Techniques, Vital Signs, Height, Weight, & General Survey

Normal Temperature

Normal ~97.7 to 99.5 degrees Fahrenheit (F) or 36.5 to 37.5 degrees Celsius © (afebrile - no fever)

Hypothalamus job:

• Regulatory center for temperature

• When the body is too warm, vasodilation & sweating occur

• When the body is too cool, epinephrine release leads to vasoconstriction, & shivering

What are the factors of temperature?

-Diurnal variation or circadian rhythm

Lower at night & early in the morning

Higher in the afternoon & evening

-Women have higher temperatures between ovulation & the onset of menses

-Labile (variable) temperatures in infants & children 

-Exercise increases body temperature

-Older Adults: May have a normal temperature that is ~ 1-3 degrees F lower than younger adults 

May experience environmental hypo/hyperthermia r/t altered temperature regulation

Environmental temperature may overwhelm the ability to adapt

What happens if a patient has a fever?

The set point in the hypothalamus increases

Heat production is > heat loss

Temperatures > 106 degrees F (41 degrees C) lead tο damage to vital organs (especially the brain) & death

How is oral temperature done?

• Apply a probe cover 

• Place the thermometer under the tongue in the posterior sublingual pocket

• It signals when done

• Disinfect 

How is temporal temperature done?

1. Apply a disposable probe cover

2. Slide the probe from the center of forehead sideways

3. You may continue by  touching behind ear down to the indentation at the bottom of the ear

4. Facts: accurate and aseptic; skin should be dry

What is different from axillary temperature?

• Less accurate but SAFE

• Axillary temperature is ~1° F < oral

How is tympanic temperature done?

1. Apply a probe cover

2. Pull the pinna up & back

3. Aim the probe at the tympanic membrane

What are some errors when doing tympanic temperature?

• not aim correctly

• Excessive cerumen leads to a false low reading

• False high readings may result if taken in the ear the patient was lying on

What are the facts of rectal temperature?

• MOST accurate

• ONLY use rectal thermometer with a RED probe

• DO NOT switch probes or put on bed

• Rectal temperature is ~1° F > oral

how is rectal temperature done?

1. Turn the patient to the left side, lubricate the tip of the probe cover, & ask the patient to take a deep breath

2. Insert the lubricated probe 2 to 3 cm (0.5 to 1 cm for children)

3. Aim towards the umbilicus 

4. HOLD the patient AND rectal thermometer in place for patient safety

How to document temperature?

Record to nearest 0.1 degree Celsius (most common) or Fahrenheit per policy

Record the  route taken (O, R, T, A or Ax)

Do NOT tell a provider that the patient has a fever

Let the NUMBER AND ROUTE speak for themselves

Pulse Rates

Normal rates vary with age

Adults 60-100 beats/minute

Bradycardia < 60 beats/minute

Tachycardia > 100 beats/minute

What are the factors affecting pulse rate?

• Age; Infants pulses are faster

• Pulse rates increase with exercise, fever, hemorrhage, & anxiety

• Pulse rates are slower in athletes (normal) & when patients take some cardiac medications

What are the pulse sites?

• Radial Pulse- Thumb side of the wrist

• Apical Pulse- AUSCULTATE in the mitral (apical) area) in the 5th intercostal space at the midclavicular line instead of palpating there

How to take a pulse?

Count 30 or 60 seconds

60 seconds, if irregular

• find the Rhythm (regular, irregular, or irregularly irregular in atrial fibrillation)

What do you do if unable to palpate?

• Auscultate the apical pulse

• Use a Doppler to hear the pulse rate

• Dopplers with an external speaker are more aseptic than those that look like a stethoscope

what is the Pulse scale?

0 absent, 1+ weak, 2+ normal, 3+ bounding

what are the factors affecting the respiratory rate?

• Respiratory rate increases with anxiety, exercise, blood loss, fever & infection

• Respiratory rate decreases with a narcotic overdose

How to assess respirations?

Pretend you are still taking the pulse

- Count 30-60 seconds

60 seconds if abnormal

Normal Adult Range is 12-20 breaths/minute

Infants breathe fastest

Assess depth & rhythm (regular, irregular or a specific pattern)

how to document respirations?

• # of breaths/minute

• Rhythm 

Regular, irregular or a specific pattern (covered with respiratory assessment) 

• Depth (normal, shallow, deep)

Characteristics (effortless vs. labored, quiet vs. noisy)

What is blood pressure?

the pressure on the arterial walls during systole AND diastole

What is hypertension?

Persistently elevated BP, NOT high anxiety

What are the stages of hypertension?

What is hypotension?

Low blood pressure (<90/60)

Low BP accompanied by dizziness and/or fainting (syncope)

What is orthostatic hypotension?

• BP 20 systolic/10 diastolic  mm Hg or more decrease in BP when changing position from lying, to sitting, or standing (need to check)

• Dizziness & falls may result

• Order/Prescription for orthostatic BPs means taking BP lying, then sitting, then standing

What are the factors affecting BP?

• BP increases with increased cardiac output (young people don’t have high BP; more older), Arteriosclerosis, Age, Exercise, Anxiety, & Obesity

• BP decreases with hemorrhage (faster bleed; more BP goes)

when using correct size cuff the width and length of the cup is?

• width 40% of the arm circumference

• 80% to 100%

Where should arm cuff go?

Place the bladder of the cuff over the artery

Most cuffs have an arrow that is placed over the artery

The BP is taken over the brachial artery (pinkie side of the antecubital space)

Do not take a BP on the 

Arm with an IV, if the other arm is available

-Arm with an AV fistula for dialysis

-Mastectomy arm

What is systolic by palpation?

FIRST pulse beat felt during deflation is the systolic BP

There is NO diastolic number

what is systolic with a doppler?

The FIRST Korotkoff sound heard during deflation is the systolic BP

There is NO diastolic number

Used when the patient has a Left Ventricular Assist Device (LVAD)

what are the facts of Radial/Forearm/Wrist BP?

• Uses the radial artery

• A radial artery BP is HIGHER than a brachial BP

• Place the wrist at HEART LEVEL or the BP may be falsely elevated

What are the facts of thigh BP?

• use as LAST resort

• Uses the popliteal artery - highest BP

  Systolic pressure may be up to 40 mm Hg higher than a brachial BP

how do you document BP?

• Document MANUAL BPs in even numbers-Systolic/diastolic

• Document Electronic BPs as displayed

• Systolic/muffling/0 - if Korotkoff sounds do NOT disappear (once and while)

• Record the site (brachial, radial) & source of BP (manual, electronic, doppler, palpation)

• Pulse Pressure: Difference between the systolic & diastolic readings

What is pulse oximetry?

Measures the % of hemoglobin saturated with oxygen

• Older pulse oximeters are NOT as accurate for patients with darker skin

Pulse oximeters accurate models for varying skin tones are available

• Normal SpO₂ 96-100%

Sensors that are less likely to be affected by peripheral artery disease or hand movement

• Ear

• Forehead

• Nose

What are indications for pulse Pulse Oximetry need to use constant?

• Managing oxygen

• Anesthesia or sedation

• Heart or lung disease

• Sleep apnea

• Critical/Emergency care

Factors affecting accuracy on pulse oximetry?

• Poor tissue perfusion r/t Hypotension (low BP) ; Hypothermia (low temp); Vasoconstriction 

• Finger movement

• Poorly positioned sensor

• Bright light: Shield the sensor from bright windows

• Dark nail polish & acrylic nails - Remove

• Abnormal hemoglobin

• Low cardiac output

What are factors of false readings for pulse oximetry?

-Automatic BP cuff is on the same arm as the pulse oximetry sensor

-Darker skin tones (older pulse oximeters)

-ANEMIA

Each hemoglobin can carry 4 oxygen molecules

If each hemoglobin carries 4 oxygen molecules, the saturation will be 100%.

Carbon monoxide poisoning

Pulse oximeter can NOT tell whether oxygen or carbon monoxide is attached to hemoglobin

What is the documentation for pulse oximetry?

Result & unit of measurement (%)

Amount & type of O₂ in use (Nasal cannula at 2 L/minute, 50% Venturi mask, etc.)

Do NOT document false readings

What to check in pit falls?

• Pulse pressure variation- Normal: notch is older during inspiration than expiration, Abnormal: difference larger in hypovolemia, intrathoracic pressure swings, and obstructive lung disease

• monitor cardiac output (check for signs of cardiac arrest, feel for peripheral central pulse indicator of pulseless).

what is the Order of taking vital signs?

Temperature, Pulse, Blood Pressure, & Pulse Oximetry

When is an electronic BP inappropriate?

Electronic BPs may need to be validated with a manual BP when the

Patient is hypotensive (< 90 systolic)

Heart rate is rapid

Rhythm is irregularly irregular (atrial fibrillation)

Patient is experiencing involuntary movements, tremors or is shivering

What is MEWS Score: Clinical Judgment?

• Modified Early Warning Score indicates risk of ICU admission or death

• Calculated by the Electronic Medical Record (EMR) using the Systolic BP, Heart Rate, Temperature, Respiratory Rate, Urine Output & Level of Consciousness 

  • < 3  Patient is stable

  • 3-4  Signs of respiratory failure

  • ≥ 5  Critical condition

what is Clinical Judgment Model?

1. Assessment (History, patient assessment, equipment, labs, etc)

2. Analyze Data (recognize & analyze cues)

3. Refine & Prioritize Hypotheses 

4. Generate Solutions

5. Take Action

6. Evaluate Outcomes (Better, worse, or the same)

Flat percussion sounds?

• Heard over bones

• Practice on the kneecap or forehead

Dull percussion sounds?

Normal over solid organs (liver, full bladder)

What is Tympany (Tympanic) percussion?

Heard over most of the abdomen d/t bowel tissue, fluid, & gas

what is Liver Percussion?

• Start below the ribs in the right midclavicular line (MCL) & percuss upward

• The sound changes from tympanic to dull over the liver

what is resonsant percussion?

• Heard over spongy air filled lung tissues (NOT the ribs)

• Hyperresonant

  • Heard over lungs that are more air filled (Emphysema)

  • Normal in children

what is Direct, Blunt or Fist Percussion?

• To detect tenderness over the liver or kidneys

what are facts about palpation?

• Be sure the hands are warm

• Palpate painful areas LAST

• Tense muscles may decrease the ability to palpate

what is Superficial Palpation?

To detect superficial tenderness & masses

• Use light circular movements with the finger pads

what is deep palpation?

• To detect deeper abnormal areas

• One hand is placed on top of the other

• The lower hand feels while the upper hand pushes down

If a mass is found, describe:

• Location

• Size

• Shape

• Consistency

• Mobility

• Tenderness

what is Temperature Palpation:

• The back of the hand is more sensitive to temperature 

• Compare temperature bilaterally

what is Auscultation?

• To listen to heart, lung & bowel sounds

• Do NOT listen through a gown or clothing

what is the Diaphragm of a stethoscope?

Press firmly against the skin to listen to high-pitched sounds

what is the bell of a stethoscope?

Used to listen to low pitched cardiovascular sounds

what is body mass index based on?

height and weight

what is Body Roundness Index (BRI)?

• Gender, age, height, weight, waist & hip size are used in the calculation

  • Assesses for body roundness associated with Diabetes & Cardiovascular Disease

  • % of body fat estimate

  • % of visceral (abdominal) fat estimate

• The green area is a healthy BRI & the Black oval is the patient’s BRI

what is Normocephalic?

• Head size is within a defined normal range

what is microcephalus?

small head

• Small Head

• Problems with brain development

• Zika virus infection

what is hydrocephalus?

• large head

• excess cerebrospinal fluid

what are growth concerns?

• Sudden decrease in the child’s percentile

• Obesity

• Change in the growth trend