VITAL SIGNS

Professor Blakey

NUR302

Vital Signs• Temperature • Pulse • Respirations• Blood Pressure• Health Status• Changes• Accuracy, Responsibility

Vital Signs

• When are they reported?

• When are they recorded?

Temperature

Sites:

Oral-

Taken routinely

Taken per MD order

Taken when fever is suspected

Oral Temperature

• Contraindicated with

• Unconscious patient

• Disorders of mouth

• Recently had fluids/smoked

• Wait 15 minutes

• Receiving nasal oxygen

Temperature• Rectal

• When?

• Assessing most accurate temp

• Alternative to oral site

Rectal Temp• Contraindicated with:• Newborns, small children• Diarrhea• Rectal surgery• Rectal disease• Concern re: vagus nerve

stimulation• Neurological disease

Axillary Temperature• When?

• Unable to use oral or rectal

• Newborn

• Contraindications:

• Axillary/Arm disorders

• After bathing

Normal Values

• Average values may vary 1 degree F higher or lower

F/ C• Oral- 98.6/ 37

• Rectal- 99.5/ 37.5

• Axillary- 97.6/ 36.5

Factors Affecting Temp• Circadian Rhythm (24 hours)

Predictable fluctuations-

Temp 1-2 degrees lower in early morning

Temp peaks late afternoon (4-7 pm)

Factors Affecting Temp• Age- very young and old

affected

• Gender- women

Progesterone at ovulation increases temp 0.5-1 degree

Environmental

Factors Affecting Temp• Hypothermia- low body temp

• Hyperthermia- high body temp

• Fever

Loss of appetite, headache, flushed, malaise

Severe- dehydration, alt urine output, seizures, lyte imbal

Reducing Fever• Cooling the body

• Increase fluids

• Monitor intake

• Monitor labs

• Antipyretics

• Antibiotics

Pulse• Normal range- 60-100

• Tachycardia- more than 100• Causes-• Decreased blood pressure• Elevated temp• Decreased oxygen• Heat, Pain, Medicatioins

Pulse• Bradycardia- less than 60• Caused by:• Slower in men• Thin person• Sleep• Hypothermia• Aging• Medications

Pulse Strength(Amplitude)

• 0- Absent

• 1+- Thready

• 2+- Weak

• 3+- Normal

• 4+- Bounding

• What would be reported?

Pulse Sites• Temporal (Temple)• Carotid (Neck)• Brachial (Bend of arm)• Radial- used frequently/palpate (Wrist)• Femoral (Groin)• Popliteal (Behind knee)• Posterior tibial (Inner ankle)• Dorsalis pedis (Top of foot)• Apical- used frequently/ auscultate (heart)

PulseEquipment

• Hands

• Doppler

• Stethoscope

Respirations• Ventilation

• Inspiration

• Expiration

• Normal rate- Adults 12-20 breaths per minute

Respirations• Patterns of Respiration

• Normal- 12/20 per minute

• Tachypnea- more than 24/min

(fever, anxiety, resp disease)

• Bradypnea- less than 10/min

(meds, brain injury)

Respirations• Hyperventilation- increased rate

and depth (Kussmaul’s)• Hypoventilation- decreased rate

and depth-narcotics/anesthesia

• Cheynes-Stokes- alt. deep/rapid with apnea

• Biot’s- erratic depth and apnea (brain injury)

RespirationsTerms

• Apnea- No breathing

• Dyspnea- Difficulty breathing

• Orthopnea- Breathing sitting upright

Factors Affecting Respirations

• Age- decreases with older age• Gender- males- diaphragmatic• Exercise- increases respirations• Disease- brain injury• Anemia- increases respirations• Anxiety- increases respirations• Medications- narcotics lower;

amphetamines- increases• Acute pain- increases

Respirations• Assessing:

Observation

(Other monitoring devices)

Blood Pressure• Systolic blood pressure-

contraction of ventricles (Highest pressure on arterial walls)

• Diastolic- relaxation (lowest pressure)

• Pulse pressure (PP)-

Systolic- Diastolic= PP

Blood PressureValues

• Normal- <120/ <80

• Prehypertension- 120-139/80-80-89

• Stage 1- 140-159/ 90-99

• Stage 2- >160/>100

Blood Pressure• Hypertension-

Sustained, above normal

Primary/essential HTN- no causeSecondary HTN- known etiology

Risk factors- Hx, obesity, smoking, sedentary, stress, diet

Blood Pressure• Hypotension- below normal B/P

• Orthostatic hypotension- Postural hypotension; weakness/ fainting when standing (esp when on prolonged bedrest)

Blood Pressure• Korotkoff Sounds:

Phase I- first faint clear tapping

Phase II- Swishing

Phase III- Distinct loud sounds

Phase IV- Muffling sounds

Phase V- Last sound

Blood PressureAssessment Sites

• Brachial Artery B/P Do not take in arm with IV, side

of mastectomy, AV shunt Popliteal Artery B/P

Systolic may be higher

Palpating B/PSystolic

Blood Pressure• False lows:• Releasing valve rapidly• Not pumping cuff high enough• Using faulty equipment• Did not insert earpieces correctly• Cuff too wide• Looking at meniscus above eye

level

Blood Pressure• False Highs:

• Cuff is not calibrated

• Looking at meniscus below eye level

• Cuff is too narrow

• Releasing valve too slowly

• Reinflating cuff during auscultation

Pain- the 5th Vital Sign

• Factors Affecting Pain:• It is what the patient says it is• Culture• Ethnicity• Gender• Age• Support of Others• Anxiety• Past experiences

Pain• JCAHO standards• Right to assessment and management• Ongoing assessment• Recorded• Policies and procedures• Pain must be managed• Education must be provided• Discharge planning includes pain mgt• Monitor effectiveness of mgt

Pain Assessment• Patient’s description• Duration• Location• Quantity/ Intensity• Quality• Chronology• Aggravating factors• Alleviating factors• Physiologic indicators of pain• Behavioral responses• Effect on activities and lifestyle

PainRating (p. 1384)

• Simple descriptive Pain Distress Scale

• Numeric Pain Scale

• Visual Analog Scale

• Wong-Baker Faces