Vital Signs

1. Vital Signs

2. What are Vital Signs? • Temperature (T) • Pulse (P) • Respiration (R) • Blood pressure (BP) • The VS are an important part of the nursing assessment in any clinical setting, even if they are delegated, because a change in VS might indicate a change in health.

3. How often should vital signs be assessed? • Upon admission to any healthcare agency. • Anytime there is a change in the patient’s condition. • Before and after surgical or invasive diagnostic procedures. • Before and after activity that may increase risk. • Before administering medications that affect cardiovascular or respiratory functioning.

4. Body Temperature Body temperature is the balance between heat _______in the body and heat ____from the body.

5. Physiology of Body Temperature • What regulates our body temperature? • Center receives messages from cold and warm thermal receptors in the body. • Center initiates responses to produce or conserve body heat or increase heat loss.

6. Heat Production • The primary source of heat production is ________________. • What mechanisms increase a patient’s metabolism and increases heat production?

7. Sources of Heat Loss What is the primary site of heat loss? • The skin • Evaporation from sweat • Warm and humidified inspired air • Eliminated urine and feces

8. Mechanisms of Heat Transfer • Radiation • Conduction • Evaporation • Convection What are nursing implications that apply to each?

9. How do each of these Factors Affect Temperature? • Age • Activity / Exercise / Sleep • Hormones • Stress • Environment • Medication • Illness

10. Range of Human Body Temperature Measured Orally

11. Normal Temperatures • Healthy Adults Axillary 97.7°F Oral 98.6°F + or – 10 Rectal/Tympanic 99.6°F • Infants – 12 years old - see Pg. 517 • Older adult -

12. AGE VARIATIONS IN TEMPERATURE True or False • Infants & Children – a mild increase could signal a serious infection. • Older adults - have a lower baseline, so “fever” range is lower and may be overlooked early in illness.

13. Assessing Body Temperature

14. What are the advantages and disadvantages of using each of these devices in assessing temperature? • Electronic Probe • Tympanic Thermometer • Temporal artery scanner • Chemical in glass

15. What are the Sites / Methods used to assess temperature and related Nursing Care?Advantages vs. Disadvantages? • Oral • Rectal • Axillary • Tympanic Temporal

16. Critical Thinking Question • The nurse is to take an axillary temperature. Which of the following activities are appropriate when preparing to take an axillary temperature? a. Dry the axilla before inserting the thermometer b. Lubricate the thermometer before insertion c. Remove the patients gown or shirt d. Abduct the arm

17. Types of thermometers used to assess body temperature: • Electronic thermometer – for oraland axillary • Tympanic membrane thermometer • Disposable paper thermometer for taking forehead temperature; the dots change color to indicate temperature. • Temporal artery thermometer

18. Sites & Safety for Assessing Temperature Oral Temp.- Insert thermometer under the tongue in the posterior sublingual pocket. Safety Alert • Wait 15 min. if patient has been smoking, eating hot/cold food or fluids, or chewing gum. Rectal Temp. - Insert thermometer into the rectum. Safety Alert • Not used in newborns, children with diarrhea, rectal disease or rectal surgery. • Can cause HR to decrease by stimulating the vagus nerve so usually not used for patients with heart disease or surgery.

19. Sites for Assessing Temperature Tympanic Temp.- Place into patient's ear canal with pinna pulled up and back (ear temp.). • The tympanic temp. is the core temp. which is the operating temp. of deep structures i.e. liver. • Children like this because it only takes a few seconds. Safety Alert • Not used with patients who have drainage from the ear. Ear wax does not effect temp. Axillary Temp. - Place thermometer in center of axilla. Safety Alert Used with newborns to avoid perforating the wall of the rectum.

20. Pulse

21. What is a Pulse? Arterial palpation of the heartbeat by trained fingertips. • Can be palpated in any place that allows an artery to be compressed against a bone, such as at the neck (carotid artery), the wrist (radial artery), behind the knee (popliteal artery), on the inside of the elbow (brachial artery), and near the ankle joint (posterior tibial artery). • Pulse (or the count of arterial pulse per minute) is equivalent to measuring the heart rate (HR). • The Apical Heart Rate can be measured by listening to the heart beat directly (auscultation), using a stethoscope and counting it for a minute.

22. Pulse Physiology • Pulse rate = number of contractions over a peripheral artery in 1 minute. • Regulated by the autonomic nervous system through cardiac sinoatrial (SA) node. • Parasympathetic stimulation—decreases heart rate. • Sympathetic stimulation—increases heart rate. • Normal Ranges

23. Factors that Affect Pulse (P) & Heart Rate (HR)

24. Equipment Doppler Ultrasound: • Used to hear pulses that are difficult to palpate or auscultate.

25. Locations of Peripheral Arterial Pulses • These arteries are located near the surface of the body. • The pulse can be detected in any of these sites by light palpation.

26. Sites for Assessing Peripheral Arterial Pulses Carotid artery - in the neck. • Used –assess this pulse in emergencies. Safety Alert • Lightly palpate on one side at a time to prevent a decrease in O2 to the brain which could cause fainting. Brachial– inner aspect of the elbow. • Used – most often with infants. • Radial– inner aspect of wrist on thumb side. • Used - most often with children & adults. • Dorsalis pedis–upper surface of the foot. • Used – to assess circulation of the legs & feet.

27. Apical Pulse Location and Rate Where should the nurse place the stethoscope when assessing an apical pulse? • Between the 5th & 6th ribs (called the “intercostal space”), and midclavicular line (about 3 inches to the left of the mid-sternal line) and slightly below the nipple line How long should the nurse count the heart beat when auscultating the apical pulse? • 15 seconds x 4 • 30 seconds x 2 • 60 seconds x 1 Landmarks

28. Question Which one of the following pulse sites is located on the inside of the elbow? A. Temporal B. Radial C. Femoral D. Brachial The temporal site is located ? The radial site is located? The femoral site is located?

29. Blood Pressure

30. Factors that Affect Blood Pressure

31. Equipment Stethoscope • The diaphragm is more useful for hearing high-frequency sounds. (Blood pressure and lung sounds) • The bell is more useful for hearing low-frequency sounds. • (Intestinal sounds and heart murmurs) Manual Digital

32. BP Equipment Sphygmomanometer “sfig-mō-ma-NAW-me-ter” • The width of the blood pressure cuff should cover about 40% of the circumference of the upper arm. • The length of the bladder should cover 2/3 of the circumference of the upper arm. Safety Alert • Using a blood pressure cuff that's too large or too small can give you inaccurate BP readings (too large = low, too small = high).

33. Assessing Blood Pressure • First sound is the systolic pressure • Change or cessation of sounds occurs is the diastolic pressure • Written as systolic/diastolic: 120/80 • Read as: “120 over 80” • Let’s listen and practice http://vimeo.com/8068713

34. BP Equipment • Three cuff sizes: • Small cuff for a child or a small or frail adult. • Normal-sized cuff for teens or adults. • Large cuff, called a leg cuff, used on a leg or an obese adult.

35. Blood Pressure Levels What is normal BP level in an adult as defined by American Heart Association? Any B/P over 120/80 is considered abnormal.

36. Identify Potential Causes of a BP Error L = Falsely low assessments H = Falsely high assessments • ___Reflating the bladder during auscultation • ___Noise in the environment • ___Applying too narrow a cuff • ___Releasing the valve too rapidly • ___Applying too wide a cuff • ___Failing to pump the cuff 30 mmHg above the disappearance of the pulse • ___Releasing the valve too slowly H L H L L L H

37. Respirations

38. Rate and Depth of Breathing • Unconsciously, breathing is controlled by centers in the brainstem. • The rate & depth of breathing changes in response to tissue demands. • The rate & depth are controlled by respiratory centers in the medulla & the pons which are activated by impulses from chemoreceptors. • Increase in carbon dioxide is the most powerful respiratory stimulant.

39. Factors that Affect RR and Depth

40. Alternative Devices for Assessing Vital Signs • Electronic blood pressure machines The patient has an IV in her right arm and her right side is closest as you enter the room. What would the nurse do to assess a B/P?

41. Normal VS Ranges Place an X on the VS value of an adult that suggests a need for treatment &/or notification of the HCP. _____ Temp 101F _____ HR 98 _____ BP 96/54 _____ RR 10 _____ Temp 96.4F _____ HR 56 _____ BP 146/96 _____ RR 24 __X___ Temp 101 F - Temp 101 or greater call HCP _____ HR 98 _____ BP 96/54 __X___ RR 10 – rate less than 12 __X___ Temp 96.4 F - less than 97F __X___ HR 56 - less than 60 __X___ BP 146/96 - diastolic greater than 90 __X___ RR 24 - rate greater than 20