Vital Signs and Vital Assessment

General Protocols for Vital Signs Assessment

• Respiratory assessments must be obtained when the patient is unaware to ensure an accurate, non-reactive rate.

• Counting respirations for $15$ or $30$ seconds and multiplying the result is to be avoided. A full assessment requires counting for exactly $60\,seconds$.

• A consistent counting method is required to obtain a respiratory rate that functions as an accurate predictor of cardiac arrest and patient deterioration.

• Vital sign measuring devices are often shared among patients and must be cleaned thoroughly between uses.

• Patients on isolation precautions must have dedicated equipment specific to them and their room; this equipment should not be shared with any other patient, even those with the same diagnosis (e.g., two patients with MRSA).

• Measurement sites for vital signs should be rotated during repeated assessments to decrease skin breakdown.

• It is the provider's responsibility to know a patient's medical history, current therapies, and prescribed medications to interpret changes in vital signs properly.

• Medications specifically influence readings; for example, if a patient on blood pressure medication has not yet received their dose, their pressure is expected to be high. If it remains high or increases after medication, it indicates a worsening condition.

• Sharing equipment without proper sanitation increases the spread of communicable diseases, including COVID-$19$.

• Ensure patients with latex allergies are provided with latex-free equipment.

• Collaborate with healthcare providers to determine the necessary frequency of vitals. While typically done once per shift or day, worsening physical conditions may require monitoring as often as every $5$ to $15\,minutes$.

• Vital sign results should never be interpreted while inside an isolation room; documentation and analysis should occur after exiting.

• All changes in vital signs must be verified, communicated, and documented accurately. Normal readings, such as $120/80\,mmHg$ or 특정 pulse rates, should not be assumed or fabricated based on previous results.

Body Temperature Assessment

• Temperature can be measured using either the Fahrenheit or Celsius scale depending on the facility.

• Normal temperature range: $36\,^{\circ}C$ to $38\,^{\circ}C$ ($96.8\,^{\circ}F$ to $100.4\,^{\circ}F$).

• Core body temperature: This is the most reliable measurement, with normal parameters ranging from $36.4\,^{\circ}C$ to $37.6\,^{\circ}C$ ($97.6\,^{\circ}F$ to $99.6\,^{\circ}F$).

• Average oral temperature: Approximately $37\,^{\circ}C$ ($98.6\,^{\circ}F$).

• Temperature Measurement Sites:

  • Oral (Mouth): The most common site, but should not be used for infants, confused patients, or those who have recently eaten or drunk.

  • Tympanic: Ear.

  • Rectal: Rectum.

  • Temporal: Forehead.

  • Axillary: Under the arms.

• Choice of site depends on patient appropriateness; always document the specific site used.

• Factors affecting body temperature include:

  • Age.

  • Recent exercise.

  • Hormonal fluctuations.

  • Circadian rhythm (day/night cycle).

  • Stress.

  • Smoking.

  • Environmental conditions.

• Hyperthermia and hypothermia can severely affect the body; for instance, hypothermia may manifest as frostbite.

Cardiovascular Assessment and Heart Sounds

• Radial pulse assessments determine the integrity of the cardiovascular system.

• There are five primary areas for auscultating heart sounds, often remembered by the mnemonic "All People Eat Turkey Meat":

  1. Aortic: Right side of the sternum, approximately $2$ to $3\,inches$ over.

  2. Pulmonic: Left side of the sternum.

  3. Erb’s Point.

  4. Tricuspid.

  5. Mitral: Also known as the Apical pulse, located at the point of maximum impulse (PMI).

• Landmarks for the Apical/Mitral site: Approximately $3\,inches$ to the left of the sternum, $4$ to $6\,intercostal\,spaces$ down, generally just under the nipple line.

• If a patient has dense chest tissue or large breasts, the Mitral sound may be difficult to hear. In such cases, the tissue should be displaced using the back of the hand, or the patient should be asked to lean forward to move the heart closer to the rib cage for a better sound.

Pulse Assessment and Pulse Points

• Factors affecting pulse rate include age, gender, exercise, fever, medications, fluid volume status, stress, and underlying disease.

• Pulse Categories:

  • Peripheral Pulses: Palpated over arteries away from the heart.

  • Apical Pulse: A central pulse auscultated at the apex of the heart.

• Key Pulse Points:

  • Temporal (Head).

  • Carotid (Neck): Never palpate both carotid pulses at the same time (bilaterally), as this can stop blood flow to the brain and cause the patient to pass out.

  • Brachial (Arm).

  • Radial (Wrist - thumb side).

  • Ulnar (Wrist - pinky side).

  • Apical (Chest).

  • Femoral (Groin).

  • Dorsalis Pedis (Top of the foot, lining up between the big toe and the second toe).

• Assessment of the most distal pulse (farthest from the heart, like the pedal pulse) indicates the health of the circulation above it.

• Pulse Rate Terminology:

  • Tachycardia: Fast heart rate.

  • Bradycardia: Slow heart rate.

• Pulse Deficit: Occurs when the radial pulse rate is slower than the apical pulse rate. The apical pulse should never be slower than a peripheral pulse.

• Pulse Intensity Scale ($0$ to $3$):

  • $3$: Bounding.

  • $2$: Normal.

  • $1$: Diminished.

  • $0$: Absent.

Medication Focus: Digoxin

• Digoxin ($D-I-G-O-X-I-N$) is a digitalis preparation used for heart failure.

• Mechanism of Action: It makes the heart contract more effectively by slowing the heart rate down.

• Administration Requirement: A provider must assess the apical pulse for a full $60\,seconds$ before administration.

• Threshold: Digoxin must only be administered if the apical pulse is greater than $60\,bpm$.

Respiration and Oxygenation Quality

• Factors affecting respiration: Age, exercise, cardiovascular/respiratory disease, fluid and electrolyte imbalance, acid-base disturbances, medications, pain, and emotions.

• Respiratory Rate Definitions:

  • Eupnea ($E-U-P-N-E-A$): Normal breathing ($12$ to $20\,breaths\,per\,minute$).

  • Tachypnea: Fast breathing ($\geq 24\,breaths\,per\,minute$ in adults).

  • Bradypnea: Slow breathing ( < 10\,breaths\,per\,minute in adults).

• Depth of Respiration:

  • Hypoventilation: Shallow ventilation, often caused by drug overdose, obesity, COPD (Chronic Obstructive Pulmonary Disease), or cervical spinal injury.

  • Hyperventilation: Deep, rapid breaths, often caused by stress, anxiety, DKA (Diabetic Ketoacidosis), or extreme exercise.

• Quality of Respiration:

  • Apnea: Temporary cessation of breathing.

  • Dyspnea: Labored or difficult breathing.

  • Orthopnea: Shortness of breath when lying flat that resolves upon sitting up.

• Oxygen saturation ($SPO2$) is measured via a pulse oximeter on the finger.

• Signs of decreased oxygenation:

  • Cyanosis: Bluish discoloration around lips, mucous membranes, or nail beds (late sign).

  • Pallor: Paleness (earlier sign).

  • Altered Level of Consciousness: Confusion occurs because the brain is not receiving enough oxygen. This is also seen in blood loss, as blood carries oxygen.

Blood Pressure and Orthostatic Hypotension

• Definitions:

  • Systolic Pressure: The peak of the pressure wave.

  • Diastolic Pressure: The lowest pressure on the arterial wall.

  • Pulse Pressure: The numerical difference between systolic and diastolic pressures.

• Factors affecting Blood Pressure: Age, gender, weight, race, circadian rhythm, head injury, food intake, and increased blood volume.

• Mastectomy Contraindication: Blood pressure should not be taken on the same side as a mastectomy, particularly if lymph nodes were involved, to avoid inaccurate readings and lymph complications. If a double mastectomy was performed, the leg should be used.

• Orthostatic Blood Pressure (Postural Hypotension):

  • Definition: A drop in blood pressure associated with a change in position (lying to standing).

  • Assessment Procedure: Patient lies down for $5\,minutes$. Measure BP and pulse. Patient stands. Measure BP and pulse after $1\,minute$ and again after $3\,minutes$.

  • Abnormal Findings: A drop in systolic or diastolic pressure of $\geq 20\,mmHg$ or a drop in diastolic pressure of $\geq 10\,mmHg$. Dizziness or lightheadedness upon standing also indicates orthostatic hypotension.

• Manual Blood Pressure Technique:

  • Use a cuff with a bladder width that is $40\%$ of the arm circumference.

  • If a cuff is too small, the reading will be falsely high. If too large, the reading will be falsely low.

  • Step-by-step: Position arm at heart level. Palpate the radial pulse. Inflate the cuff until the pulse disappears. Note this number. Deflate and wait $1\,minute$. Re-inflate the cuff $20$ to $30\,mmHg$ above the pulse-disappearance mark. Place the stethoscope over the brachial artery in the antecubital space and listen for Korotkoff sounds.

Stethoscope and Lab Evaluation Standards

• Stethoscope Use:

  • Earpieces must face forward for proper sound conduction.

  • Diaphragm (larger side): Used for high-pitched sounds like lung and bowel sounds.

  • Bell (smaller side): Used for low-pitched sounds, such as specific heart sounds.

  • Warm the stethoscope with hands before touching the patient's skin and ensure privacy.

  • Provide assessment directly on the skin (under the shirt/gown) for accuracy.

• Evaluative Metrics:

  • To pass clinical evaluation, a student's apical pulse count must be within $2\,beats\,per\,minute$ of the instructor's count.

  • Blood pressure readings must be within $4\,mmHg$ of the instructor's reading (both systolic and diastolic).

  • Communication: Clearly signal the start of counting (e.g., saying "Now") so the instructor can synchronize their observation.

Questions & Discussion

• Student Question: How far over and down do I go for the apical pulse?

• Response: Start from the sternum. Go $3\,inches$ to the left. Move $4$ to $6\,intercostal\,spaces$ down, which should place the stethoscope directly under the nipple line at the mitral area.

• Student Question: What if a patient has a lot of breast tissue and I can't hear the heart?

• Response: You must adapt. Ask the patient to displace the tissue first. If they cannot, use the back of your hand to displace it. Then, have the patient lean forward to move the heart closer to the rib cage for a better sound.

• Student Question: Are we assessing each other in lab?

• Response: You will likely assess a classmate. Be prepared to assess both males and females. Always ask for permission before placing the stethoscope under a shirt for skin contact.