Vital Signsrevised06

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Vital Signsrevised06

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Title: Vital Signsrevised06

1
Vital Signs revised06

Cardinal signs, reflects bodys physiological
status
Provides information critical to evaluate
homeostatic balance
Five critical assessments
Temperature
Pulse
Respiration
Blood Pressure (B/P)

Pain is considered the 5th vital sign
Now also checking the oxygen saturation
Vital signs are taken at regular intervals
depending on unit policy and patient condition.
These times may be
Every 8hrs
Every 4 hrs
Every 2 hrs
Every hour
Every 5-30 minutes
Depending on condition of client or medication
administration

Vital signs indicate a positive or negative
change in clients condition
If vital signs are out of range or different from
previous recordings, repeat if using mechanical
equipment find a different machine
Factors influencing Vital Signs
Age Gender Medications
Race Heredity Environment
Pain Stress Metabolism
Lifestyle Exercise
Components of Vital Signs
Temperature- regulated by hypothalamus shows
balance between heat gained and heat loss

4
Temperature

Temperature- measured by thermometer
Oral, rectal, ,axillary, tympanic, heat sensitive
tape
Electric probe with disposal cover
Always designate where temperature is taken as O,
R, A, T, tape
Register temperature as C (Centigrade) or F
(Fahrenheit)
-Mercury thermometers no longer used

Temperature-measured by thermometer
Oral Electronic with disposal cover
Tympanic- electric probe used in ear
Oral, rectal, axillary
Heat sensitive tape
Temperature variations
Newborn 36.5-37 C axillary
No newborn has rectal temp
Infants 3 mo 99.4F 1 yr 99.7F axillary or
rectal. After 4-5 yrs old can be taken orally
or ear based device

Convert centigrade to Fahrenheit
C multiply by 1.8 then add 32
Convert Fahrenheit to centigrade
F subtract 32 divided by 1.8
Temperature varies by the time of day
Highest between 500 to 700pm, late afternoon
Lowest between 200 to 600am, early morning
If possibility of contamination by body fluids
wear gloves
Most accurate is rectal, least is axillary

Temperature variations
- Newborns 36.5-37oC
No rectal temperature for newborns
1 year 99.7oF temp taken rectal or axillary
4-5 year old taken orally or tympanic
13 years 97.8oF
Elderly range between 96.6o to 98.3oF
Taken orally, axillary it unable to close mouth
may also use tympanic or heat sensitive tape

PROCEDURE
Wash hands
ID client
Explain procedure to client
Don gloves if necessary
Provide privacy
Electronic thermometer --Oral
Wait 20-30 minutes if client was eating,
drinking, smoking, exercising
Place disposal cover on probe
Place probe under tongue to sublingual pocket

Have client close mouth
When audible signal occurs (temperature has
registered) remove from clients mouth
Remove probe and dispose of probe cover
Wash hands
Record temperature with proper notations

Electronic Temperature-Rectal Temperature
Don gloves
Position client facing away from you,laying in
Sims position with upper leg flexed
Place disposal cover lubricated with water
soluble lubricant .
Insert probe ¼ to 1 inch through anal sphincter
If encounter resistance remove probe immediately
After audible signal, remove probe
Discard probe cover, tissue and gloves

Wash hands
Record temperature with proper notation of R
Digital thermometer
Clients individual thermometer
Gloves maybe necessary
Oral
Similar to electronic thermometer
Wait 20-30 minutes if activities require
Place thermometer in clients mouth under tongue
(sublinguinal pocket)

Client holds lips closed
Leave in for 45-90 seconds
Temperature displayed
Record temperature with O
Axillary
Same as Oral
Expose axilla and dry under arm
Place thermometer in center of axilla and lower
arm
Wait 1-2 minutes to register
Record temperature
Wash hands

Tympanic
Wash hands
Attach disposal probe
Turn clients head to one side
Place probe in ear and must be in contact will
all sides of canal
When inserting probe into ear use figure 8
pattern
Adults pinna upward and backward Child down and
backward
Make sure probe has firm seal in ear

Press hold temp switch till light flashes
(approx. 3 seconds)
Remove thermometer, discard probe cover Wipe lens
with alcohol swab, dry
Record temperature with Tympanic temperature
Wash hands

15
Pulse

Pulse an index of the hearts rate and rhythm,
shows heart action
Need to evaluate
Rate- number of pulsation in one minute
Rhythm- pattern, even or regular regular
irregular irregular irregular
Quality- fullness or strength- reflex stroke
volume maybe bounding, very strong, weak/
thready, absent

Pulse rate may increase or decrease for various
reasons (exercise, drugs, lack of oxygen, medical
conditionsdehydration, hemorrhage, etc)
Tachycardia pulse over 100 BPM.
Bradycardia pulse below 60 BPM
Pulse located
Carotid- avoid pressuring too hard decreases
blood flow to brain
Apical
Brachial ( site for auscultation of B/P)

Ulnar-near pinky finger
Radial- easy access near thumb
Femoral
Popliteal (behind knee)
Posterior Tibial-evaluate circulation lower
extremities
Dorsalis Pedis- evaluate circulation lower
extremities
Pulses should be felt against bone and using pads
of 3 middle fingers
DO NOT USE YOUR THUMB
NEED A WATCH WITH SECOND HAND
Client should be either in supine or sitting
position

Procedure
Always wash hands no matter where you take a
pulse
Always ID patient, provide privacy, explain
procedure to client
Always check clients activity level of previous
15 minutes
When regular pulse can count for 30 seconds and
multiplying by 2
If difficult or irregular, or taking certain
medication then MUST count for 1 full minute
Record pulse rate, rhythm and strength
Need watch with second hand

Infants and Children
Newborn 80-180/min
Toddler80-110/min
School age 50-90/min
Adolescent 50-90/min

Radial Pulse
Use pads of the 3 middle fingers, place fingers
on side of thumb
Count 30 seconds and multiply by 2
Wash hands and record rate, rhythm, volume
(strength)
Apical Pulse
-Client in supine position, expose chest.
-Locate apical impulse (palpate the Angle of
Louis below suprasternal notch, palpate
down-

ward to fifth Intercostal space
-Move to Midclavicular line
-Warm stethoscope, place diaphragm over apical
space
-Count clients apical pulse for 1 full minute
(lub-dub)
-Wash hand clean stethoscope
Record rate, rhythm, intensity of apical pulse

Apical-Radial Pulse
Equipment watch with second hand, another nurse
and stethoscope( warm in your hand)
Beginning procedure by washing hands, ID client,
provide privacy, explain procedure
Nurse one takes radial pulse and at the same time
the nurse two auscultates the apical pulse for
one full minute
Nurse one signals to stop counting.
Records rate, rhythm, volume.

Pulse Deficit- the difference between the radial
pulse and the apical pulse
Peripheral Pulse
Palpate peripheral, radial,carotid, brachial,
femoral, popliteal, dorsalis pedis and posterior
tibial
Compare bilaterally using pads of middle three
fingers
If difficult to feel, when located mark locations
with felt tip pen

May need to get Doppler.
If need to do this get conductive jelly and
Doppler
Plug in stethoscope, apply gel to clients skin
at site
Hold probe 90oangle
Turn on Doppler, and move probe around to hear
probe, will hear swooshing sound
Mark site
Wipe skin

25
Blood Pressure

Blood pressure (B/P)- is the force of blood
against arterial wall
Pulse pressure is the difference between the
systolic and diastolic pressure (normal 30-50 mm
HG
Equipment Stethoscope ( bell and diaphragm)
sphygmomanometer
Make sure B/P cuff size is based on circumference
of the limb
When unable to take B/P on arm can take on thigh
( see pg 527)

Factors affecting B/P
Cardiac output
Peripheral vascular resistance
Elasticity Distensibility of arteries
Blood volume
Blood Viscosity
Hormones Enzymes
Chemoreceptors
Age, sex, weight
Body position
Activity

Difference between recumbent and standing B/P
systolic falls 10-15points
diastolic may rise 5 points mmHG
Adults- normal range is between 100-130/60-85
No B/P taken on Neonates
Need to take B/P 2 different times days to
diagnosis high B/P.
Two types anaeroid mercury manometer
High B/P immediately after birth, lowest
3 hrs later4-6 days later rises and levels off

Normal adult B/P ranges below 120(systolic) and
less than 80(diastolic), varies with different
people
Hypertensive B/P is defined as 140 mmHG or
greater systolic and/ or 90mmHG or greater
diastolic
Systolic pressure- give data about the condition
of the heart and great arteries
Diastolic pressure- data about the arteriolar or
peripheral vascular resistance
Allow 1 to 2 minutes between taking B/P again
Always clean, wipe ear pieces with alcohol

Always wash hands
ID client
Clean ear piece, and bell/diaphragm with alcohol
B/P may be taken over brachial artery
Always explain procedure to client
Size of cuff vary depending on size of arm
If client has smoked or exercise wait 15 minute
DO NOT take B/P on arm of Dialysis or Radial
Mastectomy client

Procedure
Wash hands, ID client, explain procedure
Client is sitting or reclining position
Choose proper cuff size
Locate palpate brachial artery
Wipe stethoscope with alcohol
Close sphygmomanometer
Inflate cuff to 30points mm HG above level were
radial pulsation are no longer felt.
Bell or diaphragm on medial antecubital fossa (
bell is better for auscultation)
Deflate cuff gradually until first Korotkoff
sound heard (systolic pressure)

Read pressure on manometer at eye level
Continue to deflate until Korotkoff sound no
longer heard (diastolic pressure)
Remove cuff
Record results and wash hands
Palpable Systolic Arterial B/P
This is done when unable to hear B/P readings
Wash hands, check ID, Explain, wrap cuff on upper
arm
Locate radial artery
Inflate cuff to where radial artery pulsation

no longer felt
-Continue to palpate and release pressure on
cuff
-First palpated beat is systolic pressure ( same
point of last pulsation during inflation
Remove cuff, wash hands, record
Monitoring with Noninvasive Device
Wash hands, ID client, attach B/P cuff to client
Plug in machine in electrical outlet
Turn on switch
Press start
When reading occurs, record reading

Remove cuff and return and re-plug machine into
electrical outlet
Respirations
Respiration is the process of bringing oxygen to
the body tissue ( Inspiration) and removing
carbon dioxide (expiration)
Normal rate of adult 12-18 breaths/min.
Newborn 30- (40-60) breaths/min.
Older children 20-26 breaths/min.
Tachypnea rate over 24 breaths/min.
Bradypnea rate less than 10 breaths/min.

Apnea absence of breathing
Dyspnea difficulty breathing
Need to assess pattern, rate and depth of clients
breathing
Rhythm- pattern between inspiration and
expiration
Quality effort required to breathe
Always wash hand
ID Client
Provide privacy
Explain procedure

Factors affecting respiration
Age
Drugs
Stress
Emotions
Body position
Procedure
Wash hands, ID client, provide privacy, explain
procedure
While taking pulse check clients respirations

Observe clients respirations and count for 30
seconds and multiply by 2
If unable to accurately visualize clients
respirations may place hand on clients chest and
count respirations for 30 second and multiple by
2
Wash hands and record noting rate, rhythm and
depth
Rhythm- can be either regular or irregular
Depth- can be normal or shallow

Respirations
Newborn- 30-60/min
Toddler24-32/min
School age- 18-26/min
Adolescent- 16-20/min
Adults- 12-20/min

38
Pain

Pain is a sensation in which a person experiences
discomfort, distress, or suffering
Types of pain
Acute- occurs only in a defined period of time (6
mo or less) and is caused by specific stimuli
that damages the tissue. Usually recent onset and
varies in intensity
Chronic-prolonged, persistent nonmalignant

-Pain that occurs over 6 months period or
longer, varies in intensity and may serve no
useful function
-Malignant- recurrent, acute episodes which may
include chronic pain, may vary in intensity
and have
rapid or slow onset. May last longer than 6
months
and be intractable
JCAHO standards assess regularly and manager in
order to maintain clients hemostasis and quality
of life.
Rating scale used to rate clients pain on level
of 1 to 10 or children using different faces.
(pg135)

Measurement of pain (Ask client for all this
information about pain
Location, ( exactly where is the pain, point)
Intensity, determine strength, power or force of
pain, using numeric or face picture scale
Quality, features of characteristics the
distinguish pain as searing, dull, throbbing,
sharp, burning, etc
Pattern, how pain changes and timing of pain as
continuous, steady, intermittent, transient

Factors associated with pain
Nausea
Vomiting
Bradycardia ,tachycardia
Hypotensive, hypertensive
Profuse perspiration
Apprehension or anxiety
Precipitating Factors
-Motion affecting incision area (coughing,
turning, deep breathing)

Fear and emotional distress
Inflammation or infection
Trauma
Disease state
Aggravating Factors
Position changes
Environmental stressors
Fatigue
Inadequate pain relief measures

Alleviating Factors
Position change
Medication
Biofeedback
Visualization
Relaxation techniques
TENS
Massage
Pain Management
Listen to client

Intervention with medication
Dont allow pain to escalate, anticipate
What works for client to relieve pain
Understand various actions of drugs
Nonpharmacological approach to relieve pain
PHYSICAL METHOD
Tens, Stimulation of mild electrical current
Acupuncture, Chinese form of treatment
Biofeedback electric monitoring devices shows
effect of behavior on internal control processes