Ch 17 vitals


  • Measurements:

    • Objective (5): Temperature, pulse, respiration, blood pressure, oxygen saturation (O2\text{O}_2 sat).

    • Subjective (1): Pain (defined as whatever the patient states it is).

  • Assessment Schedules:

    • Facility policy dictates standard assessment times (e.g., every 4 hours4\,\text{hours} or 8 hours8\,\text{hours} in acute care; weekly or monthly in long-term care facilities).

    • Always assess baseline vital signs upon hospital admission, clinic or emergency room presentation, and home health or hospice visits.

  • Triggers for Additional Assessment:

    • Patient reporting feeling unusual or different.

    • Suspected change in clinical condition or nursing intuition ("gut feeling").

    • Before, during, and after administration of medications affecting cardiac or respiratory controls (e.g., opioids, IV labetalol).

    • Before, during, and after blood transfusions, surgical procedures, or invasive interventions.

    • At least every 4 hours4\,\text{hours} when one or more vital signs are abnormal.

    • Every 5 minutes5\,\text{minutes} to 15 minutes15\,\text{minutes} for unstable patients (e.g., post-surgery, trauma, delivery/birth).

    • Changes in level of consciousness, uncontrolled bleeding, suspected shock, or sepsis.

Temperature Measurement and Regulation

  • Conversion Formulas:

    • Fahrenheit to Celsius: C=(F−32)×59C = (F - 32) \times \frac{5}{9}

    • Celsius to Fahrenheit: F=(C×95)+32F = \left(C \times \frac{9}{5}\right) + 32

    • Celsius values generally range from 30∘C30^\circ\text{C} to 40∘C40^\circ\text{C}; Fahrenheit ranges from 90∘F90^\circ\text{F} to 100∘F100^\circ\text{F}.

  • Thermoregulation Concepts:

    • Body Temperature: The difference between heat produced and heat gained by the body.

    • Core Temperature: Warmer temperature deep within body tissues.

    • Thermogenesis: The production of heat in the body.

    • Basal Metabolic Rate (BMR): Heat produced by the body at rest.

    • Control Center: Central nervous system / Hypothalamus (initiates sweating when hot and shivering when cold to maintain the body's internal set point).

  • Influencing Factors:

    • Circadian Rhythm: Temperature drops overnight during sleep and can increase up to 1∘F1^\circ\text{F} in the evening.

    • Oral Intake: Eating hot food or drinking cold liquids skews oral readings; wait 15 minutes15\,\text{minutes} to 30 minutes30\,\text{minutes} before assessing oral temperature.

    • Other Factors: Environment, gender/ovulation, physical exertion, medications (e.g., antipyretics, ephedrine), stress, infection, brain or spinal cord injury.

  • Assessment Routes and Normal Readings:

    • Oral: 98.6∘F98.6^\circ\text{F}

    • Tympanic: 98.6∘F98.6^\circ\text{F}

    • Rectal: 99.6∘F99.6^\circ\text{F} (Most accurate measurement of core temperature; 1∘F1^\circ\text{F} higher than oral).

    • Axillary: 97.6∘F97.6^\circ\text{F} (1∘F1^\circ\text{F} lower than oral).

    • Temporal Artery: Scans over rich blood supply on the side of the head.

Fever and Alterations in Temperature

  • Definitions:

    • Febrile: Elevated temperature (fever), functioning as a body defense mechanism against microorganisms.

    • Afebrile: Without a fever.

    • Hypothermia: Core temperature below 98∘F98^\circ\text{F}.

    • Critical Threshold: Fevers up to 104∘F104^\circ\text{F} are sustainable; temperatures exceeding 104∘F104^\circ\text{F} (e.g., 105∘F105^\circ\text{F}) carry high risk for brain cell damage.

  • Signs and Symptoms of Fever:

    • Flushed face, hot/dry skin, dry mucous membranes, dehydration.

    • Elevated pulse rate and rapid respirations.

    • Glassy eyes, irritability, restlessness, photophobia, thirst.

    • Headache, myalgias, lethargy, diaphoresis, anorexia, nausea, confusion, seizures (especially in pediatric patients).

  • Nursing Interventions:

    • Recheck temperature at least every 2 hours2\,\text{hours}, or 1 hour1\,\text{hour} after antipyretic administration.

    • Encourage fluid intake and provide oral swabs.

    • Restrict physical exertion to reduce metabolic rate.

    • Apply cool packs to high-heat tracking areas (axillary and groin regions).

    • Administer tepid (lukewarm) baths. Avoid cold/ice baths to prevent shivering, which elevates metabolic rate and body temperature.

    • Cover with light sheets rather than heavy blankets.

Pulse Assessment and Characteristics

  • Peripheral Pulse Sites:

    • Temporal, Carotid (neck), Brachial (arm), Radial (wrist near thumb), Femoral (groin), Popliteal (knee), Posterior tibialis (ankle), Dorsalis pedis (top of foot).

    • Compare upper (radial) and lower (dorsalis pedis) pulse points to evaluate systemic circulation.

  • Apical Pulse:

    • Measured at the fifth intercostal space at the Point of Maximum Impulse (PMI) at the apex of the heart.

    • Significant discrepancy between apical and peripheral pulses indicates ineffective cardiac pumping.

  • Pulse Characteristics:

    • Normal Adult Rate: 60 bpm60\,\text{bpm} to 100 bpm100\,\text{bpm}.

    • Bradycardia: Pulse rate below 60 bpm60\,\text{bpm}.

    • Tachycardia: Pulse rate above 100 bpm100\,\text{bpm}.

    • Rhythm: Regular (evenly spaced) vs. irregular.

    • Volume/Strength Scale:

    • 00: Absent

    • 1+1+: Thready / Weak (indicates low vascular volume)

    • 2+2+: Normal

    • 3+3+: Bounding (indicates high vascular volume)

  • Capillary Refill:

    • Evaluates peripheral perfusion; pink color indicates adequate perfusion.

    • Normal refill time is within 3 seconds3\,\text{seconds} to 5 seconds5\,\text{seconds}.

Respiration and Breath Sounds

  • Physiology:

    • External Respiration: Exchange of oxygen and carbon dioxide between lungs and blood.

    • Internal Respiration: Exchange of gases between circulating blood and tissue cells.

  • Assessment Metrics:

    • Normal Adult Rate: 12 breaths/min12\,\text{breaths/min} to 20 breaths/min20\,\text{breaths/min}.

    • Bradypnea: Rate below 12 breaths/min12\,\text{breaths/min}.

    • Tachypnea: Rate above 20 breaths/min20\,\text{breaths/min}.

    • Eupnea: Normal rate, rhythm, and pattern of breathing.

    • Apnea: Total absence of breathing.

    • Dyspnea: Difficulty or labor associated with breathing.

    • Assess depth, effort, and chest expansion symmetry (unilateral chest rise indicates potential collapsed lung).

  • Respiratory Sounds:

    • Stertorous: Noisy or snoring sounds.

    • Wheezing: High-pitched, musical whistling sound caused by narrowed airways (common in asthma).

    • Crackles: Wet-sounding noise from air moving over secretions in lungs (common in pneumonia, COPD).

    • Rhonchi: Low-pitched, gravelly, rattling, or bubbling sounds from secretions or lung tumors.

    • Stridor: High-pitched crowing noise from partial upper airway obstruction or laryngeal swelling.

Blood Pressure Mechanics and Alterations

  • Circulatory Qualities:

    • Pumping strength of the heart.

    • Blood viscosity (normal ratio: 45%45\% red blood cells, 55%55\% plasma).

    • Blood volume in circulation.

    • Peripheral vascular resistance (elastic recoil of vessel walls).

  • Definitions & Components:

    • The force exerted by blood against arterial walls.

    • Systolic: Maximum force exerted during ventricular contraction ("the squeeze").

    • Diastolic: Force exerted during ventricular relaxation ("down").

    • Pulse Pressure: Difference between systolic and diastolic pressure. Normal pulse pressure is approximately 40 mmHg40\,\text{mmHg} (values <30 mmHg< 30\,\text{mmHg} or >50 mmHg> 50\,\text{mmHg} are abnormal).

  • Factors Influencing BP:

    • Age, race, physical exertion, rest, circadian rhythm, stress, and anxiety.

    • Stimulants (nicotine, caffeine, diet medications) elevate blood pressure.

    • Overhydration causes bounding pulses and elevated BP; dehydration and hemorrhage lower BP.

    • Increased intracranial pressure initially elevates blood pressure.

  • Hypertension and Hypotension:

    • Hypertension: Reading above 130/80 mmHg130/80\,\text{mmHg}.

    • Primary (Essential): Linked to disease processes.

    • Secondary: Resulting from another systemic disorder (e.g., renal failure affecting the renin-angiotensin system).

    • Treatment: Low-sodium diet, fluid hydration with water, weight loss, smoking cessation, stress reduction, exercise.

    • Hypotension: Sudden drop of 20 mmHg20\,\text{mmHg} to 30 mmHg30\,\text{mmHg} below the patient's baseline normal pressure.

Oxygen Saturation and Pain Assessment

  • Oxygen Saturation (O2\text{O}_2 Sat):

    • Normal Range: 96%96\% to 100%100\%.

    • Intervention Threshold: Sustained readings below 90%90\% require oxygen therapy and provider notification.

  • Pain Assessment:

    • Subjective vital sign defined by patient report.

    • Classification: Acute (<6 months< 6\,\text{months}) vs. Chronic (>6 months> 6\,\text{months}).

    • Documentation Requirements: Specific location/site, frequency (constant or intermittent), and descriptors (e.g., sharp, dull, stabbing, cramping, burning).

    • Pain Rating Scales:

    • Numeric Scale: 00 to 1010 self-report scale.

    • Wong-Baker Faces Scale: Visual facial expression scale.

    • FLACC Scale: Evaluates Face, Legs, Activity, Cry, and Consolability for nonverbal or pediatric patients.