

sudden decline of fever which indicates impairment of function of the hypothalamus

Lysis gradual decline of fever which indicates that the body is able to maintain homeostasis

Clinical Signs of FEVER (pyrexia):Onset (cold or chill stage) of fever

Course of feverDefervescence (fever abatement)

TEMPERATURE CONVERSIONTo change from Fahrenheit to Celsius:

subtract 32 degrees from the Fahrenheit reading

Multiply by 5/9 or divide by 9/5 (1.8)oC = (oF – 32) x 5/9

To change from Celsius to FahrenheitMultiply the Celsius reading by 9/5 or 1.8Add 32oF = (9/5 x oC) + 32 or (oC x 1.8) + 32

Special Nursing Interventions:Remove thermometer from its container and

check the temperature reading. Shake down the mercury as necessary (until mercury is below 35 C) by holding the thermometer between the thumb and forefinger at the end farthest from the bulb. Snap the wrist downward.

Wash/wipe the thermometer in a rotating manner before use, from the bulb to the stem, after use, from the stem to the bulb. This practice ensures medical asepsis.

Special Nursing Interventions:Hold the thermometer

at eye level, and rotate it until the mercury column is visible

Rinse the thermometer in tap water, dry it, shake it down and return to its container

METHODS of Temperature Taking:ORAL: most accessible and convenient

methodNursing Considerations:

Allow 15 minutes to elapse between client’s intake of hot or cold food or smoking and the measurement of oral temperature


methodNursing Consideration:

Place the thermometer under the tongue, directed towards the side and instruct client to gently close the lips not the teeth around the thermometer



Wash the thermometer before use, from the bulb to the stem, after use, from the stem to the bulb. This practice ensures medical asepsis.



Take oral temperature for 2 – 3 minutes. This ensures adequate time for recording of the temperature

Normal value:97.6 o – 99.6 oF (36.5 o – 37. 5 oC)

METHODS of Temperature Taking:Contraindications to Oral Temperature

Taking:oral lesions or oral surgerydyspneacoughnausea and vomitingpresence of oro-nasal pack, nasogastric tube seizure pronevery young childrenunconsciousrestless, disoriented, confused

METHODS of Temperature Taking:Oral Thermometers

METHODS of Temperature Taking:RECTAL: most accurate measurement of

temperatureIndications:

When there is respiratory obstruction which prevents closure of the mouth

When the mouth is dry, parched and inflamedWhen there is oral/nasal surgery or diseaseFor very young, restless and irrational childrenFor mentally disturbed, unconscious, dyspneic, irrational,

restless and convulsive patientsWhen a patient is mouth breather and with oxygen


temperatureNursing Considerations:

Assist client to assume lateral position/sims position. To expose anal area

Lubricate thermometer about 1 inch above the bulb with water soluble jelly before insertion. To reduce friction and prevent trauma to the mucous membrane in the anus



Insert thermometer by 0.5 – 1.5 inches (1.5 – 4 cm) for adults, 0.9 inch (2.5 cm) for a child and 0.5 inch (1.5 cm) for an infant or insert beyond the internal anal sphincter

Instruct the client to take a deep breath during the insertion of the thermometer. To relax the internal anal sphincter



Hold the thermometer in place for 2 minutes (for neonates, 5 minutes). To ensure recording of temperature

Do not force the insertion of thermometer. To prevent trauma in the area

Normal value:98.6 o – 100.6 oF (37.0 o – 38.1 oC)

METHODS of Temperature Taking:Contraindications to Rectal

Temperature TakingAnal/rectal conditions or surgeries, e.g.

anal fissure, hemorrhoids, hemorrhoidectomy

DiarrheaQuadriplegic clients. Vagal stimulation

may occur, causing bradycardia and syncope

METHODS of Temperature Taking:Rectal Thermometers

METHODS of Temperature Taking:AXILLARY: safest and most non-invasive

methodNursing Considerations:

Pat dry the axilla. Rubbing causes friction and will increase temperature in the area

Place the thermometer in the client’s axillaPlace the arm tightly across the chest to keep the

thermometer in place for 9 minutes (for infants and children, 5 minutes

Normal value:96.6 o – 98.6 oF (35.8 o – 37.0 oC)

METHODS of Temperature Taking:Axillary Thermometers

METHODS of Temperature Taking:Tympanic: readily accessible, reflects the

core temperature, very fastNursing Considerations:

Can be very uncomfortable and involve risks of injuring the membrane if the probe is inserted too far

Repeated measurements may vary (right and left ears may differ)

Presence of cerumen can affect the readingNormal value:

98.2 o – 100.2 oF (36.8 o – 37.9 oC)

METHODS of Temperature Taking:Tympanic Thermometers

METHODS of Temperature Taking:Other Thermometers


PULSE

PULSEwave of blood created by contraction of left

ventricle of the heartRegulated by the autonomic nervous system

through cardiac sinoatrial nodeParasympathetic stimulation — decrease heart

rateSympathetic stimulation — increases heart ratePulse rate = number of contractions over a

peripheral artery in 1 minute

Factors affecting the PULSE rateAgeSex/GenderExerciseFeverMedicationHemorrhageStressPosition changes

PULSE sites: TemporalCarotidApicalBrachialRadialFemoralPoplitealDorsalis

PedisPedal

PULSE site: TEMPORAL

PULSE site: CAROTID

PULSE site: APICAL

PULSE site: RADIAL/BRACHIAL

PULSE site: RADIAL

PULSE site: FEMORAL

PULSE site: POPLITEAL

PULSE site: POSTERIOR TIBIAL

PULSE sites: PEDAL/DORSALIS PEDIS

ASSESSMENT of the Pulse:If pulse is regular, count for 30

seconds and multiply by 2. If irregular, count for 1 minute. When obtaining baseline date, count for the pulse for a full minute

Assess pulse rhythm by noting the pattern and intervals of beat. Dysrhytmia is irregular rhythm

ASSESSMENT of the Pulse:Asses the pulse volume (amplitude) – strength of the pulseNormal pulse ca be felt with moderate pressure

Full or bounding pulse can be obliterated only by great pressure

Thready pulse can easily be obliterated (weak or feeble)

ASSESSMENT of the Pulse:Arterial wall elasticity: the artery

feels straight, smooth, soft and pliable

Presence/absence of bilateral equality: absence of bilateral equality indicates cardiovascular disorder

ASSESSMENT of the Pulse:Pulse pressure:

Systolic pressure MINUS diastolic pressurePulse deficit

Apical pulse MINUS peripheral pulsePulsus paradoxus

Systolic pressure falls by more than 15 mmHg during inhalation

Pulsus alternansAlternating strong and weak pulses

ASSESSMENT of the Pulse:Age Normal Pulse Rate

Newborn to 1 month 80 – 180 beats/min1 year 80 – 140 beats/min2 years 80 – 130 beats/min6 years 75 – 120 beats/min10 years 60 – 90 beats/minAdult 60 – 100 beats/minTachycardia – pulse rate above 100 beats/minBradycardia – pulse rate below 60 beats/min


RESPIRATION

Respirationthe act of breathingcarbon dioxide is the primary chemical

stimulus of breathing; when carbon dioxide level in the blood is high, there is stimulation for breathing

Pulmonary ventilation — movement of air in and out of lungsInhalation: breathing inExhalation: breathing out

RespirationThree processes

Ventilation: movement of gases in and out of the lungs

Diffusion: exchange of gases from an area of higher pressure to an area of lower pressure and occurs in the alveolo-capillary membrane

Perfusion: the availability and movement of blood for transport of gases, nutrients and metabolic waste products

RespirationTwo Types of Breathing:Costal (thoracic)Diagphragmatic (abdominal)

Respiratory Centers:Medulla Oblongata – primary center for respirationPons – (1) Pneumotaxic center; responsible for

rhythmic quality of breathing (2) Apneustic center; responsible for deep, prolonged inspiration

Carotid and aortic bodies – contain peripheral chemoreceptors, which take up the work of breathing when central chemoreceptors in the medulla are damaged, oxygen level concentration is low and respond to pressure.

Muscle and joints contain proprioreceptors, e.g. exercise

Factors Affecting Respiratory Rate:

ExercisePain/Stress/AnxietyEnvironmentIncreased altitudeMedicationRespiratory and cardiovascular disease Alterations in fluid, electrolyte, and acid

balancesTraumaInfection

Assessment of Respiration:With fingers still in place, after taking

pulse rate, note the rise and fall of patient’s chest with respiration. You may place the client’s arm across the chest and observe chest movement and for infants, observe the movement of the abdomen, these observes for depth of respiration

Observe rate. Count for 30 seconds if respirations are regular and multiply by 2. If irregular, count for 60 seconds.

Assessment of Respiration:Observe the respiration (inhalations

and exhalations) for regular or irregular rhythm

Observe the character or quality of respiration – the sound of breathing and respiratory effort

Assessment of Respiration:Normal rate in adult

12 – 20 breaths/minuteNormal rate in infant

20 – 40 breaths/minuteNormal rate in preschool

20 – 30 breaths/minute

Assessment of Respiration:Types of

BreathingDescription

EupneaTachypneaBradypnea

HyperventilationHypoventilation

DyspneaOrthopnea

ApneaBiot’s respiration

Kussmaul respirationApneustic

respiration

Normal respiration that is quiet, rhythmic and effortlessRapid respiration, above 20 breaths/min in an adultSlow breathing, less than 12 breaths/minute in an adultDeep rapid respiration, carbon dioxide is excessively exhaled (resp. alkalosis)Slow, shallow respiration, carbon dioxide is excessively retained (resp. acidosis)Difficult and labored breathingAbility to breathe only in an upright positionAbsence/cessation of breathingQuick, shallow inspiration followed by regular or irregular periods of apneaVery deep and labored breathing; acetone breath (metabolic acidosis)

Deep, gasping inspiration with a pause at full inspiration followed by insufficient release


BLOOD PRESSURE

Physiology of Blood PressureForce of the blood against arterial wallsControlled by a variety of mechanism to

maintain adequate tissue perfusionSound of KorotkoffPressure rises as ventricle contracts and

falls as heart relaxesHighest pressure is systolicLowest pressure is diastolic

Physiology of Blood Pressure: ..\Pictures\3DScience_Human_Heart.jpg

systolic pressure – pressure of blood as a result of contractions of the ventricles (100 – 140 mmHg); systole (contraction of the heart); numerator in BP reading

diastolic pressure – pressure exerted when the ventricles are at rest (60 – 90 mmHg); diastole (relaxation of the heart); denominator in BP reading

Physiology of Blood Pressurepulse pressure – difference between

the systolic and diastolic pressures, normal is 30 – 40 mmHg

hypertension is an abnormally high blood pressure for at least two consecutive readings

hypotension is an abnormally low blood pressure, systolic pressure below 100/60 mmHg

Determinants of Blood PressureBlood volumePeripheral resistanceCardiac outputElasticity or compliance of blood vesselsBlood viscosity

Factors Affecting Blood Pressure:Age, gender, raceCircadian rhythmFood intakeExerciseWeightEmotional stateBody positionDrugs/medicationsDisease process

Sphygmomanometers

Parts of the Stethoscope: stethoscopebasics.pdf

30 – 35 cm (12-14 inches) long0.3 cm (1/8 inch) internal diameter

Stethoscope

ASSESSING Blood Pressure:Ensure that the client is restedAllow 30 minutes to pass if the

client had engaged in exercise or had smoked or ingested caffeine before taking the BP (might tend to increase BP)

Use appropriate size of the BP cuff. Too narrow cuff causes high false reading and too wide cuff causes false low reading.

Position the client in sitting or supine position

ASSESSING Blood Pressure:Position the arm at the level of

the heart, with the palm of the hand facing up. The left arm is preferably used because it is nearer the heart

Apply/warp the deflated cuff snugly in upper arm, the center of the bladder directly over the medial aspect or 1 inch above the antecubital space or at least 2 – 3 fingers above the elbow

ASSESSING Blood Pressure:Determine palpatory BP

before auscultatory BP to prevent auscultatory gapUse the bell of the

stethoscope since the BP is a low frequency sound

Inflate and deflate BP cuff slowly, 2 -3 mmHg at a time

Wait 1 -2 minutes before making further determinations

ASSESSING Blood Pressure:Palpate the brachial

artery with your fingertipsClose the valve on hand

pump by turning the knob clockwise

Insert the ear attachment of the stethoscope in your ears so they tilt slightly forward an ensure it hangs freely from the ear to the diaphragm

ASSESSING Blood Pressure:Place the diaphragm of stethoscope

over brachial pulse and hold with the thumb and index finger

Pump out the cuff until the sphygmomanometer registers about 30 mmHg above the point where the brachial pulse disappeared

Release the valve on the cuff carefully so that the pressure decreases at the rate of 2 – 3 mmHg per second

ASSESSING Blood Pressure:

As the pressure falls, note the first sound, muffling, and last sound heard

Deflate the cuff rapidly and completely after noting the last sound

ASSESSING Blood Pressure:Read lower meniscus of the

mercury level of the sphygmomanometer at eye level to prevent error of parallaxError of parallax happens if

the eye level is higher than the lever of the lower meniscus of the mercury, this causes false low reading, if the eye level is lower, this causes false high reading


END

References:Fundamentals of Nursing, Kozier, Erb et alLippincott William and WilkinsFundamental of Nursing, UdanWorld wide web

vital signs 2008

Health & Medicine