VITAL SIGNSby: marie m.

santos r.n.man c

Pretest

Question 1The client’s temperature at 8:00 AM using an oral electronic thermometer is 36.1°C (97.2°F). If the respiration, pulse, and blood pressure are within normal range, what would the nurse do next?

1. Wait 15 minutes and retake it.2. Check what the client’s temperature was

the last time.3. Retake it using a different thermometer.4. Chart the temperature; it is normal.

Question 2Which of the following clients meets the criteria for selection of the apical site for assessment of the pulse rather than a radial pulse?

1. A client is in shock

2. The pulse changes with body position changes

3. A client with an arrhythmia

4. It is less than 24 hours since a client's surgical operation

Question 3It would be appropriate to delegate the taking of vital signs of which of the following clients to a UAP?

1. A patient being prepared for elective facial surgery with a history of stable hypertension.

2. A patient receiving a blood transfusion with a history of transfusion reactions.

3. A client recently started on a new antiarrhythmic agent.

4. A patient who is admitted frequently with asthma attacks.

Question 4A nursing diagnosis of Ineffective Peripheral Tissue Perfusion would be validated by which one of the following:

1. Bounding radial pulse2. Irregular apical pulse3. Carotid pulse stronger on the left side

than the right4. Absent posterior tibial and pedal

pulses

Question 5

The nurse reports that the client has dyspnea when ambulating. The nurse is most likely to have assessed which of the following?

1. Shallow respirations2. Wheezing3. Shortness of breath4. Coughing up blood

Rationales 1

1. Depending on that finding, you might want to retake it in a few minutes (no need to wait 15 minutes).

2. Correct. Although the temperature is slightly lower than expected for the morning, it would be best to determine the client’s previous temperature range next. This may be a normal range for this client.

3. There is no need to take temperature again with another thermometer to see if the initial thermometer was functioning properly.

4. Chart after determining that the temperature has been measured properly.

Rationales 21. For clients in shock, use the carotid or

femoral pulse.2. The radial pulse is adequate for determining

change in orthostatic heart rate.3. Correct. The apical rate would confirm the

rate and determine the actual cardiac rhythm for a client with an abnormal rhythm; a radial pulse would only reveal the heart rate and suggest an arrhythmia.

4. The radial pulse is appropriate for routine postoperative vital sign checks for clients with regular pulses.

Rationales 31. Correct. Vital signs measurement may be delegated

to UAP if the client is in stable condition, the findings are expected to be predictable, and the technique requires no modification. Only the preoperative client meets these requirements.

2. This client is unstable and vital signs measurement cannot be delegated.

3. In addition to the client being unstable, UAP are not delegated to take apical pulse measurements for the client with an irregular pulse as would be the case with the client newly started on antiarrhythmic medication.

4. This client is unstable and vital signs measurement cannot be delegated.

Rationales 4

1. Abounding radial pulse is more indicative that perfusion exists.

2. Apical pulses are central and not peripheral.

3. Carotid pulses are central and not peripheral.

4. Correct. The posterior tibial and pedal pulses in the foot are considered peripheral and at least one of them should be palpable in normal individuals.

Rationales 51. Shallow respirations are seen in tachypnea (rapid

breathing).2. Wheezing is a high-pitched breathing sound that may

or may not occur with dyspnea.3. Correct. Dyspnea, difficult or labored breathing, is

commonly related to inadequate oxygenation. Therefore, the client is likely to experience shortness of breath, that is, a sense that none of the breaths provide enough oxygen and an immediate second breath is needed.

4. The medical term for coughing up blood is hemoptysis and is unrelated to dyspnea.

Vital Signs

• Temperature, Pulse, Respiration, Blood Pressure and Pain

• Monitor functions of the body• Should be a thoughtful, scientific

assessment

When to Assess Vital Signs• On admission• Change in client’s health status• Client reports symptoms such as chest

pain, feeling hot, or faint• Pre and post surgery/invasive procedure• Pre and post medication administration

that could affect CV system• Pre and post nursing intervention that

could affect vital signs

TEMPERATURE

Body Temperature

Represents the balance between heat produced by:

Metabolism Muscular activity Other factors and heat lost through the:

Skin Lungs Body wastes

Maintenance of Body Temperature

Thermoregulatory 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 Production Primary source is metabolism

Hormones, muscle movements, and exercise increase metabolism

Epinephrine and norepinephrine are released and alter metabolism

Energy production decreases and heat production increases

Sources of Heat Loss

Skin (primary source)

Evaporation of sweat

Warming and humidifying inspired air

Eliminating urine and feces

Transfer of Body Heat to External Environment

•Radiation

•Convection

•Evaporation

•Conduction

Radiation

The diffusion or dissemination of heat by electromagnetic waves.› Ex. The body gives off waves of heat from

uncovered surfaces.

Convection

The dissemination of heat by motion between areas of unequal density.› Ex. An oscillating fan blows currents of cool

air across the surface of warm body.

Evaporation

The conversion of liquid to a vapor.› Ex. Body fluid in the form of perspiration

and insensible loss is vaporized from the skin.

Conduction

The transfer of heat to another object during direct contact.› Ex. The body transfers heat to an ice pack,

causing the ice to melt.

Factors Affecting Body Temperature • Age• Diurnal variations (circadian rhythms)• Exercise• Hormones• Stress• Environment

Equipment

Electronic digital or infrared thermometer or tympanic thermometer or glass thermometer.

Water-soluble lubricant (for rectal temp.) Gloves (for rectal temp) Facial tissue Disposable thermometer sheath or probe Alcohol pad

Sites for Measuring Body Temperature

• Oral• Rectal• Axillary• Tympanic membrane • Skin/Temporal artery

Types of Thermometers

Range of Human Body Temperature Measured Orally

Temperature: Lifespan Considerations

Tends to be lower than that of middle-aged adults

Elders

Tympanic or temporal artery sites preferred

Children

UnstableNewborns must be kept warm to prevent hypothermia

Infants

Normal Temperatures for Healthy Adults Oral – 37.0ºC, 98.6ºF Rectal – 37.5ºC, 99.5ºF Axillary – 36.5ºC, 97.6ºF Tympanic – 37.5ºC, 99.5ºF Forehead – 34.4ºC, 94.0ºF

T˚C = 5/9(T˚F – 32)

Do’s & Don’ts

Don’t avoid taking an oral temperature when the patient is receiving nasal O2

because O2 administration raises oral temperature by only about 0.3˚F (0.2˚C)

STEP-BY-STEP PROCEDURE

PULSE

PULSE•Pulse rate = number of contractions over a peripheral artery in 1 minute

Equipment

Watch with second hand Stethoscope (for auscultating apical

pulse) Doppler ultrasound blood flow detector Alcohol pad

Sites for Assessing Pulse

Palpating peripheral arteries

Auscultating apical pulse with stethoscope

Assessing apical-radial pulse

Sites for Assessing Pulse by Palpation

Thumb side of the forearm at wrist

Beside the larynx

Medial antecubital fossa (hollow in front of elbow)

Front of the ear and lateral to eyebrow

5th intercostal space just inside the midclavicular line

Halfway between the anterior superior iliac spine and the symphysis pubis, below the inguinal ligament

Behind knee in the popliteal fossa

Inner side of the ankle slightly below the medial malleolus

Dorsum of the foot with the foot plantar flexed

Factors Affecting Pulse

• Age• Gender• Exercise• Fever• Medications• Hypovolemia• Stress• Position changes• Pathology

Pulse: LifespanConsiderations

Often have decreased peripheral circulation

Elders

The apex of the heart is normally located in the fourth intercostal space in young children; fifth intercostal space in children 7 years old and older

Children

Newborns may have heart murmurs that are not pathological

Infants

Pulse Sites

Infants and children up to 3 years of age

Discrepancies with radial pulse

Monitor some medications

Apical

During cardiac arrest/shock in adultsDetermine circulation to the brain

Carotid

When radial pulse is not accessibleTemporal

Readily accessibleRadial

Pulse Sites

Circulation to the footPosterior tibial Circulation to the footDorsalis pedis

Circulation to lower legPopliteal

Cardiac arrest/shockCirculation to a leg;

Femoral

Blood pressureCardiac arrest in infants

Brachial

Characteristics of the Pulse

• Rate• Rhythm• Volume• Arterial wall elasticity• Bilateral equality

Pulse Rate and Rhythm

• Rate– Beats per minute– Tachycardia– Bradycardia

• Rhythm– Equality of beats and

intervals between beats

– Dysrhythmias– Arrhythmia

Characteristics of the Pulse

• Volume– Strength or amplitude– Absent to bounding

• Arterial wall elasticity– Expansibility or deformity

• Presence or absence of bilateral equality – Compare corresponding artery

Measuring Apical Pulse

Assessing Peripheral Pulses

Do’s & Don’ts

Don’t use your thumb to take the patient’s pulse.

because you may mistake your thumb’s own strong pulse.

STEP-BY-STEP PROCEDURE

RESPIRATION

Respiration

Interchange of gases between an organism and the medium in which it lives.

External respiration or breathing in – is the exchange of O2 and CO2 between the atmosphere and the body.

Internal respiration – takes place throughout the body at the cellular level.

Respiratory Control Mechanisms

• Respiratory centers– Medulla oblongata– Pons

• Chemoreceptors– Medulla– Carotid and – aortic bodies

• Both respond to O2,

CO2, H+ in arterial blood

Inhalation

• Diaphragm contracts (flattens)

• Ribs move upward and outward

• Sternum moves outward

• Enlarging the size of the thorax

Exhalation

• Diaphragm relaxes• Ribs move

downward and inward

• Sternum moves inward

• Decreasing the size of the thorax

Blood Circulation

C6H12O6 + O2 → ATP + CO2 + H2O

Factors Affecting Respirations

• Exercise• Stress• Environmental temperature• Medications

Respirations:Lifespan Considerations

Anatomic and physiologic changes cause respiratory system to be less efficient

Elders

Diaphragmatic breathersChildren

Some newborns display “periodic breathing”

Infants

Components of Respiratory Assessment

• Rate• Depth• Rhythm• Quality• Effectiveness

Respiratory Rate and Depth

• Rate– Breaths per minute– Eupnea– Bradypnea– Tachypnea

• Depth– Normal– Deep– Shallow

Components of Respiratory Assessment

• Rhythm– Regular– Irregular

• Quality – Effort– Sounds

• Effectiveness– Uptake and transport

of O2

– Transport and elimination of CO2

Assessing Respirations Inspection Listening with stethoscope Monitoring arterial blood gas results Using a pulse oximeter

STEP-BY-STEP PROCEDURE

To be discussed by Prof. Myrna Pares

BLOOD PRESSURE

Physiology of Blood Pressure

Force of the blood against arterial walls Controlled by a variety of mechanisms

to maintain adequate tissue perfusion Pressure rises as ventricle contracts and

falls as heart relaxes› Highest pressure is systolic› Lowest pressure is diastolic

Factors Affecting Blood Pressure

• Age• Exercise• Stress• Race• Gender• Medications• Obesity• Diurnal variations• Disease process

Blood Pressure:Lifespan Considerations

Client’s medication may affect how pressure is taken

Elders

Thigh pressure is 10 mm Hg higher than arm

Children

Arm and thigh pressures are equivalent under 1 year of age

Infants

Systolic and Diastolic Blood Pressure

• Systolic – Contraction of the

ventricles• Diastolic

– Ventricles are at rest– Lower pressure

present at all times• Pulse Pressure =

difference between systolic and diastolic pressures

• Measured in mm Hg• Recorded as a

fraction, e.g. 120/80• Systolic = 120 and

Diastolic = 80

Cardiac Cycle.mpg

Korotkoff’s Sounds

Korotkoff’s Sounds

• Phase 1– First faint, clear tapping or thumping

sounds– Systolic pressure

• Phase 2– Muffled, whooshing, or swishing sound

Korotkoff’s Sounds

• Phase 3– Blood flows freely – Crisper and more intense sound– Thumping quality but softer than in phase 1

• Phase 4– Muffled and have a soft, blowing sound

• Phase 5– Pressure level when the last sound is heard– Period of silence – Diastolic pressure

Measuring Blood Pressure

• Direct (Invasive Monitoring) • Indirect

– Auscultatory – Palpatory

• Sites– Upper arm (brachial artery)– Thigh (popliteal artery)

Equipment for Assessing Blood Pressure Stethoscope and sphygmomanometer Doppler ultrasound Electronic or automated devices

Assessing Blood Pressure Listening for Korotkoff sounds with

stethoscope › First sound is systolic pressure› Change or cessation of sounds occurs—

diastolic pressure The brachial artery and popliteal artery

are commonly used

For infant, small child, or frail adult

Normal adult-size

Measure BP on the leg or arm of an obese adult

Parts of Sphygmomanometer

Figure 29-19 Blood pressure monitors register systolic and diastolic blood pressures and often other vital signs.

Normal Ranges for Vital Signs for Healthy Adults Oral temperature — 37.0ºC, 98.6ºF Pulse rate — 60 to 100 (80 average) Respirations — 12 to 20 breaths/minute Blood pressure — 130/85

Delegating to UAP

• Body temperature– Routine measurement may be delegated to

UAP – UAP reports abnormal temperatures– Nurse interprets abnormal temperature and

determines response

Delegation to UAP

• Pulse– Radial or brachial pulse may be delegated

to UAP– Nurse interprets abnormal rates or rhythms

and determines response– UAP are generally not responsible for

assessing apical or one person apical-radial pulses

Delegating to UAP

• Respirations– Counting and observing respirations may

be delegated to UAP– Nurse interprets abnormal respirations and

determines response

Delegation to UAP

• Blood pressure– May be delegated to UAP– Nurse interprets abnormal readings and

determines response

• Oxygen saturation– Application of the pulse oximeter sensor

and recording the Sp02 may be delegated to UAP

– Nurse interprets oxygen saturation value and determines response

Post Test1. The proper time frame for waiting to check a temperature for the

patient who has just had a drink of water is

a. 2 minutes.

b. 5 minutes

c. 10 minutes

d. 15 minutes

2. The best thing to do when you get a reading on a digital thermometer that does not seem quite right is to

a. record that temperature

b. do nothing

c. repeat the temperature measurement

d. report the measurement immediately

1. The best location for taking the apical pulse is

a. Over the base of the heartb. At the 5th intercostal space just inside the midclavicular

linec. Upper left chest near nippled. At the 3rd intercostal space just inside the midclavicular

line.

2. The location for assessing peripheral pulses are

a. Radial, temporal, carotid, clavicular femoral, popliteal, pedal, and posterior tibial

b. Radial, temporal, carotid, brachial, femoral, crucial, pedal, and posterior tibial

c. Radius, temporal, carotid, brachial, femoral, crucial, pedal, and posterior tibial

d. Radial, temporal, carotid, brachial, femoral, popliteal, pedal, and posterior tibial

3. A patient who is experiencing eupnea is said to be

a. Breathing slowlyb. Breathing rapidlyc. Breathing normallyd. Not breathing

1. A normal respiratory rate for the adult is

a. 10 to 20 breaths per minuteb. 12 to 20 breaths per minutec. 14 to 20 breaths per minuted. 16 to 20 breaths per minute

2. Which of these factors can affect blood pressure? (Choose all that apply)

a. Ageb. Heightc. Recent activityd. Position

3. The point which the heart is beating and exerting its greatest force is called

a. Systolic pressureb. Diastolic pressurec. Pulse pressured. Basal pressure

Answers

1. d2. c3. b4. d5. c6. b7. a, c, d8. a

TOTAL POINTS = 10