Detailed Notes on Vital Signs Assessment

Vital Signs Overview

• Vital signs are critical indicators of a patient's health status, encompassing:
  • Temperature
  • Pulse
  • Respirations
  • O2 saturation
  • Blood Pressure

Understanding Vital Signs

• Vital signs are related to homeostasis and regulation, including:
  • Thermoregulation
  • Gas exchange
  • Perfusion
  • Important measurements: TPR (Temperature, Pulse, Respiration), BP (Blood Pressure)

When to Measure Vital Signs

• Common scenarios include:
  • During a health visit
  • Upon patient admission
  • Before and after invasive/surgical procedures
  • Before, during, and after medication administration (especially cardiac medications)
  • Based on physician/NP/routine orders

Purposes of Monitoring Vital Signs

• Vital signs are taken for several reasons:
  • Screening for potential health issues
  • Establishing baseline data
  • Monitoring response to treatment
  • Checking for any changes in health status
  • Observing for potential complications

Technique for Taking Vital Signs

• Start with a general survey and health history; associated signs and symptoms are important.
• Ensure correct technique and verify results if uncertain (re-check readings).
• Always first check the patient before proceeding.

Body Temperature

• Regulation: Hypothalamus controls temperature with a diurnal pattern (0.5 to 1 degree variation).
• Normal range: 36.5-37.5 °C (oral reading).
  • Fever: > 38.0 °C (oral).
  • Differences by measurement site:
  • Axillary: ~0.5 °C lower
  • Tympanic & Rectal: ~0.5 °C higher
• Important notes for measurement: Wait 15 minutes after exposure to cold environments.

Understanding Fever

• Fever guidelines indicate:
  • 41°C or higher indicates hyperthermia or heat stroke.
  • 39.4°C often associated with serious conditions like meningitis or pneumonia.
  • 38.3-39.4°C suggests flu, strep throat, etc.
  • Pediatric considerations: >38°C indicates urgency in infants under 3 months.
• Remember, fever responses can vary among individuals.

Temperature Measurement Techniques

• Oral:
  • Place sublingual, wait 15 minutes post eating/drinking.
  • Pros: Accessible, comfortable; Cons: Affected by recent intake (e.g., ice).
• Axillary:
  • Place against torso; longer measurement time.
• Rectal:
  • Extremely accurate for core temperature, invasive; best for unconscious patients or infants.

Pulse Measurement

• Technique:
  • Use finger pads on radial artery; measure pulse in 30-second intervals (multiply by 2).
• Key metrics:
  • Rate: Normal 60-100 bpm; Tachycardia >100 bpm; Bradycardia <60 bpm.
  • Rhythm: Regular/irregular.
  • Strength: Scale of amplitude from 0-4+.

Respiratory Rate and Quality

• Mechanics:
  • Inspiration: Active; Expiration: Passive.
• Measure RR in 30 seconds (multiply by 2).
• Normal rates: 12-20 breaths/min; tachypnea: >20 bpm; bradypnea: <12 bpm.
  • Quality and rhythm must be assessed with no accessory muscle use.

Oxygen Saturation

• Expectation: >92-100% oxygen saturation; if borderline, reassess.

Blood Pressure Measurement

• Definition: The force exerted on arterial walls.
• Components:
  • Systolic pressure: Highest when ventricles contract.
  • Diastolic pressure: Lowest when ventricles relax.
  • MAP: Mean arterial pressure; essential for good perfusion (≥ 60mmHg).
  • Calculation of MAP: ext{MAP} = rac{SBP + (2 imes DBP)}{3}.

Accurate Blood Pressure Measurement Techniques

• Maintain correct body position, arm level, and appropriate cuff size to avoid inaccuracies.
• Use the two-step method:
  1. Estimate systolic, palpate at radial artery. Inflate until pulse disappears, then increase by 30 mmHg.
  2. Measure with stethoscope on brachial artery, inflate to estimated systolic, release air gradually and observe Korotkoff sounds to determine systolic and diastolic pressures.

Pediatric Considerations

• Use appropriate techniques for child age: axillary, tympanic, and temporal readings for screening; oral and rectal for definitive measurements (if not contraindicated).
• Note that child respiratory rates and heart rates trend lower as they age until reaching adult levels by ages 12-15.

Emergency Red Flags

• Monitor for acute changes in health:
  • New chest pain, respiratory changes, abnormal heart rates, significant BP changes, and temperature extremes.
• These findings require immediate clinical attention.

Common Errors in Vital Signs Assessment

• Be aware of rounding errors, missing auscultatory gaps, incorrect deflation rates, cuff size issues, and examiner bias during assessments

Summary

• Vital signs are essential indicators and each has a specific purpose and method for measurement that can change based on clinical circumstances, particularly in pediatric populations. Correct technique and understanding of normal ranges are pivotal for accurate assessment.