1.Nelia B. Perez, RN, MSN PCU Mary Johnston College of Nursing

2. reflects changes in body functions that otherwise might not be observed Temperature Pulse Respiration Blood pressure Pain 3. Vital Signs One of the most frequent assessments made as a nurse Nurse is Responsible for measuring, interpreting significance and making decisions about care Knowing normal ranges Knowing history and other therapies that may affect VS 4. Vital Signs Nurse must Know environmental factors that affect vital signs Exercise, stress, etc. Use a systematic, organized approach Verify and communicate changes in vital signs Monitor VS regularly Frequency determined by MD order; nursing judgement, client condition and facility standards 5. Vital Signs: Facility standards Hospital: Every 4-8 hours Home health: each visit Clinic: Each visit Skilled facility Daily and as needed 6. When to Assess Vital Signs Upon admission to any healthcare agency Based on agency institutional policy and procedures Any time there is a change in the patients condition Before and after surgical or invasive diagnosticprocedures Before and after activity that may increase risk Before administering medications that affect cardiovascular or respiratory functioning 7. Special Nursing Interventions: Wash hands before and after a procedureto maintain asepsis Gather equipment needed including watch with a second hand to maximize time and reduce effort Greet client and introduce oneself to promote clients sense of well-being 8. Special Nursing Interventions: Inform client what you will do to elicit cooperation andallay anxiety Check for proper lighting and diminish noise when necessary to obtain accurate baseline data Assist to a comfortable resting position, for a child, have the parent remain close by and position the child comfortably in the parents arm to ensure comfort Record/document appropriately and transfer readings to TPR sheet 9. BODY TEMPERATURE 10. Body Temperature the balance between the heat produced by the bodyand the heat lost from the body Types: 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 11. Maintenance of Body Temperature Thermoregulatory center in thehypothalamus 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 12. Heat Production Primary source is metabolism Hormones, muscle movements, and exerciseincrease metabolism Epinephrine and norepinephrine are released and alter metabolism Energy production decreases and heat production increases 13. Factors affecting Heat Production Basal metabolic rate (BMR) Muscle activity Thyroxine output Epinephrine, norepinephrine andsympathetic stimulation Increased temperature of the body cells (fever) 14. Sources of Heat Loss Skin (primary source) Evaporation of sweat Warming and humidifying inspired air Eliminating urine and feces 15. Processes involved in Heat Loss Radiation transfer of heat loss from the surface of one object to thesurface of another without contact between two objects Convection dissipation of heat by air currents Evaporation continuous vaporization of moisture from the skin, oral mucous,respiratory tract; insensible heat loss Conduction Transfer of heat from one surface to another transfer of heat from one surface to another, which requirestemperature difference between two surfaces 16. Factors affecting TEMPERATURE Age Diurnal variations Exercise Hormones Stress 17. TYPES of FEVER (pyrexia): Intermittent temperature fluctuates between periods of fever and periods of normal/subnormal temperature Remittent temperature fluctuates within a wide range over the 24 hour period but remains above normal range Relapsing temperature is elevated for few days, alternated with 1 or 2 days of normal temperature Constant body temperature is consistently high 18. Decline of FEVER (pyrexia): Crisis/flush/defervescent stage sudden decline of fever which indicatesimpairment of function of the hypothalamus Lysis gradual decline of fever which indicates that the body is able to maintain homeostasis 19. Clinical Signs of FEVER (pyrexia): Onset (cold or chill stage) of fever Course of fever Defervescence (fever abatement) 20. TEMPERATURE CONVERSION To 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 Fahrenheit Multiply the Celsius reading by 9/5 or 1.8 Add 32 oF = (9/5 x oC) + 32 or (oC x 1.8) + 32 21. Special Nursing Interventions: Remove thermometer from its container and check thetemperature 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. 22. Special Nursing Interventions: Hold the thermometer ateye level, and rotate it until the mercury column is visible Rinse the thermometer intap water, dry it, shake it down and return to its container 23. METHODS of Temperature Taking: ORAL: most accessible and convenient method Nursing Considerations: Allow 15 minutes to elapse between clients intakeof hot or cold food or smoking and the measurement of oral temperature 24. METHODS of Temperature Taking: ORAL: most accessible and convenient method Nursing Consideration: Place the thermometer under the tongue, directedtowards the side and instruct client to gently close the lips not the teeth around the thermometer 25. METHODS of Temperature Taking: ORAL: most accessible and convenient method Nursing Consideration: Wash the thermometer before use, from the bulb to the stem, after use, from the stem to the bulb. This practice ensures medical asepsis. 26. METHODS of Temperature Taking: ORAL: most accessible and convenient method Nursing Consideration: 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) 27. METHODS of Temperature Taking: Contraindications to Oral Temperature Taking: oral lesions or oral surgery dyspnea cough nausea and vomiting presence of oro-nasal pack, nasogastric tube seizure prone very young children unconscious restless, disoriented, confused 28. METHODS of Temperature Taking:Oral Thermometers 29. METHODS of Temperature Taking: RECTAL: most accurate measurement of temperature Indications: When there is respiratory obstruction which prevents closure of the mouth When the mouth is dry, parched and inflamed When there is oral/nasal surgery or disease For very young, restless and irrational children For mentally disturbed, unconscious, dyspneic, irrational, restless and convulsive patients When a patient is mouth breather and with oxygen 30. METHODS of Temperature Taking: RECTAL: most accurate measurement of temperature Nursing Considerations: Assist client to assume lateral position/simsposition. 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 31. METHODS of Temperature Taking: RECTAL: most accurate measurement of temperature Nursing Considerations: Insert thermometer by 0.5 1.5 inches (1.5 4 cm) foradults, 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 32. METHODS of Temperature Taking: RECTAL: most accurate measurement of temperature Nursing Considerations: 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) 33. METHODS of Temperature Taking: Contraindications to Rectal TemperatureTaking Anal/rectal conditions or surgeries, e.g. anal fissure, hemorrhoids, hemorrhoidectomy Diarrhea Quadriplegic clients. Vagal stimulation may occur, causing bradycardia and syncope 34. METHODS of Temperature Taking: Rectal Thermometers 35. METHODS of Temperature Taking: AXILLARY: safest and most non-invasive method Nursing Considerations: Pat dry the axilla. Rubbing causes friction and will increasetemperature in the area Place the thermometer in the clients axilla Place 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) 36. METHODS of Temperature Taking: Axillary Thermometers 37. METHODS of Temperature Taking: Tympanic: readily accessible, reflects the coretemperature, very fast Nursing Considerations: Can be very uncomfortable and involve risks of injuring themembrane if the probe is inserted too far Repeated measurements may vary (right and left ears may differ) Presence of cerumen can affect the reading Normal value: 98.2 o 100.2 oF (36.8 o 37.9 oC) 38. METHODS of Temperature Taking: Tympanic Thermometers 39. METHODS of Temperature Taking: Other Thermometers 40. PULSE 41. PULSE wave of blood created by contraction of left ventricleof the heart Regulated by the autonomic nervous system through cardiac sinoatrial node Parasympathetic stimulation decrease heart rate Sympathetic stimulation increases heart rate Pulse rate = number of contractions over a peripheral artery in 1 minute 42. Factors affecting the PULSE rate Age Sex/Gender Exercise Fever Medication Hemorrhage Stress Position changes 43. PULSE sites: Temporal Carotid Apical Brachial Radial Femoral Popliteal Dorsalis Pedis Pedal 44. PULSE site: TEMPORAL 45. PULSE site: CAROTID 46. PULSE site: APICAL 47. PULSE site: RADIAL/BRACHIAL 48. PULSE site: RADIAL 49. PULSE site: FEMORAL 50. PULSE site: POPLITEAL 51. PULSE site: POSTERIOR TIBIAL 52. PULSE sites: PEDAL/DORSALIS PEDIS 53. ASSESSMENT of the Pulse: If pulse is regular, count for 30 seconds andmultiply 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 54. ASSESSMENT of the Pulse: Asses the pulse volume (amplitude) strength of the pulse Normal 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) 55. ASSESSMENT of the Pulse: Arterial wall elasticity: the artery feelsstraight, smooth, soft and pliable Presence/absence of bilateral equality:absence of bilateral equality indicates cardiovascular disorder 56. ASSESSMENT of the Pulse: Pulse pressure: Systolic pressure MINUS diastolic pressure Pulse deficit Apical pulse MINUS peripheral pulse Pulsus paradoxus Systolic pressure falls by more than 15 mmHg during inhalation Pulsus alternans Alternating strong and weak pulses 57. ASSESSMENT of the Pulse: Age Normal Pulse Rate Newborn to 1 month 80 180 beats/min 1 year 80 140 beats/min 2 years 80 130 beats/min 6 years 75 120 beats/min 10 years 60 90 beats/min Adult 60 100 beats/min Tachycardia pulse rate above 100 beats/min Bradycardia pulse rate below 60 beats/min 58. RESPIRATION 59. Respiration the act of breathing carbon 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 lungs Inhalation: breathing in Exhalation: breathing out 60. Respiration Three processesVentilation: 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 61. Respiration The exchange of oxygen and carbon dioxide in thebody Two separate process Mechanical chemical 62. respiration Mechanical Pulmonary ventilation; breathing Ventilation: Active movement of air in and out of the respiratory system Conduction Movement through the airways of the lung 63. Respiration Chemical Exchange of oxygen and carbon dioxide Diffusion Movement of oxygen and CO2 between alveoli and RBC Perfusion Distribution of blood through the pulmonary capillaries 64. Mechanics of ventilation Inspiration Drawing air into the lung Involves the ribs, diaphragm Creates negative pressure-allows air into lung Expiration Relaxation of the thoracic muscles and diaphragm causing air to be expelled 65. Variations in assessment of respirations Rate: regulated by blood levels of O2, CO2 and ph Chemial receptors detect changes and signal CNS(medulla) Normal: 12-20 breaths per minute Apnea: no breathing Bradypnea: abnormally slow Tachypnea: abnormally fast Observe for one full minute 66. Variations in assessment findings Depth Normal: diaphragm moves inch Deep Shallow Rhythm Assessment of the pattern Abnormal Cheyne stokes, Kusmaul, 67. Variations in assessment of respirations Effort Work of breathing Dypsnea: labored breathing Orthopnea: inability to breath when horizontal Observe for retractions, nasal flaring and restlessness 68. Variations in breath sounds Wheeze High pitched continuous musical sound; heard on expiration Rhonchi Low pitched continuous sounds caused by secretions in large airways Crackles Discontinuous sounds heard on inspiration; high pitched popping or low pitched bubbling 69. Variations in breath sounds Stridor Piercing, high pitched sound heard during inspiration Stertor Labored breathing that produces a snoring sound 70. oxygenation Hyperventilation Rapid and deep breathing resulting in loss of CO2 (hypocapnea); light headed and tingly Hypoventilation Rate and depth decreased; CO2 is retained Cheyne Stokes Irregular, alternating periods of apnea and hyperventilation 71. Tools to measure oxygenation ABG directly measures the partial pressures of oxygen, carbon dioxide and blood ph normal= paCO2 80-100) Pulse oximetry non invasive method for monitoring respiratory status; measures O2 saturation normal= >95% 72. Respiration Two Types of Breathing: Costal (thoracic) Diagphragmatic (abdominal) 73. Respiratory Centers: Medulla Oblongata primary center for respiration Pons (1) Pneumotaxic center; responsible for rhythmic quality of breathing (2) Apneustic center; responsible for deep, prolonged inspiration Carotid and aortic bodies contain peripheralchemoreceptors, 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 74. Factors Affecting Respiratory Rate: Exercise Pain/Stress/Anxiety Environment Increased altitude Medication Respiratory and cardiovascular disease Alterations in fluid, electrolyte, and acid balances Trauma Infection 75. Assessment of Respiration: With fingers still in place, after taking pulse rate, note the rise and fall of patients chest with respiration. You may place the clients arm across the chest and observe chest movement and forinfants, 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. 76. Assessment of Respiration: Observe the respiration (inhalations andexhalations) for regular or irregular rhythm Observe the character or quality ofrespiration the sound of breathing and respiratory effort 77. Assessment of Respiration: Normal rate in adult 12 20 breaths/minute Normal rate in infant 20 40 breaths/minute Normal rate in preschool 20 30 breaths/minute 78. Assessment of Respiration: Types of Breathing Eupnea Tachypnea Bradypnea Hyperventilation HypoventilationDescription Normal respiration that is quiet, rhythmic and effortless Rapid respiration, above 20 breaths/min in an adult Slow breathing, less than 12 breaths/minute in an adult Deep rapid respiration, carbon dioxide is excessively exhaled (resp. alkalosis) Slow, shallow respiration, carbon dioxide is excessively retained (resp. acidosis) Difficult and labored breathing Ability to breathe only in an upright position Absence/cessation of breathing Quick, shallow inspiration followed by regular or irregular periods of apnea Very deep and labored breathing; acetone breath (metabolic acidosis)Dyspnea Orthopnea Apnea Biots respiration Kussmaul respiration Apneustic Deep, gasping inspiration with a pause at full inspiration followed by respiration insufficient release 79. BLOOD PRESSURE 80. Physiology of Blood Pressure Force of the blood against arterial walls Controlled by a variety of mechanism to maintain adequate tissue perfusion Sound of Korotkoff Pressure rises as ventricle contracts and falls as heart relaxes Highest pressure is systolic Lowest pressure is diastolic 81. Physiology of Blood Pressure: ..Pictures3DScience_Human_Heart.jpgsystolic 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 82. Physiology of Blood Pressure pulse 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 83. Determinants of Blood Pressure Blood volume Peripheral resistance Cardiac output Elasticity or complianceof blood vessels Blood viscosity 84. Factors Affecting Blood Pressure: Age, gender, race Circadian rhythm Food intake Exercise Weight Emotional state Body position Drugs/medications Disease process 85. Sphygmomanometers 86. Sphygmomanometers 87. Parts of the Stethoscope:stethoscopebasics.pdf30 35 cm (12-14 inches) long 0.3 cm (1/8 inch) internal diameter 88. Stethoscope 89. ASSESSING Blood Pressure: Ensure that the client is rested Allow 30 minutes to pass if theclient 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 90. ASSESSING Blood Pressure: Position the arm at the level of theheart, 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 91. ASSESSING Blood Pressure: Determine palpatory BP beforeauscultatory BP to prevent auscultatory gap Use 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 92. ASSESSING Blood Pressure: Palpate the brachial arterywith your fingertips Close 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 93. ASSESSING Blood Pressure: Place the diaphragm of stethoscopeover 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 94. ASSESSING Blood Pressure: As the pressure falls, note the first sound, muffling, and last sound heard Deflate the cuff rapidly and completely afternoting the last sound 95. ASSESSING Blood Pressure: Read lower meniscus of themercury level of the sphygmomanometer at eye level to prevent error of parallax Error 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 96. Tools Indirect Equipment Sphygomanometer and stethescope Korotkoffs sounds 1st 2nd 3rd 4th 5th 97. Korotkoffs sounds 1st As you deflate the cuff; occurs during systole 2nd Further deflation of the cuff; soft swishing sound 3rd Begins midway through; sharp tapping sound 4th Similar to 3rd sound but fading 5th Silence, corresponding with diastole 98. Other BP issues Orthostatic or postural hypotension Sudden drop in BP on moving from lying to sitting or standing position Primary or essential hypertension Diagnosed when no known cause for increase Accounts for at least 90% of all cases of hypertension 99. Vital signs Combination of skills which provide an indication ofstate of health and body functionality Nurses can delegate the activity of VS, but are responsible for interpretation, trending and decisions based on the findings 100. Pain 5th vital sign It is what the client says it is Nurse must know how to assess for it Establish acceptable comfort levels Follow up within appropriate time frame after intervention 101. Pain Data collection Location (place and position) Intensity 1-10 Strength and severity What is your pain at present? What makes it worse? What is the best that it gets? 102. Pain data collection Describe Aching, stabbing, tender, tiring, numb,.. Duration When did it start? Is is always there? Aggrevate/alleviate What makes it better/worse? 103. How does the pain affect Energy Appetite Sleep Activity Mood Relationships Memory concentration Nurse checks for VS Knowledge of pain Med history Side effects of meds Use of non pharmacological therapies 104. References: Fundamentals of Nursing, Kozier, Erb et al Lippincott William and Wilkins Fundamental of Nursing, Udan World wide webEND