Vital Signs

1
Vital Signs

• By Diana Blum MSN
• NURS 1510

2
What are they?

• Pulse
• Respirations
• BP
• Temperature
• Oxygen Sats

3
How often?

• As ordered
• Q1hour
• Q2 hours
• Q4 hours
• Routine (Q8hours)
• Based on client condition

4
WHY?

• Baseline values establish the norm against which
  subsequent measures are compared
• Nurse is
• Responsible for measuring, interpreting
  significance and making decisions about care
• Knowing normal ranges
• Knowing history and other therapies that may
  affect VS

5
Temperature

• Degree of heat maintained by the body
• Heat produced minus heat lost equals body
  temperature
• Organs have receptors that monitor core body
  temperature

6
Temperature

• Core temperature
• Normal
• 96.2 degrees F to 100.4 degrees F
• 36.2 degrees C to 38 degrees C
• Surface temperature
• Lower than core temperature
• Use oral and axillary method

7
Regulation of Temperature

• Neural control
• Hypothalmus acts as thermostat
• Vascular control
• Vasoconstriction ---hypothalmus directs the body
  to decrease heat loss and increase heat
  production
• If cold, vasoconstriction will conserve
  heatshivering will occur

8
Regulation of temperature

• Vasodilation
• If body temp is above normal, the hypothalamus
  will direct the body to decrease heat production
• Perspiration and increased respiratory rate
• Body heat production
• Bodys cells produce heat from foodreleasing
  energy.
• BMR rate of energy used in the body to maintain
  essential activities

9
Changes in temperature

• Conduction
• Transfer of heat from a warm to cool surface by
  direct contact
• Convection
• Transfer of heat through currents of air or water
• Radiation
• Loss of heat through electromagnetic waves from
  surfaces that are warmer than the surrounding air
• Evaporation
• Water to vapor lost from skin or breathing

10
Factors affecting Temperature

• Age
• Exercise
• Hormones
• Circadian cycle
• Stress
• Ingestion of food
• Smoking
• Environment
• (Page 529)

11
Variances in temperature

• Fever (pyrexia)
• Abnormally high body temperature (gt100.4 F)
• Occurs in response to pyrogens (bacteria)
• Pyrogens induce secretion of prostoglandins that
  reset the hypothalmic thermostat to a higher
  temperature
• Hyperpyrexia
• Fever gt 105.8

12

• Febrile has fever
• Afebrile no fever
• Intermittent fever
• Remittent fever
• Relapse fever
• Constant fever
• Fever spike rises rapidly then normal within a
  few hours

13
Not a true fever _at_!?

• Heat exhaustion
• Heat stroke
• Prolonged exposure to heat source (Ex. SUN)
• Depression of hypothalmus
• Emergency
• S/S hot, dry skin, confusion, delirium

14
Serious variations in temperature

• Hypothermia
• Below 95 degrees
• Uncontrolled shivering, loss of memory,LOC
  decreases
• Limits 77-109 degrees F

15
Physiologic responses

• Temp increases
• Immune system stimulates hypothalmus to new set
  point
• Chills, shivers
• Feels cold even though temp increasing
• When body temp is reset, chills subside

16
Physiologic responses

• Metabolism increases
• O2 consumption increases
• HR and RR increase
• Energy stores are used
• Dehydration and confusion
• When cause is removed, set point drops

17
Physiologic responses

• Vasodilation
• Warm flushed skin and diaphoresis
• Benefits
• Activates the immune system
• Interleukin 1 stimulates antibody production
• Fights viruses by stimulating interleukin
• Serves as a diagnostic tool

18
Routes for taking temperatures

• Oral
• Most accessible and accurate
• Do not use if unconscious, confused recent oral
  or facial OR
• Rectal
• 99 F
• Avoid with MI and after lower GI
• Axillary
• 97 Fleast accurate, most safe
• Tympanic
• 98 Favoid with infection, after exercise, if
  hearing aid
• Infrared
• Temporal

19
Pulse

• The wave begins when the left ventricle contracts
  and ends when the ventricle relaxes
• Indirect measure of cardiac output

20
Pulse

• Each contraction forces blood into the already
  filled aorta, causing increased pressure within
  the arterial system
• Systole
• Diastole
• Cardiac OutputSV x HR
• Stroke volume
• The quantity of blood pumped out by each
  contraction of the left ventricle

21
Pulse

• Measured in beats per minute (bpm)
• Normal
• 60-100 bpm
• Females slightly higher
• Average
• 70-80 bpm

22
Obtaining pulse rate

• Apical is most accurate
• Use a standard stethescope to auscultate the
  number of heartbeats at the apex of the heart
• A heartbeat is one series of the LUB and DUB
  sounds

23
Common pulse points

• Apical at the apex of the heart
• Carotid between midline and side of neck
• Brachial medially in the antecubital space
• Radial laterally on the anterior wrist
• Femoral in the groin fold
• Popliteal behind the knee
• Post tibial
• Dorsalis pedis
• ulnar

24
Variances in pulse rates

• Bradycardia rate lt 60 bpm
• Tachycardia rategt 100 bpm
• Is the rate regular?
• What is the quality?
• Bounding?
• Thready?
• Dysrhythmia (arrhythmia)
• Pulse deficit
• Difference between radial and apical

25
Factors affecting pulse rate

• Exercise
• Body temperature
• Anxiety
• Position
• Age
• Gender

• Emotions
• Medications
• Hemorrhage
• Pulmonary condition
• Stress
• Fluid Volume

26
Color Change Circulation problem

• Normal pink warm dry
• Cyanosis
• Bluish-grayish discoloration of the skin due to
  excessive carbon dioxide and deficient oxygen in
  the blood

• Pallor
• Paleness of skin when compared with another part
  of the body

27
RespirationThe exchange of oxygen and carbon
dioxide in the body

• Chemical
• Exchange of oxygen and carbon dioxide
• Diffusion
• Movement of oxygen and CO2 between alveoli and
  RBC
• Perfusion
• Distribution of blood through the pulmonary
  capillaries

• Mechanical
• Pulmonary ventilation breathing
• Ventilation Active movement of air in and out
  of the respiratory system
• Conduction
• Movement through the airways of the lung

28
Mechanics of ventilation

• Inspiration
• Drawing air into the lung
• Involves the ribs, diaphragm
• Creates negative pressure-allows air into lung
• Expiration
• Relaxation of the thoracic muscles and diaphragm
  causing air to be expelled

29
Variations in assessment of respirations

• Rate regulated by blood levels of O2, CO2 and ph
• Chemial receptors detect changes and signal CNS
  (medulla)
• Normal 12-20 breaths per minute
• Apnea no breathing
• Bradypnea abnormally slow
• Tachypnea abnormally fast
• Observe for one full minute

30
Variations in assessment findings

• Depth
• Normal diaphragm moves ½ inch
• Describe as deep or shallow
• Rhythm
• Assessment of the pattern
• Abnormal
• Cheyne stokes
• Kussmal's
• Effort
• Work of breathing
• labored or unlabored
• Observe for retractions, nasal flaring and
  restlessness

31
Variations in breath sounds

• Wheeze
• High pitched continuous musical sound heard on
  expiration
• Rhonchi
• Low pitched continuous sounds caused by
  secretions in large airways
• Crackles
• Discontinuous sounds heard on inspiration high
  pitched popping or low pitched bubbling

32
Variations in breath sounds

• Stridor
• Piercing, high pitched sound heard during
  inspiration
• Stertor
• Labored breathing that produces a snoring sound
• Both may indicate obstruction

33

• Hyperventilation
• Rapid and deep breathing resulting in loss of CO2
  (hypocapnea) light headed and tingly

• Hypoventilation
• Rate and depth decreased CO2 is retained

34
Tools to measure oxygenation

• ABG
• directly measures the partial pressures of
  oxygen, carbon dioxide and blood ph
• normal paCO2 80-100)
• Pulse oximetry
• non invasive method for monitoring respiratory
  status measures O2 saturation
• normal gt95-100

35
Blood pressure

• Force exerted by blood against arterial walls
• Work of the heart reflected in periphery via BP
• Measured in millimeters of mercury (mm Hg)
• Recorded as systolic over diastolic

36
BP regulation

• The body constantly adjusts arterial pressure to
  supply blood to body tissues
• Influenced by three factors
• Cardiac function
• Peripheral vascular resistance
• Blood volume
• Normal 5000 ml
• Volume increasesBP increases
• Volume decreases BP decreases
• Viscosity reaction same as volume

37
Potential Misreads

• Palpation
• Used when BP is too weak to hear
• Errors
• Wrong size cuff, deflating too rapidly, incorrect
  placement
• Thigh
• Measures 30-40 mm HG less than normal

38
Factors affecting BP

• Age
• Stress
• Gender
• Race
• Exercise

• Diurnal
• Medications
• Nutrition
• Obesity
• Disease

39
Variations in BP

• Values
• Normal lt 120/80 mm Hg
• Hypotension SBPlt 100mm HG
• Pre hypertension gt 120/80 mm Hg
• Hypertension 140/90 Stage 1 160/100 Stage 2
• Persistant increase in BP
• Damage to vessels loss of elasticity decrease
  in blood flow to vital organs

40
Korotkoffs sounds

• Phase 1
• As you deflate the cuff occurs during systole
• Phase 2
• Further deflation of the cuff soft swishing
  sound
• Phase 3
• Begins midway through sharp tapping sound
• Phase 4
• Similar to 3rd sound but fading
• Phase 5
• Silence, corresponding with diastole
• Auscultatory Gap occurs in HTN pts
• The sound disappears at high cuff pressure
• And reappears at low levels

41
Measurement of BP

• Indirect
• Most common, accurate estimate
• Direct
• In patient setting only
• Catheter is threaded into an artery under sterile
  conditions
• Attached to tubing that is connected to
  monitoring system
• Displayed as waveform on monitoring screen

42
Other BP issues

• Orthostatic or postural hypotension
• Sudden drop in BP on moving from lying to sitting
  or standing position
• Primary or essential hypertension
• Diagnosed when no known cause for increase
• Accounts for at least 90 of all cases of
  hypertension

43

• Nurses can delegate the activity of VS, but are
  responsible for interpretation, trending and
  decisions based on the findings

44
Pain

• 5th vital sign
• It is what the client says it is
• Nurse must know
• how to assess for it
• Establish acceptable comfort levels
• Follow up within appropriate time frame after
  intervention

45
Data to be collected

• Location (place and position)
• Intensity
• 1-10
• Strength and severity
• What is your pain at present? What makes it
  worse? What is the best that it gets?
• Describe
• Aching, stabbing, tender, tiring, numb,..
• Duration
• When did it start? Is is always there?
• Aggrevate/alleviate
• What makes it better/worse?

46
How does the pain affect

• Energy
• Appetite
• Sleep
• Activity
• Mood
• Relationships
• Memory
• concentration

• Nurse checks for
• VS
• Knowledge of pain
• Med history
• Side effects of meds
• Use of non pharmacological therapies

47
ANY QUESTIONS????