Vital Signs: Definitions, Measurement, and Clinical Significance in Nursing

What do Vital Signs reflect?

The health status of a

patient

• Best indicator for

cardiopulmonary arrest,

unplanned ICU admissions, and

unexpected deaths.

Why is assessing vitals important?

Monitoring and evaluating

trends is a part of early

detection, timely intervention,

and better patient outcomes.

Definition of Temperature?

Difference between amount of

heat produced by body and

amount of heat lost to the

environment measured in

degrees.

Body Temperature is controlled by what?

Thermoregulatory center in the hypothalamus.

Radiation + Example?

* Transfer of heat to

cooler objects in

the environment

(no contact).

- Patient lying near a

cold window loses

heat to the glass.

Convection + Example?

*Heat carried away

by moving air or

fluid.

- Patient uncovered in

a drafty room loses

heat as air circulates

across skin.

Evaporation + Example?

* Heat loss when

moisture changes

to vapor.

- Surgical patient loses

heat as antiseptic

solution or sweat

evaporates from skin.

Conduction + Example?

* Direct transfer of

heat to a cooler

surface.

-Infant placed on a

cold scale or patient

on cold stretcher.

Factors affecting Temperature?

- Circadian

rhythms

- Age and Biologic

Sex

- Physical activity

- State of Health

- Environmental

Adult Temp?

96.4-99.5

Old Adult Temp?

96.4-98.3

Elevated Temp?

Greater than 100.4

Elevated Temp Interventions?

ASA (Aspirin), ibuprofen, acetaminophen. No Aspirin for patients < 19 y.o

• Increase heat transfer: cool sponge baths, cool

packs, cooling blankets

• Oral fluids

Decreased Temp; to be concerned with?

Less than 95

Decreased Temp Interventions?

• Warm blankets

• Warm oral/IV fluids

Contraindications for Oral temp?

confused, coma, oxygen mask, oral cavity,

nose/mouth surgery

Oral temp normal?

• 96.6 - 99.5 F

Contraindications for temporal artery temp?

scar, open lesion, or abrasions

temporal artery temp normal?

• 98.7 - 100.5 F

Axillary temp normal?

•95.6-98.5

Contraindications for rectal temp?

newborns, children with diarrhea, rectal

disease/surgery, low platelet count

Rectal Temp Normal?

97.4 - 100.5 F

What does the pulse look at or check?

Cardiac Function

If pulse can't be found?

Use doppler or stethoscope

What regulates the pulse?

autonomic nervous system through the SA

node.

Factors that affect pulse?

1. Age

- babies are higher

2. Sex

3. Physical Activity

4. Fever/ Body Temp

- increase due to metabolic demand

5. Stress/ Emotion

6. Meds

7. Blood Loss/Hemorrhage

- increases to compensate for loss

8. Postural changes

- orthostatic

9. Chronic Conditions

What does the respiration process consist of?

Ventilation, diffusion, perfusion

What are respirations controlled by?

cerebral cortex

What is a respiratory stimulant?

CO2

What could a change in respirations an early sign of?

Decline

Respirations low but normal O2 sats is what?

Impaired gas exchange

Respiration rate and depth is in response to what?

tissue demands

Factors affecting respirations?

* Exercise

• Disease

• Alterations in fluid

• Electrolyte and acid-base imbalances

• Medications

* Trauma

- Neuro

* Infection

* Pain

* Emotion

Orthopnea?

breathes better sitting up, SOB laying down

Dyspnea?

subjective, increased effort to breathe.

SPO2 normal w/ COPD?

88-92

Hypoxic SPO2 and interventions?

94-85; Assess for underlying disease and start O2 therapy.

Severely Hypoxic SPO2 and interventions?

Less than 85%; Start supplemental O2 therapy immediately

Blood Pressure?

force of the moving blood against arterial walls

where maximum blood pressure is exerted on the walls

of the arteries when the left ventricle of the heart

contracts and pushes blood through the aortic valve

into the aorta at the beginning of systole.

Neural Regulation of BP?

Cardiovascular center transmits impulses to the heart and

vascular smooth muscle

Humoral Regulation of BP?

vasoconstriction, ADH, water retention

Long Term regulation of BP is done by what?

Kidneys

Factors affecting BP?

• Age: older has decreased elasticity of arteries

• Circadian rhythm: lowest in the morning and higher in

the evening

• Biologic sex: women have lower blood pressure until

menopause

• Weight

• Position

• Race

• Meds: oral contraceptives

• Exercise/activity

• Rest at least 5 minutes

• Caffeine

• Smoking

• Stress

BP considered HTN?

BP > 130/80

Complications of Hypertension?

• Myocardial infarction (heart attack)

• Cerebrovascular accident (stroke)

• Kidney damage

• Heart failure

• Ventricular hypertrophy

BP considered Hypotension?

BP < 90/60

Orthostatic Hypotension changes?

Sustained decrease in SBP > 20, DBP > 10

Symptoms of Orthostatic Hypotension?

Dizziness, lightheadedness,

pallor, diaphoresis, or syncope

MAP?

the average pressure in the arteries during 1 cardiac cycle

MAP normal

70-100 mmHg, >65 mmHg

MAP formula?

• SBP + 2(DBP) ÷ 3

• BP= 76/28; for MAP

44

BP= 102/54; for map

70

What is the responsibility of the nurse and vitals?

• Obtaining accurate data

• Trend VS data

• Identify likely reason(s) for trends

• Prioritize concerns and determine if your client:

- Is having a problem

- Is at increased risk of developing a problem

• Take appropriate action in a timely manner

What is the most appropriate nursing intervention for a client with a

temperature of 39C (102.2F) and flushed skin?

Provide cool compresses and encourage fluid intake