Vital Signs

Vital Signs: Overview

• Vital signs are clinical measurements that include blood pressure, pulse, body temperature, respiration, and oxygen saturation.

• They provide a baseline for comparison with future findings.

• They help identify trends or patterns that may indicate a change in a client’s condition.

• They guide treatment decisions and nursing interventions.

Vital Sign Types

• Blood pressure: A measurement of the force, or pressure, of the circulating blood on the interior walls of the blood vessels.

• Pulse: The rhythmic dilation of the arteries that occurs with the beating of the heart.

• Body temperature: The balance of heat produced by the body and the heat lost to the environment.

• Respiratory rate: The number of breaths taken per minute.

• Oxygen saturation: The estimated amount of oxygen bound to the hemoglobin molecule in red blood cells, indicating the amount of oxygen being transported to body tissues.

Blood Pressure

• Systolic BP: The maximum amount of pressure exerted when the heart contracts and forces blood into the aorta.

• Diastolic BP: The minimum amount of pressure exerted when the heart is relaxed.

Alteration in Blood Pressure: Hypertension

• Hypertension is a blood pressure above the expected reference range.

• Stage I hypertension: when the systolic pressure is $130\text{ to }139\ \text{mmHg}$ or the diastolic pressure is $80\text{ to }89\ \text{mmHg}$.

• Stage II hypertension: when the systolic pressure is > 140\ \text{mmHg} or the diastolic pressure is > 90\ \text{mmHg}.

• Hypertensive crisis: systolic pressure is > 180\ \text{mmHg} and/or diastolic pressure is > 120\ \text{mmHg}.

Alteration in Blood Pressure: Hypotension

• Hypotension is a blood pressure that is below the expected reference range as determined by a client’s usual baseline measurement.

• In the absence of baseline data, a systolic pressure less than $90\ \text{mmHg}$ or a diastolic pressure less than $60\ \text{mmHg}$ is typically considered hypotension for an adult.

• Manifestations of hypotension can include dizziness, nausea, blurred vision, increased pulse, and fatigue.

Nursing Interventions for Hypertension

• Encourage the client to adopt lifestyle interventions such as:

  • Exercise

  • Stress reduction techniques

  • Low-sodium diet

  • Weight loss if needed

• Provide the client with information about antihypertensive medications, if prescribed by the provider, including:

  • Expected adverse effects

  • When the provider should be notified

Nursing Interventions for Hypotension

• Increase fluids.

• Place in a supine position unless medically contraindicated.

• Evaluate the medications the client is taking.

• Instruct the client about the risk for dizziness and falling.

• Encourage the client to change positions slowly.

• Avoid extremes in temperature.

• Stay well hydrated.

Pulse

• The pulse is the rhythmic dilation of the arteries and pulsation of blood flow that occurs with each contraction of the heart.

• The expected reference range is $60-100\ \text{beats per minute}.$

• The pulse rate is variable and influenced by many factors including:

  • Body position

  • Age

  • Activity level

  • Health conditions

  • Body temperature

Grading Pulses

• 0 = pulse that is absent/nonpalpable

• +1 = pulse that is weak/diminished

• +2 = pulse that is normal

• +3 = pulse that is increased/strong

• +4 = pulse that is bounding

Alteration in Pulse Rate: Tachycardia

• Tachycardia: pulse greater than $100\,bpm$ .

• Possible causes: Exercise, Anxiety, Certain medications, Caffeine and nicotine, Abnormality in the electrical system of the heart.

• Some clients experience no symptoms; some report a “racing” feeling in the chest.

Alteration in Pulse Rate: Bradycardia

• Bradycardia: pulse less than $60\,/\text{minute}$.

• Possible causes:

  • Expected in physically fit individuals

  • Congenital cardiac abnormalities

  • Heart failure

  • Heart muscle damage

  • Hypothyroidism

• There are often no symptoms in physically fit individuals. Other individuals may report dizziness, fatigue, shortness of breath, chest pain, or confusion.

Body Temperature

• The measurement of the balance of heat produced by the body and the heat lost to the environment.

• Measured in degrees.

• Normal/expected body temperature is between $36^{\circ}\text{C}$ and $38^{\circ}\text{C}$ ( $96.8^{\circ}\text{F}$ and $100.4^{\circ}\text{F}$).

• Average temperature for most clients is $37^{\circ}\text{C}$ ( $98.6^{\circ}\text{F}$).

Alteration in Body Temperature: Fever/Hyperthermia

• A fever is an increase in body temperature above the expected reference range of $38^{\circ}\text{C}$ ( $100.4^{\circ}\text{F}$).

• Commonly caused by infection.

• Symptoms may include flushed face, diaphoresis, skin that feels “hot,” tachycardia, and increased respiratory rate.

Nursing Interventions for Fever and Hyperthermia

• Encourage sips of cool fluids.

• Remove excess clothing.

• Administer medications as ordered.

• Antipyretics to reduce or prevent fever.

• Antibiotics or antivirals if an infection is present.

• Place the client in a cooler environment.

• Give a tepid bath.

Respiratory System

• Respiration consists of inspiration and expiration.

• Inspiration: the intake of air by the lungs in order to oxygenate body tissues and support cellular function.

• Expiration: expels carbon dioxide from the lungs.

• Expected reference range is $12\text{ to }20\ \text{breaths per minute}.$

Alteration in Respiration: Tachypnea

• Tachypnea: respiratory rate above the expected reference range (greater than $20\ \text{breaths per minute}$).

• Possible causes: Physical activity, Anxiety, Pain, Health conditions (e.g., asthma).

• Common symptoms: Dizziness, Tingling in the hands.

Alteration in Respiration: Bradypnea

• Bradypnea: respiratory rate that is below the expected reference range (less than $12\ \text{breaths per minute}$).

• Possible causes: Health conditions, Medications such as opioids or sedatives.

• Common symptoms: Dizziness, Fatigue, Weakness, Confusion, Impaired coordination.

Oxygen Saturation

• Oxygen saturation is the estimated amount of oxygen bound to the hemoglobin.

• Expressed as a percentage.

• Direct reflection of a client’s respiratory status.

• Expected reference range is $95\%\text{ to }100\%.$

Alterations in Oxygenation

• Decreased oxygen saturation is a level below $95\%.$

• Possible causes: Health condition (e.g., pneumonia, chronic lung disease, pulmonary edema, poor cardiac output).

• Common symptoms: Decrease in mental alertness, Confusion