Vital Signs

Chapter 12Bethann Davis MSN,NP

PNU Fall 2015

Learning Objectives

• List the components measured during assessment of “vital signs”

• Name various sites used and differences in measurement when assessing a temperature.

• Discuss factors that affect a person’s temperature.

Learning Objectives (cont)• Define following terms about a

temperature

afebrile

antipyretics

febrile

fever

pyrexia

hypothermia

hyperthermia

Learning Objectives (cont)

• List three signs/symptoms that accompany a fever.

• Name the sites used for pulse assessment.

• Identify three characteristics noted when assessing a pulse.

Learning Objectives (cont)

• Define following terms

bradycardia

palpitation

tachycardia

Learning Objectives (cont)

• Differentiate between normal and abnormal breathing patterns.

apnea

bradypnea

dyspnea

tachypnea

Learning Objectives (cont)

• Explain the difference between systolic and diastolic blood pressure.

Describe the five phases of Korotkoff blood pressure sounds.

• List factors that can affect a person’s blood pressure.

• Name the various methods for assessing a blood pressure.

Learning Objectives (cont)

• Define the following terms

pulse pressure

hypertension

hypotension

postural hypotension

Learning Objectives (cont)

• Identify the action and nursing implications for

Cardiotonics

Antihypertensives

Bronchodilator medications

Vital Signs

• Body temperature

• Pulse

• Respiratory rate

• Blood pressure

• Pain (5th sign)

Vital Signs

Frequency of assessment:

on admission – baseline data

post operative

change in condition

severely ill

blood transfusion

Vital Signs

Frequency of assessment (cont)

medical orders

before & after giving cardiac

medications

nursing judgment

Temperature

Definition:

warmth of the human body

produced from exercise & metabolism of food

heat lost through skin, lungs and body waste products

Temperature

• Core temperature:

warmth in deeper sites of body,

brain & heart

• Shell temperature:

warmth at skin surface

Temperature

Normal Adults:

range 96.6° F to 99.3 ° F

Elderly :

normally lower than adult readings

Newborns & young children:

slightly higher than adult readings

Temperature

Pyrexia (fever): above 99.3° F

Hyperpyrexia, hyperthermia: high fever, above 106° F interventions: antipyretics, cool

baths, cool blankets, cool drinks

Temperature

Hypothermia: below normal limits

death may occur if below 93.2 °F

chemical reactions & metabolic

demands for oxygen are

decreased

Temperature

Factors affecting temperatureagefood intakeexerciseclimateillnessmedications

Temperature

Assessment sites: normal temps will vary, depending on site – must

record site

oral (most often used) - 98.6°ear (closest to core) - 99.5°

Temperature

rectal - 99.5°temporal artery - 99.4°axillary - 97.5°

Pulse

• Produced by the movement of blood during the heart’s contraction

• (L) ventricle ejects blood into aorta

• Can be felt by palpation

Pulse

Assessment of pulse

rate

rhythm

volume (quality of beat)

Pulse

Assessment sites

heart – apical pulse

peripheral – carotid, temporal,

brachial, radial, femoral,

popliteal, posterior tibial,

dorsalis pedis

apical/radial pulse – both at same

time

Pulse

Terms

• tachycardia – rate above 100 bpm

• bradycardia – rate below 60 bpm

• pulse deficit – difference between apical and radial pulses

Pulse

Terms (cont)

• Stroke volume – amount of blood pumped from (L) vent. w/ each contraction

• Cardiac output – amt. of blood pumped from (L) vent. per min.

(stroke volume x heart rate)

Pulse

Doppler ultrasound device

To be used over a peripheral artery when pulse cannot be palpated

Respirations

Definition

The act of breathing in (inspiration) and breathing out (expiration)

Exchange of oxygen and carbon dioxide

Respirations

Assessment

assess chest/back according to a

pattern

rate – normal 14-20

quality – normal, shallow, deep

Respirations

Terms:

tachypnea – over 20 per min

bradypnea – under 12 per min.

apnea – absence of breathing

dyspnea – difficulty breathing

Respirations

Terms (cont)

orthopnea – high Fowlers position

for breathing

Cheyne Stokes – gradual ↑, then ↓

in resp, then period of apnea;

repeating

Respirations

Breath sounds

normal

abnormal (adventitious)

crackles

gurgles

wheezes

Blood Pressure

Definition:

• The force of blood against the arterial walls

• Cuff (sphygmomanometer)

• Numbers (manometer)

Blood Pressure

Systolic blood pressure (top number):

maximum pressure of arteries

when (L) vent. contracts & pushes

blood into aorta

Blood Pressure

Diastolic blood pressure (bottom number):

lowest pressure on arterial walls

when heart is at rest; refilling

w/ blood

Blood Pressure

Pulse pressure:

difference (in numbers) between systolic and diastolic pressures.

30 – 50 normal

120/80 = 40

Blood Pressure

Factors affecting BPelasticity of blood vessels

pumping action of heart

blood volume,

viscosity of blood

Blood PressureFactors affecting BP (cont) age, exercise

pain

medications

gender, circadian rhythm

cuff size

Blood Pressure

Assessment sites

• Brachial artery

• Popliteal artery

Blood Pressure

Terms:Korotkoff sounds – 5 sounds

heard during taking of BP

hypertension - sustained above 130/89

hypotension – sustained below normal range

Blood Pressure

Terms (cont)

orthostatic or postural hypotension:

associated with dizziness or

fainting when sitting or

standing

Considerations

Many older clients have dysrhythmias

check P, BP carefully

Make sure BP cuff is secure, not too tight or loose - can give false readings

Clients talking during BP readings can give false high

Considerations

Wait at least 10 min. after a client has had a drink to take temp.

Must have 2 people to do apical radial pulse correctly

Always document vital signs after taking them.