Vital Signs

Chapter 8

What vital signs data reflects body system status? (4)

• cardiovascular (HR, BP)

• neurologic

• peripheral vascular (pulse symmetry)

• respiratory

Order of taking Vitals

1. temperature

2. pulse

3. respirations

4. blood pressure

Why do you always take BP last?

• gives patient time to calm down

Body Temp Equation

• heat produced - heat loss = temperature

What causes body temperature to rise?

• strenuous exercise

• stress

• ovulation

• hyperthermia

• viral or bacterial infections

• malignancies

• trauma

• various, blood, endocrine, and immune disorders

Surface Temperatures (2)

• oral (O)

• axillary (Ax)

• skin

Core Temperature

• tympanic (E)

• temporal

• rectal (R)

Oral Temp

• 98.6 F

• (NPO for 15 to 20 minutes)

Axillary Temp

• 97.7 F

Tympanic Temp

• 98.6 F

• (hold a couple seconds)

Rectal Temp

• 99.5 F

• (steps: lubricate 0.5”, insert only 1”, hold)

What affects BP?

• cardiac output

• elasticity of arteries

• blood volume

• blood velocity (HR)

• blood viscosity (thickness)

Pulse Defintion

• palpable bounding of blood that can be sensed by fingertip as blood passes through a peripheral artery each time the heart contracts

Pulse Physiology Equation

• heart rates (HR) - stroke volume (SV) = cardiac output (CO)

Stroke Volume (SV)

• amount of blood (60-70ml) with each beat of the heart

What does anxiety do to pulse?

• raises pulse

What does fluid volume do to pulse?

• raises pulse

• (makes heart work more)

What does gas exchange do to pulse?

• raises pulse

What does hypothermia do to pulse?

• raises pulse

What does pain do to pulse?

• raises pulse

What does tissue perfusion do to pulse?

• raises pulse

What does tissue damage do to pulse?

• raises pulse

What are the pulse characteristics? (4)

• rate

• quality

• rhythm

• equality

Why can’t we take a pulse with thumbs?

• thumbs have a pulse, so can’t feel the patients

What does bpm stands for?

• beats per minute

What is the normal pulse rate range for 2 year olds to adults?

• 60-100 bpm

What is the normal pulse rate range for newborns?

• 100-180 bpm

What is the normal pulse rate range for 1 week to 3 month babies?

• 100-220 bpm

What is the normal pulse rate range for 3 months to 2 year olds?

• 80-120 bpm

What is a pulse under 60 called?

• bradycardia

What is a pulse over 100 called?

• tachycardia

What are the types of rhythm?

• regular = symmetrical and a metronome

• irregular (need to test for full minute if so)

What is the different qualities (strength) of pulse?

• 0 = absent

• +1 = thready, weak

• +2 = normal

• +3 = bounding

How do you check for pulses equality?

• check pulse on both wrists to feel symmetrical

• usually done with radial pulse

What happens to elasticity of pulse as you get older?

• becomes more difficult to find

• because veins are stretched

What are the pulse sites? (9)

• temporal

• carotid

• brachial

• radial

• ulnar

• femoral

• popliteal

• posterior tibial

• dorsalis pedis

Where is the temporal pulse?

• temple, forehead

Where is the carotid pulse?

• neck

Where is the apical pulse?

• right over heart

Where is the brachial pulse?

• upper arm

• used when taking manual BP

• also commonly used for taking pulse of peds patients

Where is the radial pulse?

• thumb side of wrist

• “radical thumb”

Where is the ulnar pulse?

• pinky side of wrist

Where is the femoral pulse?

• groin

Where is the popliteal pulse?

• behind knee

Where is the posterior tibial pulse?

• behind ankle bone

Where is the dorsalis pedis pulse?

• bridge of foot

What is respiration?

• the exchange of oxygen and carbon dioxide between air, lungs, blood vessels, and body cells

What are the mechanisms of respiration? (3)

• ventilation

• diffusion

• perfusion

What is the definition of ventilation?

• movement of gas in and out of lungs

What is the definition of diffusion?

• movement of oxygen and carbon dioxide between the blood and alveoli

What is the definition of perfusion?

• distribution of red blood cells to and from the pulmonary capillaries (cap refill)

How is breathing regulated?

• by CO2, O2, and H+

What is one of the first indicators of respiration failure?

• CO2 levels drop

Define Hypoxemia

• low levels of arterial oxygen

What type of breathing is this?

• normal

What type of breathing is this?

• Cheyne-Stokes breathing

• (related to heart failure or stroke)

What type of breathing is this?

• Kussmaul’s breathing

• (super tacky, acidotic = trying to breath of acid gas)

What type of breathing is this?

• central neurogenic hyperventilation

• (common sign of patient about to enter a comma, if 25 resp/min)

What type of breathing is this?

• Ataxic (Biot’s) pattern

• (if braindead but brainstem is working)

What is rapid respirations, with rate rising 4 bpm/degree > than normal body temp?

• Tachypnea

What is slow regular respirations with <12 bpm?

• bradypnea

What is deep respirations at normal rate?

• hyperpnea

What is it called when there is absence of breathing?

• apnea

What is the rate range of respiration at rest?

• 12-20

What is the ratio of respiration rhythms?

• regular

• 1:2 IE (double time to exhale)

What are the respiration characteristics?

• rate

• rhythm

• quality (depth)

  • unlabored/labored

Why do you need other be sneaky about taking respirations?

• because it passive, patients can become conscious of it and skew the results accidentally

Define BP

• the force on the walls of an artery by pulsing blood

Contrast systolic and diastolic BPs

• systolic:

  • “peak of max pressure”

  • during the hearts contraction as blood is forced under high pressure into aorta

  • measurement of BP in arteries when ventricles contracted

• diastolic:

  • minimum pressure present when ventricles are relaxed

  • “minimal pressure exerted against arterial walls”

  • measurement of BP in arteries when ventricles relaxed

List the types of peripheral resistance in BP (5)

• vasoconstriction

• vasodilation

• blood volume

• viscosity

• elasticity

How does vasoconstriction affect BP?

• causes BP to rise

How does vasodilation affect BP?

• causes BP to drop

How does blood volume affect BP?

• if not enough BV = dehydrated

• so BP goes up since heart has to work harder

How does viscosity affect BP?

• if more viscose = BP rises

• if less viscose = BP drops

How does elasticity affect BP?

• causes BP to drop if less elastic

What are the risks for hypertension? (7)

• family history

• obesity

• age

• being male

• african americans

• high stress

• smoking and alcohol

Define hypertension

• a chronic condition where blood force against artery walls is consistently too high

Name some signs of hypertension

• >160 mmHg systolic

• vasoconstriction

What are some risks of hypotension?

• myocardial infarction (MI)

• blood loss

What does a systolic <90mmHg and vasodilation tell us?

• patient might have hypotension (which is connected to blood loss and MIs)

• can be life threatening

What is orthostatic hypotension and what risk does it cause?

• getting up too fast, getting dizzy and tunnel vision

  • common cause is dehydration

• risk for falls

What is the treatment for orthostatic hypotension?

How is a sphygmomanometer used?

• measuring indirect BP (putting a cuff on)

What is used when measure BP directly?

• arterial line

What are the Korotkoff sounds? (5)

• I = first noise, tapping, at least 2 in a row

• II = whooshing noise

• III = intense

• IV = muffled sounds

• V = disappearance of sound

What is the range for systolic and diastolic BP in adults?

• 100 to 120 for systolic

• 60 to 80 for diastolic

List the BP Procedure Steps

1. assess factors of interference

2. size of cuff

3. place antecubital (2.5 above) palpate brachial artery

4. fit snug, arms at heart level

5. if no baseline: palpate radial pulse, inflate cuff until pulse disappears

   1. deflate cuff and wait 30 seconds

   2. inflate cuff 30 mm/Hg past the point of pulse loss

6. deflate cuff 2-3 mmHG per second and auscultate for Sounds of Korotkoff

What are some assessment considerations for pulse and BP? (5)

• consider daily fluctuations

• consider medications and treatments

  • need 2+ hours for effect

• factors that may influence or interfere with accuracy

• influencing medical conditions

• pertinent lab values

When do you not use a specific side while taking BP?

• mastectomy

  • do side with breast, if both gone use a leg

• dialysis shunt

• IV fluids

• stroke affected side, hemiparesis, paralysis

  • use non affected side

• surgery or injury to that extremity

• recent blood draw

• cast

Is the following statement true or false?

Normally, pulsation is slightly stronger in left wrist.

• false

• pulse should be equal

What are possible normal temperature ranged for older patients?

• 95-97.5 F

• so my be considered hypothermic if below 96 F

Osteoporotic thinning and collapse of vertebrae secondary to bone loss may result in what?

• kyphosis = bend of thoracic

How does gait change for men as they age?

• gate may be wider based

• with arms held outward

How does gait change for women as they age?

• gait may be a narrow base

• so may waddle to compensate

What is arteriosclerotic mean?

• build up of place

  • cholesterol related to this

• if in brain, may cause stroke

• if in heart, may cause cardiac arrest