Vital SignsNursing 125

Vital SignsTemperature, pulse, respiration, blood pressure (B/P) & oxygen saturation are the most frequent measurements taken by HCP.

Because of the importance of these measurements they are referred to as Vital Signs. They are important indicators of the bodys response to physical, environmental, and psychological stressors.

Vital SignsVS may reveal sudden changes in a clients condition in addition to changes that occur progressively over time. A baseline set of VS are important to identify changes in the patients condition.

VS are part of a routine physical assessment and are not assessed in isolation. Other factors such as physical signs & symptoms are also considered.

Important Consideration:A clients normal range of vital signs may differ from the standard range.

When to take vital signsOn a clients admission According to the physicians order or the institutions policy or standard of practiceWhen assessing the client during home health visitBefore & after a surgical or invasive diagnostic procedureBefore & after the administration of meds or therapy that affect cardiovascular, respiratory & temperature control functions.When the clients general physical condition changes LOC, painBefore, after & during nursing interventions influencing vital signsWhen client reports symptoms of physical distress

Body TemperatureCore temperature temperature of the body tissues, is controlled by the hypothalamus (control center in the brain) maintained within a narrow range.

Skin temperature rises & falls in response to environmental conditions & depends on bld flow to skin & amt. of heat lost to external environment

The bodys tissues & cells function best between the range from 36 deg C to 38 deg C

Temperature is lowest in the morning, highest during the evening.

Thermometers 3 typesGlass mercury mercury expands or contracts in response to heat. (just recently non mercury)

Electronic heat sensitive probe, (reads in seconds) there is a probe for oral/axillary use (red) & a probe for rectal use (blue). There are disposable plastic cover for each use. Relies on battery power return to charging unit after use.

Infrared Tympanic (Ear) sensor probe shaped like an otoscope in external opening of ear canal. Ear canal must be sealed & probe sensor aimed at tympanic membrane retn to charging unit after use.

Sites (P&P p. 216)

Assessing Radial PulseLeft ventricle contracts causing a wave of bld to surge through arteries called a pulse. Felt by palpating artery lightly against underlying bone or muscle. Carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis P&P p. 226Assess: rate, rhythm, strength can assess by using palpation & auscultation.

Pulse deficit the difference between the radial pulse and the apical pulse indicates a decrease in peripheral perfusion from some heart conditions ie. Atrial fibrillation.

Procedure for Assessing PulsesPeripheral place 2nd, 3rd & 4th fingers lightly on skin where an artery passes over an underlying bone. Do not use your thumb (feel pulsations of your own radial artery). Count 30 seconds X 2, if irregular count radial for 1 min. and then apically for full minute.

Apical beat of the heart at its apex or PMI (point of maximum impulse) 5th intercostal space, midclavicular line, just below lt. nipple listen for a full minute Lub-DubLub close of atrioventricular (AV) values tricuspid & mitral valvesDub close of semilunar valves aortic & pulmonic valves

Assess: rate, rhythm, strength & tensionRate N 60-100, average 80 bpm Tachycardia greater than 100 bpmBradycardia less than 60 bpm

Rhythm the pattern of the beats (regular or irregular)

Strength or size or amplitude, the volume of bld pushed against the wall of an artery during the ventricular contraction weak or thready (lacks fullness) Full, bounding (volume higher than normal)Imperceptible (cannot be felt or heard)

0----------------- 1+ -----------------2+--------------- 3+ ----------------4+Absent Weak NORMAL Full Bounding

Normal Heart Rate

Assess (cont.)Tension or elasticity, the compressibility of the arterial wall, is pulse obliterated by slight pressure (low tension or soft)

Stethoscope Diaphragm high pitched sounds, bowel, lung & heart sounds tight sealBell low pitched sounds, heart & vascular sounds, apply bell lightly (hint think of Bell with the L for Low)

Respirations Assess by observing rate, rhythm & depthInspiration inhalation (breathing in)Expiration exhalation (breathing out) I&E is automatic & controlled by the medulla oblongata (respiratory center of brain)Normal breathing is active & passiveWomen breathe thoracically, while men & young children breathe diaphramatically ***usually

Asses after taking pulse, while still holding hand, so pt is unaware you are counting respiratons

Assessing Respiration

Blood PressureForce exerted by the bld against vessel walls. Pressure of bld within the arteries of the body lt. ventricle contracts bld is forced out into the aorta to the lg arteries, smaller arteries & capillariesSystolic- force exerted against the arterial wall as lt. ventricle contracts & pumps bld into the aorta max. pressure exerted on vessel wall.Diastolic arterial pressure during ventricular relaxation, when the heart is filling, minimum pressure in arteries.

Factors affecting B/P lower during sleepLower with bld lossPosition changes B/PAnything causing vessels to dilate or constrict - medications

B/P (cont.) P&P p. 240 see table 9-3Measured in mmHg millimeters of mercuryNormal range syst 110-140 dias 60-90Hypertensive - >160, >90Hypotensive

B/P (cont.)Cuff inflatable rubber bladder, tube connects to the manometer, another to the bulb, important to have correct cuff size (judge by circumference of the arm not age)Support arm at heart level, palm turned upward - above heart causes false low readingCuff too wide false low readingCuff too narrow false high readingCuff too loose false high reading

Listen for Korotkoff sounds series of sounds created as bld flows through an artery after it has been occluded with a cuff then cuff pressure is gradually released. P&P p. 240.

Do not take B/P in Arm with cast Arm with arteriovenous (AV) fistulaArm on the side of a mastectomy i.e. rt mastectomy, rt arm

Procedure B/P

Procedure (cont.)

B/P Lower ExtremityBest position prone if not supine with knee slightly flexed, locate popliteal artery (back of knee).

Large cuff 1 inch above artery, same procedure as arm. Systolic pressure in legs maybe 10-40 mm hg higher

If unable to palpate a pulse you may use a doppler stethoscope

Oxygen Saturation (Pulse Oximetry)Non-invasive measurement of oxygen saturation

Calculates SpO2 (pulse oxygen saturation) reliable estimate of arterial oxygen saturationProbes finger, ear, nose, toePatient with PVD or Raynauds syndrome difficult to obtain.

Normal 90-100% Remove nail polishWait until oximeter readout reaches constant value & pulse display reaches full strengthDuring continuous pulse oximetry monitoring inspect skin under the probe routinely for skin integrity rotate probe.

Procedure Vital Signs

Vital Signs (cont.)

Clients who lack sweat gland function are not able to tolerate warm temperatures b/c they cant cool themselves adequately.Glass thermometers have been standard for many years, however b/c of risk of mercury exposure from accidental breakage, many health care agencies are eliminating mercury thermometers. Mercury is highly permeable through the skin & mucous membranes, inhaled vapors diffuse rapidly into the blood.Apical heart beat is best auscultated with the HOB elevated or with the patient sitting up.Capillaries minute vessels connecting arterioles & venules, the walls of which act as a semipermeable membrane for interchange of various substances b/w the bld & tissue fluid.Aneroid sphygmomanometers not as reliable as mercury due to the metal parts in the aneroid are subject to temperature expansion and contraction. Aneroid sphyg. Must be calibrated regularly.