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CHAPTER 4 VITAL SIGNS Overview 2 Vital signs (VS) are used to: Determine the general status of the patient Establish a baseline Monitor response to therapy Observe for trends Determine the need for further evaluation or intervention Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Obtaining VS and Clinical Impression 3 Four classic VS Temperature Pulse Respirations Blood pressure Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Additional Observations 4 Height and weight LOC Level and type of pain General Pulse appearance oximetry Frequency of VS Measurement 5 Depends on patient’s condition Baseline measurement On admission At beginning of each shift Before and after procedure Any time patient’s condition changes Based on protocol or physician's order As often as necessary for patient safety Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Trends in Vital Signs 6 Isolated measurement provides limited information Normal VS for a patient depend on: Age Presence of chronic disease Treatment protocols Trend = baseline + measurements over time Multiple-day graph Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Trending 7 Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. 9 Comparing VS Information 10 Shows change in patient’s condition: Comparing changes in VS, signs, and symptoms Establishing differential diagnosis Determining if patient is improving or deteriorating Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Comparing VS Information (Cont.) 11 Key to expert assessment: Constant awareness of change Look Listen Touch Reassess and analyze Trend, trend, trend Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. 12 Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Height and Weight 13 Routinely measured Pt needs an admission weight Document in kilograms (1 kg = 2.2 lb) Follow up every 24 to 48 hours Dehydration or fluid overload Follow intake/output (I&O) Scales must be age appropriate and regularly calibrated Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. General Clinical Impression 14 Gives clues to levels of distress and severity of illness Information about personality, hygiene, culture, and reaction to illness May dictate order of care, physical examination Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. General Clinical Impression (Cont.) 15 Cardiopulmonary distress suggested by: Labored, rapid, irregular, or shallow breathing Coughing, Chest choking, and/or wheezing pain and/or cyanosis Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. General Clinical Impression 16 Anxiety may be suggested by: Restlessness Fidgeting Tense look Difficulty communicating General Clinical Impression (Cont.) 17 Pain may be suggested by: Drawn features Moaning and guarding Shallow breathing and/or refusal to take deep breath Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Head-to-toe inspection 18 Hearing Smelling Seeing Touching Perception 19 Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Pain Level and Type 20 “Fifth vital sign” Pain intensity scales Ranking of 1 to 10 Quantifies a subjective measure Corresponding facial expressions and verbal description to assess pain level Find associated symptoms as well as alleviating and aggravating factors Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. 21 Level of Consciousness 22 Measure cerebral oxygenation Evaluation of time, place, and person “Oriented × 3” Deterioration from restlessness to coma Cerebral hypoxia Side effect to medications or drug overdose Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. LOC 23 Status of sensorium Directs treatment plan Patient cooperation, coordination Glasgow Coma Scale 24 Temperature 25 Normal: 98.6° F (37° C), range (97°-99.5° F) Daily variations (1°-2° F) Lowest in morning Highest late afternoon Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Temperature 26 Normal increase during exercise, ovulation, and first months of pregnancy Balance of heat production and loss Dissipation through sweating, peripheral vasodilation, and hyperventilation Fever 27 Elevation of temperature (febrile) From normal activities (exercise) = hyperthermia From disease (infection) = fever Body temperature of >102° F usually indicates infection Not all infections result in fever Immunocompromised patients may not be able to generate fever despite infection Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Fever (Cont.) 28 Increases O2 consumption and CO2 production O2 consumption and CO2 production increase 10% for each 1 C elevation in body temperature Patients with limited respiratory function may develop respiratory failure in response to fever Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Hypothermia 29 Body temperature below normal Head injury Cold exposure Compensatory mechanisms Shivering Peripheral vasoconstriction Reduces O2 consumption and CO2 production Slow and shallow breathing Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. 30 Inducing mild therapeutic hypothermia in selected patients surviving out-of-hospital sudden cardiac arrest can significantly improve rates of long-term neurologically intact survival and may prove to be one of the most important clinical advancements in the science of resuscitation. 31 Measuring Body Temperature 32 Sites: Mouth, ear, axilla, rectum, forehead Axillary: Safe and accurate in infants and small children 1 F lower than oral, 2 F lower than rectal Fahrenheit and Celsius conversion ° F = (° C × 9/5) + 32 ° C = (° F – 32) × 5/9 Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Pulse 33 Evaluate: Rate, rhythm, and strength Normal rate: 60-100 beats/min for adults The younger the patient, the faster the rate Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Heart Rate - Tachycardia 34 HR HR greater than 100 b/min can increase from hypoxemia, pain, anxiety, stress, fever, drug reactions, MI, hypovolemia, or cardiac output defects. Heart Rate 35 Bradycardia = <60 beats/min Diseased heart, athletes, medication side effects, hypoxemia in infants, low CO Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Arrhythmia = Irregular rhythm 36 37 Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Measurement of Pulse Rate 38 Right radial artery = Most common site Index and middle fingers Avoid thumb: examiner’s own pulsation Central pulses if hypotension present Carotid, femoral Pulse counted for a full minute If regular, counted for 15 sec × 4 or 30 sec × 2 Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Taking a Pulse 39 Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. 40 Pulse Rhythm and Pattern 41 Regular, regularly irregular, irregularly irregular Irregularly irregular is unfavorable finding Bigeminy = Rhythm coupled in pairs Trigeminy = Rhythm grouped in three beats Pulse deficit = Auscultated – Palpated Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. 42 Pulse Rhythm and Pattern (Cont.) Volume of the pulse Described as: bounding, full, normal, weak, thready, absent Pulsus paradoxus Strength decreases with inspiration Alternans = strong and weak pulses Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Respiratory Rate and Pattern 43 Sensitive Marker of Acute Respiratory Distress Tachypnea = rate above normal Atelectasis, Anxiety, hypoxemia, hypercapnia pain, exertion, metabolic acidosis Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Respiratory Rate and Pattern 44 Bradypnea = rate below normal Uncommon Head injury, hypothermia, side effect of medications (narcotics), drug overdose 45 Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Measurement of Respiratory Rate 46 Watching abdomen or chest wall movement Can be done as you assess radial pulse When regular = Count for 30 sec × 2 Assess depth and pattern Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Blood Pressure 47 Blood Pressure (BP) 48 Force exerted against arterial walls Systolic: peak force during ventricular contraction Diastolic: force during ventricular relaxation Normal: 120/80 mm Hg Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Blood Pressure Pulse pressure = P systolic – P diastolic Normal: 35-40 mm Hg <30 mm Hg: poor peripheral perfusion 49 50 Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Hypertension and Hypotension 51 Hypertension BP of >140/90 mm Hg Risk factor for heart, vascular, renal disease Major modifiable risk factor for stroke, CAD, CHF, peripheral vascular disease Cause in most cases is unknown Hypotension BP of <90/60 mm Hg If symptomatic: dizziness, fainting Causes: left ventricular failure, blood loss, peripheral vasodilation Orthostatic hypotension: resulting from changes in posture Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. 52 Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Measurement of Blood Pressure 53 Sphygmomanometer Occluding cuff, stethoscope, manometer Continuous noninvasive arterial pressure Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Blood Pressure 54 Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. 55 Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. Errors in Blood Pressure Measurement 56 Erroneously High Too narrow a cuff Cuff applied too tightly or too loosely Excessive pressure in cuff during measurement Incomplete deflation of cuff between measurements Erroneously Low Too Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. wide a cuff Blood Pressure 57 Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. 58 Effects of the Respiratory Cycle on BP Systolic pressure decreases (2-4 mm Hg) with inspiration Pulsus paradoxus: if BP drops >10 mm Hg Asthma, cardiac tamponade are two common causes Pulsus paradoxus in asthma signifies a more severe case Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc.
