Vital Signs Notes

Vital Signs (VS)

• Vital signs include:

  • Blood Pressure (BP)

  • Temperature (T)

  • Pulse (P)

  • Respiration (R)

  • Pulse Oximetry (Pulse Ox)

Objectives for VS

• Describe the procedure used to assess the vital signs: temperature, pulse, respirations, blood pressure.

• Describe factors that can influence each vital sign.

• Identify equipment used to assess VS.

• Demonstrate correct procedure for assessing vital signs.

• Obtain accurate vital sign readings.

• Recognize normal and abnormal VS values.

• Report and record vital signs and changes in VS which occur during patient care.

• Analyze VS trends and how these trends influence the nursing plan of care.

• Identify nursing interventions when abnormal vital signs are obtained.

• Interpret BP readings utilizing the NIH BP classification guidelines.

Purpose for taking VS

• Most frequent measurement.

• Provides baseline data.

• Indicators of health status.

• Identifies changes.

• Assessment helps determine problems, plans, interventions, and evaluation.

When to measure VS

• Admission.

• Home Health visit.

• Surgery/Invasive diagnostic procedure (before, during, after).

• Blood transfusion.

• Administration of a med that changes VS.

• General condition change.

• With nursing procedures that influence VS.

• Patient c/o nonspecific symptoms of distress.

General Nursing Guidelines

*Delegation

• Analysis
  *Determine interventions

• Communicate

• Document

• Educate

• Equipment functional and appropriate.

• Know baseline.

• Know history, therapies, and meds.

• Environmental control.

• Systematic approach.

• Determine frequency.

Analyze VS

• Compare to normal ranges.

• Compare to patient’s baseline.

• Compare to patient’s trends.

• Assess for factors that could affect the patient’s VS.

Normal Vital Signs (Adults)

• Temperature: 36ºC - 38ºC (96.8ºF - 100.4 ºF)

• Heart Rate: 60 – 100 beats/minute

• Respiratory Rate: 12 – 20 breaths/minute

• Blood Pressure: < 120/80

• Pulse Oximetry: 97 – 100 % saturation

Document & Report

• Documentation

  • Timely manner

  • Follow facility policies

• Report

  • Significant abnormals

Blood Pressure

• Measurement

  • Terminology

    • Systolic

    • Diastolic

    • Hypertension

    • Hypotension

    • Orthostatic

    • Korotkoff

Blood Pressure (BP) Definition

• Systolic pressure

• Diastolic pressure

• Documented Systolic/Diastolic

  • 120/80

Physiology of BP

• Cardiac output

• Peripheral vascular resistance

• Volume of circulating blood

• Viscosity

• Elasticity of vessel walls

Factors Influencing BP

• Age

• Gender

• Ethnicity

• Diurnal rhythm

• Weight

• Emotions

• Stress

• Smoking

• Medications

• Disease

Categories of BP in Adults

Individuals with SBP and DPB in 2 categories should be designated to the higher BP category.

Proper Cuff Fit

• The size is based on the circumference of the midpoint of the limb.

• Width: 40% of the circumference.

• Length: The bladder enclosed by the cuff should encircle 80% of the arm/thigh.

Placement of Cuff

• Cuff should be applied snugly (not falling down the arm).

• Applied 1-2 inches above the inner aspect of the elbow with the bladder over the brachial artery.

• Manometer gauge should be at eye level.

General Instructions for BP Measurement

• Quiet environment.

• Do not take over clothing.

• If sitting – feet flat on floor.

• Maintain standard precautions.

• Check for contraindications.

  • Mastectomy

  • Fistula

  • Trauma

  • Paralysis

  • IV lines

• Initial assessment – take in both arms.

• Initial assessment – use a manual cuff.

Korotkoff Sounds

• Phase 1 = Systolic BP (first clear tapping sound).

• Phase 2 = sound has a swishing quality.

• Phase 3 = crisper sound like knocking.

• Phase 4 = abrupt muffling.

• Phase 5 = silence. The last sound heard is the Diastolic BP.

Two Step Method for BP Measurement

• Determine approximate SBP by inflating cuff while palpating the radial or brachial artery noting the point of obliteration.

• When the pulse disappears continue to inflate 30 mm Hg above this disappearance point.

• Slowly deflate the cuff and note the point when the pulse returns.

• Deflate cuff fully and wait 30 seconds.

• Put on stethoscope and place the diaphragm over the brachial artery.

• Re-inflate BP cuff 30 mmHg above which the palpated pulse disappeared.

• Release the valve slowly, controlling the rate of descent to about 2-4 mmHg/sec.

• Note beginning and end of sound.

• Continue to release the pressure slowly until 10 mmHg below when you heard the last sound.

• Then completely deflate the cuff.

• May repeat measurement once– wait approximately 30-60 seconds before repeating the BP procedure.

One Step Method for BP Measurement

• Use when you know the BP baseline or in an Emergency.

• Palpate brachial pulses – use arm with strongest.

• Apply cuff, manometer at eye level, stethoscope on pulsation site.

• Close valve, quickly inflate cuff 30mmHg higher than baseline SBP.

• Release valve and deflate cuff 2-4 mmHg/sec.

• Note beginning and end of sound.

• When 10 mmHg below final sound deflate cuff.

• Document.

Lower Extremity BP Measurement

• Thigh cuff - popliteal auscultation.

• Calf cuff - posterior tibial site.

Electronic BP Device

• Efficient and easy to use.

• Do not use with irregular heart rate, shivering, seizures, inability to cooperate, systolic < 90.

• Use proper sized cuff.

BP by Palpation/Doppler

• Inflate cuff while palpating the radial or brachial artery noting the point of obliteration.

• Continue to inflate 30 mm Hg above this disappearance point.

• Slowly deflate the cuff and note the point when the pulse returns. This is systolic “by palpation”.

• Same method using doppler instead of palpating pulse

  • SBP “by doppler”.

Orthostatic BP Measurement

• Measure BP & pulse in 3 positions.

• Wait 1-3 minutes after position change.

• Positive if:

  • SBP decreases 20 points or more

  • DBP decreases 10 points or more

  • and/or HR increases 20 or more points

• Positive if symptomatic.

Documentation for BP

• Numeric value.

• Site where obtained.

• Position of patient.

• 0800 2/3/2015 BP 132/80, taken on left arm with patient flat in bed. S. Toad RN.

Health Promotion for BP

• Teach normal values.

• Risks for hypertension.

• Hypertension – lack of symptoms, no cure, benefits of tx.

• Teach caregiver or patient how to take BP.

• Safety with low or orthostatic BP.

Pulses

• Terminology

  • Tachycardia

  • Bradycardia

  • Stroke volume

  • Cardiac output

Pulse Definition

• Measured in beats per minute (bpm).

• Normal 60-100 bpm.

• Average 70-80 bpm.

Pulse Assessment

• Palpation

• Auscultation

  • Stethoscope

    • Bell

    • Diaphragm

Pulse Characteristics

• Strength

  • 0 no pulse detected

  • 1+ pulse diminished, weak, thready

  • 2+ easily palpable, normal pulse

  • 3+ Full pulse, increased

  • 4+ Strong, bounding pulse

• Regular/Irregular

• Equality

  • Check for equal strength and symmetry.

  • Pulse deficits.

Factors Affecting Pulse

• Gender

• Exercise

• Food

• Stress

• Fever

• Disease

• Blood loss

• Medications

Pulse Assessment Sites

• Temporal

• Carotid

• Apical

• Brachial

• Radial

• Ulnar

• Femoral

• Popliteal

• Posterior tibial

• Dorsalis pedis

Carotid Pulse

• Closest to heart, use in emergencies.

• Never palpate both sides at once.

Radial Pulse

• Used most commonly in adults.

• The radial pulse is felt on the wrist, just below the thumb

Apical Pulse

• Most accurate

• Assess rhythm

• Use when rhythm is irregular

• Locate the Apical Pulse

  • 5th intercostal space to the left of the sternum

  • Left mid-clavicular line

  • Count Lub-Dub (S1S2) sound as being one heart beat.

Brachial Pulse

• Used in infants and children

• Auscultated in BP

Femoral Pulse

• Used in emergencies

Popliteal, Posterior Tibial & Dorsalis Pedis Pulses

• Used to monitor circulation to lower extremities

Documentation of Pulses

• Site where obtained

• Numeric value

• Regular/Irregular

• Strength

• Symmetry

• 0800 2/3/2015 Bilateral radial pulses 84 bpm. Regular, 2+, and equal bilaterally S. Toad RN

Respirations Terminology

• Eupnea

• Apnea

• Tachypnea

• Bradypnea

• Cheyne-Stokes

• Kussmauls

Respirations Definitions

• One respiratory breath is the full inspiration/expiration process

• Normal rate 12-20 breaths/minute (adult)

Obtaining Respiratory Rate

• Count while palpating radial pulse. WHY??

• Count for 30 seconds if respirations are regular

• 60 seconds if respirations are irregular

• 60 second is recommended for increased accuracy

• Observe rate, rhythm, depth, and any usage of accessory muscles

Breathing Patterns

• Eupnea (normal)

• Apnea

• Tachypnea

• Agonal

• Hyperpnea

• Bradypnea

• Cheyne-Stokes

• Shallow

• Kussmaul's

• Sighing

Factors Affecting Respirations

• Age

• Exercise

• Pain

• Stress

• Smoking

• Fever

• Hemoglobin

• Disease

• Medications

• Position

Documentation of Respirations

• Numeric value

• Regular/Irregular

• Depth

• Abnormalities

• 0800 2/3/2015 Respirations 18/min. Regular with average depth.

  • S. Toad RN

Temperature Terminology

• Hyperthermia

• Hypothermia

• Axillary

• Rectal

• Tympanic

• Temporal

• Diaphoresis

Temperatures

• Core “deep body” temp relatively constant 37.2 °C or 99 °F

• Surface temp varies – depends on blood flow to skin and heat loss to environment

• Normal 96.8 – 100.4 (36-38 °C)

• Average oral/tympanic 37 °C (98.6 °F)

• Average rectal 37.5 °C (99.5 °F)

• Average axillary 36.5 °C (97.7°F)

Heat Production

• Normal by-product of metabolism

Conservation of heat

• Vasoconstriction

• Voluntary movement

• Shivering

Heat Loss

• Vasodilation

• Diaphoresis

• Inhibit heat production

• Peripheral vasodilation

Factors that Influence Temperature

• Age

• Diurnal variations

• Exercise

• Hormones

• Stress

• Environment

• Illness

Temperature

• Hyperthermia

• Hypothermia

Temperature Equivalents

• 104.0 °F = 40.0 °C

• 98.6 °F = 37.0 °C

Obtaining Temperatures

• Oral

• Rectal

• Axillary

• Tympanic

• Temporal Artery

Oral Temperatures

Advantages

• Comfortable for patient

• Most accurate surface reading

• Reflects rapid change in core temp

• Easily accessible: no position changes

Disadvantages

• Affected by food/drink/smoking

• Not for patients w/oral surgery, trauma, history of epilepsy, or shaking chills

• Not for infants

• Risk for body fluid exposure

Rectal Temperature

Advantages

• Most closely resembles core temperature

• Always lubricate the tip

• Place in adults ½ inch

• Always clean glass thermometers after procedure

Disadvantages

• Not for patients with rectal issues

• Not to be used in newborns or in children with diarrhea

• May be embarrassing

• Risk of body fluid exposure

Axillary Temperature

Advantages

• Can be used for newborns and uncooperative patients

• Safe and inexpensive

Disadvantages

• Least accurate

• Lags behind core temperatures especially during rapid temp changes

• Takes a long time (at least 5 – 10 minutes if using glass) and must be held in place by staff

Tympanic Membrane Thermometer

Advantages

• Most reliable

• Easily accessible

• Rapid measurements

• Unaffected by oral intake

• Used in newborns

• Obtained without disturbing patient

Disadvantages

• Otitis media and cerumen impaction distort readings

• Do not use in ear surgery

• Requires disposable sensor cover

Temporal Artery Temperature

Advantages

• Noninvasive

• Closely matches core temp

• Easily accessible

• Rapid measurements

• Unaffected by oral intake

Disadvantages

• Diaphoresis affects accuracy

• Airflow across face (fan) affects accuracy

• Forehead and behind- the-ear method – must remove eyeglasses

Pulse Oximetry

• Oxygen saturation of the hemoglobin

  • 95-100% = normal

  • 70% or less = life threatening

• Can detect hypoxemia before cyanosis

Pulse Oximetry (con't)

• Sensor placement

• What can affect this measurement's accuracy?

Documentation of Pulse Oximetry

• Numeric value

• Site

• Room air/Oxygen

• 0800 2/3/2015 Pulse ox on left index finger 94% on room air. S. Toad RN

Responsibilities

• Validating abnormal VS if taken by an CNA or Tech

• Recognizing critical changes in vital signs

• Reporting and recording VS in a prompt manner, esp. abnormal VS

• Intervening to protect the patient

• Recording of accurate vital signs is mandatory. If you do not record it, it was not done!

• Each hospital has its own policy for recording of VS ranging from flow sheets to computer entry