Vital SignsNEO 111

Melanie Jorgenson, RN, BSN

Vital Signs

Temperature (T) Pulse (P) Respiration (R) Blood pressure (BP) Pain (often called the fifth vital sign) Oxygen Saturation

Occasions for Measuring Vital Signs

Upon admission to a healthcare setting When certain medications are given Before and after diagnostic and

surgical procedures Before and after certain nursing

interventions In emergency situations

Body Temperature

Definition: the heat of the body measured in degrees› The difference between production of heat and

loss of heat› Normal temperature: 97.0ºF (36.0ºC) to 99.5ºF

(37.5ºC) Process: heat is generated by metabolic

processes in the core tissues of the body, transferred to the skin surface by the circulating blood, and dissipated to the environment

Sites for Measurement of Temperatures

Core temperatures› Tympanic and rectal› Esophagus and pulmonary (invasive

monitoring devices) Surface body temperatures

› Oral (sublingual) › Axillary

Inserting Tympanic Thermometer into Patient’s Ear

Contraindications to Temperature Measurement sites

Oral: impaired cognitive functioning, inability to close lips around thermometer, diseases of the oral cavity, and oral or nasal surgery

Rectal: newborns, small children, patients who have had rectal surgery, or have diarrhea or disease of the rectum, and certain heart conditions

Tympanic: earache, ear drainage, and scarred tympanic membrane

Characteristics of the Pulse

Pulse rate› Measured in beats per minute

Pulse quality (amplitude)› The quality of the pulse in terms of its

fullness Pulse rhythm

› Pattern of the pulsations and the pauses between them Normally regular

Methods of Assessing the Pulse

Palpating the peripheral arteries Auscultating the apical pulse with a

stethoscope Using a portable Doppler ultrasound

Common Pulse Sites

Temporal Carotid Brachial Radial Femoral Popliteal Posterior tibial Dorsalis pedis

Palpating the Radial Pulse

Assessing an Apical Pulse

Indications› Patient is receiving medications that alter

heart rate and rhythm› A peripheral pulse is difficult to assess

accurately because it is irregular, feeble, or extremely rapid

Method› Count the apical rate 1 full minute by listening

with a stethoscope over the apex of the heart › Most reliable method for infants and small

children; can be palpated with fingertips

Assessing Respirations (Normal Findings)

Rate› Adults: 12 to 20 times per minute› Infants and children breathe more rapidly

Depth› Varies from shallow to deep

Rhythm› Regular: each inhalation/exhalation and

the pauses between occur at regular intervals

Assessing Respiratory Rate, Depth, and Rhythm

Method› Inspection (observing and listening)› Listening with the stethoscope› Counting the number of breaths per minute

Considerations› If respirations are very shallow and difficult

to detect visually, observe sternal notch › Patients should be unaware of the

respiratory assessment to prevent altered breathing patterns

Factors Affecting Respirations

Exercise Medications Smoking Chronic illness or conditions Neurologic injury Pain Anxiety

Signs of Respiratory Distress

Retractions Nasal flaring Grunting Orthopnea (breathing more easily in an

upright position) Tachypnea (rapid respirations)

Sample Nursing Diagnoses Related to Respiratory Status

Ineffective Breathing Pattern Impaired Gas Exchange Risk for Activity Intolerance Ineffective Airway Clearance Excess Fluid Volume Ineffective Tissue Perfusion

Blood Pressure

Definition› The force of the blood against arterial walls

Systolic pressure › The highest point of pressure on arterial

walls when the ventricles contract Diastolic pressure

› The lowest pressure present on arterial walls during diastole (Taylor, 2007).

Measuring Blood Pressure

Blood pressure is measured in millimeters of mercury (mm Hg)

Blood pressure is recorded as a fraction› The numerator is the systolic pressure› The denominator is the diastolic pressure

Pulse pressure› The difference between the systolic and

diastolic pressure

Blood Pressure Assessment (Methods)

Using a stethoscope and sphygmomanometer

Using a Doppler ultrasound Estimating by palpation Assessing with electronic or automated

devices

Measuring Blood Pressure

Ensuring an Accurate Blood Pressure Reading

Use a cuff that is the correct size for the patient

Ensure correct limb placement Use recommended deflation rate Correctly interpret the sounds heard

Factors Affecting Blood Pressure Reading

Age Exercise Position Weight Fluid balance Smoking Medications

Using a Pulse Oximeter

Purpose› Measure the arterial oxyhemoglobin

saturation of arterial blood Method

› A sensor or probe, uses a beam of red and infrared light which travels through tissue and blood vessels

› The oximeter calculates the amount of light absorbed by arterial blood

› Oxygen saturation is determined by the amount of each light absorbed

Uses for Pulse Oximetry

Monitoring patients receiving oxygen therapy

Titrating oxygen therapy Monitoring those at risk for hypoxia Monitoring postoperative patients

Questions?