Module 3 Pt 2 Vitals Pt 2

Learning objectives:

  • explain the physiologic processes involved in homeostatic regulation of temperature, pulse, respirations, and BP

  • Compare and contrast factors that increase or decrease body temp, pulse, respirations, and BP

  • Identify sites for assessing temp, pulse, and BP

  • Demonstrate knowledge of the normal ranges for temp, pulse, respirations, and BP for adults

  • Demonstrate accurate documentation of vital signs

When to assess V/S

  • On admission to any health care facility or institution

  • Based on facility or institutional policies and procedures

  • Any time there is a change in patient conditions

  • Any time there is a loss of consciousness

  • Before and after any surgical or invasive diagnostic procedures

  • Before and after and activity that may increase risk such as ambulation after surgery

  • Before administering medications that affect cardiovascular and respiratory function

  • Whenever the patient reports a change in status, pain or distress

Physiology of body temp

  • The hypothalamus is responsible for controlling thermoregulation by conserving body heat or increasing heat loss → difference between amount of heat produced by the body and amount of heat lost to the environment → factors affecting body temp: time of day, biologic sex, age, physical activity, state of health, environmental temperatures→ core body temp locations include intracranial, intrathoracic, intraabdominal → the body’s tissues and cells function best between the range of 36ºC to 37.5ºC

Blood Pressure Assessment

  • have correct cuff size (judge by circumference of the arm not age)

  • The cuff should cover 40% of the arm circumference and the bladder should cover 2/3 of the arm

  • Support arm at heart level, palm turned upward (above heart causes false low reading)

  • Cuff too wide – false low reading, Cuff too narrow – false high reading, Cuff too loose – false high reading

  • Listen for Korotkoff sounds

  • Limb Alerts

    • PICC lines

    • Arteriovenous (AV) fistula

    • Arm on the side of a mastectomy

Oxygen Saturation (Pulse Oximetry)

  • Non invasive oxygen saturation measurement

  • Calculates SPO2 reliable estimate of arterial oxygen saturation

  • Finger, ear, nose, toes

  • Remove thick nail polish, wait until it reaches a constant value

PQRST pain scale

  • P: provocation/relief

  • Q: quality

  • R: region and radiation

  • S: Severity

  • T: time

Vital signs may reveal sudden changes in a clients condition in addition to changes that occur progressively over time. A baseline set of V/S are important to identify changes in the patients condition


Learning Objectives

  • Explain the physiological processes involved in homeostatic regulation of temperature, pulse, respirations, and blood pressure (BP).

  • Compare and contrast factors that influence vital signs, including those that increase or decrease body temperature, pulse, respirations, and BP.

  • Identify key sites for assessing vital signs: temperature, pulse, and BP.

  • Demonstrate a thorough understanding of the normal ranges for temperature, pulse, respirations, and BP in adults.

  • Ensure accurate documentation of vital signs to maintain high-quality patient care.

  • Understand when to assess vital signs:

    • Upon admission to any healthcare facility or institution.

    • In accordance with facility or institutional policies and procedures.

    • Whenever there is a notable change in patient conditions or status.

    • Any time there is a loss of consciousness.

    • Before and after surgical or invasive diagnostic procedures.

    • Before and after activities that may increase risk, such as ambulation after surgery.

    • Before administering medications that affect cardiovascular and respiratory functions.

    • Whenever a patient reports changes in health status, pain, or distress.

Physiology of Body Temperature

  • The hypothalamus plays a crucial role in thermoregulation, acting as the body’s thermostat. It regulates body temperature by balancing heat production and heat loss.

  • Body temperature is influenced by various factors:

    • Time of day: Core body temperature is typically lower in the morning and higher in the late afternoon/evening.

    • Biological sex: Hormonal fluctuations, particularly in females, can impact body temperature.

    • Age: Infants and elderly individuals often have different normal temperature ranges.

    • Physical activity: Exercise increases metabolic rate and heat production.

    • State of health: Illness can raise or lower body temperature based on the metabolic response.

    • Environmental temperatures: Exposure to extreme heat or cold can significantly influence body temperature.

  • Core body temperature is best assessed at deep body sites such as intracranial, intrathoracic, and intra-abdominal areas.

  • Optimal body tissue and cellular function is maintained within a range of 36ºC to 37.5ºC.

Blood Pressure Assessment

  • Ensure the correct cuff size for accurate BP readings; the cuff must be judged by the circumference of the arm, not by the patient’s age.

  • The cuff should cover approximately 40% of the arm circumference, and the bladder inside the cuff should ideally cover two-thirds of the arm.

  • Support the patient’s arm at heart level, with the palm facing upward, as positioning above heart level can lead to misleadingly lower readings.

  • Key points to note about cuff application:

    • Cuff too wide: may result in a false low reading.

    • Cuff too narrow: may give a false high reading.

    • Cuff too loose: can also result in a false high reading.

  • Listen for Korotkoff sounds during BP measurement, as these sounds indicate the flow of blood and assist in determining systolic and diastolic pressures.

  • Consider limb alerts when assessing BP. Avoid measuring on limbs with:

    • PICC lines (Peripherally Inserted Central Catheter).

    • Arteriovenous (AV) fistula.

    • On the arm of a patient who has had a mastectomy.

Oxygen Saturation (Pulse Oximetry)

  • Pulse Oximetry is a non-invasive measurement that calculates Spo2, providing a reliable estimate of arterial oxygen saturation levels.

  • Common sites for assessment include fingers, ears, noses, and toes, though finger measurements are most typical.

  • Ensure that thick nail polish is removed before assessment, and allow the reading to stabilize to ensure accuracy.

PQRST Pain Scale

  • The PQRST pain scale is a systematic approach that helps assess pain, breaking it into key elements:

    • P (Provocation/Relief): What causes the pain? What alleviates it?

    • Q (Quality): What does the pain feel like (sharp, dull, throbbing, etc.)?

    • R (Region and Radiation): Where is the pain located? Does it spread anywhere?

    • S (Severity): How severe is the pain on a scale of 0 to 10?

    • T (Time): How long have you been experiencing the pain? Is it constant or intermittent?

Importance of Vital Signs

  • Vital signs can reveal sudden changes in a client’s condition, as well as progressive changes over time.

  • A baseline set of vital signs is essential to effectively identify deviations from normal range, enabling timely intervention and appropriate clinical responses.