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JUDITH M. WILKINSON LESLIE S. TREAS KAREN BARNETT MABLE H. SMITH FUNDAMENTALS OF NURSING Chapter 20: Measuring Vital Signs Copyright © 2016 F.A. Davis Company Vital Signs • A means of assessing vital or critical physiological functions • Variations reflect a person’s state of health and/or functional ability of the body systems Copyright © 2016 F.A. Davis Company Vital Signs (cont’d) • One of the most frequent assessments you will make as a nurse • The importance of accurate assessments, interpretation, and documentation of VS cannot be overemphasized. Copyright © 2016 F.A. Davis Company Monitoring Vital Signs • Performed on a regular basis • Frequency determined by – Provider’s prescription and/or nursing judgment – Client’s condition – Facility standards Copyright © 2016 F.A. Davis Company Facility Standards for Monitoring • Hospital: every 4 to 8 hr • Home health setting: each visit • Clinic: each visit • Skilled nursing facilities (SNFs): weekly to monthly Copyright © 2016 F.A. Davis Company Temperature • Degree of heat maintained by the body • Heat produced minus heat lost Copyright © 2016 F.A. Davis Company Core Temperature • The “old standby” normal range: 97°F to 100.8°F (36.1°C to 38.2°C) with some variation • Typically 1°F to 2°F (0.6°C to 1.2°C) higher than skin temperature Copyright © 2016 F.A. Davis Company Surface Temperature • Lower than core temperature • Use oral and axillary method Copyright © 2016 F.A. Davis Company Changes in Temperature Can Occur Via… • Conduction: Transfer of heat from a warm to a cool surface by direct contact • Convection: Transfer of heat through currents of air or water Copyright © 2016 F.A. Davis Company Changes in Temperature Can Occur Via… (cont’d) • Radiation: Loss of heat through electromagnetic waves emitting from surfaces that are warmer than the surrounding air • Evaporation: Water is converted to vapor and lost from the skin (as perspiration) or the mucous membranes (through the breath) Copyright © 2016 F.A. Davis Company Variances in Temperature Fever (pyrexia) • Abnormally high body temperature (>100°F or 37.8°C) • Occurs in response to pyrogens (e.g., bacteria) • Pyrogens induce secretion of substances (prostaglandins) that reset the hypothalamic thermostat at a higher temperature Hyperpyrexia • Fever >105.8°F (41.0°C) Copyright © 2016 F.A. Davis Company Variances in Temperature (cont’d) Hypothermia • Core temperature below normal (<95°F or 35°C) • Associated with extended exposure to cold (e.g., extreme weather, immersion in cold water, or lack of shelter and clothing) Copyright © 2016 F.A. Davis Company Course of Fever • Initial—Febrile episode • Second—Course • Third—Defervescence or crisis Copyright © 2016 F.A. Davis Company Pulse The “wave” that begins when the left ventricle contracts and ends when the ventricle relaxes Copyright © 2016 F.A. Davis Company Pulse (cont’d) • Each contraction forces blood into the already-filled aorta, causing increased pressure within the arterial system. • Systole is the peak of the wave, or contraction of the heart. • Diastole is the trough or resting phase of the heart. Copyright © 2016 F.A. Davis Company Pulse (cont’d) Pulse rate • Measured in beats per minute (bpm) – Normal range for healthy adults = 60 to 100 bpm – Average = 70 to 80 bpm Copyright © 2016 F.A. Davis Company Obtaining a Pulse Rate • Apical is most accurate • Use a stethoscope to auscultate the number of heartbeats at the apex of the heart • A heartbeat is one series of the LUB and DUB sounds Copyright © 2016 F.A. Davis Company Common Pulse Points • Apical: At the apex of the heart • Carotid: Between midline and side of neck. Only for CPR-trained professional; and assessing circulation to the head • Brachial: Medially in the antecubital space • Radial: Laterally on the anterior wrist • Femoral: In the groin fold • Popliteal: Behind the knee Copyright © 2016 F.A. Davis Company Variances in Pulse Rates • Bradycardia: Rate <60 bpm • Tachycardia: Rate >100 bpm • Is the rate regular or irregular? • What is the quality of the pulse? – Bounding? – Thready? Copyright © 2016 F.A. Davis Company Cardiac Efficiency • Stroke volume: The quantity of blood pumped out by each contraction of the left ventricle • Cardiac output: Stroke volume × pulse (heart) rate Copyright © 2016 F.A. Davis Company Inadequate Circulation If circulation is compromised, pallor or cyanosis may be present • Pallor: Paleness of skin when compared with another part of the body • Cyanosis: A bluish or grayish discoloration of the skin due to excessive carbon dioxide and deficient oxygen in the blood Copyright © 2016 F.A. Davis Company Respiration • The exchange of oxygen and carbon dioxide in the body • Two separate processes – Mechanical – Chemical Copyright © 2016 F.A. Davis Company Respiration (cont’d) Mechanical • Pulmonary ventilation; breathing • Active movement of air in and out of the respiratory system Copyright © 2016 F.A. Davis Company Respiration (cont’d) Chemical • Exchange of oxygen and carbon dioxide • Transport of oxygen and carbon dioxide throughout the body • Exchange of gases between capillaries and tissues Copyright © 2016 F.A. Davis Company Mechanics of Respiration/ Pulmonary Ventilation Inspiration • Drawing air into the lungs • Involves the ribs and diaphragm, creating negative pressure and allowing air to flow into the lungs Copyright © 2016 F.A. Davis Company Mechanics of Respiration/ Pulmonary Ventilation (cont’d) Expiration • Relaxation of thoracic muscles and diaphragm, causing air to expel from the lungs Copyright © 2016 F.A. Davis Company Changes in the Thoracic Cavity Copyright © 2016 F.A. Davis Company Variations in Assessment Findings • Rate – Apnea: Cessation of breathing – Bradypnea: Abnormally slow – Tachypnea: Abnormally fast • Depth – Deep – Shallow Copyright © 2016 F.A. Davis Company Variations in Assessment Findings (cont’d) • Rhythm – Assessment of the pattern of respirations – Abnormal: Cheyne-Stokes, Biot • Effort – Work of breathing – Dyspnea: Labored breathing – Orthopnea: Inability to breathe when horizontal Copyright © 2016 F.A. Davis Company Variations in Breath Sounds • Wheeze: High-pitched continuous musical sounds, usually heard on expiration • Rhonchi: Low-pitched continuous sounds caused by secretions in the large airways • Crackles: Discontinuous sounds usually heard on inspiration; may be high-pitched popping sounds or low-pitched bubbling sounds Copyright © 2016 F.A. Davis Company Variations in Breath Sounds (cont’d) • Stridor: A piercing, high-pitched sound heard primarily during inspiration • Stertor: Labored breathing that produces a snoring sound Copyright © 2016 F.A. Davis Company Ventilation and Oxygenation Hyperventilation • Rapid and deep breathing resulting in excess loss of CO2 (hypocapnea) • Client may complain of feeling light-headed and tingly. Copyright © 2016 F.A. Davis Company Ventilation and Oxygenation (cont’d) Hypoventilation • The rate and depth of respirations are decreased and CO2 is retained. Copyright © 2016 F.A. Davis Company Tools to Measure Oxygenation Arterial blood gases (ABGs) • Directly measures the partial pressures of oxygen, carbon dioxide, and blood pH Copyright © 2016 F.A. Davis Company Tools to Measure Oxygenation (cont’d) Pulse oximetry • Noninvasive method of monitoring respiratory status • Uses an external device that measures oxygen saturation Copyright © 2016 F.A. Davis Company Counting the Respiratory Rate • The nurse should count the respiratory rate (RR) after taking the radial pulse. • The patient can alter the rate and pattern of respirations. • RR must be accurate, especially in older adults. Copyright © 2016 F.A. Davis Company Blood Pressure (BP) Pressure of the blood as it is forced against arterial walls during cardiac contraction Copyright © 2016 F.A. Davis Company Blood Pressure (BP) (cont’d) Systolic pressure • Peak pressure exerted against arterial walls as the ventricles contract and eject blood Copyright © 2016 F.A. Davis Company Blood Pressure (BP) (cont’d) Diastolic pressure • Minimum pressure exerted against arterial walls between cardiac contractions when the heart is at rest Copyright © 2016 F.A. Davis Company Blood Pressure (BP) (cont’d) • Measured in millimeters of mercury (mm Hg) • Recorded as systolic pressure over diastolic pressure (e.g., 120/80 mm Hg) • Pulse pressure: The difference between the systolic and diastolic pressures Copyright © 2016 F.A. Davis Company BP Regulation Influenced by three factors • Cardiac function • Peripheral vascular resistance • Blood volume Copyright © 2016 F.A. Davis Company BP Regulation (cont’d) The body constantly regulates and adjusts arterial pressure in order to supply blood to body tissues via perfusion of the capillary beds. Copyright © 2016 F.A. Davis Company Measuring BP Indirect or noninvasive • Most common • Accurate estimate of arterial BP obtained by external measuring devices Copyright © 2016 F.A. Davis Company Measuring BP (cont’d) Direct method • This is done only in in-client setting. • A catheter is threaded into an artery under sterile conditions. • It is attached to tubing that is connected to an electronic monitoring system. • Pressure is constantly displayed as a waveform on the monitor screen. Copyright © 2016 F.A. Davis Company Measuring BP (cont’d) Indirect method Equipment • Sphygmomanometer – Consists of a vinyl or cloth cuff, a pressure bulb with a regulating valve, and a manometer • Stethoscope – Used to auscultate the systolic and diastolic pressures Copyright © 2016 F.A. Davis Company Measuring BP (cont’d) Copyright © 2016 F.A. Davis Company Measuring BP (cont’d) (Check the procedure in Volume 2 for the complete set of steps for measuring BP.) • Place stethoscope over an artery. • Inflate the cuff; the artery is occluded as the pressure of the cuff exceeds the pressure in the artery. • Deflate the cuff; blood begins to flow rapidly through the partially open artery, producing turbulent flow you will hear through the stethoscope. Copyright © 2016 F.A. Davis Company Korotkoff’s Sounds First sound • As you deflate the BP cuff, a sound that occurs during systole (systolic BP) Second sound • As you further deflate the cuff, a soft swishing sound caused by blood turbulence Copyright © 2016 F.A. Davis Company Korotkoff’s Sounds (cont’d) Third sound • Begins midway through the BP and is a sharp, rhythmic tapping sound Fourth sound • Similar to the third sound, but softer and fading Fifth sound • Silence, corresponding with diastole (diastolic BP) Copyright © 2016 F.A. Davis Company Hypotension • Systolic blood pressure <100 mm Hg; some clients normally have low BP; ask if client is light-headed or dizzy. • Orthostatic or postural hypotension is a sudden drop in BP on moving from a lying to a sitting or standing position. Copyright © 2016 F.A. Davis Company Hypertension Prehypertension • BP reading of 120 to 130 mm Hg systolic or 80 to 89 diastolic mm Hg • Obtained with two readings, taken 6 min apart, with the client sitting (JNC 7, 2003) Copyright © 2016 F.A. Davis Company Hypertension (cont’d) Hypertension • Diagnosed when BP is persistently higher than normal. • Diagnosed when BP is >140 mm Hg systolic or >90 mm Hg diastolic on two or more separate occasions. Copyright © 2016 F.A. Davis Company Hypertension (cont’d) • This is a major cause of illness and death in the United States. • It increases the stress on the heart and blood vessels. • If untreated, it can lead to heart, renal, cerebral, or respiratory complications. • Severity is directly related to the degree of elevation. Copyright © 2016 F.A. Davis Company Hypertension (cont’d) Primary or essential hypertension • Diagnosed when there is no known cause for the increase • Accounts for at least 90% of all cases of hypertension Copyright © 2016 F.A. Davis Company Vital Signs: Combination of Skills • Vital signs – – – – Temperature Pulse Respirations BP • Provide an indication of a person’s state of health and functioning of the body systems. Copyright © 2016 F.A. Davis Company Responsibility and Delegation Nurses can delegate the activity of taking vital signs, but the nurse is responsible for interpretation of vital signs, vital sign trends, and decisions based on abnormal vital sign findings. Copyright © 2016 F.A. Davis Company Responsibility and Delegation (cont’d) As a student nurse, you are responsible for functioning within your scope of knowledge. Copyright © 2016 F.A. Davis Company Think Like a Nurse Recall the clients you encountered at the community health fair (Meet Your Patients, in Volume 1). Two-year-old Jason’s axillary temperature was 101.8°F (38.8°C); his skin was warm, dry, and flushed. His mother told you that he had been eating poorly and was very irritable. • What changes in behavior alert you that something is wrong? • Do you have enough theoretical knowledge or patient data to know what is going on? • What, if any, additional information about the patient situation do you need to understand the meaning of Jason’s temperature reading? Copyright © 2016 F.A. Davis Company