Vital Signs

• Body temperature, pulse, respirations, and Blood Pressure

• Many agencies have designated pain as 5th vital signs.
• Monitor functions of the body
• Should be a thoughtful, scientific assessment

When to Assess Vital Signs

• On admission
• Change in client’s health status
• Client reports symptoms such as chest pain, feeling hot, or faint
• Pre and post surgery/invasive procedure
• Pre and post medication administration that could affect CV system
• Pre and post nursing intervention that could affect vital signs

Body Temperature

• Reflects the balance between the heat produced and the heat lost from the body
• Measured by heat units called degrees

KINDS OF BODY TEMPERATURE

1. CORE temperature - is the temperature of the deep tissues of the body, such as the abdominal cavity
and pelvic cavity.
2. SURFACE temperature - is the temperature of the skin, the subcutaneous tissue, and fat.

FACTORS AFFECTING BODY HEAT PRODUCTION

1. Basal Metabolic Rate
2. Muscle activity
3. Thyroxine output
4. Epinephrine, norepinephrine, and sympathetic/stress response
5. Fever

FACTORS AFFECTING BODY TEMPERATURE

• Age
• Diurnal variations (circadian rhythms)
• Exercise
• Hormones
• Stress
• Environment

NORMAL RANGE
• Babies and children. In babies and children, the average body temperature ranges from 97.9°F
(36.6°C) to 99°F (37.2°C).
• Adults. Among adults, the average body temperature ranges from 97°F (36.1°C) to 99°F (37.2°C).
• Adults over age 65. In older adults, the average body temperature is lower than 98.6°F (36.2°C).
 • Alterations in Body Temperature
• Pyrexia, Hyperthermia, Fever - body temperature above the usual range
• Febrile - a client who has a fever
• Afebrile - a client who does not have fever
• Hypothermia - core body temperature below the lower limit of normal

CLINICAL MANIFESTATIONS OF HYPERTHERMIA

Fever
I. ONSET (COLD OR CHILL PHASE)
1. increased heart rate
2. increased RR and depth
3. Shivering
4. Pallid, cold skin
5. Complaints of feeling cold
6. Cyanotic nail beds
7. Gooseflesh appearance of the skin
8. Cessation of sweating

II. COURSE (Plateau Phase)

• Absence of chills
• Skills that feels warm
• Photosensitivity
• Glassy-eyed appearance
• Increased pulse and respiratory rates
• Increased thirst
• Mild to severe dehydration
• Drowsiness, restlessness, delirium, or convulsions
• Herpetic lesions of the mouth
• Loss of appetite
• Malaise, weakness and aching muscles
• DEFERVESCENCE
• Skin that appears flushed and feels warm
• sweating
• decreased shivering
• possible dehydration

III. CLINICAL MANIFESTATIONS OF HYPOTHERMIA

• Decreased body temperature, pulse, and respirations.
• Severe shivering (initially)
• Feelings of cold and chills
• Pale, cool, waxy skin
• Frostbite (discolored, blistered nose, fingers, toes)
• Hypotension
• Decreased urinary output
• Lack of muscle coordination
• Disorientation
• Drowsiness progressing to coma
NURSING INTERVENTIONS FOR CLIENTS WITH FEVER
• Monitor vital signs
• Assess skin color and temperature
• Monitor white blood cell count, hematocrit value and other pertinent laboratory reports for
indicators of infection or dehydration
• Remove excess blankets when the client feels warm, but provide extra warmth when the client
feels chilled.
• Provide adequate nutrition and fluids to meet the increased metabolic demands and prevent
dehydration
• Measure intake and output
• Reduce physical activity to limit heat production, especially during the flush stage
• Administer antipyretics as ordered
• Provide oral hygiene to keep the mucous membranes moist
• Provide a tepid sponge bath to increase heat loss through conduction
• Provide dry clothing and bed linens

NURSING INTERVENTIONS FOR CLIENTS WITH HYPOTHERMIA

• Provide a warm environment
• Provide dry clothing
• Apply warm blankets
• Keep limbs close to body
• Cover the client's scalp with a cap or turban
• Supply warm oral or intravenous fluids
• Apply warming pads
• Sites for Measuring Body Temperature
• Oral
• Rectal
• Axillary
• Tympanic membrane
• Skin/Temporal artery
• Types of Thermometers
• Electronic
• Chemical disposable
• Infrared (tympanic)
• Scanning infrared (temporal artery)
• Temperature-sensitive tape
• Glass mercury

Sites For Measuring Body Temperature

• Oral
• Rectal
• Axillary
• Tympanic membrane
• Skin/Temporal artery

Types of Thermometers
• Electronic
 • Chemical disposable
• Infrared (tympanic)
• Scanning infrared (temporal artery)
• Temperature-sensitive tape
• Glass mercury

Advantages/Disadvantages of Sites Used for Body Temp Measurements

Site Advantages Disadvantages

Oral Accessible and convenient • Thermometers can break if bitten.

• Inaccurate if client has just injested hot or cold food
or fluid or smoked.
• Could injure the mouth following oral surgery
Recta Reliable measurement • Incovenient and more unpleasant for clients; difficult
l for clients who cannot turn to the side.
• Could injure the rectum.
• Presence of stool may interfere with thermometer
placement.

Oral Accessible and convenient • Thermometers can break if bitten.

• Inaccurate if client has just injested hot or cold food
or fluid or smoked.
• Could injure the mouth following oral surgery
Recta Reliable measurement • Incovenient and more unpleasant for clients; difficult
l for clients who cannot turn to the side.
• Could injure the rectum.
• Presence of stool may interfere with thermometer
placement.

Temperature: Life Span Consideration

Infants Unstable
Newborns must be kept warm to prevent hypothermia
Children Tympanic or temporal artery sites preferred
Elders Tends to be lower than that of middle-aged adults

Convert:
1. Fahrenheit (°F) = (Temperature in degrees Celsius (°C) * 9/5) + 32.

Ex. Celcius reading is 38.5 °C

(38.5 x 9/5) + 32
(38.5 x 1.8) + 32
(69.3) + 32
= 101.3 °F
 2. Celcius = (Fahrenheit temp - 32) x 5/9
Ex. Fahrenheit reading is 100 0F
C = (100-32) x 5/9
(68) x 5/9
(68) x 0.5555
= 37.7 0C

II. Pulse
• Is a wave of blood created by contraction of the left ventricle of the heart
• Represents the amount of blood that enters the arteries with each ventricular contraction
• Peripheral pulse- a pulse located away from the heart Ex. Foot or wrist
• Apical pulse- is the central pulse that is located at the apex of the heart
• Cardiac Output
• CO is the volume of blood pumped into the arteries by the heart and equals the result of the
stroke volume (SV) times the heart rate (HR) per minute.
• 65 ml x 70 beats per min. = 4.55 L of blood each minute

Factors Affecting Pulse

• Age
• Gender
• Exercise
• Fever
• Medications
• Hypovolemia
• Stress
• Position changes
• Pathology

Pulse Sites

Pulse: Lifespan Considerations

 Radial Readily accessible
Temporal When radial pulse is not accessible
Carotid During cardiac arrest/shock in adults
Determine circulation to the brain
Apical Infants and children up to 3 years of age
Discrepancies with radial pulse
Monitor some medications

brachial Blood pressure

Cardiac arrest in infants
Femoral Cardiac arrest/shock
Circulation to a leg;
Popliteal Circulation to lower leg
Posterior tibial Circulation to the foot
Dorsalis pedis Circulation to the foot

Infants Newborns may have heart murmurs that are not

pathological
Children The apex of the heart is normally located in the
fourth intercostal space in young children; fifth
intercostal space in children 7 years old and older
Elders Often have decreased peripheral circulation

Characteristics of the Pulse

• Rate
tachycardia- over 100 BPM
bradycardia- less than 60 BPM
• Rhythm
dysrhytmia or arrhythmia- irregular pulse
• Volume
force of blood with each beat
absent to bounding
• Arterial wall elasticity
• Bilateral equality

Pulse Rate and Rhythm

• Rate
​Beats per minute
​Tachycardia
​Bradycardia
• Rhythm
​Equality of beats and intervals between beats
​Dysrhythmias
​Arrhythmia

Characteristics of the Pulse

• Volume
​Strength or amplitude
​o - absent
​1+ weak, diminished (easy to obliterate)
​2+ Normal (obliterate with moderate pressure)
​3+ Bounding (unable to obliterate or requires firm pressure)
• Arterial wall elasticity
​Expansibility or deformity
• Presence or absence of bilateral equality
​Compare corresponding artery
• Measuring Apical Pulse

RESPIRATIONS

• act of breathing
• Inhalation or inspiration refers to the intake of air into the lungs.
• Exhalation or expiration refers to the breathing out or the movement of gases from the lungs to
the atmosphere.
• Ventilation - also used to refer to the movement of air in and out of the lungs.

2 Types of Breathing:
1. costal (thoracic)
2. diaphragmatic (abdominal)

Factors Affecting Respirations

• Exercise
• Stress
• Environmental temperature
• Medications
• Inhalation
• Diaphragm contracts (flattens)
• Ribs move upward and outward
• Sternum moves outward
• Enlarging the size of the thorax
• Exhalation
• Diaphragm relaxes
• Ribs move downward and inward
• Sternum moves inward
• Decreasing the size of the thorax
• Respiratory Control Mechanisms
• Respiratory centers
​Medulla oblongata
​Pons
• chemoreceptors
​centrally in the medulla
​peripherally in the carotid and aortic bodies.

Components of Respiratory Assessment

• Rate
• Depth
• Rhythm
• Quality
• Effectiveness
• Respiratory Rate and Depth
• Rate
​Breaths per minute
​Apnea – absence of breathing
​Bradypnea- abnormally slow respirations
​Tachypnea- abnormally fast respirations
• Depth
​Normal
​Deep
​Shallow
• Eupnea - breathing that is normal in rate and depth.
​Components of Respiratory Assessment
• Rhythm - regularity of the expirations and the inspirations
​Regular
​Irregular
• Quality- those aspects of breathing that are different from normal, effortless breathing.
​Effort
​Sounds
• Sound - normal breathing is silent
• Effectiveness
​Uptake and transport of O2
​Transport and elimination of CO2
• Altered Breathing Patterns
• Rate
​Tachypnea – quick, shallow breaths
​Bradypnea- abnormally shallow breathing
​Apnea- absence or cessation of breathing
• Volume
-Hyperventilation- overexpansion of the lungs characterized by rapid and deep breaths
-Hypoventilation- underexpansion of the lungs characterized by shallow respirations
• Altered Breathing Patterns
• Rhythm
​Cheyne- Stroke breathing- rhythmic waxing and waning of respirations, from very deep to very shallow
breathing and temporary apnea
• Ease or Effort
​Dyspnea- difficult and labored breathing during which the individual has a persistent, unsatisfied need
for air and feels distressed
​Orthopnea- ability to breathe only in upright sitting or standing positions

Altered Breath Sounds

• Stridor – a shrill, harsh sound heard during inspiration with laryngeal obstruction
• Stertor - snoring or sonorous respiration, usually due to a partial obstruction of the upper airway
• continuation...
• Wheeze- continuous, high pitched musical squeak or whistling sound occurring on expiration
• Bubbling - gurgling sounds heard as air passes through moist secretions in the respiratory tract.

CHEST MOVEMENTS
• Intercostal retraction - indrawing between the ribs
• Substernal retraction - indrawing beneath the breastbone
• Suprasternal retraction - indrawing above the clavicles

SECRETIONS AND COUGHING

• Hemoptysis - the presence of blood in the sputum
• Productive cough - a cough accompanied by expectorated secretions
• Non-productive cough - a dry, harsh cough without secretions
• Respirations:
Lifespan Considerations

BLOOD PRESSURE

• Arterial BP is a measure of the pressure exerted by the blood as it flows through the arteries.
• Blood moves in waves.
• Systolic and Diastolic Blood Pressure
• Systolic
​Contraction of the ventricles
• Diastolic
​Ventricles are at rest
​Lower pressure present at all times
Pulse Pressure = difference between systolic and diastolic pressures
• Measured in mm Hg
• Recorded as a fraction, e.g. 120/80
• Systolic = 120 and Diastolic = 80
• Factors Affecting
Blood Pressure
• Age
• Exercise
• Stress
• Race
• Gender
• Medications
• Obesity
• Diurnal variations
• Disease process
 • Korotkoff’s Sounds

Infants Some newborns display “periodic breathing”

Children Diaphragmatic breathers
Elders Anatomic and physiologic changes cause respiratory
system to be less efficient

Korotkoff’s Sounds
• Phase 1
​First faint, clear tapping or thumping sounds
​Systolic pressure
• Phase 2
​Muffled, whooshing, or swishing sound
• Korotkoff’s Sounds
• Phase 3
​Blood flows freely
​Crisper and more intense sound
​Thumping quality but softer than in phase 1
• Phase 4
​Muffled and have a soft, blowing sound
• Phase 5
​Pressure level when the last sound is heard
​Period of silence
​Diastolic pressure
• Korotkoff's Sounds

COMMON ERRORS IN ASSESSING BP

• Measuring Blood Pressure
• Direct (Invasive Monitoring)
• Indirect
​ uscultatory
A
​Palpatory
​
• Sites
​Upper arm (brachial artery)
​Thigh (popliteal artery)
​
• Blood Pressure:
Lifespan Considerations
• Pulse Oximetry
• Pulse Oximetry
• Noninvasive
• Estimates arterial blood oxygen saturation (SpO2)
• Normal SpO2 85-100%; < 70% life threatening
• Detects hypoxemia before clinical signs and symptoms
• Sensor, photodetector, pulse oximeter unit
 • Pulse Oximetry

Factors that affect accuracy include:

​1. Hemoglobin level
​2. Circulation
​3. Activity
​4. Carbon monoxide poisoning

Pulse Oximetry
• Prepare site
• Align LED and photodetector
• Connect and set alarms
• Ensure client safety
• Ensure accuracy
• Delegation of Measurement
of Vital Signs
• General considerations prior to delegation
​Nurse assesses to determine stability of client
​Measurement is considered to be routine
​Interpretation rests with the nurse
• Delegating to UAP
• Body temperature
​Routine measurement may be delegated to UAP
​UAP reports abnormal temperatures
​Nurse interprets abnormal temperature and determines response
• Delegation to UAP
• Pulse
​Radial or brachial pulse may be delegated to UAP
​Nurse interprets abnormal rates or rhythms and determines response
​UAP are generally not responsible for assessing apical or one person apical-radial pulses
• Delegating to UAP
• Respirations
​Counting and observing respirations may be delegated to UAP
​Nurse interprets abnormal respirations and determines response
• Delegation to UAP
• Blood pressure
​May be delegated to UAP
​Nurse interprets abnormal readings and determines response
• Oxygen saturation
​Application of the pulse oximeter sensor and recording the Sp02 may be delegated to UAP
​Nurse interprets oxygen saturation value and determines response.
• Resources
• Audio Glossary
• HyperHEART
Shows the heart pumping and talks about diastolic and systolic cycles. Has tutorials for atrial
systole and others. Very fun site.
• Best Practice--Vital Signs
Reviews research studies related to vital signs. Covers all aspects of vital signs and even gives
implications for practice and recommendations.
• The Medical Center--Vital Signs
Provides an overview of vital signs. Nicely done.
• Resources
• The National Women's Health Information Center
Good overview of blood pressure, especially high blood pressure, and its effects on women.
• MEDLINEplus--Blood Pressure
Describes blood pressure in detail
• MEDLINEplus--Pulse
Describes pulse in detail
• MEDLINEplus--Temperature measurements
Describes temperatures in detail
• A Practical Guide to Clinical Medicine--Vital Signs
An in-depth look at vital signs. Has graphic pictures to explain vital signs.