ASSESSING VITAL SIGNS

RLE 1a

VITAL SIGNS
Also known as Cardinal Signs
Includes TEMPERATURE, PULSE,

RESPIRATION, and BLOOD PRESSURE A persons physiologic status is reflected by these indicators of body function

Vital Signs are commonly assessed:

1. Screenings at health fairs and clinics 2. In the home 3. Upon admission to a healthcare setting 4. When certain medications are given
Taylors p. 4

Vital Signs are commonly assessed:

5. Before and after diagnostic and surgical procedures 6. Before and after certain nursing interventions 7. In emergency situations

Purposes of assessing Vital Signs

1. To obtain baseline measurement of the patients vital signs 2. To assess patients response to treatment or medication 3. To monitor patients condition after invasive procedures

ASSESSING TEMPERATURE
Taylors p. 8

TEMPERATURE heat of the body measured in degrees Difference between production of heat and loss of heat

PROCESS OF HEAT PRODUCTION DONE THROUGH:

1. Food Metabolism and Activity 2. Increased thyroxin production 3. Chemical thermogenesis

PROCESS OF HEAT LOSS IS DONE THROUGH:

1. Radiation surface to surface by waves 2. Conduction contact between 2 surfaces 3. Convection movt by air currents or fluid 4. Evaporation water to steam 5. Elimination urination, defecation

TYPES of TEMPERATURE
Core Temperature measured thru tympanic and rectal routes Surface Temperature measured thru oral and axillary routes

FACTORS AFFECTING BODY TEMPERATURE

1. 2. 3. 4. 5. 6. 7. Age Sex Exercise Time of day Emotions Environment Others; food, drugs

COMMON SITES FOR ASSESSING BODY TEMPERATURE

1. Oral most frequently used, least disruptive, most convenient CONTRAINDICATIONS:
Infants and very young children Patients with oral surgery Unconscious or irrational patients Seizure-prone patients Mouth breathers and pts. with oxygen

COMMON SITES FOR ASSESSING BODY TEMPERATURE

2. Rectal most accurate route, but invasive and uncomfortable to patient CONTRAINDICATIONS:
Rectal abnormalities Diarrhea Certain heart conditions Immunosuppressed

COMMON SITES FOR ASSESSING BODY TEMPERATURE

3. Axillary safer than the oral method, non-invasive, least accurate 4. Tympanic accessible, less invasive CONTRAINDICATIONS:
Presence of ear ache Significant ear drainage Scarred tympanic membrane Sleeping with the head turned on one side

ROUTE
ORAL
RECTAL AXILLARY TYMPANIC

SPECIAL CONSIDERATIONS
Done for 3 minutes Upon intake of hot/cold fluids, wait 30 minutes Done for 2-3 minutes Presence of fecal matter could result to a false reading Lubricate tip prior to inserting Done for 10 minutes Within two seconds Up/back for adult Down/back for pedia

ASSESSING TEMPERATURE (axillary route)

Taylors p.14

Unexpected Situations in assessing TEMPERATURE

Temperature higher/lower than expected based on how skin feels (re-assess with new thermometer) Feeling lightheaded or passes out during rectal temp assessment (remove thermometer immediately, assess BP & HR, notify doctor, dont take another rectal temp)
Taylors p. 16

Pyrexia Hyperpyrexia Intermittent fever

Elevated BT BT above 41C

BT alternates regularly between periods o fever, normal or subnormal temperature

Remittent fever
Constant fever Relapsing fever Resolution of Pyrexia by crisis

Fluctuations of several degrees above normal, but not reaching normal between fluctuations
Consistently elevated and fluctuates very little Returns to normal for at least a day then the fever occurs

Elevated BT returns to normal suddenly

ASSESSING PULSE
T a PULSE y A wave of blood being pumped into l the o arterial circulation by the contraction r of the left ventricle
Taylors p. 16

Throbbing sensation palpated over a peripheral artery

ASSESSMENT PARAMETERS / CHARACTERISTICS OF PULSE

1. Rate number of beats per minute
AGE GROUP Newborn Adults Elderly PULSE RANGE 80-180 bpm 60-100 bpm 60-100 bpm

ASSESSMENT PARAMETERS / CHARACTERISTICS OF PULSE

2. Rhythm pattern or regularity of beats and interval between each beat
Term Pulsus regularis Arrhythmia Premature beat
Heart rhythm

Meaning Equal rhythm Irregular rhythm

Beat that occurs between normal beats Time interval between each heartbeat

ASSESSMENT PARAMETERS / CHARACTERISTICS OF PULSE

3. Volume/amplitude amount of blood pumped with each heartbeat Cardiac Output 5-6 Liters of blood is forced out of the left ventricle per minute Pulse Deficit difference between the apical and radial counts taken simultaneously

ASSESSMENT PARAMETERS / CHARACTERISTICS OF PULSE

Amplitude Interpretation
+4
Bounding:felt by exerting only light pressure over artery

+3
+2 +1 0

Normal
weak
Feeble/thready: difficult to feel & easily obliterated by pressure

absent

LOCATION OF PERIPHERAL PULSES

Taylors p. 5

FACTORS AFFECTING PULSE RATE

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Age Sex Exercise Emotions Prolonged heat application Body positions Pain Decreased BP Increased temperature Any conditions resulting to poor oxygenation of blood ex. CHF

ASSESSING A PULSE
Taylors p. 17

ASSESSING RESPIRATION
Respiration
Pulmonary ventilation (breathing) movement of air in and out of the lungs Inspiration (inhalation) act or breathing in Expiration (exhalation) act of breathing out External respiration exchange of O2 and CO2 between alveoli and blood Internal respiration exchange of O2 and CO2 between blood and tissue cells

ASSESSMENT PARAMETERS / CHARACTERISTICS OF RESPIRATION

1. Rate number of breaths per minute
AGE GROUP Newborn RESPIRATORY RANGE 30 60 bpm

Adults

12-20 bpm

ASSESSMENT PARAMETERS / CHARACTERISTICS OF RESPIRATION

2. Rhythm regularity of respiration, inhalation and exhalation are evenly spaced
Regular Irregular Effortless, quiet Abnormal

ASSESSMENT PARAMETERS / CHARACTERISTICS OF RESPIRATION

3. Depth assessed by watching the movement of the chest

2 TYPES OF BREATHING
1. Costal/thoracic breathing involves external intercostal muscles and other accessory muscles
Observed thru upward and outward movement of the chest

2. Diaphragmatic/abdominal breathing involving the contraction and relaxation of diaphragm

Observed by the movement of the abdomen

FACTORS AFFECTING RESPIRATION

1. 2. 3. 4. 5. 6. Exercise Certain infections Age Emotions Cardiac illness stress

TERMINOLOGIES REGARDING RESPIRATION

Eupnea Tachypnea Bradypnea Apnea Hyperpnea Cheyne stokes
Biots
Normal, effortless breathing
RR > 24 bpm RR < 10 bpm Absence of breathing Deeper respiration with normal rate
Resp. becomes faster and deeper then slower

with alternate periods of apnea(20-60sec)

Faster and deeper than normal with abrupt pauses in between each breath

TERMINOLOGIES REGARDING RESPIRATION

Kussmauls
Apneustic Dyspnea Orthopnea Wheezing Stridor

Faster and deeper respi. without pauses in between panting Prolonged grasping followed by extremely short insufficient exhalation difficulty of breathing DOB unless sitting narrowing of airways, causing whistling or sighing sounds high-pitched sounds heard on inspiration

TERMINOLOGIES REGARDING RESPIRATION

Rales sound caused by air passing thru fluid or mucus in the airways usually heard on inhalation sound caused by air passing thru airways narrowed by fluids, edema, muscle spasm usually heard during exhalation

Rhonchi

ASSESSING RESPIRATION
Taylors p. 20

BLOOD PRESSURE
-Force of the blood against the arterial walls -Measured in millimeters of mercury (mmHg) Systole the highest pressure Diastole the lowest pressure Pulse pressure difference between the systole and diastole

BLOOD PRESSURE
Basic Terms: Korotkoffs sound Hypertension above 140/90 mmHg Hypotension below 90/60 mmHg Orthostatic Hypotension decrease in Bp when changing position

Factors that control Blood Pressure

1. Cardiac Output amount of blood ejected from the heart per contraction 2. Blood Volume adult has about 5-6 liters of circulating blood 3. Elasticity of arterial walls yields upon systole and retracts upon diastole

Factors affecting Blood pressure

1.Age 2.Emotions 3.Exercise 4.Drugs 5.Environment

To ensure accuracy in taking the BP, you must:

1.Let the patient rest for a minimum of 5 minutes for routine assessment 2. Should not have ingested caffeine or nicotine 30 minutes before 3.Delay assessing if patient is in pain, emotionally upset, have just exercised.

Assessing Blood Pressure

Taylors p. 23