Assessing HealthVital Signs

Shurouq Qadous22 / 8/2010

Vital signs are body temperature, pulse, respiration, blood pressure and pain, pulse oximetry.

- Signs should be looked at in total, are checked to monitor the functions of the body.

- The signs reflect changes in function that otherwise might not be observed.

- Monitoring a client’s V/S should not be automatic or routine procedure, it should be a thoughtful, scientific assessment.

- When and how often to assess a specific client’s V/S are chiefly nursing judgments, depending on the client’s health status.

- A nurse should measure V/S more often if the client’s health status requires it.

 

Frequency of vital signs: vital signs are assessed at least every 4 hours in hospitalized patients with elevated temperatures, with low or high blood pressures, with changes in pulse rate or rhythm or with respiratory difficulty as well as in patients who are taking medications that effect cardiovascular or respiratory function or who had a surgery.

Times to assess vital signs: ( Box 29-1 page 527)• On admission to a health care agency to obtain

baseline data• When a client has a change in health status or

report symptoms such as chest pain or feelings hot or faint.

• Before and after surgery or an invasive procedure• Before and/or after the administration of a

medication that could affect the respiratory or cardiovascular systems such as before giving digitalis preparation

• Before and after any nursing interventions that could affect the vital signs such as ambulating a client who has been on bed rest.

Body Temperature Body temperature reflects the balance between the heat

produced and the heat lost from the body, and is measured in heat units called degrees. There are two kinds of body temperature:

Core temperature is the temperature of the deep tissues of the body such as abdominal cavity and pelvic cavity; it remains relatively constant. The surface temperature is the temperature of the skin, the subcutaneous tissue, and fat. It rises and falls in response to the environment. When the amount of heat produced by the body equals the amount of heat loss, the person is in heat balance.

A number of factors affect the body's heat production:• Basal metabolic rate "BMR" is the rate of energy

utilization in the body required to maintain essential activities such as breathing. MR ↓ with age.

• Muscle activity; including shivering , increases the metabolic rate.

• Thyroxine output; increased thyroxine output increases the rate of cellular metabolism throughout the body. This effect is called chemical thermogenesism, the stimulation of heat production in the body through ↑ cellular metabolism.

• Epinephrine, norepinephrine, and sympathetic stimulation/stress response. These hormones immediately increases the rate of cellular metabolism in many body tissues. Epinephrine and norepinephrine directly affect liver and muscle cells, thereby ↑ cellular metabolism.

• Fever . Fever increases the cellular metabolism rate and thus increases the body's temperature further.

Heat is lost from the body through :

Radiation; the transfer of heat from the surface of one object to the surface of another without contact between the two objects, mostly in the form infrared rays.

Conduction; is the transfer of heat from one molecule to a molecule of lower temperature such as the body transfers heat to an ice pack causing the ice to melt. The amount of heat transferred depends on the temperature difference and the amount and duration of the contact.

  

Convection is the dispersion of heat by air currents. The body usually has a small amount of warm air adjacent to it. This warm air rises and is replaced by cooler air.

Vaporization; is continuous evaporation of moisture from the respiratory tract and from the mucosa of the mouth and from the skin. This continuous and unnoticed water loss is called Insensible water loss, and the accompanying heat loss is called insensible heat loss. Insensible heat loss accounts for about 10% of basal heat loss.

Regulation of body temperature

The system that regulates body temperature has three main parts: sensors in the shell and in the core, an integrator in the hypothalamus, and an effector system that adjust the production and loss of heat.

Most sensors or sensory receptors are in the skin.

The skin sensors detect cold more efficiently than warmth.

When the skin becomes chilled over the entire body, three physiologic processes to ↑ the body temperature take place:

1. Shivering ↑ heat production.

2. Sweating is inhibited to ↓ heat loss.

3. Vasoconstriction ↓ heat loss.

When the sensors in the hypothalamus detected heat, they send out signals intended to reduce the temperature, that is , to decrease heat production and increase heat loss. In contrast, when the cold sensors are stimulated, signals are sent out to increase heat production and decrease heat loss.

The signals from the cold sensitive receptors of the hypothalamus initiate effectors, such as vasoconstriction, shivering, and the release of epinephrine, which increase cellular metabolism and hence heat production. When the warmth sensitive receptors in the hypothalamus are stimulated, the effector system sends out signals that initiate sweating and peripheral vasodilation.

Factors affecting body temperature:• Age; the infant is greatly influenced by the

temperature of the environment and must be protected from extreme changes. Children’s temperatures continue to be more variable than those of adults until puberty.

• Diurnal variations; body temperatures normally

change throughout the day, varying as much as 1.0C

between the early morning and the late afternoon.

 

• Exercise, hard work or strenuous exercise can increase body temperature.

• Hormones; women tend to have more fluctuations in body temperature than men as a result of hormones changes

• Stress; stimulation of the sympathetic nervous system can increase the production of epinephrine and norepinephrine thereby increasing metabolic activity and heat production.

• Environment. Extremes in environmental temperature can affect a person’s temperature regulatory systems. If the temperature is assessed in a very warm room and the body temperature cannot be modified by convection, conduction, or radiation, the temperature will be elevated.

Alterations in body temperature

There are two primary alterations in body temperature: pyrexia and hypothermia.

 PyrexiaA body temperature above the usual range is called

pyrexia, hyperthermia, or fever.Hyperpyrexia; is a very high fever usually above 41

°C and survival is rare when the temperature Reaches 44 °C and death due to damaging effects on the respiratory center.

The client who has a fever is referred to as febrile; the one who does not is afebrile.

The signs and symptoms of fever: loss of appetite, headache, hot, dry skin, flushed face, thirst and general malaise. Young children or other people with high fevers may experience periods of delirium or seizures.

Nursing Interventions for Client's with fever: Box 29-2 page 531• Monitor vital signs• Assess skin color and temperature• Monitor WBC, HCT, and other laboratory reports for

indications of infection or dehydration• Remove excess blanket when the client feels warm,

but provide extra warmth when the client feels chilled.

• Measure intake and output• Provide adequate nutrition and fluid• Reduce physical activity to limit heat production.

• Administer antipyretic

• Provide oral hygiene to keep the mucous membrane moist.

• Provide a tepid sponge bath to increase heat loss through conduction.

• Provide dry clothing and bed linens.

Hypothermia; is a core body temperature below the lower limit of normal. The three physiologic mechanisms of hypothermia are:

• Excessive heat loss

• Inadequate heat production to counteract heat loss

• Impaired hypothalamic thermoregulation

The clinical signs of hypothermia:

–Decreased body temperature, pulse, and respiration

–Severe shivering

–Feelings of cold and chills

–Pale, cool skin

–Hypotension

–Decreased urinary output

–Lack of muscle coordination

–Disorientation

–Drowsiness progressing to coma

–Frostbite (nose, fingers, toes)

Nursing Interventions for Client's with Hypothermia

»Provide a warm environment

»Provide dry clothing

»Apply warm blanket

»Keep limbs close to body

»Cover the client's scalp with a cap

»Supply warm oral or intravenous fluids

»Apply warming pads

Assessing Body Temperature The four most common sites for measuring body

temperature are oral, rectal, axillary, and the tympanic membrane and the skin / temporal artery.

  Advantages and disadvantages of four sites for body

temperature measurement –box 29-1

Orally Temperature

- The nurse should wait 30minutes before taking the temperature orally to ensure that the temperature of the mouth is not affected by the temperature of the food, fluid, or warm smoke.

Rectally; are considered to be very accurate.

Contra indication of rectal temperature

• Clients with M.I (vagal stimulation)

• Diarrhea

• Rectal surgery

• Clotting disorders

• Hemorrhoids "pile“

• Immunosuppressed

Axillary; is the preferred site for measuring temperature newborn because it is accessible and safe.

Tympanic membrane or nearby tissue in the ear canal because the membrane has an abundant arterial blood supply.

- Risk for membrane injury or perforation.

Forehead using a chemical thermometer or a temporal artery thermometer are most useful for infants and children where a more invasive measurement is not necessary.

Temperature scales

The body temperature is measure in degreed on two scales: Celsius (centigrade) and Fahrenheit.

C= (Fahrenheit temperature – 32) * 5/9

F = (Celsius temperature * 9/5) +32

PulsePulse; is a wave of blood created by contraction of the

left ventricle of the heart. Pulse wave represent the SV or the amount of blood that enters the arteries with each ventricular contraction.

Compliance of the arteries is their ability to contract and expand. When person’s arteries lose their distensibility, as can happen in old age, greater pressure is required to pump the blood into the arteries.

Cardiac output; is the volume of blood pumped into the arteries by the heart and equals the result of the stroke volume times the heart rate per minute.

A peripheral pulse; is a pulse located away from the heart such as in the foot, wrist neck.

Apical pulse; is a central pulse; that is, located at the apex of the heart.

Factors affecting pulse• Age; as age increases, the pulse rate gradually

decreases.• Gender. After puberty male’s pulse rate is slightly

lower than the female’s.• Exercise; the pulse rate normally increase with

activity• Fever; the pulse rate increases in response to the

lowered blood pressure that results from peripheral vasodilatation associated with elevated temperature and because of the increased metabolic rate.

• Medications; some medications decrease the pulse rate, and others increase it such as digitalis decrease the heart rate.

• Hypovolemia; loss of blood from the vascular system normally increase pulse rate.

• Stress; in response to stress, sympathetic nervous system stimulation increases the overall activity of the heart.

• Position changes. when a person is sitting or standing, blood usually pools in dependent vessels of the venous system.

• Pathology; certain diseases such as some heart conditions or those with impair oxygenation can alter the resting pulse rate.

Pulse Sites

– Temporal; passes over the temporal bone of the head. The site is superior and lateral to the eye.

– Carotid; at the side of the neck between the trachea and the sternocleiodomastoid muscle.

– Apical; at the apex of the hearty. About 8cm to the left of the sternum and at the fourth and sixth intercostals space.

– Brachial; at the inner aspect of the biceps muscle of the arm

Pulse Sites

– Radial; on the thumb side of the inner aspect of the wrist

– Femoral; alongside the inguinal ligaments– Popliteal; behind the knee– Posterior tibial; on the medial surface of the ankle– Pedal “dorsalis pedis”; over the bones of the feet

Assessing the Pulse A pulse is normally palpated by applying

moderate pressure with the three middle fingers of the hand. A pulse is commonly assessed by palpation “feeling’ or auscultation “hearing”.

Apical pulse; if the peripheral pulse is difficult to assess accurately because it is irregular. The apical pulse located at 5-6 intercostals rib.

A Doppler ultrasound stethoscope (DUS) is used for pulses that are difficult to assess.

The nurse should aware of the following:• Any medications that could affect the heart rate.• Whether the client has been physically active.• Whether the client should assume a particular 

position. 

When assessing the pulse the nurse collect the following data:

1. Rate, an excessively fast heart rate over 100 BPM in an adult is called Tachycardia. A heart rate in an adult of less than 60BPM is called Bradycardia.

2. Rhythm is the pattern of the beats and the intervals between the beats. Equal time elapses between beats of a normal pulse.A pulse with an irregular rhythm is referred to as a dysrhythmia or arrhythmia.

3. Pulse volume, also called pulse strength or amplitude, refers to the force of blood with each beat. It can range from absent to bounding.

4. Elasticity of the arterial wall reflects its expansibility or its deformities. A healthy, normal artery feels straight, smooth, soft, and pliable. Elders often have inelastic arteries that feel twisted and irregular upon palpation.

 

Apical-Radial Pulse AssessmentIt may need to be assessed for clients with certain cardiovascular disorders. Normally the apical pulse and radial are identical.

Pulse deficit; the discrepancy between the radial pulse and apical pulse.

RespirationRespiration is the act of breathingInhalation or inspiration refers to the intake of air into the lungs.

Exhalation or expiration refers to breathing out  or the movement of gases from the lungs to the atmosphere.

Ventilation is also used to refer to the movement of air in and out of the lungs.

There are two types of breathing:- Costal (thoracic) breathing -  diaphragmatic (abdominal) breathing

Mechanics and regulation of breathingDuring inhalation, the diaphragm contracts the

ribs move upward and outward, and the sternum moves outward, thus enlarging the thorax and permitting the lungs to expand.

During exhalation. The diaphragm relaxes, the ribs move downward and inward, and the sternum moves inward, thus decreasing the size of the thorax as the lungs are compressed.

Respiration is controlled by (a) respiratory centers in the medulla oblongata and the pons of the brain and (b) by chemo receptors located centrally in the medulla and peripherally in the carotid and aortic bodies. These centers and receptors respond to changes in the concentrations of O2, CO2,H+ in the arterial blood.

Assessing Respiration

Nurses should be aware of the following before having respiration rate:

• The client’s normal breathing pattern

• The influence of the client’s health problems on respirations

• Any medications or therapies that might affect respirations

• The relationship of the client’s respiration to cardiovascular function

The respiratory rate is normally described in breaths per minute, normal in depth and rate called eupnea. Bradypnea; abnormally slow respirations. Tachypnea; abnormally fast respirations. Apnea; the absence of breathing.

Factors affecting Respirations

Factors increase the rate:

• Exercise

• Increase metabolism

• Stress

• Increased environmental temperature

• Lowered oxygen concentration

Factors decrease respiration rate:

• Decreased environmental temperature

• Certain medications such as narcotics

• Increased intra cranial pressure

 

Respiration depth; is generally described as normal, deep, or shallow. Deep respirations; large volume of air is inhaled and exhaled, inflated most of the lungs.

Shallow breathing involve the exchange of a small volume of air and often the minimal use of a lung tissue.

During a normal inspiration and expiration, an adults takes in about 500ml of air.

Hyperventilation; refers to very deep, rapid respiration.

Hypoventilation; refers to very shallow respirations

Respiratory rhythm refers to the regularity of the expirations and the inspirations .An respiratory rhythm can be described as regular or irregular.

- Cheyne-stokes breathing, from very deep to very shallow breathing and temporary apnea.

 

    Kussmaul …….. Increased rate and depth of respiration above 20bpm

Respiratory quality, usually breathing does not require noticeable effort. Dyspnea, difficult and labored breathing. Orthopnea, ability to breath only in upright sitting or standing positions.

Breath sounds- Stridor, harsh sound heard during inspiration

with laryngeal obstruction- Stertor, snoring respiration usually due to a

partial obstruction of the upper airway.- Wheeze, continuous, high pitched musical

sound occurring on expiration when air moves through narrowed or partially obstructed air way.

Secretions and coughing

- Hemoptysis, the presence of blood in the sputum

- Productive cough, a cough accompanied by expectorated secretions

- Nonproductive cough, a dry, harsh cough without secretions

Blood Pressure

Arterial blood pressure is a measure of the pressure exerted by the blood as it flows through the arteries.

The systolic pressure is the pressure of the blood as a result of contraction of the ventricles.

Diastolic pressure is the pressure when the ventricles are at rest. Diastolic pressure, then, is the lower pressure present at all times within the arteries. The differences between the two called the pulse pressure

Determinants of blood pressure

• Pumping action of the heart

when the pumping action of the heart is weak, less blood is pumped into arteries "lower cardiac output", and the blood pressure decreases.

• Peripheral vascular resistance

peripheral resistance can increase blood pressure. The diastolic pressure especially is affected. Some factors that create resistance in the arterial system are the capacity of the arterioles and the capillaries, the compliance of the arteries, and the viscosity of the blood

• Blood volume; when the blood volume decreases as a result of hemorrhage, the blood pressure decreases because of the decreased fluid in the arteries.

• Blood viscosity; blood pressure is higher when the blood is highly viscous "thick" that is, when the proportion of RBC to the blood plasma is high.

Factors affecting Blood Pressure

• Age; the pressure rises with age, reaching a peak at the onset of puberty, and then tend to decline.

• Exercise; physical activity increases the cardiac output and hence in blood pressure; thus 20-30 minutes of rest following exercise is indicated before the resting blood pressure can reliably assessed.

• Stress; stimulation of the nervous system increases cardiac output and vasoconstriction of the arterioles, however severe pain can decrease blood pressure greatly by inhibiting the vasomotor center and provide vasodilatation

• Race (African American males over 35 years have higher BP than European American males)

• Gender; after puberty, female usually have lower blood pressure than males at the same age. After menopause the female has higher blood pressure than males

• Medications• Obesity; predispose to high blood pressure• Diurnal variations; pressure is usually lowest early in the morning when metabolic rate is low.

• Disease process; any condition affecting the cardiac output, blood volume, blood viscosity, and compliance of the arteries has a direct effect on the blood pressure.

Hypertension  Hypertension; an abnormally high blood

pressure, over 140mm Hg systolic and 90 mm Hg diastolic.

Factors associated with hypertension

• Thickening of the arterial walls, which reduces the size of the arterial lumen

• Inelasticity of the arteries

• Lifestyle such as as cigarette smoking,

• Obesity

• Lack of physical exercise

• High blood cholesterol level

• Continued exposure to stress

Hypotension; blood pressure below normal that is systolic reading between 85-110mm Hg.

Orthostatic hypotension, is a blood pressure that falls when the client sits or stands. It is usually the result of peripheral vasodilatation in which blood leaves the central body organs especially the brain and moves to the periphery, often causing the person to feel faint.

Hypotension can be caused by:

• Analgesics

• Bleeding

• Severe burn

• Dehydration.

It is important to monitor hypotensive clients carefully to prevent falls.

When assessing for orthostatic hypotension:– Place the client in a supine position for 2-3

minutes

– Record the client's pulse and blood pressure

– Assist the client to slowly sit or stand. Support the client in case of faintness

– Immediately recheck the pulse and blood pressure in the same sites as previously.

– Repeat the pulse and blood pressure after 3 minutes.

– Record the results, a rise in pulse of 15 to 30 beats per minute or a drop in blood pressure of 20mmHg systolic or 10 mmHg diastolic indicates orthostatic hypotension

Equipments used to assess pulse and blood pressure

• Stethoscope; is used to auscultated and assess body sounds including the apical pulse and the blood pressure

• Sphygmomanometer; is used to assess blood pressure consist of cuff, good selection of the cuff in order to obtain accurate blood pressure.

Blood pressure sites

Assessing the blood pressure on a client’s thigh is indicated in these situations:– The blood pressure can not be measured on either

arm due to burn or other trauma

– The blood pressure in one thigh is to be compared with the blood pressure in the other thigh

Blood pressure is not measured on a particular clients’ limb in the following situations:

1)The shoulder, arm, or hand is injured or diseased.

2) The client has had surgical removal of axilla lymph nodes on that side, such as for cancer.

3) The client has intravenous infusion in that limb

4) The client has an arteriovenous fistula for dialysis in that limb

Oxygen Saturation

A pulse oximeter; is a non invasive device that measures a client's arterial blood oxygen saturation by means of a sensor attached to the client's finger, toe, nose, earlobe, or forehead. The pulse oximeter can detect hypoxemia before clinical signs and symptoms such as dusky skin color and dusky nailbed color.

Factors affecting oxygen saturation reading

• Hemoglobin; if the hemoglobin is fully saturated with oxygen, the saturation will appear normal even if the total hemoglobin level is low

• Circulation

• Activity; shivering or excessive movement of the sensor site may interfere with accurate reading.

• Carbon monoxide poisoning.