Chapter 4 - VITAL SIGNS for Nursing 101

Discuss the importance of accurately assessessing vital signs.

1) They indicate basic body functioning 2) It is appropriate to begin physical assessment by obtaining these data 3) Provide basis for problem solving 4) Enables identification of nursing diagnoses to implement planned interventions and to evaluate success when vital signs have returned to normal values.

Identify guidelines for vital signs measurement

1) Measure vital signs correctly 2) Understand and interpret the values 3) Communicate findings appropriately 4) Begin interventions as needed

Accurately assess Oral temperature assessment

- most accessible site; comfortable for patient; does not need any position changes - do not use for patients who could be injured by thermometer, who are unable to hold thermometer properly, or who might bite down on thermometer. - do not use for infants or small children - do not use for disoriented or unconscious patients; patient who just had oral surgery; patients with trauma to face or mouth - do not use in patients who breathe only with mouth open - do not use in patients with history of convulsions or patients experiencing a chill

Accurately assess Rectal temperature assessment

- argued to be more reliable when oral temperature cannot be obtained - use sensitivity because it is embarrassing - do not use in patients after rectal surgery ; patients who have a rectal disorder such as tumors or hemorrhoids; or patients who cannot be positioned for proper thermometer placement such as those in traction - there is risk of body fluid exposure, and lubrication is required

Accurately assess Axillary temperature assessment

- safe method because it is noninvasive - least accurate

Accurately assess Tympanic Temperature Assessment

- noninvasive, accurate, safe - provides core reading; lessens need to handle newborns, which aids in preventing heat loss - excessive cerumen has the possibility to interfere with accurate reading; - continuous measurement of temperature is not possible - new disposable probe cover necessary for each patient.

Describe the procedure for determining the respiratory rate

1) Prepare hand hygiene, introduce self to patient, identify the patient (takes away patient anxiety) 2) Explain procedure (seeks cooperation and assistance from patient 3) Assemble all necessary supplies 4) Provide privacy (decreases patient's anxiety) 5) If patient has been active, wait for 5 to 10 minutes 6) Be sure patient is in a comfortable position, head of bed elevated to 45 to 60 degrees. (Discomfort causes rapid breathing. Erect sitting position promotes full ventilation 6) Place fingertip as if to obtain a radial pulse because patients alter respiratory rate when being observed. 7) Observe respiratory rate for 60 seconds (ensures accuracy). One inhalation and one exhalation = one respiration. 8) Provide patient comfort 9) Document results

Normal Vital Sign limits for healthy adults

Heart Rate: 60 - 100 Respiratory Rate: 12-20 Blood Pressure: Systolic 100-120, Diastolic 70-80 100/70 through 120/80 Temperature: Oral and Tympanic: 98.6; Rectal 99.5, Axillary 97.6 Normal Range 97 to 99.6

Factors that affect Vital Sign Readings

1) Age 2) Exercise 3) Hormonal Influences 4) Diurnal (daily) variations 5) Stress 6) Environment 7) Ingestion of hot and cold liquids 8) Smoking 9) Disease 10) Family history (heredity)

Accurately Assess the Height and Weight measurements

1) Height and weight determination is important because it helps assess normal growth and development 2) It aids in proper drug calculation 3) Used to assess effectiveness of drug therapy 4) Never accept stated height and weight 5) 1 Liter of fluid is the same as 2.2 lbs and is the same as 1 kg. 6) Weigh the patient at the same time of day, on the same scale, and in the same type or amount of clothing to allow an objective comparison of subsequent weights. An ideal time to weigh patients is at 6 am, after voiding and before breakfast is served.

Discuss the optimal frequency of vital sign measurements

1) During admission and discharge to a health care facility 2) On a routine schedule 3) Before and after surgical procedures 4) Before and after invasive diagnostic procedures 5) Before and after administration of certain medications 6) When a patient reports non-specific symptoms 7) During a home health visit

List the various sites of pulse measurement

1) Brachial pulse 2) Femoral pulse 3) Popliteal pulse 4) Radial pulse 5) Ulnar pulse 6) Dorsalis Pedis pulse 7) Posterior Tibial pulse

Accurately assess an apical pulse

1) Have the person sit in a chair or lie down. 2) Find the first rib on the left side of the chest. Count down to the fifth rib. Slide your finger into the space between the fifth and sixth rib. 3) Imagine a line from the left nipple straight down the chest. Slide the finger that is in the space between the fifth and sixth ribs on the left side of the chest until it intersects the imaginary vertical line and remains in the space between the ribs. 4) Use the free hand to put the tips of the stethoscope ear pieces in your ears. Then place the diaphragm of the stethoscope over the space marked with the other hand on the person's chest. 5) Using the watch with a second hand, count the beats heard for 60 seconds. Listen for missed beats, loudness, strength or extra sounds.

Accurately assess a radial pulse

The radial artery is found close to the inside part of your wrist near your thumb. You will need a watch with a second hand to count your pulse. The following steps may help you take your radial pulse. 1) Bend your elbow with your arm at your side. The palm of your hand should be up. 2) Using your middle (long) and index (pointer) fingers, gently feel for the radial artery inside your wrist. You will feel the radial pulse beating when you find it. Do not use your thumb to take the pulse because it has a pulse of its own. 3) Count your radial pulse for a full minute (60 seconds). Notice if your pulse has a strong or weak beat. 4) Write down your pulse rate, the date, time, and what wrist (right or left) was used to take the pulse. Also write down anything you notice about your pulse, such as it being weak, strong, or missing beats. 5) The radial artery is an easy artery to use when checking your heart rate during or after exercise.

Accurately assess a pulse deficit

Pulse deficit is a clinical sign wherein , one is able to find a difference in count between heart beat (Apical beat or Heart sounds ) and peripheral pulse .This occurs even as the heart is contracting , the pulse is not reaching the periphery.This can occur in few clinical situations . 1 . Atrial fibrillation. 2. Very early diastolic ventricular ectopic beats 3. Some patients with Pacemaker. The mechanism is , the ventricular contractions are too weak and unable to open the aortic valve , but at the same time they are good enough to close the mitral valve. To open the aortic valve it has to generate at least 60-80 mm hg pressure , while mitral valve closes even as LV generates 8-14 mm hg .(LV/LA pressure cross over). So intermittently the second heart sound is missed while S1 is retained, producing more heart sounds and less pulse count in the periphery. The S1 is either felt or heard at the apex but the corresponding pulse is missing . Further , this intermittent absence of S2 results in totally irregular S1 /S 2 relation. Apical Pulse - Radial Pulse = Pulse Deficit Done by two people simultaneously looking at the same clock

Describe procedure for determining respiratory rate

1) Observe the person's stomach or chest and watch until you see it rise and fall. 2) Count the number of times the stomach or chest rises for 15 seconds and multiply by 4, or for 30 seconds and multiply by 2. This tells you the respiratory rate per minute. 3)Note the rhythm of the breathing. Is it regular or irregular? 4) Note how much effort it takes for the person to breathe. Is the breath labored, or effortless? 5) Note if the breathing is deep or shallow. 6) Smell the breath for any unusual odor, especially noting a fruity odor or a fecal odor. 7) Record your findings in the following manner: rate, rhythm, effort, depth, noise and odors. For example: "Respiratory rate is 30, irregular, labored, shallow, gurgling and with no odor."

Accurately assess blood pressure

Part I. A digital BP monitor: This is the best way to check your own BP. Read the instructions before you use the digital BP monitor. Each monitor may work in a different way. Sit or lie down with your arm extended. Your arm needs to be at the same level as your heart. The device has a built-in pump that inflates the cuff. The BP is shown on the digital display. The following steps may be helpful to take a BP: a) Put the cuff about 1 inch (2.5 cm) above your elbow. Wrap the cuff snugly around your arm. The BP reading may not be correct if the cuff is too loose. b)Turn on the BP monitor and follow the directions. c) Write down your BP, date, time, and which arm was used to take the BP. Let the air out of the cuff. Turn off the monitor and take off the BP cuff. Part II. BP cuff and stethoscope: This device has an inflatable cuff, bulb, and a gauge that shows the BP. You will also need a stethoscope so you can listen for the person's heartbeat. Have the person sit up or lie down, with his arm stretched out. The arm should be level with the heart. a) Put the cuff about 1 inch (2.5 cm) above the elbow. Wrap the cuff snugly around the arm. The BP reading may not be correct if the cuff is too loose. b) Use your middle and index fingers to gently feel for a pulse in the bend of the elbow. c) Put the end of the stethoscope over the pulse. Listen for the heartbeat with the earpieces in your ears. d) Tighten the screw on the bulb and quickly squeeze and pump the bulb. This will cause the cuff to tighten. Squeeze the bulb until the gauge reads 160. You may have to squeeze until the gauge reads 10 points higher than the last heartbeat you heard. e) Slowly loosen the screw to let air escape from the cuff. Let the gauge fall about 5 points a second. Carefully look at the gauge and listen to the sounds. Remember the number on the gauge where you first heard the beating begin. This is the systolic, or top number. f) Continue to listen and read the gauge at the point where the beating stops. This is the diastolic, or bottom number. g) Write down the BP, date, time, and which arm was used to take the BP. Let the air out of the cuff and remove it.

Discuss methods by which the nurse can ensure accurate measurement of vital signs

1) Have the right equipment 2) Assess the patient before measurement of vital signs to verify if the moment to do so is the right time 3) Explain procedure to patient to avoid anxiety 4) Observe standard procedures for hygiene and infection control 5) Observe the proper process for each assessment of vital signs 6) Document accurately and immediately

Identify the rationale for each step of the vital signs procedure

For Temperature: 1) Physical signs and symptoms may indicate abnormal temperature. Nurse can assess nature of variations 2) Smoking or oral intake of food can cause false temperature readings 3) Patients are curious about results and should be encouraged to wait for the right time before reading the device. 4) Reduce transmission of organisms For Blood Pressure a) Right size is makes reading accurate b) Right position of the patient avoids false reading c) Proper preparation allows more accurate reading For respiration a) Proper position allows accurate reading b) Proper education promotes accurate reading For Pulse a) Same rationale for assessing respirations

Describe the benefits and the precautions to follow for self-measurement of blood pressure

Self-measurement of blood pressure is useful in selected patients with high blood pressure, can be used to monitor blood pressure closely outside health care facilities, and can determine whether patients have white coat hypertension. The involvement of patients in their own blood pressure management is increased and self measurement may result in more rapid achievement of target blood pressure readings, improvement in adherence to anti-hypertensive therapy and decreased health care utilization. However, some patients may not be suited to monitor their own blood pressure and some may experience an increase in anxiety regarding their health. With careful training and selection of patients, most can accurately assess their blood pressure. Self-measured readings are generally lower than readings in a physician's clinic (or office) and this must be accounted for in assessing response to therapy and usual levels of blood pressure. Self-measured readings are a valuable supplement to clinic readings in many patients.

Accurately record and report vital signs measurement

1) Vital Signs need to be recorded immediately and frequently; as objective and as accurate as possible without subjective interpretations or implied diagnosis. 2) Documentation should include site, time, and findings. 3) When abnormal findings are obtained, any assessments should be included. 4) Also document all the results of the times that vital signs were measured. That is, if blood pressure is done twice, it should be recorded twice.

Apical Pulse (p. 73)

Represents the actual beating of the heart. Use the apical pulse when taking the pulse rate of an infant. When you auscultate the apical rate, the "lubb-dubb" you hear represents one cardiac cycle or heartbeat

Auscultate (p. 70)

You will AUSCULTATE (listen for sounds within the body to evaluate the condition of heart, lungs, pleura, intestines, or other organs or to detect fetal heart tones) bowel, lung, and heart sounds using diaphragm.

Blood Pressure (p. 77)

Blood pressure is the pressure exerted by the circulating volume of blood on the arterial walls, the veins, and the chambers of the heart. Blood pressure is measured in millimeters of mercury (mm Hg)

Bradycardia (p. 70)

The condition of the heart and the patient's age, sex, emotional state, size, temperature, and amount of physical activity can influence the pulse rate. If the pulse rate is slower than 60 beats per minute, the person has BRADYCARDIA. One cause of Bradycardia is unrelieved severe pain; pain stimulates the parasympathetic nervous system, which slows the heart rate. Some drugs such as beta blockers, lower the heart rate. Resting in a supine position also has the potential to decrease the heart rate, as will the cardiac condition called HEART BLOCK

Bradypnea (p. 77)

The normal respiratory rate for an adult is between 12 and 20 respirations per minute. A slow respiratory rate, below 10 per minute, is known as BRADYPNEA. Normally, 500 mL of air is inspired with each breath.

Cheyne-Stokes Respiration (p. 77)

Abnormal pattern of respiration characterized by alternating periods of apnea and deep, rapid breathing. The periods of apnea increase as time goes on. Cheyne-Stokes respirations are note in the critically or terminally ill patient.

Diastolic (p. 78)

The lower number of the blood pressure reading, the second pressure, is the DIASTOLIC pressure. It represents the pressure within the artery between beats, that is, between contractions of the atria or the ventricles, when blood enters the relaxed chambers from the systemic circulation and the lungs.

Dyspnea (p. 77)

Breathing with difficulty. It is possible that the patient is laboring to get enough oxygen, with pursed lips, flared nostrils, and clavicular and costal retractions (the visible sinking-in of the soft tissues of the chest between and around the firmer tissues of the cartilaginous and body ribs, as occurs with increased respiratory effort).

Dysrhythmia (p. 71)

If the amount of time between beats varies, there will be an irregular pulse or DYSRHYTHMIA (any disturbance or abnormality in a normal rhythmic pattern, specifically, irrgularity in the normal rhythmic pattern of the heart). In the normal pulse, the amount of time between beats is even.

Febrile (p. 61)

The terms PYREXIA, FEBRILE AND HYPERTHERMIA describe the condition of above normal body temperature. Fever is actually a body defense. Elevated body temperature will destroy invading bacteria. Temperatures exceeding 105 F (40.5 C) also have the potential to damage normal body cells. Fevers are classified as constant, intermittent, or remittent. Constant fevers remain elevated consistently and fluctuate very little. Intermittent fevers rise and fall (e.g. normal or subnormal in the morning and then elevates in the afternoon). Remittent are similar to intermittent except temperatures do not return to normal at all until patient becomes well.

Hypertension (p. 79)

The elevated presure is sustained above 140/90 mm Hg. The diagnosis of hypertension in adults is not made with only one random elevated reading. For this diagnosis, an average of 90 mm Hg or higher of two or more diastolic readings on at least two visits. Primary, or essential hypertension is the most common form. The cause is unknown, but is believed to be related to aging.

Hyperthermia (p. 61)

The terms PYREXIA, FEBRILE AND HYPERTHERMIA describe the condition of above normal body temperature. Fever is actually a body defense. Elevated body temperature will destroy invading bacteria. Temperatures exceeding 105 F (40.5 C) also have the potential to damage normal body cells. Fevers are classified as constant, intermittent, or remittent. Constant fevers remain elevated consistently and fluctuate very little. Intermittent fevers rise and fall (e.g. normal or subnormal in the morning and then elevates in the afternoon). Remitten are similar to intermittent except temperatures do not return to normal at all until patient becomes well.

Hypotension (p. 79)

A blood pressure below normal is HYPOTENSION. It is healthy to have a low blood pressure provided that there are no ill effects, such as vertigo (dizziness) or syncope (fainting). ORTHOSTATIC HYPOTENSION (a drop of 25 mm Hg in systolic pressure and a drop of 10 mm Hg in diastolic pressure) when a person moves from a lying to a sitting or from a sitting to a standing position. The patient frequently feels lightheaded and unstable. Advise patient to rise slowly from lying to sitting to standing, preventing blood volume from sudden shifts.

Hypothermia (p. 62)

When the body temperature is normally low. Death is at risk when body temperature falls below 93.2 F (34 C). Certain conditions such as hypothyroidism produce a subnormal temperature

Korotkoff Sounds (p. 80)

The pulsating sounds heard with a stethoscope at the brachial artery. The sounds go through five phases: 1) Phase 1 - a sharp thump 2) Phase 2 - a blowing or whooshing sound 3) Phase 3 - A softer thump than phase 1 4) Phase 4 - A softer blowing sound that fades 5) Phase 5 - Silence When you hear the first sound, note the point on the sphygmomanometer, and note again when it disappears. The first point is the sytolic pressure, the second is the diastolic pressure

Orthostatic Hypotension (p. 79)

A blood pressure below normal is HYPOTENSION. It is healthy to have a low blood pressure provided that there are no ill effects, such as vertigo (dizziness) or syncope (fainting). ORTHOSTATIC HYPOTENSION (a drop of 25 mm Hg in systolic pressure and a drop of 10 mm Hg in diastolic pressure) when a person moves from a lying to a sitting or from a sitting to a standing position. The patient frequently feels lightheaded and unstable. Advise patient to rise slowly from lying to sitting to standing, preventing blood volume from sudden shifts.

Pulse (p. 70)

A rhythmic beating or vibrating movement. In the body, it signifies the regular, recurrent expansion and contraction of an artery produced by the waves of pressure that are caused by the ejection of blood from the left ventricle of the heart as it contracts. Each pulse beat corresponds to a contraction of the heart. The adult pulse rate is normally between 60 and 100 beats per minute, with the approximate average being 80.

Pulse Deficit (p. 73)

The difference between radial and apical pulse. To confirm a pulse deficit, one nurse listens to the apical rate and a second nurse palpates the radial pulse at the same time, using the same watch for 1 full minute. There is a deficit when the radial rate is less than the apical rate. A pulse deficit signifies that the pumping action of the heart is faulty, often seen in Atrial fibrillation.

Respiration (p. 75)

The taking in of Oxygen, its utilization in the tissues, and the giving off of carbon dioxide; the act of breathing, i.e., inhaling and exhaling, are both internal and external. Internal respiration refers to the exchange of gas at the tissue level caused by the process of cellular oxidation (any process in which the oxygen content of a compund is increased), as well as the gas exchanged that occurs in the alveoli of the lungs. The breathing movements of the patient that we observe are external respirations: INSPIRATION and EXPIRATION. INSPIRATION is inhaling air with oxygen into the lungs EXPIRATION is exhaling air with carbon dioxide out of the lungs. The rate of respiration is controlled by the medulla oblongata in the brain.

Sphygmomanometer (p. 80)

A device for measuring arterial blood pressure that consists of an inflatable cuff and gauge. The gauge is aneroid (mercury-calibrated manometers) no longer advised.

Stethoscope (p. 69)

Placed against the patient's chest or back, it hears heart and lung sounds. The major parts of the stethoscope are earpieces, binaurals, tubing, and chestpiece. Earpieces should fit snugly and comfortably. Earpieces should follow contour of ear canal, pointing toward your face when the stethoscope is in place. Chestpiece consists of a bell and a diaphragm. Diaphragm is the circular flat-surfaced portion of the chestpiece covered with a thin plastic disk. It transmits high-pitched sounds created by the high velocity movement of air and blood. You will listen for sounds to evaluate conditions of the heart, lungs, pleura, instestines or other organs or to detect fetal heart tones, bowel sounds, lung and heard sounds using the diaphragm. It should make a tight seal against a patient's skin with enough pressure to leave a temporary red ring. The bell is the bowl-shaped chestpiece that transmits low-pitched sounds created by low-velocity movement of blood. You will listen to heart and vascular sounds using the bell. The bell should be applied lightly. Compressing the bell against the skin reduces low pitched sound and creates a "diaphragm of the skin".

Systolic (p. 78)

The systolic pressure is the higher number and represents the ventricles contracting, forcing blood into the aorta and the pulmonary arteries. The occurence of the systole is indicated by the first sound heard on auscultation.

Tachycardia (p. 70)

Pulse is faster than 100 beats per minute. Potential causes: shock, hemorrhage leading to hypovolemia (abnormally low circulating blood volume), exercise, fever, medication (epinephrine) or substance abuse, and acute pain.

Tachypnea (p. 76)

A person with a rapid respiratory rate above the normal range of 12 and 20. Temperature (p. 61) A relative measure of sensible heat or cold of 98.6 F (37 C) that is considered normal. However, variations from 97 F to 99.6 F (36.1 C to 37.5 C) is within normal range. Regulation of body temperature is the job of the hypothalamus, located in the brain, forming the floor and part of the lateral wall of the third ventricle. Hypothalamus helps maintain a balance between heat lost and heat produced by the body. Body temperature falls into CORE temperature and SURFACE temperature.

Tympanic (p. 68)

Tympanic membrane shares its blood supply with the hypothalamus, the body's temperature control center, a good source for obtaining core-temperature readings.

Vital Signs (p. 56)

Vital signs include temperature, pulse, respirations, and blood pressure. They are indications of basic body functioning. They enable the identification of nursing diagnoses to implement planned interventions and to evaluate success when vital signs have returned to acceptable values