Vital Signs: Unlocking the Mysteries of the Client’s Health Status

Vital Signs Provide One of the Most Important Keys to the Client’s Baseline Status and Response to Medical or Nursing Treatment

Guidelines for Taking Vital Signs Collection of vital signs during the routine assessment provides a

baseline for future assessments. The nurse is responsible for vital signs interpretation, but may delegate

activity to an unlicensed personnel. Equipment must be functional and appropriate for age. Important to know the usual values for the individual client. Trends

are most important. Important to recognize the effects of medical history and current

medications. Minimize environmental factors that affect the vital signs. The nurse should demonstrate vital signs in an organized, systemic

approach with a calm and caring manner. Medications may be administered based on vital sign values. Physician

or other responsible care providers should be notified of abnormalities.

Physiology of Body Temperature Body temperature is the

difference between heat produced by internal processes and heat lost through the external environment.

Temperature control mechanisms keep the the body’s core temperature relatively constant.

Acceptable range is 36.5-37.5 degrees C (97.6 – 99.6 degrees F).

Various sites may be used but the pulmonary artery is the most accurate.

Thermoregulation Hypothalamus –

“thermostat” of the body, is located between the cerebral hemispheres.

Anterior – reduces body temperature.

Posterior – increases body temperature.

Basal metabolic rate (BMR)

Heat loss – radiation, conduction, convection, evaporation, diaphoresis

Skin plays an important role in temperature regulation.

Behavioral control affects temperature.

Temperature Alterations Hyperpyrexia (fever) – heat loss is unable to keep pace with excess

heat production Pyrogens – bacteria and viruses cause a rise in body temperature. Febrile – state of elevated body temperature Afebrile – absence of fever Fever is an important defense mechanism. Mild temp (< 102.2 degrees F) can enhance the immune system. FUO – fever of unknown origin Hyperthermia – elevated body temperature Malignant hyperthermia – hereditary condition of uncontrolled heat

production, occurs in susceptible persons that receive certain anesthetic drugs.

Hypothermia – decreased body temperature, classified by core temperature measurements.

Temperature AssessmentS u rface & C ore S ites

* tym p an ic m em b ran e(A lso con s id ered co re )

axilla ry

o ra l (m ou th ) rec ta l

Surface S ites

Core S itesesop h ag u s , p u lm on ary a rte ry,

u rin ary b lad d er

Thermometers Glass

• Oral – slim or elongated

• Stubby can be used for all sites

• Red bulb – rectal only

Electronic• Blue – oral or

axillary• Red – rectal

Tympanic

Temperature Conversions

F = (9/5 x C) + 32

104 F = (9/5 x 40 C) +32

C = (F-32) x 5/9

40 C = (104F –32) x 5/9

Converting Fahrenheit to Centigrade

101*F 99.6*F

C = (F – 32) x 5/9

C = ( 101 – 32 ) x 5/9

C = 69 x 5/9

C = 38

C = (99.6F – 32) x 5/9

C = 67.6 x 5/9

C = 37.5

Convert Centigrade to Fahrenheit

38*C

F = (C x 9/5) + 32 F = (38C x 9/5) +32 F = 68.4 + 32 F = 100.4

Treating a Fever

Tepid sponge bath

Ice packs Antipyretics

Hypothermia blanket

Cooling fans Avoid the stimulation of shivering

Pulse Palpable bounding of blood flow noted at various points of

the body. Blood flows in a continuous circuit. Electrical impulses are initiated by the SA node and

stimulated the heart muscle to contract. Stroke volume – amt of blood pumped from the heart with

each contraction. Cardiac output – amt of blood ejected from the heart in 1

min.– CO = SV x HR– Normal CO = 4-6 liters/min

Mechanical, neural, and chemical factors regulate the strength of contractions and stroke volume.

Pulse Sites

•Carotid most common in emergencies.

•Radial is most common for routine examination.

•Apical pulse provides a more accurate assessment of heart function.

Temporal Carotid

Radial Ulnar

Brachial Apical

Femoral Popliteal

Dorsal

pedis

Posterior

tibial

Assessment of the Pulse

RateApical S1 = lub

S2 = dubRhythmStrength (Quality)Equality

Questions

Which pulse point would allow you to best assess the circulation to the feet.

A. temporal B. brachial C. posterior tibial D. pedis ulnus

An irregular rhythm requires a full minute of assessment.

True or False?

Respirations Ventilation –

movement of gases in and out of lungs

Diffusion – movement of oxygen and CO between alveoli and RBC

Perfusion – the distribution of RBC to and from pulmonary capillaries

Physiological Control Inspiration is active Respiratory center of the

brain controls respirations Normal rate 12-20/min

(adult) and 40- 60/min (infants)

Levels of CO2 help regulate ventilation - Increased CO2 leads to increased ventilation

- In COPD patients low levels of O2 stimulate respirations

Hypoxemia – low levels of arterial O2.

Mechanics of Breathing Inspiration is active

process initiated by impulses from phrenic nerve. Diaphragm contracts and chest wall moves out.

Expiration is passive process. Diaphragm relaxes and chest wall returns to normal position.

Assessment of Respirations

A ssess in g R esp ira tion s

R ateO b serve in sp ira to ry

& exp ira to ry m ovem en ts

V en tila to ry D ep thD eg ree o f m ovem en t

V en tila to ry R h yth mO b serve ch es t &

ab d om in a l m ovem en ts

Oxygen Saturation SaO2 = percent of

hemoglobin that is bound with oxygen in the arteries.

Normal SaO2 is 95-100%.

Pulse oximeter is utilized to provide indirect measurement of oxygen saturation.

Values obtained with pulse oximetry are less reliable if the SaO2 is <70%.

May apply probe to finger or earlobe. Sole of foot may be used in infants.

Questions

An infant is brought into the emergency by his mother with a fever for 2 days. You find the following respiration rate of 40 which is regular and unlabored.

A. You notify the provider immediately B. You document the finding as R 40 C. You set the infant upright and apply

oxygen.

Blood Pressure Definition – lateral force on the walls of the artery

by the pulsing blood under pressure from the heart.

Blood is forced from atria to ventricles to aorta. Systolic = peak of maximum pressure when

ejection occurs. Diastolic = minimum pressure, the ventricles have

relaxed and the blood remaining in the arteries is at the lowest pressure.

Pulse pressure = difference between systolic and diastolic. Normally 30 – 50 mm Hg.

Physiology of Blood Pressure

Cardiac Output – volume of blood ejected over 1 minute. CO = SV x HR

Stroke Volume – amount of blood ejected from the heart with each contraction.

Blood pressure is affected by cardiac output and peripheral vascular resistance.– BP = CO x resistance– Peripheral resistance, blood volume, viscosity,

and elasticity all play a role in blood pressure.

Factors Affecting Blood Pressure

Age Stress Race

Medications Diurnal Variation

Gender

Abnormalities in Blood Pressure Hypertension – (JNC7) the average of 2 or

more properly measured, seated BP readings: SBP 140-159 or DBP 90-99, classified as stage 1 hypertension.

HTN associated with family hx, cigarette smoking, obesity, heavy alcohol consumption, high Na intake, sedentary lifestyle, diabetes, age, and race.

Hypotension – SBP < 90 mm Hg. Associated S/S are pallor, decreased UOP, increased HR, clamminess, confusion.

Orthostatic hypotension – Decreased in BP with increase in HR and resp. Associated by volume depletion.

Questions

This is the first time you have seen this 45 year old female. She has no prior medical history. Her blood pressure reading is 148/94. Does this support the diagnosis of hypertension? Why or why not?

She comes back in one week for a recheck of her blood pressure. Her BP is 154/90. She is diagnosed with hypertension by the primary care provider. Which of the following could be affecting her BP?

A. age B. weight 185, height 5’4” C. stress D. inadequate equipment

Pediatric Considerations

Best results – count resp 1st, pulse 2nd, and temp last. If VS cannot be taken without disturbing the child, record

the child’s behavior (crying). Other s/s of increased temp: flushed skin, increased resp

and heart rates, malaise, and “glassy look” to eyes. Radial pulse in children > 2yrs. Infants < 2 yrs should use

apical pulse. Count for 1 full min d/t irregularities. Respirations – infants require observation of abdominal

movements d/t diaphragmatic breathing. Count for 1 full min.

Normal Pediatric Blood Pressure

Systolic– 1-7 years:

Age in years + 90

– 8-18 yrs: (2 x age in years) + 83

Diastolic– 1-5 yrs: 56

– 6-18 yrs: Age in years + 52