Vital Signs

Vital SignsMeasurements of

physiologic functioning, specifically body

temperature, pulse, respirations, and blood

pressure; may include pain and pulse oximetry

When to Assess Vital SignsOn admissionChange in client’s health statusClient reports symptoms such as chest

pain, feeling hot, or faintPre and post surgery/invasive

procedurePre and post medication administration

that could affect CV systemPre and post nursing intervention that

could affect vital signs

Body Temperature

Two kinds of body temperature Core temperature – temperature on deep

tissue on the body, such as abdominal cavity an pelvic cavity

Surface temperature – temperature of the skin, subcutaneous tissue and fat; rises and falls in response to the environment

Thermoregulation center Hypothalamus

Alterations in body temperature Pyrexia, hyperthermia, Fever (in lay terms)

○ a body temperature above the usual range○ A client who has fever is referred to as febrile,

the one who has not is afebrile. Hyperpyrexia

○ A very high fever such as 41 oC (105.8 OF)

Four Common types of feverIntermittent – alternates at regular interval – periods

of fever and periods of normal (malaria) Remittent – a wide range of temperature fluctuations

occurs over 24 hour period (colds, influenza) Relapsing – short febrile episodes of few days,

interspersed – 1 to 2 days of normal temp. Constant - fluctuates minimally; always remain in

above normal (typhoid fever)

○ Fever spike – temp. rises to fever rapidly following a normal temp and then returns to normal within few hours.

Temperature: Lifespan ConsiderationsInfants Unstable

Newborns must be kept warm to prevent hypothermia

Children Tympanic or temporal artery sites preferred

Elders Tends to be lower than that of middle-aged adults

Copyright 2008 by Pearson Education, Inc.

Sites for Measuring Body Temperature

Oral Rectal Axillary Tympanic membrane Skin/Temporal artery


Types of Thermometers

Electronic Chemical disposable Infrared (tympanic) Scanning infrared (temporal artery) Temperature-sensitive tape Glass mercury


Nursing Care for Fever

Monitor vital signs Assess skin color

and temperature Monitor laboratory

results for signs of dehydration or infection

Remove excess blankets when the client feels warm

Provide adequate nutrition and fluid

Measure intake and output

Reduce physical activity

Administer antipyretic as ordered

Provide oral hygiene Provide a tepid

sponge bath Provide dry clothing

and bed linens


Nursing Care for Hypothermia Provide warm environment Provide dry clothing Apply warm blankets Keep limbs close to body Cover the client’s scalp Supply warm oral or intravenous fluids Apply warming pads


Pulse Sites

Radial Readily accessible

Temporal When radial pulse is not accessible

Carotid During cardiac arrest/shock in adultsDetermine circulation to the brain

Apical Infants and children up to 3 years of ageDiscrepancies with radial pulseMonitor some medications


Pulse Sites

Brachial Blood pressureCardiac arrest in infants

Femoral Cardiac arrest/shockCirculation to a leg;

Popliteal Circulation to lower leg

Posterior tibial

Circulation to the foot

Dorsalis pedis

Circulation to the foot


Factors Affecting Pulse Age Gender Exercise Fever Medications Hypovolemia Stress Position changes Pathology


Pulse: LifespanConsiderations

Infants Newborns may have heart murmurs that are not pathological

Children The apex of the heart is normally located in the fourth intercostal space in young children; fifth intercostal space in children 7 years old and older

Elders Often have decreased peripheral circulation


Characteristics of the Pulse Rate Rhythm Volume Arterial wall elasticity Bilateral equality


Pulse Rate and Rhythm Rate

Beats per minuteTachycardiaBradycardia

RhythmEquality of beats and

intervals between beats

DysrhythmiasArrhythmia


Characteristics of the Pulse Volume

Strength or amplitudeAbsent to bounding

Arterial wall elasticityExpansibility or deformity

Presence or absence of bilateral equality Compare corresponding artery


Measuring Apical Pulse


Apical-Radial Pulse Locate apical and radial sites Two nurse method:

Decide on starting timeNurse counting radial says “start”Both count for 60 seconds Nurse counting radial says “stop”Radial can never be greater than apical


Inhalation Diaphragm contracts

(flattens) Ribs move upward

and outward Sternum moves

outward Enlarging the size of

the thorax


Exhalation Diaphragm relaxes Ribs move downward

and inward Sternum moves

inward Decreasing the size

of the thorax


Respirations:Lifespan Considerations

Infants Some newborns display “periodic breathing”

Children Diaphragmatic breathers

Elders Anatomic and physiologic changes cause respiratory system to be less efficient


Respiratory Control Mechanisms

Respiratory centersMedulla oblongataPons

ChemoreceptorsMedullaCarotid and aortic bodies

Both respond to O2, CO2, H+ in arterial blood


Components of Respiratory Assessment Rate Depth Rhythm Quality Effectiveness


Respiratory Rate and Depth

RateBreaths per minuteEupneaBradypneaTachypnea

DepthNormalDeepShallow


Components of Respiratory Assessment Rhythm

Regular Irregular

Quality Effort Sounds

Effectiveness Uptake and transport of

O2

Transport and elimination of CO2

CO2 Major Chemical Stimuli for respirations

Hypoxemia or Hypoxia Hyperventilation Hypoventilation


Systolic and Diastolic Blood Pressure Systolic

Contraction of the ventricles

Diastolic Ventricles are at restLower pressure

present at all times Pulse Pressure =

difference between systolic and diastolic pressures

Measured in mm Hg Recorded as a

fraction, e.g. 120/80 Systolic = 120 and

Diastolic = 80


Blood Pressure:Lifespan Considerations

Infants Arm and thigh pressures are equivalent under 1 year of age

Children Thigh pressure is 10 mm Hg higher than arm

Elders Client’s medication may affect how pressure is taken


Korotkoff’s Sounds


Korotkoff’s Sounds

Phase 1First faint, clear tapping or thumping soundsSystolic pressure

Phase 2Muffled, whooshing, or swishing sound


Korotkoff’s Sounds Phase 3

Blood flows freely Crisper and more intense soundThumping quality but softer than in phase 1

Phase 4Muffled and have a soft, blowing sound

Phase 5Pressure level when the last sound is heardPeriod of silence Diastolic pressure


Measuring Blood Pressure

Direct (Invasive Monitoring) Indirect

Auscultatory Palpatory

SitesUpper arm (brachial artery)Thigh (popliteal artery)


Pulse Oximetry


Pulse Oximetry Noninvasive Estimates arterial blood oxygen

saturation (SpO2) Normal SpO2 85-100%; < 70% life

threatening Detects hypoxemia before clinical signs

and symptoms Sensor, photodetector, pulse oximeter

unit


Pulse Oximetry

Factors that affect accuracy include:Hemoglobin levelCirculationActivityCarbon monoxide poisoning


Pulse Oximetry

See Skill 29-7 Prepare site Align LED and photodetector Connect and set alarms Ensure client safety Ensure accuracy


Delegation of Measurement of Vital Signs General considerations prior to

delegationNurse assesses to determine stability of

clientMeasurement is considered to be routineInterpretation rests with the nurse


Documentation of Plan of Care/Reporting Documenting

A process of making entry on a client record; also know as recording, or charting.

Clinical record, also called a chart or client record, is a formal, legal documents that provides evidence of a client’s care.

Ethical and Legal Considerations The nurse has a duty to maintain

confidentiality of all patient information (American N urses Association Code of Ethics 2001)

Clients record if protected legally as private record of the clients care

Access to the record is restricted to health professionals involved in giving care to the client.

The institution, agency, or hospital is the rightful owner of the clients record.

Purposes of client Records Purpose is for education and research Students and graduate health

professionals are allowed to access to the clients record.

The records are used in client conferences, clinics, rounds, clients studies, and written papers.

Purposes : Communication – serves as the vehicle Planning Client Care – baseline and ongoing data to

evaluate the effectiveness of the NCP.Auditing Health Agencies – review of client records for quality assurance Research – information contained in record can be a

valuable source of data for research. Education – provide comprehensive view of the client,

illness, effective treatment strategies. Reimbursement – to facilitates payment from the

federal government and other insurance companies. Legal Documentation – admissible in court as evidence;

order from the court – “ Subpoena Ducestecum ” Health Care Analysis – health care planners to identify

agencies needs.

Documentation System

Source-Oriented Record – traditional client record – different department or persons makes notations in a separate sections – narrative charting.

Problem Oriented Medical Record (POMR) – data arranged according to problems Four basic components – database,

problem list, plan of care, progress notes.

Source-oriented Records

Traditional client record Each discipline makes notations in a

separate section Information about a particular problem

distributed throughout the record Narrative charting used


Problem-oriented Medical Records (POMR)

Data arranged according to client problem Health team contributes to the problem list,

plan of care, and progress notes for each problem

Uses SOAP, SOAPIE, SOAPIER documentation

Encourages collaboration Easier to track status of problems Vigilance required to maintain problem list Less efficient documentation process


PIE Documentation

Groups information into three categories: Problem, Interventions, Evaluation

Consists of client assessment, flow sheet, and progress notes


Focus Charting

Focus on client concerns and strengths Progress notes organized into DAR

format Holistic perspective of client and client’s

needs Nursing process framework for the

progress notes


Charting by Exception (CBE) Incorporates flow sheets, standards of

nursing care, bedside chart forms Agencies develop standards of nursing

practice Documentation according to standards

involves a check mark Exceptions to standards described in

narrative form on nurses’ notes


Sample Vital Signs Graphic Record


Computerized Documentation

Developed to manage volume of information

Use of computers to store the client’s database, new data, create and revise care plans and document client’s progress

Information easily retrieved Possible to transmit information from

one care setting to another


Computerized Charting


Legal and Ethical Standards for Documentation Client’s record is a legal document May be used to provide evidence in

court


Factors to Consider

Timing Legibility Permanence Accepted

terminology Correct spelling Signature

Accuracy Sequence Appropriateness Completeness Conciseness Legal prudence


Guidelines for Reporting Client Data Should be concise, including pertinent

information but no extraneous detail Types of reporting:

Change-of-shift reportTelephone reportsCare plan conferenceNursing rounds


Guidelines for Change-of-Shift Report Follow a particular order Provide basic identifying information For new clients provide the reason for

admission or medical diagnosis/es, surgery, diagnostic tests and therapies in the past 24 hours

Significant changes in client’s condition


Guidelines for Change-of-Shift Report Provide exact information Report client’s need for emotional support Include current nurse and physical-prescribed

orders Provide a summary of newly admitted clients,

including diagnosis, age, general condition, plan of therapy, and significant information about the client’s support people

Report on clients who have been transferred or discharged

Clearly state priorities of care and care due after the shift begins

Be concise


Guidelines for Receiving a Telephone Report Document date and time Record the name of person giving the

information Record the subject of the information

received Repeat information to ensure accuracy Sign the notation


Guidelines for Giving a Telephone Report Be concise and accurate State name and relationship to client State the client’s name, medical diagnosis,

changes in nursing assessment, vital signs related to baseline, significant laboratory data, related nursing interventions

Have chart ready to give any further information needed

Document the date, time, and content of the call


Guideline for Receiving Telephone and Verbal Orders Know the state nursing board’s position

on who can give and accept Know the agency policy Ask prescriber to speak slowly and

clearly Ask prescriber to spell out the

medication if unfamiliar Question the drug, dosage, or changes

if seem inappropriate


Guideline for Receiving Telephone and Verbal Orders Write the order down or enter into a

computer Read the order back to the prescriber Use words instead of abbreviations Write the order on the physician’s order

sheet, record date, time, indicate it was a telephone order, and sign name with credentials


Guideline for Receiving Telephone and Verbal Orders When writing a dosage always put a

number before a decimal, but never after a decimal

Write out units Transcribe the order Follow agency protocol about signing

the telephone order Never follow a voice-mail order


Prohibited Abbreviations, Acronyms, and Symbols JCAHO National Patient Safety Goals

(2004) “Do Not Use” list Many banned abbreviations refer to

medications Others derived from Latin


Health and Illness Health – presence or absence of

diseases“A state of complete physical, mental and

social well-being, and not merely the absent of disease or infirmity. (WHO 1948)

Wellness – a state of well-being. The whole being of the individual

Illness – highly personal state in which persons holistic views of functioning is thought to be diminished

Dimensions of Wellness Variables influencing health status

Health status Health beliefsHealth behaviors/practices

Internal Variables – non-modifiable variables Biologic dimension – genetic, gender, agePsychological dimension (emotional) – mind-body

interactions and self conceptCognitive dimensions – intellectual factors, lifestyle choices

and spiritual and religious belief. External Variables – modifiable, variables affecting

Environment, standards of living, family and cultural beliefs and social support network.

Dimensions of Wellness


Physical Dimension

Ability to carry out daily tasks Achieve fitness

Maintain nutrition Avoid abuses


Social Dimension

Interact successfully Develop and maintain intimacy

Develop respect and tolerance for others


Emotional Dimension

Ability to manage stress Ability to express emotion


Intellectual Dimension

Ability to learn Ability to use information effectively


Spiritual Dimension

Belief in some force that serves to unite


Occupational Dimension

Ability to achieve balance between work and leisure


Environmental Dimension

Ability to promote health measure that improvesStandard of livingQuality of life


Health – Illness Continua

Grids or graduated scales – used to measure persons perceived level of wellnessDunn’s High Level wellness (environmental

axis)

Travi’s Illness-Wellness Continuum

Health-Illness Continuum Measure person’s perceived level of wellness Health and illness/disease opposite ends of a health

continuum Move back and forth within this continuum day by day Wide ranges of health or illness


Three levels of Prevention Prevention – avoiding the development of

diseases in the future.

Primary Prevention Health promotionProtection against specific health problems Purpose is to decrease the risk or exposure of

individual or community to disease. ○ Example of primary prevention

Stop smoking, avoid prolong exposure to the sunSupport antipollution legislationPractice safe sex, monogamy, or abstinence

Secondary preventions Early identifications of health problems Prompt intervention o alleviate health

problems Goal is to identify client in an early stage of

disease process and limiting future disabilityExamples:

○ Undergo screening for tuberculosis ○ Have yearly, papinicolaou smears and

mammograms per recommended guidelines . ○ Practice monthly SBE & STE

Tertiary level of prevention Focuses on restoration and rehabilitation Returning the individual to an optimal level

of functioning. Examples:

○ Have a speech therapy after stroke○ Have a complete blood count before

chemotherapy○ Participate in stroke or coma rehabilitation ○ Substance abuse or drug addict rehabilitation

center.

Levels of Care

Health Promotion Behavior motivated by the desire to increase

well being and actualize human health potential (Pender, Murdaugh, Parsons; 2006)

Not disease orientedSeeks to expand positive potential for health

Disease Prevention Also known as Health protection Illness of injury specific Motivated by avoidance of illnessSeeks to thwart the occurrence of insults to health and

well being

Health Maintenance Maintaining the current healthy status

Curative cures diseases or condition

Rehabilitative Assisting clients to restore their health and recuperate

Health Promotion Model (HPM)

Link to HPM Figure 16-4 pg. 279 Competence or approach-oriented

model Motivational source for behavior

changes based on individual’s subjective value of the change


Variables of HPM Individual characteristics and experiences

Prior related behaviorsPersonal factors

Behavior-specific cognitions and affectPerceived benefits of actionPerceived barriers to actionPerceived self-efficacyActivity-related affectInterpersonal factorsSituational influences


Variables of HPM

Commitment to a plan of action Immediate competing demands and

preferences Behavioral outcome


Documents

Vital Signs