Vitals

Normal temperature range

T \= 96.8-100.4 F (36-38 C)

Normal pulse rate

P\= 60-100 beats per minute

Normal respiratory rate

R/RR 12-20 breaths per minute

normal blood pressure

BP 120/80 mmHg

Normal pulse oximetry

Sp02 95%-100%

When to measure vital signs

-Upon admission

-Routine scheduled based facility policy/HCP order

-change in pt condition, before & after administration of medication that might affect for example: respiratory/cardiovascular function/ temperature control function/ physical activities as appropriate,

-Before, during, & after surgery/diagnostic procedures/ blood transfusions

Guidelines for measuring vital signs

-Select appropriate equipment

-Know baseline vs for the pt / medications the pt is taking that may affect vs

-Consider environmental factors

-Take vs using an organized, systematic approach

-Results: analyze results; determine significant findings, Document VS, communicate any concerning findings

Physiology of the hypothalamus

Sensed body temperature & adjust to maintain "set point"

Mechanism of control decrease cold temperature

Vasodilation

Sweating

Inhibition of heat production

Mechanism of control increase hot temperature

Vasoconstriction

Muscle contraction

Shivering

heat production -

Metabolism (primary)

Physical exertion

Hormones

Shivering

heat loss \= body temperature

Evaporation

Convection

Conduction

Radiation

Heat is a by-product of

Metabolic

The primary source of heat loss is the

Evaporation

Factors affecting body temperature

Age, exercise, hormone level, circadian rhythm, stress, environment, and temperature alterations

Temperature

Adult range 96.8-100.4

Average oral/tympanic temperature

98.6 F

Average temporal temp

97.6 F

Average axillary temp

97.7 F

36.5 C

Average rectal temp

99.5 F

What's an electronic probe used for

Oral

Rectal

Axillary

Proper way to use disposable device

Oral

Rectal

Axillary

Proper way to use temporal artery scanner

Forehead to posterior ear

Proper way to use tympanic device

Ear canal

Oral Assessment sites

Oral- insert thermometer under the tongue in the posterior sublingual pocket

Safety alert for oral temp

If pt ate, drank, chewed gum or smoked, wait 15-30 minutes

Rectal assessment sites

Rectal- insert lubricated thermometer into the rectum

safety alert rectal temp

Avoid in pts with heart disease or heart surgery. May stimulate the vague nerve, causing bradycardia

Do not perform on pts with rectal disease or those who have had rectal surgery

tympanic assessment

Place into pts ear canal pulling pinna up and back

Tympanic

Obtains core temperature

Ear wax does not affect temperature reading

Safety alert for tympanic

Do not perform on patients who have drainage from the ear

axillary assessment

Place thermometer in the center of the Axillary

Axillary safety alert

Axillary must be dry to obtain accurate reading

If temperature is abnormal

Verify thermometer is functioning and that proper technique was used. Then, reassess.

If the temperature remains abnormal,

Document and notify the hcp

Consider the relationship of vs to each other,

To previous findings and to other assessment data

physiology of pulse

Electrical impulses initiated each heart beat

Heart beat generates rhythmic blood flow which dilates arteries

A palpable sensation (pulse) is produced at various sites on the body

heart rate (HR) x

Beats per minute

Normal: 60-100 beats/min

Stroke Volume (SV) \=

Amount of blood pumped by the left ventricle in one contraction

Normal: 70 mL/beat

Cardiac Output (CO)

Volume of blood pumped by the heart over 1 minute

Normal: 5000 mL/min

heart rate x stroke volume \= cardiac output

70 bpm x 70 ml/beat \= 4900 ml

46 bpm x 60 ml/beat \= 2760 ml

Adequate hr and stroke volume

Are essential for sufficient co

Adequate co

Is necessary for adequate BP

Factors that increase pulse tachycardia (\> 100 beats/min)

Hemorrhage decrease in co and pulse pressure is sensed by receptors in the aorta ~\> increased blood to vital organs ~\> tachycardia

Factors that increase pulse tachycardia (\> 100 beats/min)

Activity the heart compensatory ability activates to meet the body's requirements for more oxygen

Factors that increase pulse tachycardia (\> 100 beats/min)

Fever increases 10 beats/min for each 1 f above normal

Factors that increase pulse tachycardia (\> 100 beats/min)

Pain acute or chronic

Factors that increase pulse tachycardia (\> 100 beats/min)

Emotions fear, anger, or anxiety

Factors that decrease pulse bradycardia(< 60 beats/min)

Elderly : have lower baseline HR. May be related to an arrhythmia, especially if onset is sudden

Factors that decrease pulse bradycardia(< 60 beats/min)

Endurance athletes : heat adapts to physical stress caused by exercise ~\> increased stroke volume ~\> fewer required beats to deliver blood

Factors that decrease pulse bradycardia(< 60 beats/min)

Beta blockers: block the effects of epinephrine

Calcium channel blockers: reduce electrical conduction of the heart

Factors that decrease pulse bradycardia(< 60 beats/min)

Hypothermia

Assessment site for temporal

Over the temporal bone, above and lateral to eye

Assessment site for carotid

Medial aspect of sternocleidomastoid muscle in the neck.

Typically used in emergencies when other sites are not palpable.

*safety alert: lightly palpate one side at a time to prevent diminished O2 to the brain

Assessment for apical

5th intercostal space at the mid clavicular line

Assessment for brachial

Grove between biceps and triceps at antecubital space

Assessment for radial

Thumb side of forearm at the wrist . Most common site for pulse assessment

Assessment for femoral

Between symphysis pubis and the anterior iliac spine & typically used in emergencies when other sites are not palpable

Assessment for popliteal

Behind the knee in popliteal fossa

Assessment for dorsalis pedis

Dorsal aspect of foot midline near navicular bone

Assessment for posterior tibial

Between medial malleolus and Achilles tendon

If radial pulse is abnormal/ the pt is taking medication that affects the heart rate,

The apical pulse provides a more accurate assessment

Count apical pulse for

1 minute