NEO 111 Vital Signs Melanie Jorgenson, RN, BSN. Vital Signs include… ▫Blood Pressure (B/P) ▫Pulse (P or HR)—Radial or Apical ▫Respirations (RR) ▫Temperature—Oral,

NEO 111Vital Signs

Melanie Jorgenson, RN, BSN

Vital Signs include…

▫Blood Pressure (B/P)

▫Pulse (P or HR)—Radial or Apical

▫Respirations (RR)

▫Temperature—Oral, Rectal (R), Axillary (Ax),

▫Tympanic (Tymp), Temporal Artery

▫Pain Assessment Pulse Oximetry

Vital Signs – When?

•On admission•Based on policy and procedure•When there is a change in patient condition

•Before and after surgery or a procedure•Before and after activity that may increase risk

•Prior to medication administration that may affect CV or respiratory function

Pain “The 5th Vital Sign”

Pain is subjective—what ever the patient says it is

WILDA or HILDA assessmentWord/How does your pain feel (description)Intensity (pain scales)Location (new or chronic?)Duration (constant or intermittent?)Aggravating and Alleviating Factors (what

makes the pain worse/better, what interventions have been tried?)

Pain “The 5th Vital Sign”Nonverbal indicators of pain

GrimacingGuardingDecreased activity/mobility Increased pulse & B/P (acute pain only)Shallow respiration

Regular ongoing re-evaluation & re-evaluation after an intervention to determine effectiveness

Blood Pressure•Blood pressure is the force of blood against

arterial walls

•Systolic pressure is the highest pressure and correlates with ventricular contraction (systole)

•Diastolic pressure is the lowest pressure and correlates with ventricular relaxation (diastole)

•Blood pressure is written as Systolic/Diastolic

Blood Pressure

• Blood pressure should be taken with the proper size cuff ▫Index line within the range on the cuff or ▫The cuff height should be approx 40% of the

circumference of the limb used▫Too small cuff results in a false high reading▫Too large cuff results in a false low reading

• Exercise, Caffeine & Nicotine may alter B/P and pulse

• Avoid BP on extremity that has AV fistula, Peripheral or central IV or side that has had mastectomy and/or axillary node dissection

Blood Pressure

•Line up the artery line indicator with the artery (position the tubes on either side of the artery—tubes always located distal)

•Estimate your patient’s systolic B/P•1st Korotkoff sound = systolic pressure•Cessation of sound = diastolic pressure •B/P is read and recorded to the nearest

even number•Important to know patient’s baseline

blood pressure for comparison as well as “normal blood pressure” values

Reading a Sphygmomanometer

Normal & Abnormal Blood Pressure Values

• Normal <120 mm Hg systolic*; <80 mm Hg diastolic

• Always consider what is “normal” for your particular patient. (medications, age, etc…)

• Pulse pressure is the difference between the systolic and diastolic reading▫An increased or widening pulse pressure (>60

mm Hg) is concerning for cardiac disease (stiffening of arteries, atherosclerosis or other medical condition)

Orthostatic Hypotension (postural hypotension)How are Orthostatic B/P readings performed?

Have pt lay down for 3-5 mins take BP and pulse, sit for 2 min take BP and Pulse, stand for 2 min take BP and pulse

What indicates positive orthostatic hypotension?Drop in systolic BP of 25 mm Hg (text) 20 mm Hg (practice)

or a drop in diastolic by 10 mmg Hg when changing from a lying to sitting or sitting to standing position

Increase in pulse by 20 beats per minute when changing form a lying to sitting or sitting to standing position

Teach pt to rise slowly, raise HOB, dangle on side, slowly stand, return to a sitting or lying position if symptomatic.

Pulse

Record rate, rhythm and amplitude/quality

Normal pulse rate for an adult is 60-100 bmp

Normal pulse rate for a child (6-8 year old) is 75-110

Normal pulse rate for an infant is 80-180 (newborn); 80-140 (1-3 year old)

More about pulses

•Name Peripheral pulse sites….

•Pulse volume variations: 0, 1+, 2+, 3+, 4+

Palpating the radial pulse

Apical Pulse

•Where do you place the stethoscope to listen to the apical pulse?

•How long do you listen to apical pulse?

Apical Pulse

Respirations

Observe at the sternal notch

Assess rate, rhythm, effort, depth ( if applicable)

An increase in carbon dioxide is the most powerful respiratory stimulant

Pulse oximeter

Questions….What is a “normal” respiratory rate in an

adult?12-20 breaths per minute

What is a “normal” respiratory rate in an child?15-25 (6-8 year olds)

What is a “normal” respiratory rate in an infant?30-60 (newborn); 20-40 (1-3 year old)

Abnormal Respirations

•Hyperventilation, Hypoventilation

•Apnea—apnea that lasts longer than 4-6 minutes may lead to brain damage and death

•Dyspnea, grunting, nasal flaring, retractions

•Orthopnea, Tachypnea, Bradypnea

Oxygen saturation

•Measures arterial oxyhemoglobin saturation (SaO2 or SpO2)

•Often need to remove artificial nails and nail polish

•Alternative sites-toe, earlobe, bridge of nose

Questions

•What is considered a “normal SaO2 range?▫ 95%-100%

•When is less than 95% an expected finding?

•Know pt’s Hgb level…why?

Temperature

•Surface & Core Temperatures▫Surface—Temperature of skin—Oral &

Axillary▫Core—Deep tissue—Rectal, Temporal Artery

& Tympanic

Temps are lowest in early morning and highest in late afternoon

Normal Value Relative to SiteOral used as a baseline 98.6°F or 37.0°C

Oral Temperature

•Patient should not drink, smoke, eat, chew gum for 15-30 minutes prior

•You should avoid and oral temp:▫ disease of mouth ▫ surgery of nose/mouth,▫ receiving oxygen by mask ▫ unable to close mouth

Axillary Temperature

•Often used for newborns

•If axilla just washed wait 15-30 mins

•Watch placement

Correct placement for axillary thermometer

Rectal Temperature

•Most accurate

•When should you avoid a rectal temperature▫ Newborns▫ small children▫ pt who had rectal surgery▫ diarrhea or disease of rectum▫ people with certain heart diseases (vagus nerve)▫ neutropenic pt▫ some neurologic disorders

Tympanic Temperature

Need good seal

Point probe toward opposite eye/jaw

When should you avoid taking a tympanic temperature?Drainage from ear, scars on tympanic membrane,

infection, radiation, narrow ear canal, hat

The pinna should be positioned up and back for an adult and down and back for a child

Documentation•Pt’s age, gender, race •Vital Signs:•T Ax, Tympanic, Rectal, O (assumed)•P Rate, Rhythm, Amplitude•R Rate, Rhythm, Effort (Depth if

needed)•BP result, extremity used, pt position•SpO2 receiving O2 or RA, where

assessed•Pain Assessment

Documentation

•October 2, 2009•0730 34 yr old Caucasian male VS: T

98.2°F L Tympanic R 16 regular, shallow, unlabored, P 86 L radial, regular, 2+, BP 126/86 L arm sitting. SpO2 96% on 2L NC L index finger. Pt states pain in left leg 1 on 1-10 scale. Patient in bed watching TV. Call bell in reach.----------------M Jorgenson, RN

References

• Images from:• Lynn, Pamela RN, MSN Taylor's Clinical Nursing Skills A Nursing Process

Approach, 2nd Edition. Lippincott, • Hutson, Janice & Constantino, Sheri, Use of Powerpoint material. 2010