Vital Signs

Teresa V. Hurley. MSN, RN

What are vital signs?

Blood Pressure Pulse Respiratory Rate and Oxygen Saturation Temperature Abbreviated as T, P, R. Spo2 and B/P

Nursing Responsibility

Know range of acceptable values Client patterns Frequency of taking based on client’s

condition

Temperature

What is body temperature?How is heat generated?What is the core body temperature range

in degrees C and F?Which sites are most often used to

measure the core temperature?Which sites are most often used to

measure body surface temperatures?

Temperature

Hypothalamus Range: 36 to 37.5 C or 97-99.5 F Heat Production Heat Loss

Radiation

Convection

Evaporation

Conduction

Factors Affecting Body Temperature

Circadian Rhythms Age Exercise Sex Hormone levels Stress Environment

Body Temperature

Afebrile Febrile

• Fever or Pyrexia

• Alteration in in hypothalmic set-point

• Increase in cellular metabolism and consumption of o2• Increase in heart and respiratory rates

• Prolonged fever leads to cellular, myocardial and or cerebral hypoxia

Temperature Alterations

Hyperthermia Hypothermia• Heatstroke -Frostbite

• Heat exhaustion

Temperature Assessment

Devices Tympanic: infrared sensors Rectal: electronic or digital Oral Axillary Temporal Artery Automated Monitoring

Mercury Thermometers: Glass

Toxic hazard effecting CNS via contact with its vapors and by touching it

Clean-up and Disposal

Pulse

Number of pulsations/minute over a peripheral artery

Rate: Beats per minute• 60-100 Beat per minute

• Bradycardia

• Tachycardia

Rhythm: regular or irregular (dysrhythmia) Amplitude

• 0 to 4+

Apical Pulse

Site: PMI at 5th ICS at left MCL

A/R rate correspond usually

Pulse Deficit is the difference between the A/R rate

Peripheral Sites

Temporal Carotid Brachial Radial Femoral Popliteal Posterior tibial Dorsalis pedis

Pulse Assessment

Stethoscope for apical pulse using bell side to hear low frequency sounds of heart and blood

Doppler Ultrasound Cardiac Monitor Palpation of peripheral arterial pulse

Factors Influencing Pulse Rates

Exercise Temperature Emotional States Drugs Hemorrhage Postual Changes Pulmonary Conditions

Factors influencing Respirations

Exercise Acute pain Anxiety Smoking Body Position Medications Neurological Injury Hemoglobin Levels

Respirations Passive process regulated by brain stem Ventilation regulated most importantly by high arterial

CO2 (hypercarbia) COPD regulation is by hypoxemia (low 02 levels) via

chemoreceptors in carotid artery and aorta

Respiratory Rate• Eupnea: 12 to 20 breaths/min

• Tachypnea

• Bradypnea

Respiratory Alterations

Apnea Dyspnea Hyperventilation

• Increase in rate

• Decrease in depth

• Fear

Hypoventilation• Decrease in rate

• Decrease in depth

Respiratory Alterations

Cheyne Stokes• Deep, rapid

• Periods of apnea

Biot’s• Severe brain damage

• Varying rate and depth

• Periods of apnea

Pulse Oximetry Spo2

Spo2 acceptable ranges: 90%-100% Sp02 85%-89% acceptable for chronic

diseases Spo2 less than 85% is unacceptable

Complete Blood Count (CBC)

Measure of RBC’s count, volume of RBC’s. and Hgb concentration which is the capacity to carry O2

Blood Pressure

What is Blood Pressure?

Systolic Diastolic Pulse Pressure

• Difference between systolic and diastolic pressure

Blood Pressure

Neural and Hormonal B/P Average 120/80 mm Hg Pulse Pressure difference between systolic

and diastolic• Range: 30-50 mm Hg

Hypertension

Asymptomatic Diastolic 80-89 mm Hg on 2 subsequent visits Systolic 120-139 mm Hg on 2 subsequent

visits HTN greater than 140/90 Greater peripheral vascular resistance with

decrease in blood flow to heart, brain and kidneys

HTN Factors

What persons are more at risk for developing for HTN?

Hypotension Systolic B/P falls below 90 mm Hg Hemorrhage Pump failure of heart Pallor Mottling of skin Clamminess Confusion Increase in HR Decrease in urinary output

Hypotension

Orthostatic (Postual)• Risk Factors

• Dehydration

• Anemia

• Prolonged bedrest

• Recent blood loss

Blood Pressure

Variations in B/P• Peripheral resistance and compliance

• Wall elasticity

• Neural and humoral mechanisms• Renin-angiotensin-aldosterone

• Increase per vascular resitance

• Increase Na and H2O retention

Cardiac Output• 3.5-8 Liters average

Blood Pressure Assessment

Non-invasive Monitoring Equipment: stethoscope and

sphygmomanometer Select appropriate cuff size Sites

• Brachial artery

• Popliteal if brachial artery inaccessible

B/P Measurement

Kortokoff Sounds Phases I through V What is the ausculatory gap? During which phase is there a distinct

change in sound? When does phase V occur?

What factors may influence accuracy of B/P measurement?

Exercise Caffeine Smoking Cuff size Too rapid or too slow release of valve

• Release so descent is 2-3mm Hg

Korotkoff Sounds

Phase I = 1st thump sound Phase II = whooshing sound Phase III = softer thump than Phase I Phase IV = soft blowing that fades Phase V = silence

B/P Variation Factors Age Diurnal Rhythms Stress Ethnicity Weight Gender Body Position Exercise Medications [anti-HTN, cardiac, opiod analgesics,

contraceptives]