RNSG 1115 Chapter 26 Vital Signs

Vital Signs

indicators of physiologic functioning and reflect the overall health status of the patient

Change in a patient’s vital signs=

change in patient’s overall health

Four vial signs:

• temperature

• pulse

• respirations

• blood pressure

Pain can be considered a patient’s 5th vital sign

Pulse oximetry is often used as well

When to Assess Vital Signs

• on admission

• based on facility or institutional policies/procedures

• any time there’s a change in the patient’s condition

• any time there’s a loss of consciousness

• before and after activity that may increase risk, such as ambulation afrer surgery

• before administering medications that affect cardiovascular and respiratory function

Frequency in which to obtain vital signs depends on many different factors:

• patient’s medical diagnosis

• co-morbidities

• types of treatments received

• patient’s level of acuity

Normal Vital Sign Ranges (Adults): Oral temperature

35.8–37.5°C (96.4 - 99.5°F)

Normal Vital Sign Ranges (Adults): Pulse rate

60-100 beats/min

Normal Vital Sign Ranges (Adults): Respirations

12-20 breaths/min

Normal Vital Sign Ranges (Adults): Blood pressure

<120/80

Heat Production:

• primary source is metabolism

• hormones, muscle movements, and exercise increase metabolism

• epinephrine and norepinephrine are released when additional heat is required, and alter metabolism

• thyroid hormone and shivering also increase heat production

• energy production decreases and heat production increases

Heat Loss:

• skin (primary source)

• evaporation of sweat

• warming and humidifying inspired air

• eliminating urine and feces

Transfer of Heat

• radiation

• convection

• evaporation

• conduction

Factors Affecting Body Temperature

• circadian rhythms

• age and gender

• physical activity

• state of health

• environmental temperature

Thermometer Types

• oral

• rectal

• axillary

• tympanic

• forehead

Oral Thermometer Range

35.9 - 37.5°C; 96.6 - 99.5°F

Rectal Thermometer Range

36.3 - 38.1°C; 97.4 - 100.5°F

Axillary Thermometer Range

35.4 - 36.9°C; 95.6 - 98.5°F

Tympanic Thermometer Range

36.8 - 38.3º C; 98.2 - 100.9°F

Forehead (temporal artery) Thermometer Range

36.3 - 38.1°C; 98.7 - 100.5°F

Fever (Pyrexia):

an increase above normal body temperature

• signals an increased immune function and inflammation and is a reliable indicator of health status

• generally not normal unless very elevated (>104 F)

Types of Fever:

• intermittent

• remittent

• sustained or continuous

• relapsing or recurrent

Types of Fever: Intermittent

the body temperature returns to normal at least once every 24 hours

Types of Fever: Remittent

the body temperature does not return to normal and fluctuates a few degrees up or down

Types of Fever: Sustained or Continuous

the body temperature remains above normal with minimal variations

Types of Fever: Relapsing or Recurrent

the body temperature returns to normal for one or more days with one or more episodes of fever, each as long as several days

Effects of Fever:

• decreased appetite

• headache

• hot/dry skin

• muscle aches

• fatigue

• increased pulse rate

• fluid and electrolyte imblances

Fever Treatment: Pharmacologic: antipyretic (fever reducing)
drug

• aspirin (not given to pt’s <19)

• ibuprofen

• acetaminophen

Fever Treatment: Nonpharmacologic

• hypothermia blankets

• cool sponge baths

• cool packs

• oral hydration

Hypothermia:

body temperature below the lower limit of normal

Physical effects of hypothermia:

• poor coordination

• slurred speech

• poor judgement

• weak and irregular pulse

• hypotension

• stupor

Treatment of hypothermia:

rewarm the patient

• additional blankets

• heating blankets

• radiant warmers

• heating pads

• warm fluids

• increasing ambient temperature in the room

Physiology:

regulated by the automatic nervous system through sinoatrial (SA) node (the pacemaker) of the heart

Parasympathetic stimulation:

stimulated via the vagus nerve; decreases the heart rate

Sympathetic stimulation:

increases heart rate and force of contraction

Pulse rate:

number of contractions over a peripheral artery in 1 minute; usually corresponds to the same rate at which the heart is beating

Factors affecting the pulse:

• age

• gender

• physical activity

• fever

• strees

• medications

• disease

Pulse Rates:

• normal: 60-100 beats/min

• tachycardia: 100-180 beats/min

• bradycardia: below 60 beats/min

Pulse Amplitude:

• grade 0: absent, unable to palpate

• grade +1: diminished, weaker than expected

• grade +2: brisk, expected (normal)

• grade +3: bounding

Assessing the Peripheral Pulse

assessed by palpating peripheral arteries, by auscultating the aplical pulse with a stethoscope, or by ultrasound

Palpation:

most common; use two fingers to palpate (feel) the artery

Ausculation:

the apical pulse is auscultated with a stethoscope

Doppler Ultrasound:

may be used to assess pulses that are difficult to palpate or ausculate, such as the pedal pulse

Respirations:

a component of vital signs that is the measurement of ventilation; allows for a baseline assessment of respiratory function

involves ventilation, diffusion, and perfusion

Ventilation (breathing):

movement of gases in and out of the lungs

Inspiration (inhalation):

the act of breathing in

Expiration (exhalation):

the act of breathing out

Diffusion:

the exchange of oxygen and carbon dioxide between the alveoli of the lungs and circulating blood

Perfusion:

the exchange of oxygen and carbon dioxide between the circulating blood and tissue

Factors affecting respiration:

• age

• exercise

• acid-base balance

• brain lesions

• increase in altitude

• respiratory disease

• anemia

• anxiety

• medications

• pain

Assessing Respiratory Rate:

respiratory rate: breaths/min

Assessing Respiratory Rate Eupnea:

normal, unlabored respiration; one breath to 4 heartbeats

Assessing Respiratory Rate Tachypnea:

an increased respiratory rate

Assessing Respiratory Rate Bradypnea:

decreased respiratory rate

Assessing Respiratory Rate Hyperventilation:

any condition that causes an increase in carbon dioxide and a decrease in oxygen in the blood; results in increasing the rate and depth of respirations

Assessing Respiratory Rate Apnea:

periods where there is no breathing

Assessing Respiratory Rate Dyspnea:

difficult or labored breathing

Assessing Respiratory Rate Orthopnea:

changes in breathing when sitting or standing

Assessing Respiratory Rate Depth:

• deep

• shallow

Assessing Respiratory Rate Rhythm:

• regular

• irregular

Assessing Respiratory Rate Assessment

• visual inspection

• auscultation

Blood pressure:

the force of moving force against arterial walls

measured in millimeters of mercury (mmHg) and recorded as a fraction

Blood pressure fraction:

systolic pressure/diastolic pressure (ex: 120/80 mmHg)

Systolic pressure:

the highest pressure; created during ventricular contraction

Diastolic pressure:

the lowest pressure; present on arterial walls when the heart rests between beats

Pulse pressure:

the difference between systolic and diastolic pressures

How is blood pressure regulated short-term?

either neural (nerve) or humoral (pertaining to body fluids)

______ will affect blood pressure

cardiac output (strength of heart contractions)

What slows the heart rate?

stimulation of the vagus nerve (parasympathetic impulses)

What increase the heart rate?

Sympathetic stimulation

What are baroreceptors and what do they do?

they’re pressure sensors in the heart and arterial walls that detect blood pressure changes and signal the cardiovascular center of the brain

_______ raises pressure

renin-angiotensin-aldosterone

Factors affecting blood pressure:

• age; race

• circadian rhythm

• biologic sex

• food intake

• exercise

• weight

• emotional state

• body position

• drugs/ medications

Assessing blood pressure:

• B/P reading can be measured on two or more occasions before determining if the B/P is outside acceptable parameters

• measurements should be taken after the patient is at rest for at least 5 minutes and hasn’t consumed coffee or smoked for 30 minutes before the assessment

• a rise of fall of 20-30 mmHg is significant, even if it’s within the accepted normal range

Assessing blood pressure equipment needed

• stethoscope and sphygmomanometer

• doppler ultrasound

• electronic or automated devices

Korotkoff sounds:

series of sounds to listen for when assessing the BP with a stethoscope

sounds are only heard when using a stethoscope to assess BP

First sound heard through the stethoscope represent the _______

systolic pressure

The level at which the sound disappear completely represents the ______

diastolic pressure

Blood pressure shouldn’t be assessed in an arm that has an:

• IV

• PICC line

• AV fistula

• on side where a patient had a mastectomy