Guidelines for Measuring Vital Signs Establish a baseline for future assessmentsEstablish a baseline for future assessments Be able to understand and interpret

Guidelines for Measuring Guidelines for Measuring Vital SignsVital Signs

• Establish a baseline for future Establish a baseline for future assessmentsassessments

• Be able to understand and interpret Be able to understand and interpret valuesvalues

• Appropriately delegate measurementAppropriately delegate measurement• Communicate findingsCommunicate findings• Ensure equipment is in working orderEnsure equipment is in working order• Document findings accuratelyDocument findings accurately

© 2009 Elsevier Australia 1Wotton, K.. (2009) ‘Vital Signs’ in eds J. Crisp & C. Taylor, Potter and Perry's Fundamentals of Nursing, 3rd

edn, Elsevier, Sydney, p. 545-588.

Factors Affecting Body Factors Affecting Body TemperatureTemperature

AgeAge ExerciseExercise

Hormonal levelHormonal level Circadian rhythmCircadian rhythm

EnvironmentEnvironment Temperature Temperature alterationsalterations



Temperature RangeTemperature Range

• Temperature sites:Temperature sites:– Oral, rectal, axillae, tympanic membrane, Oral, rectal, axillae, tympanic membrane,

oesophageal, urinary bladder, pulmonary oesophageal, urinary bladder, pulmonary arteryartery

© 2009 Elsevier Australia 3

Wotton, K.. (2009) ‘Vital Signs’ in eds J. Crisp & C. Taylor, Potter and Perry's Fundamentals of Nursing, 3rd


Assessment of PulseAssessment of Pulse

• SitesSites

• Use of stethoscopeUse of stethoscope

• Character of pulse:Character of pulse:– RateRate– RhythmRhythm– StrengthStrength– EqualityEquality



Assessment of PulseAssessment of Pulse



RespirationRespiration



Assessment of VentilationAssessment of Ventilation

• Respiratory rateRespiratory rate

• Ventilatory depthVentilatory depth

• Ventilatory rhythmVentilatory rhythm

• Ventilatory soundVentilatory sound

• Assessment of diffusion and Assessment of diffusion and perfusionperfusion– Arterial oxygen saturationArterial oxygen saturation



Assessment of VentilationAssessment of Ventilation

• Respiratory rateRespiratory rate



Nursing Process and Nursing Process and Respiratory Vital SignsRespiratory Vital Signs

• Measurements include:Measurements include:– Respiratory rate, pattern, depth, SpORespiratory rate, pattern, depth, SpO22

• These measurements provide information These measurements provide information about ventilation, diffusion and perfusionabout ventilation, diffusion and perfusion

• Nursing diagnosisNursing diagnosis

• InterventionsInterventions

• PlanningPlanning

• Evaluation Evaluation © 2009 Elsevier Australia 9

Wotton, K.. (2009) ‘Vital Signs’ in eds J. Crisp & C. Taylor, Potter and Perry's Fundamentals of Nursing, 3rd edn, Elsevier, Sydney, p. 545-588.

Blood Pressure: Physiology Blood Pressure: Physiology

• Force exerted on walls of an arteryForce exerted on walls of an artery

• Systolic blood pressureSystolic blood pressure– Peak pressure during cardiac Peak pressure during cardiac

contractioncontraction

• Diastolic blood pressureDiastolic blood pressure– Pressure in the arteries with ventricular Pressure in the arteries with ventricular

relaxationrelaxation




• Cardiac outputCardiac output– Blood pressure depends on cardiac outputBlood pressure depends on cardiac output

• Peripheral resistancePeripheral resistance– Tone of vasculature and diameter of blood Tone of vasculature and diameter of blood

vesselsvessels• Blood volumeBlood volume

– Amount of blood circulating in vasculatureAmount of blood circulating in vasculature• ViscosityViscosity

– Thickness of blood (cells to fluid ratio)Thickness of blood (cells to fluid ratio)• ElasticityElasticity

– Amount of elastic and distensibility of arteriesAmount of elastic and distensibility of arteries




Haemodynamic factors to control blood pressureHaemodynamic factors to control blood pressure



Factors Influencing Blood PressureFactors Influencing Blood Pressure

• Age Age

• StressStress

• MedicationsMedications

• Daily VariationDaily Variation

• GenderGender



Hypertension and HypotensionHypertension and Hypotension

• HypertensionHypertension– More common than More common than hypotension hypotension– Thickening of wallsThickening of walls– Loss of elasticityLoss of elasticity– Family historyFamily history– Risk factorsRisk factors

• HypotensionHypotension– SBP < 90 mm HgSBP < 90 mm Hg– Dilation of arteriesDilation of arteries– Loss of blood Loss of blood volumevolume– Decrease of blood Decrease of blood flow to vital organsflow to vital organs– Orthostatic/posturalOrthostatic/postural



Measurement of Blood Measurement of Blood PressurePressure

• EquipmentEquipment

• AuscultationAuscultation

• Assessment in childrenAssessment in children

• Ultrasonic stethoscopeUltrasonic stethoscope

• PalpationPalpation

• Lower extremityLower extremity

• Automatic blood pressure devicesAutomatic blood pressure devices







Auscultation (Korotkoff sounds):Auscultation (Korotkoff sounds):

1.1. onset of the sound (onset of the sound (systolic pressuresystolic pressure))

2.2. murmur or swishing sound occurs as the murmur or swishing sound occurs as the cuff deflatescuff deflates

3.3. crisper and more intense tappingcrisper and more intense tapping

4.4. muffled and low-pitched as the cuff is muffled and low-pitched as the cuff is further deflatedfurther deflated

5.5. absence of sound (absence of sound (diastolic pressurediastolic pressure))




Korotkoff soundsKorotkoff sounds




Nursing Process and Blood Nursing Process and Blood Pressure DeterminationPressure Determination

• Assessment of blood pressure and Assessment of blood pressure and pulse evaluates the general state of pulse evaluates the general state of cardiovascular healthcardiovascular health

• Hypertension, hypotension, Hypertension, hypotension, orthostatic hypotension or narrow / orthostatic hypotension or narrow / wide pulse pressures define nursing wide pulse pressures define nursing diagnosesdiagnoses



Documents

Guidelines for Measuring Vital Signs Establish a baseline for future assessmentsEstablish a baseline for future assessments Be able to understand and interpret