Vital Signs

Shurouq Qadose17/2/2008

Vital signs are temperature, pulse, respiration, blood pressure and pain. A change in vital signs may indicate a change in health.

 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:• 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.

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

• Thyroxine output; increased thyroxine output increases the rate of cellular metabolism throughout the body.

• Epinephrine, norepinephrene, and sympathetic stimulation/stress response. These hormones immediately increases the rate of cellular metabolism in many body tissues

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

Mechanism of heat loss:

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.

  

Vaporization; the conversion of a liquid to vapor such as body fluid in the form of perspiration and insensible loss is vaporized from the skin.

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.

Factors affecting body temperature:

• Circadian Rhythms; predictable fluctuations in measurement of body temperature and blood pressure such as body temperature is usually lower in the morning than in the evening.

• Age; the body temperature of infants and children changes more rapidly in response to both heat and cold.

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

• Stress; the body respond to both emotional and physical stress as a threat increasing the production of epinephrine and nor epinephrine as a result the metabolic rate increases raising the body temperature

• Environmental temperature; we are responding to a change in environment either by wearing or less clothes.

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

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:

• 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.

 Orally: It reflects changing body temperature more

quickly than the rectal method. Oral thermometers may have long, short, or rounded tips

 

Contra indication of oral temperature:

•  Breathing is difficult or rapid

• Can't close mouth for any reason

• Breathing through mouth

• Mouth is inflamed

• Confused or comatose

• Infant or young children

• Oral surgery/ broken jaw

• Unconscious/agitated people

Rectally; are considered to be very accurate.

Contra indication of rectal temperature

• Diarrhea

• Rectal surgery

• Clotting disorders

• Hemorrhoids "pile"

Axillary; is the preferred site for measuring temperature newborn because it is accessible and offers no possibility rectal perforation.

Contraindication of axillary temperature

• Thin patient

• Local inflammation

• Unconsciousness, shocked patients

• Constricted peripheral blood vessels.

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

Temporal artery thermometer are most useful for infants and children where a more invasive measurement is not necessary.

Advantages and disadvantages of four sites for body temperature measurement

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

Pulse

Pulse; is a wave of blood created by contraction of the left ventricle of the heart.

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.

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, 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 change; when the 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. A pulse with an irregular rhythm is referred to as a dysrhythmia or arrhythmia.

3. Volume is 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.

Mechanics and regulation of breathing

During 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.

External respiration; the interchange of oxygen and carbon dioxide between the alveoli of the lungs and the pulmonary blood. Internal respiration; the interchange of these same gases between the circulating blood and the cells of the body tissues.

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

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

Blood pressure is referred to the force of the blood against arterial walls. Maximum blood pressure is exerted on the walls of arteries when the left ventricles of the heart pushes blood through the aortic valve into the aortas during contraction, the highest pressure thus called systolic pressure.

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

Determination 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 vascular 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, 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• Elasticity of the arteries • Lifestyle 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. It occurs as a result of peripheral vasodilatation in which blood leaves the central body organs especially the brain and moves to the periphery

Factors associated with hypotension

• Analgesics

• Bleeding

• Severe burn

• Dehydration.

It is important to monitor hypotensive clients carefully to prevent falls. When assessing the 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

– After one minute in the upright position, check the pulse and blood pressure in the same site as previously

– Record the results, a rise in pulse of 40 beats per minute or a drop in blood pressure of 30mm Hg indicates abnormal vital signs.

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 on 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) Avoid having blood [pressure in injured or an area with cast

2) The client has had removal of axilla lymph node on that site

3) The client has intravenous line 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.