Vital Signs - Slides

What are Vital Signs?

1. Temperature

  2. Pulse rate

  3. Respiratory rate

  4. Blood pressure

 We also think of PAIN assessment as the 5^th vital sign.

 On acute care units – Pulse Oximetry is included as vital sign

Taking vital signs is a simple task however interpretation of vitals requires knowledge, critical thinking and experience

Vital Signs Table

When to measure vital signs?

 Inpatient settings - minimal frequency will be ordered.

 Upon admission to health care facility or when making home visits

 Evaluation of treatment- For example: before and/or after medication; before during and after blood transfusion

 Establish baseline – For post-operative evaluation and monitoring

 When a patient’s condition changes or ”I feel funny”

 In stable patients – taking vital signs may be delegated, however, the nurse will analyze the results.

 Monitor trends!!!

Temperature

 Normal adults is 36.5^o to 37.5^oC (97.7^o to 99.5^oF)

 Average oral= 37⁰C (98.6⁰ F)

 Rectal– may be 1^o F higher

 Axillary – may be 1^o F lower

 Route – mouth, rectum, ear, forehead and axilla

 Body temp varies with age

 Elderly may have lower temps –  36-36.8^o C  (96.8- 98.3^oF)

Neural & Vascular Control of Temperature

Hypothalamus = body’s  ‘thermostat’

 Hypothalamus response to decreased temperature

◦Vasoconstriction

◦Shivering occurs if vasoconstriction ineffective

 Hypothalamus response to increased  temperature

◦Vasodilation

◦Sweating

Body Temperature Factors

 Age  (Newborns at risk for hypothermia; Elders may have lower average body temperatures (36^o C or 96.8^oF)

 Exercise (temp increases with exercise)

 Hormones (progesterone hormone increase temp for women)

 Time of Day/Circadian rhythm (temp commonly lowest in morning)

 Stress (can elevate temp)

 Environment (exposure to extreme heat or cold)

Fever (pyrexia)

 An important defense mechanism

 Results when heat-loss mechanisms are unable to keep pace with excessive heat production:

◦Example: When pyrogens alter hypothalmus set point

 Metabolism and oxygen consumption increase during a fever

Heat Loss

 Radiation:  Transfer of heat from one surface to the other without actual contact (heat lost from the body to a cold room)

 Conduction:  Transfer of heat  from the body to another surface (bathing a patient with cool cloth)

 Convection:  Dispersion of heat by air currents (wind blowing across exposed skin - fan)

 Evaporation:  Heat loss through water vapor (sweating, diaphoresis)

Tempurature Procedure

Oral temperature?

• Insert under tongue into posterior sublingual pocket of mouth, ask to close lips and hold

 Rectal temperature?

• Ask patient to take a deep slow breath 

• Insert thermometer into  anus towards belly button 

• 1in for child and 1.5 in for adult

 Axillary temperature?

• Place against middle of axilla, fold arm down and place across chest, enclosing thermometer 

 Tympanic temperature?

• Pull pinna back up and out (6mo-3yr= down and back)

• Rotate handle towards jawline

Nursing Interventions:
Hyperthermia

•Pyrexia (fever) – not harmful if below 39^oC, and enhance the body’s immune system.

•An abnormally elevated body temperature. Exceeds 39^o C (102.2 F)

•Cool environment if possible.

•Obtain blood cultures if ordered prior to antibiotic administration.

•Administer antipyretics. Aspirin is not recommended for management of fever in children with viral illness.

•Non-pharmacologic methods - cooling blanket (follow instructions) ; tepid bath - Watch for shivering.

•Encourage oral fluids (3 L/day) and rest.

•* if cardiac and renal status normal

•Provide frequent mouth care q4h and prn

•Those with cardiac or respiratory disease, fever=stress

Nursing Interventions:
Hypothermia < 35 C (<95 F)

•Caused by prolonged exposure to cold; may be intentional in a surgical procedure.

•Remove wet clothes

•Blankets; cover head

•Warm liquids (if conscious)

•Increase room temperature

•Warmed IV fluids

Pulse

 Indicator of circulatory status

 Pulse is indirect measurement of cardiac output

 Pulse can be palpated at multiple sites in body. Rate is usually assessed at radial or apical site

 Evaluate rate, rhythm, intensity, and equality

 Recorded as beats per minute (bpm)

 Measure 30 seconds X 2

 If irregular: count for one entire minute!

Pulse and Pressure Points

What is a normal pulse rate?

•Adult = 60-100 beats per minute (bpm)

•Tachycardia > 100 bpm in adults

•Bradycardia < 60 bpm in adults

•Infant = 80-160 bpm. Pulse will decrease as the child ages. Average pulse of a 14-year-old is 60-90 bpm

•Normal pulse has regular rhythm

•Strength of pulses is described as:  Bounding (4+); Full or Strong (3+); Normal (2+); Diminished or barely palpable (1+); or Absent (0)

•Equality: pulses should be equal when comparing right and left side of body

Factors Affecting Heart Rate

•Conditioning (Athletes have lower heart rates)

•Medications

•Decreases pulse (Beta blockers, Calcium channel blockers, digoxin)

•Meds can cause postural changes – pulse temporarily increases when a person changes from lying to a sitting or standing position

•Temperature: Fever increases; hypothermia decreases

•Acute pain and anxiety: Increases pulse – sympathetic stimulation

•Chronic pain: Decreases rate - Parasympathetic

•Deficient fluid (dehydration, hemorrhage): Increases rate

RESPIRATORY RATE

 One respiratory cycle = inhalation plus exhalation

 Mechanics of breathing (musculature, effort)

 Character of respirations

◦Women tend to be chest breathers

◦Men tend to be diaphragmatic breathers

◦Infants & children – irregular pattern is normal

Respiratory Assessment

 Assess rate, depth, and rhythm of respiratory pattern

 Assess mechanics of breathing- intercostals, accessory muscles, nasal flaring

 How hard are they working??

 Assess respirations in context- exercise, position, pain, smoking, medication (opioids), and anxiety

Respirations by age
Rate, Depth, Rhythm

Respiratory rate decreases with age:

•Newborn: 35-40/minute

•Infant: 30-50/minute

•School-aged child: 20-30 /minute

•Adolescent: 16-20 / minute

•Adult: 12-20 / minute

 

•Bradypnea:

•Tachypnea:

•Hyperpnea:

•Apnea:

•Hyperventilation:

•Hypoventilation:

•Cheyne-Stokes:

•Kussmaul:

•Dyspnea:

•Bradypnea: < 12 per minute

•Tachypnea: > 20 per minute

•Hyperpnea: > 20 and deep, labored (ie post exercise)

•Apnea: absence of respiration

•Hyperventilation: rapid or deep breathing

•Hypoventilation: slow or shallow breathing

•Cheyne-Stokes: rate & depth irregular, alternating apnea/hyperventilation

•Kussmaul: abnormal deep, regular, increased rate

•Dyspnea: feeling shortness of breath

Pulse Oximetry

•Noninvasive measurement of the oxygen saturation of the blood.

•A pulse oximeter is a device with a clip-on sensor that is secured to the patient’s finger, toe, nose, earlobe or forehead.

•Normal values are 95-100%.

•Acceptable values: 93 and above. Results <90% indicate an emergency!

BLOOD PRESSURE (what+sbp,dbp)

•BP reading is recorded as SBP/DBP in mmHg (millimeters of mercury)

•Systolic blood pressure (SBP)

•Diastolic blood pressure (DBP)

•2 ways to take a blood pressure reading:

oManual BP

oAutomatic BP

Cuff Size

Choose the Correct Size Cuff

(newborn, infant, child, adult, large adult, thigh)

If BP cuff is too large, BP reading will be falsely low

If BP cuff is too small, BP reading will be falsely high

Bp systole/diastole, variation

•Systolic- heart at work

•Diastolic- heart at rest

•Sitting is the preferred position

•Onset of the sound corresponds to the systolic BP. What is this sound called? (Korotkoff Sounds)

 •The disappearance of the sounds corresponds with the diastolic pressure

•5-10 mm difference between arms is normal

•Older adults sometimes have an increase in systolic pressure while diastolic pressure remains the same.

 

Classifications of BP for Adults

 <120/<80 = NORMAL

 120-139 OR 80-89 = PREHYPERTENSION

 140-159 OR 90-99 = STAGE 1 HYPERTENSION

 > 160 OR > 100 = STAGE 2 HYPERTENSION

Average Optimal BP for Age

•1 month old = 85/54

•1 year old = 95/65

•6 years old = 105/65

•10-13 years old = 110/65

•14-17 years old = 119/75

•18 years or older = < 120/ < 80

Factors Influencing BP

•Age (BP gradually increases with age)

•Stress/Anxiety/Pain (commonly increase BP)

•Ethnicity (African Americans at risk for high BP)

•Time of day (BP highest in the morning)

•Medications (for example, diuretics can decrease BP)

•Activity and weight (increases BP)

•Smoking/caffeine (increases BP)

•Fluid depletion (decreases BP)

Hypertension vs Hypotension

HYPER

More common than hypotension

• Thickening of walls

• Loss of elasticity

• Family history

• Risk factors

HYPO

•Systolic <90 mm Hg

•Dilation of arteries

•Loss of blood volume

•Decrease of blood flow to vital organs

•Orthostatic/postural

 

What do you do if the BP is abnormal? Select all that apply

A. ___ Panic

B. ___ Pretend it is normal

C. ___ Ask the patient if they know their usual BP

D. ___ Assess proper cuff size, positioning

E. ___ Check the blood pressure in the opposite arm

F. ___ Assess level of consciousness, pulse, color,   temperature, pain level, wounds, intake and   output status……

cdef

Risk Factors for Hypertension

•Family History

•Excessive sodium intake

•Physical inactivity

•Obesity

•Heavy alcohol consumption

•African American

•Hyperlipidemia

•Stress

BP Considerations

 There are many instances when you would not take a BP in an arm:

•IV location

•AV Fistulas (shunts)

•Post mastectomy

•Casts

•Hand trauma

 Patient may have a wristband indicating “No BP”

Orthostatic BP Assessment

•Orthostatic hypotension (postural hypotension) – lowering of BP when a patient rises. (Drop in SBP of at least 20mmHg, or drop in diastolic of 10mmHg with increase in heartrate of al least 10 beats per minute

•How to measure? Obtain BP reading before and 1-3 minutes after changing position. This is an RN assessment (do no delegate)

•Associated symptoms: Dizziness and/or Syncope. Advise pt to lie down if these symptoms occur.

•Who gets orthostatic? Patients who are anemic or dehydrated, elderly, medication side effects (particularly BP meds), or fluid depletion.

•Education: Advise pt to get up slowly, avoid sudden changes in position or ask for assistance when getting up from sitting or lying.

PAIN: The ‘5th Vital Sign’

•Rated on 0 to 10 scale

•0 equals no pain

•10 equals the worst pain ever experienced

•Check pain level with every VS assessment

BP Remember this…

•You do not need an order to assess vital signs

•If you notice a sudden change in patient status – ASSESS VS

•Assess trends, do not simply fill in boxes

•Context is important in your VS interpretation

•When in doubt, check it out & report it!