Vital Signs

1
Vital Signs

• Lee Ann Mitchell, MSN
• August 28,2007

2
Objectives

• Discuss the physiologic processes that affect
  temperature, pulse, respirations, and blood
  pressure.
• Identify alterations in vital signs.
• Educate patients/family members about assessing
  vital signs at home.

3
Vital Signs

• A persons temperature, pulse, respirations, and
  blood pressure comprise vital signs.
• The nurse is responsible for reporting accurate
  vital sign data and any abnormal readings even if
  the task is delegated.
• Frequency of vital sign assessment is dependent
  upon institutional policy and the patients
  condition.

4
Temperature

• The heat of the body measured in degrees.
• Normal core body temperature ranges from 36.0 C
  to 37.5 C (97.0 F to 99.5 F).
• Maintained by the thermoregulatory center in the
  hypothalamus
• Bodys primary heat source is metabolism heat
  is a byproduct of cellular activity
• Body heat is lost primarily via the skin.

5
Temperature

• Factors affecting body temperature
• Circadian rhythms
• Age
• Gender
• Environmental temperature
• Hypothermia body temperature below 36.0 C
• Hyperthermia body temperature above37.5 C, not
  related to fever

6
Temperature

• A patient with a normal body temperature is
  considered afebrile.
• An increase in body temperature due to illness or
  trauma is called a fever.
• A patient with a fever is considered febrile.
• Onset may be sudden or gradual
• Symptoms include shivering, headache, thirst,
  flushing of the skin, and increased pulse rate.

7
Temperature

• Nursing interventions to reduce fever
• Administration of antipyretics (aspirin or
  acetaminophen)
• Cool sponge baths or shower
• Cool packs
• Cooling blankets
• Removing blankets
• Offer/force fluids if not contraindicated

8
Temperature

• Equipment types of thermometers
• Electronic/digital
• Tympanic membrane
• Glass
• Disposable

9
Temperature

• Assessment sites
• Sublingual
• Surface temperature
• Must be able to close mouth around probe
• Need to wait 15 to 30 minutes after drinking or
  smoking
• Contraindicated?
• Tympanic
• Considered a core temperature
• Easily accessed
• Ear canal must be large enough to accommodate
  probe
• Contraindicated?

10
Temperature

• Assessment site
• Rectal
• Core temperature, most accurate
• Uncomfortable for patients
• Contraindicated?
• Axillary
• Surface temperature
• Site of choice for newborns

11
Pulse

• A throbbing sensation that can be palpated over a
  peripheral artery or auscultated over the apex of
  the heart (the apical pulse).
• Pulse rate is the number of pulsations palpated
  or heard in one minute.
• Normal pulse rate for adolescents and adults is
  60 to 100 beats per minute.
• What are some factors that would affect pulse
  rate?

12
Pulse

• Tachycardia pulse rate of 100 to 180 beats per
  minute, sustained tachycardia will eventually
  lead to decreased cardiac output. Review Box
  24-3, page 566.
• Bradycardia pulse rate below 60 beats per
  minute.
• Can be normal
• May be related to medications
• When should you be concerned about bradycardia?

13
Pulse

• Pulse amplitude refers to the quality of the
  pulse and is indicative of left ventricular
  strength.
• See Table 24-6, page 567
• The rhythm of the pulse is described as regular
  or irregular. An irregular pulse pattern is
  referred to as a dysrhythmia.
• A pulse deficit occurs when the apical pulse and
  peripheral pulses do not match.

14
Pulse

• Assessment sites
• Apical pulse is assessed over the apex of the
  heart using a stethoscope.
• Count for a full 60 seconds.
• Necessary when giving certain medications, such
  as digoxin
• Peripheral pulse can be palpated over several
  arteries.
• See Figure 24-3 on page 569
• When would it be important to palpate a pedal
  pulse?

15
Respirations

• A respiratory cycle involves both inspiration and
  expiration.
• The number of complete cycles per minute comprise
  the respiratory rate.
• Normal rate is 12 to 20 cycles per minute.
• What are some factors that affect respiratory
  rate?
• Depth and rhythm are also assessed
• Depth of respirations varies from shallow to
  deep.
• Normal respirations have a regular rhythm.

16
Respirations

• Tachypnea refers to a rapid respiratory rate,
  usually shallow in depth.
• Caused by increased metabolic demand
• Bradypnea refers to a decrease in respiratory
  rate.
• May have a pathological cause or can be a side
  effect of certain medications
• Apnea refers to periods without respirations.
• Dyspnea refers to difficult or labored
  respirations
• Review Table 24-7, page 572

17
Blood Pressure

• A measurement of the force of the blood against
  the arterial walls.
• Systolic pressure measurement of the force on
  the arterial walls as the left ventricle
  contracts.
• Diastolic pressure measurement of the force on
  the arterial walls as the left ventricle relaxes.
• Pulse pressure the difference between the
  systolic an diastolic pressure.

18
Blood Pressure

• The sounds heard during blood pressure assessment
  are called Korotkoff sounds.
• The first sound (or beat) represents the systolic
  pressure.
• A change in or cessation of the loud, distinct
  sounds represents the diastolic pressure.

19
Blood Pressure

• Peripheral resistance describes the resistance to
  blood flow resulting from the arterioles always
  being partially contracted.
• This allows continuous flow of blood into the
  capillaries.
• The elasticity of the artery walls combined with
  arteriole resistance helps maintain normal blood
  pressure
• Blood pressure is also affected by several
  hormonal and humoral mechanisms as the body
  attempts to maintain homeostasis.

20
Blood Pressure

• Cardiac output has a direct effect on blood
  pressure.
• Cardiac output is equal to the stroke volume
  times the heart rate.
• An increased cardiac output results in increased
  blood pressure.
• Conversely, blood pressure decreases as cardiac
  output decreases.
• Example?

21
Blood Pressure

• A normal blood pressure is less than 120/80 mm
  Hg.
• There is a wide range of normal, therefore
  baseline readings are critical.
• An elevation or fall or 20 to 30 mm Hg is
  significant.
• Hypertension is sustained blood pressure above
  normal.
• Major risk factor for heart disease and stroke
• See Table 24-8, page 575

22
Blood Pressure

• Hypotension below normal blood pressure
• May be normal
• May be pathologic
• When should you be concerned?
• Orthostatic hypotension or postural hypotension
  occurs when blood pressure drops during rising to
  a sitting or standing position.

23
Blood Pressure

• Manual blood pressure is assessed with a
  stethoscope and sphygmomanometer.
• Accurate readings depend on using
  appropriate-size cuffs
• Electronic blood pressure monitors sense
  vibrations in the artery wall to determine blood
  pressure.
• Most common site is the brachial artery.
• When would you choose an alternate site?

24
Patient education

• Teaching vital signs for home care