Download Vital Signs: Unlocking the Mysteries of the Client’s

Vital Signs: Unlocking the
Mysteries of the Client’s
Health Status
Vital Signs Provide One of the Most
Important Keys to the Client’s
Baseline Status and Response to
Medical or Nursing Treatment
Guidelines for Taking Vital Signs
 Collection of vital signs during the routine assessment provides a
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baseline for future assessments.
The nurse is responsible for vital signs interpretation, but may delegate
activity to an unlicensed personnel.
Equipment must be functional and appropriate for age.
Important to know the usual values for the individual client. Trends are
most important.
Important to recognize the effects of medical history and current
medications.
Minimize environmental factors that affect the vital signs.
The nurse should demonstrate vital signs in an organized, systemic
approach with a calm and caring manner.
Medications may be administered based on vital sign values. Physician
or other responsible care providers should be notified of abnormalities.
Physiology of Body Temperature
 Body temperature is the
difference between heat
produced by internal
processes and heat lost
through the external
environment.
 Temperature control
mechanisms keep the the
body’s core temperature
relatively constant.
 Acceptable range is 36.537.5 degrees C (97.6 –
99.6 degrees F).
Various sites may be used
but the pulmonary artery is the
most accurate.
Thermoregulation
 Hypothalamus –
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“thermostat” of the body,
is located between the
cerebral hemispheres.
Anterior – reduces body
temperature.
Posterior – increases body
temperature.
Basal metabolic rate
(BMR)
Heat loss – radiation,
conduction, convection,
evaporation, diaphoresis
Skin plays an important role
in temperature regulation.
Behavioral control affects
temperature.
Temperature Alterations
 Hyperpyrexia (fever) – heat loss is unable to keep pace
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with excess heat production
Pyrogens – bacteria and viruses cause a rise in body
temperature.
Febrile – state of elevated body temperature
Afebrile – absence of fever
Fever is an important defense mechanism. Mild temp
(< 102.2 degrees F) can enhance the immune system.
FUO – fever of unknown origin
Hyperthermia – elevated body temperature
Malignant hyperthermia – hereditary condition of
uncontrolled heat production, occurs in susceptible persons
that receive certain anesthetic drugs.
Hypothermia – decreased body temperature, classified by
core temperature measurements.
Temperature Assessment
Surface & Core Sites
Core Sites
esophagus, pulmonary artery,
urinary bladder
Surface Sites
*tympanic membrane
(Also considered core)
oral (mouth)
axillary
rectal
Thermometers
 Glass
• Oral – slim or
elongated
• Stubby can be used
for all sites
• Red bulb – rectal
only
 Electronic
• Blue – oral or
axillary
• Red – rectal
Tympanic
Temperature Conversions
 F = (9/5 x C) + 32
104 F = (9/5 x 40 C)
+32
 C = (F-32) x 5/9
40 C = (104F –32) x
5/9
Converting Fahrenheit to Centigrade
 101*F
 99.6*F
C = (F – 32) x 5/9
C = ( 101 – 32 ) x 5/9
C = 69 x 5/9
C = 38
C = (99.6F – 32) x 5/9
C = 67.6 x 5/9
C = 37.5
Convert Centigrade to Fahrenheit
 38*C
 F = (C x 9/5) + 32
 F = (38C x 9/5) +32
 F = 68.4 + 32
 F = 100.4
Treating a Fever
Tepid sponge
bath
Ice packs
Antipyretics
Hypothermia
blanket
Cooling fans
Avoid the
stimulation of
shivering
Pulse
 Palpable bounding of blood flow noted at various
points of the body.
 Blood flows in a continuous circuit.
 Electrical impulses are initiated by the SA node
and stimulated the heart muscle to contract.
 Stroke volume – amt of blood pumped from the
heart with each contraction.
 Cardiac output – amt of blood ejected from the
heart in 1 min.
– CO = SV x HR
– Normal CO = 4-6 liters/min
 Mechanical, neural, and chemical factors regulate
the strength of contractions and stroke volume.
Pulse Sites
Temporal
Carotid
Radial
Ulnar
Brachial
Apical
Femoral
Popliteal
Dorsal
pedis
Posterior
tibial
•Carotid most
common in
emergencies.
•Radial is most
common for routine
examination.
•Apical pulse
provides a more
accurate assessment
of heart function.
Assessment of the Pulse
 Rate
 Apical
S1 = lub
S2 = dub
 Rhythm
 Strength (Quality)
 Equality
Questions
 Which pulse point would allow you to best
assess the circulation to the feet.
 A. temporal
 B. brachial
 C. posterior tibial
 D. pedis ulnus
 An irregular rhythm requires a full minute
of assessment.
 True or False?
Respirations
 Ventilation –
movement of gases in
and out of lungs
 Diffusion – movement
of oxygen and CO
between alveoli and
RBC
 Perfusion – the
distribution of RBC to
and from pulmonary
capillaries
Physiological Control
 Inspiration is active
 Respiratory center of the
brain controls respirations
 Normal rate 12-20/min
(adult) and 40- 60/min
(infants)
 Levels of CO2 help
regulate ventilation
- Increased CO2 leads
to increased
ventilation
- In COPD patients
low levels of O2
stimulate
respirations
 Hypoxemia – low
levels of arterial O2.
Mechanics of Breathing
 Inspiration is active
process initiated by
impulses from phrenic
nerve. Diaphragm
contracts and chest
wall moves out.
 Expiration is passive
process. Diaphragm
relaxes and chest wall
returns to normal
position.
Assessment of Respirations
Assessing Respirations
Rate
Observe inspiratory
& expiratory movements
Ventilatory Depth
Degree of movement
Ventilatory Rhythm
Observe chest &
abdominal movements
Oxygen Saturation
 SaO2 = percent of
hemoglobin that is
bound with oxygen in
the arteries.
 Normal SaO2 is 95100%.
 Pulse oximeter is
utilized to provide
indirect measurement
of oxygen saturation.
 Values obtained with
pulse oximetry are less
reliable if the SaO2 is
<70%.
 May apply probe to
finger or earlobe. Sole
of foot may be used in
infants.
Questions
 An infant is brought into the emergency by
his mother with a fever for 2 days. You find
the following respiration rate of 40 which is
regular and unlabored.
 A. You notify the provider immediately
 B. You document the finding as R 40
 C. You set the infant upright and apply
oxygen.
Blood Pressure
 Definition – lateral force on the walls of the artery
by the pulsing blood under pressure from the
heart.
 Blood is forced from atria to ventricles to aorta.
 Systolic = peak of maximum pressure when
ejection occurs.
 Diastolic = minimum pressure, the ventricles have
relaxed and the blood remaining in the arteries is
at the lowest pressure.
 Pulse pressure = difference between systolic and
diastolic. Normally 30 – 50 mm Hg.
Physiology of Blood Pressure
 Cardiac Output – volume of blood ejected
over 1 minute. CO = SV x HR
 Stroke Volume – amount of blood ejected
from the heart with each contraction.
 Blood pressure is affected by cardiac output
and peripheral vascular resistance.
– BP = CO x resistance
– Peripheral resistance, blood volume, viscosity,
and elasticity all play a role in blood pressure.
Factors Affecting Blood Pressure
Age
Stress
Race
Medications
Diurnal
Variation
Gender
Abnormalities in Blood Pressure
 Hypertension – (JNC7) the average
of 2 or more properly measured,
seated BP readings: SBP 140-159 or
DBP 90-99, classified as stage 1
hypertension.
 HTN associated with family hx,
cigarette smoking, obesity, heavy
alcohol consumption, high Na
intake, sedentary lifestyle, diabetes,
age, and race.
 Hypotension – SBP < 90 mm Hg.
Associated S/S are pallor, decreased
UOP, increased HR, clamminess,
confusion.
 Orthostatic hypotension – Decreased
in BP with increase in HR and resp.
Questions
This is the first time you have seen this 45
year old female. She has no prior medical
history. Her blood pressure reading is
148/94. Does this support the diagnosis of
hypertension? Why or why not?
 She comes back in one week for a recheck
of her blood pressure. Her BP is 154/90.
She is diagnosed with hypertension by the
primary care provider. Which of the
following could be affecting her BP?
 A. age
 B. weight 185, height 5’4”
 C. stress
 D. inadequate equipment
Pediatric Considerations
 Best results – count resp 1st, pulse 2nd, and temp last.
 If VS cannot be taken without disturbing the child, record
the child’s behavior (crying).
 Other s/s of increased temp: flushed skin, increased resp
and heart rates, malaise, and “glassy look” to eyes.
 Radial pulse in children > 2yrs. Infants < 2 yrs should use
apical pulse. Count for 1 full min d/t irregularities.
 Respirations – infants require observation of abdominal
movements d/t diaphragmatic breathing. Count for 1 full
min.
Normal Pediatric Blood Pressure
 Systolic
– 1-7 years:
Age in years + 90
– 8-18 yrs:
(2 x age in years) + 83
 Diastolic
– 1-5 yrs: 56
– 6-18 yrs:
in years + 52
Age