Assessing Vital Signs Handouts

ASSESSING VITAL SIGNS RLE 10 @VITAL SIGNS • Also known as Cardinal Signs

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Includes (1) TEMPERATURE, (2) PULSE, (3) RESPIRATION, and (4) BLOOD PRESSURE & recently PAIN as the 5th V/S in some facilities

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A person’s physiologic status is reflected by these indicators of body function Checked to monitor the functions of the body, functions that might not be observed

Should be evaluated with reference to the client’s present and prior health status, are compared to the client’s usual (if known) and accepted normal standars

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When and where? Chiefly a nursing judgement or depending on facility or physician’s order

@Vital Signs are commonly assessed: • Screenings at health fairs and clinics

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In the home Upon admission to a healthcare setting to obtain baseline data When certain medications are given (meds that could affect respi or cardio system ex. Digitalis) @Before and after diagnostic and surgical procedures (there might be internal bleeding)

Before and after certain nursing interventions that could affect V/S (ex. Ambulating a client who has been on bed rest, b/c he may have activity intolerance • In emergency situations or when client has change in health status or reports symptoms such as chest pain or feeling hot or faint @Purposes of assessing Vital Signs • To obtain baseline measurement of the patient’s vital signs

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To assess patient’s response to treatment or medication To monitor patient’s condition after invasive procedures

@I. ASSESSING TEMPERATURE BODY TEMPERATURE • heat of the body measured in degrees • Difference between production of heat and loss of heat from the body @PROCESS OF HEAT PRODUCTION OCCURS THROUGH: • Food Metabolism and Activity – basal metabolic rate (BMR) or the rate of energy utilization in the body

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Increased thyroxin production - increased cellular metabolism is d/t inc thyroxine output from the thyroid gland, this effect is called CHEMICAL THERMOGENESIS • Chemical thermogenesis

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Epinephrine, norepi, SNS stimulation Fever = inc metabolic rate Muscle activity = inc metabolic rate

@PROCESS OF HEAT LOSS OCCURS THROUGH: • Radiation – surface to surface by waves therefore no contact (ex. Nude person standing in room @ normal temperature) • Conduction – contact between 2 surfaces; heat transfer to a surface of lower temperature (ex. immersion in cold water) • Convection – mov’t by air currents

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Evaporation – water to steam; continuous & unnoticed evaporation of moisture from the respiratory tract & from mucosa of mouth & from skin • Elimination – urination, defecation @TYPES of TEMPERATURE • Core Temperature

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Temperature of the deep tissues of the body such as abdominal cavity & pelvic cavity; relatively constant

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measured thru tympanic and rectal routes Surface Temperature Temperature of the skin, subcutaneous tissue & fats; rises and falls in response to the environment measured thru oral and axillary routes

@FACTORS AFFECTING BODY TEMPERATURE – nurses should be aware so that they can recognize normal temperature variations & understand the significance of the body temperature measurements that deviate from normal • Age – infant is greatly influenced by the temperature of environment and must be protected from extreme changes; people 75 y.o & up are at risk for hypothermia (T < 36C or 96.8F) for a variety of reasons such as inadequeate diet, loss of subcutaneous tissue, lack of activity & decreased thermo-regulatory efficiency • Sex – d/t hormones; women > men hormone fluctuations; progesterone during ovulation rises body temperature • Exercise – can inc temp to as high as 38.3C to 40C (101-104F) rectally

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Time of day – also “diurnal variations” or “circadian rhythms”; @ 1C between early am and late pm; highest @ 8pm and midnight; lowest @ sleep between 4-6 am • Emotions/stress – stimulation of SNS

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Environment – extremes in environmental temp Others; food, drugs

@4 COMMON SITES FOR ASSESSING BODY TEMPERATURE 1. Oral – most frequently used, least disruptive, most convenient, done for 3 minutes ; wait 30 mins if client ate or drank cold or hot food/fluids CONTRAINDICATIONS: • Infants and very young children • Patients with oral surgery • Unconscious or irrational patients • Seizure-prone patients • Mouth breathers and pts. with oxygen 2. @ Rectal – most accurate route, but invasive and uncomfortable to patient; done for 2-3 mins CONTRAINDICATIONS:  Rectal abnormalities – ex. Significant hemorroids  Diarrhea  Certain heart conditions – ex. CHF; may result to vagal stimulation = bradycardia  Immunosuppressed - may inc risk of infection  Clotting disorder 3. @Axillary – safer than the oral method, non-invasive, least accurate; Done for 10 minutes; for clients with oral problem( oral inflammation, wired jaws, oral surgery) 4. @Tympanic membrane – accessible, less invasive; has abundant arterial blood supply; Within two seconds Up/back for adult Down/back for pedia

CONTRAINDICATIONS: • Presence of ear ache • Significant ear drainage • Scarred tympanic membrane @ASSESSING TEMPERATURE (axillary route) Taylor’s p. 14 @Route vs Special Considerations (table)

ROUTE

ORAL

RECTAL

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

AXILLARY

TYMPANIC

• Within two seconds • Up/back for adult • Down/back for pedia

@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, don’t take another rectal temp) @ Assessment Findings Pyrexia

Elevated BT

Hyperpyrexia

BT above 41˚C

Intermittent fever

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

Remittent fever

Fluctuations of several degrees above normal, but not reaching normal between fluctuations

Constant fever

Consistently elevated and fluctuates very little

Relapsing fever

Returns to normal for at least a day then the fever occurs

Resolution of Pyrexia by crisis

Elevated BT returns to normal suddenly

@Types of Thermometer 1. Tympanic Thermometer/infrared thermometer – senses body heat in form of infra red energy given off by the heat source which is the ear canal (tympanic membrane) 2. Electronic or Digital Thermometer – can read temp in 2-60 sec depending on manufacturer 3. Glass Thermometer – traditional; “mercury-in-glass thermometers” 4. Temperature – sensitive Tape – does not indicate core temp; w/ liquid crystals that change color; placed at forehead or abdomen 5. Chemical Thermometer – uses crystal dots/bars or sensitive tape applied @ forehead @II. ASSESSING PULSE Taylor’s p. 16 PULSE • A wave of blood being pumped into the arterial circulation by the contraction of the left ventricle • Throbbing sensation palpated over a peripheral artery • Assessed by palpation (feeling) or auscultation (hearing) • Middle three fingertips are used for palpating all pulse sites except the apex of the heart; a stethoscope is used for assessing apical pulses & FHT @ASSESSMENT PARAMETERS / CHARACTERISTICS OF PULSE

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Rate – number of beats per minute AGE GROUP PULSE RANGE Newborn

80-180 bpm

Adults

60-100 bpm

Elderly

60-100 bpm

Assessment Findings: Tachycardia, bradycardia

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Rhythm – pattern or regularity of beats and interval between each beat Term Meaning

Pulsus regularis

Equal rhythm

Arrhythmia

Irregular rhythm

Premature beat

Beat that occurs between normal beats

Heart rhythm

Time interval between each heartbeat

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@Volume/amplitude – also pulse strength; amount of blood pumped with each heartbeat Normal pulse – can be felt w/ moderate pressure of the fingers & can be obliterated w/ greater pressure Full or bounding pulse – forceful or full blood volume that is obliterated only with difficulty Weak, feeble, thready – pulse that is readily obliterated w/ pressure from the fingers 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 @LOCATION OF PERIPHERAL PULSES >temporal – superior and lateral to the eye >carotid - @ side of cheek >brachial – inner aspect of the bicep muscle of the arm or medially in the antecubital space >radial - @ the thumb side of the inner aspect of the wrist >femoral - @ inguinal ligament >politeal – behind the knee >posterior tibial – medial surface of the ankle >dorsalis pedis/ pedal – over the bones of the foot

@Reasons for Using Specific Pulse Site Pulse Site

Reasons for Use

Radial Temporal Carotid

Readily accessible Used when radial pulse is not accessible Used in cases of cardiac arrests Used to determine circulation to the brain

Apical

Routinely used for infants 7 children up to 3 yrs. Used to determine discrepancies with radial pulse Used in conjunction with some medications

Brachial

Used to measure blood pressure Used during cardiac arrest for infants

Femoral

Used in cases of cardiac arrest Used for infants and children Used to determine circulation to the leg

Popliteal Posterior tibial , Pedal

Used to determine circulation to the lower leg Used to determine circulation to the foot

@Factors Affecting Pulse Rate 1. Age – inc age, dec PR 2. Sex/gender – after puberty male’s pulse is slightly lower than femlae’s 3. Exercise – inc exercise, inc PR 4. Emotions/stress – SNS stimulation (fear, anxiety, perception of pain) 5. Prolonged heat application – inc metabolic rate, inc PR 6. Body positions- when sitting or standing, blood usually pools in dependent vessels of venous system  transient dec in venous return to the heart  inc HR to compensate 7. Pain – d/t SNS stimulation 8. Decreased BP – inc HR as compensatory mechanism 9. Increased temperature – inc metabolic rate

10. Any conditions resulting to poor oxygenation of blood ex. CHF – inc HR to compensate @ASSESSING PULSE Taylor’s p. 17 @Respiration – act of breathing  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 @III. ASSESSMENT PARAMETERS / CHARACTERISTICS OF RESPIRATION 1. Rate – number of breaths per minute AGE GROUP RESPIRATORY RANGE Newborn

30 – 60 bpm

Adults

12-20 bpm

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@Rhythm – regularity of respiration, inhalation and exhalation are evenly spaced; AF – regular, irregular Regular

Effortless, quiet

Irregular

Abnormal

3. @Depth – assessed by watching the movement of the chest AF – normal, deep or shallow 4. ease & effort AF – dyspnea, orthopnea 5. breath sounds AF – stridor, bubbling, rales 6. volume – AF: hyperventilation (overexpansion of lungs), hypoventilation (underexpansion of lungs) @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 – involves contraction & relaxation of the diaphragm @FACTORS AFFECTING RESPIRATION 3. Exercise – inc RR 4. Certain medications – eg. Narcotics 5. Age 6. Emotions – inc RR 7. Cardiac illness 8. Stress – inc RR 9. inc ICP = dec RR

@ASSESSMENT FINDINGS REGARDING RESPIRATION Eupnea

Normal, effortless breathing

Tachypnea

RR > 24 bpm

Bradypnea

RR < 10 bpm

Apnea

Absence of breathing

Hyperpnea

Deeper respiration with normal rate

Cheyne stokes

Resp. becomes faster and deeper then slower with alternate periods of apnea(2060sec) Faster and deeper than normal with abrupt pauses in between each breath

Biot’s

@A.F. REGARDING RESPIRATION

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Kussmaul’s Faster and deeper respiration without pauses in between panting Apneustic Prolonged grasping followed by extremely short insufficient exhalation Dyspnea difficulty of breathing Orthopnea DOB unless sitting Wheezing narrowing of airways, causing whistling or sighing sounds Stridor high-pitched sounds heard on inspiration @Rales - sound caused by air passing thru fluid or mucus in the airways usually heard on inhalation • Rhonchi sound caused by air passing thru airways narrowed by fluids, edema, muscle spasm usually heard during exhalation @ASSESSING RESPIRATION P 20 TAYLOR’S IV. BLOOD PRESSURE -

Force of the blood against the arterial walls - Measured in millimeters of mercury (mmHg) Since blood moves in waves, there are 2 BP measures: 1. Systole – the highest pressure; pressure of the blood as a result of contraction of ventricles 2. Diastole – the lowest pressure; pressure of the blood when ventricles are at rest Pulse pressure – difference between the systole and diastole @AF: • Hypertension – above 140/90 mmHg • Hypotension – below 90/60 mmHg • Orthostatic Hypotension – decrease in Bp when changing position @Korotkoff’s sound –schematic diagram

@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 – Age – newborns systolic = 75mmHg; BP rises w/ age – Emotions/stress – SNS stimulation = inc BP – Exercise – inc cardiac output = inc BP – Drugs – dopamine, dobutamine, epinephrine – Obesity – predispose to hypertension – Disease process – any dse affecting C.O., blood volume, blood viscosity and compliance of the arteries Assessment Findings: 1. hypertension – dx made when the ave of 2 or more diastolic readings on 2 visits subsequent to initial assessment is 90 mmHg or higher or ave of multiple systolic BP readings is higher than 140mmHg 2. hypotension = systolic pressure is consistently between 85-110 mmHg To ensure accuracy in taking the BP, you must: 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: a. in pain b. emotionally upset, or c. have just exercised. Parts of BP apparatus Assessing BP Taylor’s p. 23 The End