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Vital Signs unit 2
Fundamentals (NUR155)
Galen College of Nursing
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Vital Signs
- Are a basic but very important component of the physiologic assessment of the patient.
- They are used to monitor the functioning of body systems.
- Assessment of Vital Signs allows the nurse to detect changes in the health status of the patient, identify early warning signs of life-threatening health conditions and evaluate the effectiveness of interventions.
- Vital Signs consist of body temperature (T), pulse (P), respirations (R), and blood pressure (BP).
o Terminology Temperature refers to the measurable heat of the human body. Pulse is the detection of rhythmic expansion of an artery that occurs with the pumping action of the beating heart; thus, the pulse rate is measured as the number of heartbeats per minute with pulse intensity and pattern often specified as well. Respiration is the act of breathing, so respirations are assessed for frequency or breaths per minute; abnormal quality and pattern of breathing also should be noted. Blood pressure is the measurable pressure of blood within the systemic arteries. The Joint Commission has required that every patient be assessed and treated for pain, although some hospitals refer to pain as a vital sign TJC does not endorse pain as a vital sign. Pulse Oximetry, which is measuring the amount of oxygen available to tissues typically included with reported vital signs. The pulse oximeter reading is the percentage of hemoglobin that combines with oxygen (SpO 2 ). o Vital Sign Measurement Vital Sign assessment is typically done every 4-8 hours for stable patients, every 15- minutes for post-operative patients, and every 5 minutes or continuously for critical or unstable patients. Vital Signs are interpreted based on current health status and previously established normal values for the patient. Normal values vary with patient age and normal ranges for each vital sign component have been established for various age groups. Accuracy of vital sign values obtained depends on the precision of measurement. Careless measurement can result in inappropriate or missed interventions and care decisions. Both normal and abnormal vital sign results are appropriately documented and communicated to all members of the healthcare team. o Situations That Require Vital Sign Assessment On admission to a health care agency, to establish a baseline. As part of a physical assessment During an inpatient stay, as routine monitoring With any change in health status, especially complaints of chest pain and shortness of breath or feeling hot, faint, or dizzy. Before and after surgery or invasive procedures to establish baselines and monitor effects
Before and after administration of medications that affect cardiac, respiratory, or thermal regulation systems. Before and after interventions such as ambulation In ongoing care, to detect improvement in patient condition. Before discharge or transfer from a unit, validate patient readiness. o Temperature Healthy people can maintain body temperature within the normal range even when exposed to temperature extremes for short periods. A person’s ability to manage body temperature depends on certain behavioral abilities and thought processes such as adequate mobility to leave an area of extreme heat or cold. Normal Parameters of Body Temperature Measured in degrees, represented by the symbol. The core body temperature remains relatively constant within the range of 97. and 99. The average oral temperature is 98. A person who maintains this normal body temperature is known as afebrile. Axillary temperatures may be approximately 1 degree less than oral reading which in turn are approximately 1 degree less than rectal. o Physiology of Heat Production and Loss Humans are warm-blooded, which means that they maintain a consistent internal temperature independent of the outside environment. Body temperature reflects the difference between the amount of heat lost to the external environment. The hypothalamus in the brain acts as the body’s thermostat. o Heat Production
Heat produced in the body is a by-product of metabolism, the chemical process responsible for generating energy for cellular functions. Food is the primary fuel source for metabolism. Exercise, increased release of epinephrine and norepinephrine, and increased production of thyroid hormones all can increase heat production. o Heat Loss Heat production and loss occur simultaneously. The skin regulates temperature through the insulation of the body with subcutaneous tissue and fat, and in conjunction with the circulatory system, it is the primary source of heat loss. Core Temperature is the temperature of deep tissues. Radiation: the transfer of heat as waves or particles of energy. No actual contact occurs between the object transmitting the heat and the object absorbing it. Conduction: the transfer of and reaction to heat through direct contact. The heat from the body is lost when it meets a cooler object such as an ice pack or cool cloth. Convection: This is the transfer of heat by movement or circulation of warm matter such as air or water.
Environment: Extended exposure to extreme heat or extreme cold can affect core body temperature. Heat and cold applications used as a treatment for pain, injuries, or swelling can affect body temperature. Smoking: Smoking causes vasoconstriction, which can cause a drop in the temperature of the skin and mucous membranes. o Assessment of Temperature The five sites commonly used to measure temperature are the mouth, ear, rectum, forehead (temporal artery), and axilla. Oral Temperature The most common site for measuring temperature is under the tongue. The patient must be able to close the mouth around the thermometer. The advantages of this site are that is ready, accessible, and comfortable for the patient. Eating, drinking, smoking, and the use of oxygen by cannula or mask can affect measurements obtained at the oral site. It is not a preferred site for infants, young children, unconscious patients, post-oral surgery patients, or people with seizure disorders. Rectal Temperature Rectal temperature readings are very accurate. The rectum, however, is a site that patients do not prefer. The rectal route is contraindicated in newborns, patients who are neutropenic, and patients with a spinal cord injury. It should not be used with a patient with diarrhea or rectal disease, post-rectal surgery, or quadriplegic patients. Ear (Tympanic) Temperature The tympanic membrane temperature is a core temperature. The thermometer does not touch the tympanic membrane. It was very easily accessed for both adults and children. The use of the tympanic route is appropriate for patients who are confused or unconscious. Forehead (Temporal Artery) Temperature The temporal artery thermometer is a small handheld unit that is scanned across the forehead to measure heat emitted from the temporal artery. This measurement is well tolerated by infants and young children. It is not affected by mild perspiration when performed correctly. Axillary Temperature The axillary may be used when the oral and rectal sites are not accessible. The site is frequently used for newborn healthy babies. o Factors Affecting Body Temperature o Pulse The pulse is palpable, bounding blood flow created by the contraction of the left ventricle of the heart. It can be assessed at various points of the body, and it is a direct indicator of circulatory status.
The apical pulse is a central pulse that can be auscultated over the apex of the heart at the point of maximal impulse (Mitral, 5th intercostal space, midclavicular line) Peripheral Pulses are those that can be palpated over arteries located away from the heart, at the foot or wrist. o Factors Affecting Pulse Rate Age: As age increases from infancy to adulthood, the pulse rate decreases. Gender: After puberty, the average male pulse is lower than that of the average female. Fever: Pulse increases with fever because of the increased metabolic rate and peripheral vasodilation that occurs. Medications: Various medications may either increase or decrease the pulse rate. Hypovolemia: Loss of blood normally increases the pulse rate from sympathetic nervous system stimulation. Hypoxia and hypoxemia: When oxygen levels decrease, cardiac output increases to attempt to compensate, resulting in an increased pulse rate. Stress: Sympathetic nervous system stimulation from stress (e., fear, anxiety, and the perception of pain) increases the heart rate. Pathology: Heart Conditions or illnesses that impair oxygenation can alter the pulse rate as cardiac output attempts to compensate for low oxygen levels. Head injuries can cause a drop in pulse to compensate for increased intracranial pressure. Electrolyte imbalance: Changes in potassium and calcium affect pulse rate and rhythm. o Sites for Assessing Pulse Pulse Sites
- Temporal: Where the temporal artery passes over the temporal bone of the head, above and lateral to the eye; used when the radial pulse is not accessible
- Carotid: At the side of the neck where the carotid artery runs between the trachea and the sternocleidomastoid muscle; used in cases of cardiac arrest and for determining circulation to the brain
- Apical or Point of Maximal Impulse (PMI): Apical, at the apex of the heart, and PMI, at the fifth intercostal space, midclavicular line; used for infants and children up to 3 years of age, placed in the supine position, to determine discrepancies with the radial pulse, and used in adults in conjunction with some diseases and medications and during a head-to-toe assessment
- Brachial: At the inner aspect of the arm; used to assess pulse in pediatric emergencies and to measure blood pressure
- Radial: On the thumb side of the inner aspect of the wrist where the radial the artery runs along the radial bone
- Femoral: Where the femoral artery passes alongside the inguinal ligament; used in cases of cardiac arrest and for assessing circulation to the leg
- Popliteal: Behind the knee where the popliteal artery passes; used to determine circulation to the lower leg
- Posterior tibial: Medial surface of the ankle; used to determine circulation to the foot
o Physiology and Regulation of Breathing and Ventilation. Chemoreceptors located in the aortic arch and carotid arteries are especially sensitive to low oxygen levels in the blood, aka Hypoxemia. Receptors in the medulla are especially sensitive to high levels of carbon dioxide aka Hypercapnia. o Factors Affecting Respiration Age: Respiratory rate decreases with age through late adolescence when it stabilizes. Exercise: Respiratory rate and depth increase with exercise. Illness processes: cardiovascular disease and hematologic disorders such as anemia causes an increased respiratory rate. Sickle cell disease reduces the ability of hemoglobin to carry oxygen, resulting in increased respiratory rate and depth. respiratory diseases can be manifested by difficulty breathing, use of accessory muscles, increased rate, and shallower depth. Smoking alters airways, resulting in an increased rate. Acid-base balance: Acidosis results in increased rate and depth of respirations in an attempt to rid the body of excess carbon dioxide. Alkalosis results in decreased respiratory rate as the body tries to retain carbon dioxide. Medications: Some medications such as narcotics and general anesthesia, slow respirations. Alternatively, drugs such as amphetamines and cocaine increase respirations. Bronchodilators slow the respiratory rate by dilating the airways. Pain: Acute pain increases respiratory rate while decreasing respiratory depth. Emotions: Fear or anxiety can cause increased respiratory rate and decreased depth. o Assessment of Respirations
Assessment always includes measurement of the breathing rate, depth, and rhythm. It routinely includes the measurement of levels of oxygen saturation (amount of oxygen in the arterial blood) by pulse oximetry. o Respiratory Status The assessment of respirations begins with observing the chest and abdominal movements for effort and symmetry. Rate is assessed by counting the number of breaths taken per minute. One inspiration and one expiration are counted as one breath. o Respiratory Rate Normal respiration with a normal rate and depth for the patient’s age is termed Eupnea. Tachypnea is an increase in respiratory rate to more than 24BPM in the adult, and any condition that causes an increased need for oxygen and increased metabolic rate (high altitude or fever) or an increase in carbon dioxide levels (chronic lung disease) is called Tachypnea. Bradypnea is a decrease in respiratory rate to less than 10 bpm in an adult and can be caused by medications, especially opioids, metabolic disorders, or brain injury. o Depth of Respirations The depth of respirations normally varies from shallow to deep. Periodic sighs are deep inhalations that fill the lungs with more air than during normal inspiration.
Hypoventilation is characterized by shallow respirations, it is associated with drug overdose and obesity as well as COPD, and cervical spine injury. Hyperventilation is exhibited by deep, rapid respirations and is caused by stress or anxiety. o Quality of Respirations. Apnea is an absence of breathing, and brain damage occurs after 4 to 6 minutes of apnea. Dyspnea is the difficult labored breathing, usually with a rapid shallow pattern that may be painful. Difficulty breathing experienced in positions other than sitting or standing is termed orthopnea. o Oxygen Saturation Measurement of respiratory rate is not a measurement of how much oxygen enters the bloodstream. The SpO2 reflects the percentage of hemoglobin that combines with oxygen which is usually 95% to 100%. Factors that affect SpO2 include lung disease, decreased circulation, and hypotension. Cyanosis is a bluish discoloration of the skin and mucous membranes resulting from decreased oxygen levels in arterial blood. o Arterial Blood Gasses
Measurement of arterial blood gases (ABG’s) is a way of assessing the respiratory component of acid-base balance and adequacy of oxygenation. ABG values include the CO2 levels and pH. They are used to determine the need for and response to treatment. Arterial Blood is used for assessment because values for venous blood gases are highly variable depending on the metabolic demands of the tissues that empty into the vein where the sample is drawn. ABG studies are used to establish baseline values, identify respiratory disorders, and evaluate the effectiveness of interventions. ABG samples are also drawn to monitor patients who are critically ill. o Blood Pressure BP can adapt to various stimuli and remain within normal range. An increase or decrease of 20 to 30 mmHg in a person’s blood pressure is considered a significant change. A sustained change in blood pressure is considered abnormal. o Physiology of Blood Pressure Blood pressure is the force of the blood against arterial walls. The left ventricle pushes blood through the aortic valve and into the aorta. The pressure rises at the ventricle contracts and falls as the heart relaxes creating a pressure wave through the arterial system. The peak of the pressure wave is the systolic pressure and the lowest pressure on the arterial walls which occurs when the heart rests is the diastolic pressure. Blood pressure is measured in millimeters of mercury (mmHg) and recorded as a fraction. The numerator of the fraction is systolic and the denominator is diastolic. Pulse pressure is the difference between diastolic and systolic.
Blood pressure can be measured manually using a stethoscope and sphygmomanometer, electronically through intermittent or continuous monitoring, or through the placement of arterial catheter. o Sites for Assessing Blood Pressure Brachial Artery is the standard measurement. However, the patient should receive their blood pressure taken at a different spot if they are an arteriovenous fistula or shunt, when the arm, shoulder, or hand is diseased, if a cast or bulky dressing is in place or when intravenous fluids are being infused. Blood pressure should not be taken on the side of the body where axillary nodes were dissected, or a mastectomy was performed. o Arterial Lines An arterial line is an indwelling catheter inserted into an artery by a physician or an APRN to monitor blood pressure. This invasive procedure is used for patients with unstable blood pressure necessitating frequent monitoring. It may be used for patients who are dangerously hypotensive or hypertensive or who are receiving blood pressure medications, requiring titration, or regulating and monitoring. o Korotkoff Sounds
The sounds to which the nurse listens when assessing pressure are called Korotkoff Sounds. An auscultatory gap may occur in the latter of Phase I and during Phase II. This is the absence of Korotkoff sounds noted in some patients after the initial systolic pressure. Normally blood pressure is recorded as a two-number fraction, however, the American Heart Association recommends that when abrupt change followed by the cessation of sounds occurs all three numbers should be recorded such as 122/86/78. The middle number would be the Korotkoff phase Iv sound. On some occasions, sounds may be heard all the way to zero on the cuff, this measurement would be recorded as 122/78/0. Each facility will have a procedure on how to record blood pressure, this procedure should be followed for consistency in measurements.
Vital Signs unit 2
Course: Fundamentals (NUR155)
University: Galen College of Nursing
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