What are Vital Signs? Temperature (T) Pulse (P) Respiration (R) Blood pressure (BP) The VS are an important part of the nursing assessment in.

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.

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.

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

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.

The primary source of heat production is ________________.

What mechanisms increase a patient’s metabolism and increases heat production?

What is the primary site of heat loss?

A.The skin B.Evaporation from sweatC.Warm and humidified inspired air D.Eliminated urine and feces

Radiation

◦Conduction

Evaporation

Convection What are nursing implications that apply to each?

Age Activity / Exercise / Sleep Hormones Stress Environment Medication Illness

Healthy Adults

Axillary 97.7°FOral 98.6°F + or – 10

Rectal/Tympanic 99.6°F

Infants – 12 years old - see Pg. 517 Older adult -

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.

Electronic Probe

Tympanic Thermometer

Temporal artery scanner

Chemical in glass

Oral

◦Rectal

Axillary

Tympanic

Temporal

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

A. Electronic thermometer – for oral and axillary

B. Tympanic membrane thermometer

C. Disposable paper thermometer for taking forehead temperature; the dots change color to indicate temperature.

D. Temporal artery thermometer

Oral Temp.- Insert thermometer under the tongue in the posterior sublingual pocket.Safety AlertWait 15 min. if patient has been smoking, eating hot/cold food or fluids, or chewing gum.

Rectal Temp. - Insert thermometer into the rectum.Safety AlertNot 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.

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 AlertNot used with patients who have drainage from the ear. Ear wax does not effect temp.

Axillary Temp. - Place thermometer in center of axilla.Safety AlertUsed with newborns to avoid perforating the wall of the rectum.

19

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.

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

VS Factors that Increase PulseTachycardia in an adult - >100 beats/min.

Factors that Decrease PulseBradycardia in an adult - <60 beats/min.

Pulse Bleeding – increase in pulse when there inadequate oxygen delivered to the tissues and organs. By the negative mechanism these receptors send the signals to the brain and thus stimulate heart to pump faster.

Older adults - have a lower baseline pulse rate.

Activity – the heart’s compensatory ability attempts to meet the need for increase blood circulation.

Sleeping

Strong emotions – pain, fear, anger, anxiety, and being surprised.

Exercise – slower in trained athletes.

Fever – increases 10 beats/min. for each 1° F above normal.

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

24

These arteries are located near the surface of the body.

The pulse can be detected in any of these sites by light palpation.

25

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.oUsed - most often with children & adults.

Dorsalis pedis –upper surface of the foot.oUsed – to assess circulation of the legs & feet.

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?A.15 seconds x 4B.30 seconds x 2C.60 seconds x 1

Landmarks

Which one of the following pulse sites is located on the inside of the elbow?A. TemporalB. RadialC. FemoralD. Brachial

The temporal site is located ?

The radial site is located?

The femoral site is located?

VS Factors that Increase BP Hypertension – greater than 140/90mm Hg

Factors that decrease BP Hypotension - less than Systolic of 90mm Hg

BP Older adult – have decreased elasticity of the arteries, which increases peripheral resistance and then increases BP.

Men – more have high BP than women the same ageWomen – get high BP after menopause.

Women - lower BP than men of the same age until menopause.

Exercise – Systolic BP rises during periods of exercise.

Exercise – lower in trained athletes.

Weight – BP higher in people who are obese than those who are thin.

Body Position – BP tends to lower in prone or supine position than sitting or standing.

Emotion State - Pain, fear, anger, anxiety and surprise raise BP; BP falls back to normal when the situation passes.

Orthostatic hypotension (postural hypotension) - drop in SBP >20 or DBP >10) within 3 minutes of standing. S&S = dizziness, diaphoresis, blurred vision).

Race – High BP more prevalent and more severe in African American men/women.

StethoscopeThe 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

31

Sphygmomanometer“sfig-mō-ma-NAW-me-ter”

A.The width of the blood pressure cuff should cover about 40% of the circumference of the upper arm. B.The length of the bladder should cover 2/3 of the circumference of the upper arm.

Safety AlertUsing a blood pressure cuff that's too large or too small can give you inaccurate BP readings (too large = low, too small = high).

32

◦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 practicehttp://vimeo.com/8068713

A. Three cuff sizes:1. Small cuff for a child or a small or

frail adult.

2. Normal-sized cuff for teens or adults.

3. Large cuff, called a leg cuff, used on a leg or

an obese adult.

34

What is normal BP level in an adult as defined by American Heart Association?

Any B/P over 120/80 is considered abnormal.

L = Falsely low assessmentsH = Falsely high assessments1.___Reflating the bladder during auscultation2.___Noise in the environment3.___Applying too narrow a cuff4.___Releasing the valve too rapidly5.___Applying too wide a cuff6.___Failing to pump the cuff 30 mmHg

above the disappearance of the pulse7.___Releasing the valve too slowly

1. H2. L 3. H4. L5. L6. L7. H

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.

VS Factors that Increase RR Tachypnea in an adult is a RR > than 24 breaths/min.

Factors that Decrease RRBradypnea in an adult is a RR < 10 breaths/min.

RR Age – A newborn RR ranges from 30-60 breaths/min.

Age – An older adult has a lower baseline RR. An adult’s normal range of RR is 12-20 breaths / min.

Activity – The RR increases due to the increased energy demands placed upon the body. The rate increases to keep up with these energy demands.

Activity – slower in trained athletes.

Anemia – Decrease in hemoglobin, which carries O2, may increase RR.Medications – Cocaine and amphetamines, known as "uppers," may increase rate and depth.

Medications – Narcotics, sedatives and general anesthetics slow rate and depth.

Pain – acute pain may increase rate but decrease respiratory depth.

Pain – acute pain may increase rate but decrease respiratory depth.

Smoking – alters the pulmonary airways causing increased RR, even at rest.

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?

Place an X on the VS value of an adult that suggests a need for treatment &/or notification of the HCP.1._____ Temp 101F2._____ HR 983._____ BP 96/544._____ RR 105._____ Temp 96.4F6._____ HR 567._____ BP 146/968._____ RR 24

1.__X___ Temp 101 F - Temp 101 or greater call HCP 2._____ HR 983._____ BP 96/544.__X___ RR 10 – rate less than 125.__X___ Temp 96.4 F - less than 97F 6.__X___ HR 56 - less than 607.__X___ BP 146/96 - diastolic greater than 908.__X___ RR 24 - rate greater than 20