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Vital Signs

Taking Vital Signs

Vital signs may include:

  • Respirations, Pulse, Oxygen saturation, Temperature, Blood pressure, Pain

______

Check suspicious condition

Monitor existing condition

Limitations

May or may not detect important physiologic changes

  • Indicate further investigation
  • Normal does not equal ______

Temperature

Cellular metabolism requires a stable core, or “deep body,” temperature of a mean of 37.2° C (99° F)

Body maintains steady temperature through a thermostat, or feedback mechanism, regulated in hypothalamus of brain

Thermostat balances heat production (from metabolism, exercise, food digestion, external factors) with heat loss (through radiation, evaporation of sweat, convection, conduction)

Various routes of temperature measurement reflect body’s core temperature

Celsius vs Fahrenheit

Most facilities document in celsius (universal)

Fahrenheit to Celsius (°F - 32) x 5/9 = °C

Celsius to Fahrenheit (°C × 9/5) + 32 = °F

°F to °C Deduct 32, then multiply by 5, then divide by 9 °

C to °F Multiply by 9, then divide by 5, then add 32

Variables affecting Temperature

Circadian (______) Rhythms

  • Trough occurs in early morning hours and peak occurring in late afternoon to early evening

Hormones (progesterone)

Age (infant, elderly)

Exercise

Stress

Environment

Temperature Routes

Oral

  • 37° C (98.6° F), with a range of 35.8° C to 37.3° C (96.4° F to 99.1° F)
  • Convenient, accessible
  • Right or left posterior sublingual pocket
  • Accuracy varies ingestions of hot/cold drinks immediately prior to assessment
  • Wait 15-20 minutes

Rectal

  • 0.4° C to 0.5° C (0.7° F to 1° F) higher than oral
  • Considered most accurate
  • Invasive and uncomfortable
  • Used in infants and children
  • Use gloves, probe covers, and lubrication
  • Risk for ______
  • Insert only ½-1 inch
  • Check setting on digital thermometer

Axillary

  • 0.4° C to 0.5° C (0.7° F to 1° F) lower than oral
  • Safe and noninvasive
  • Placement and position of thermometer tip affects reading
  • Middle of armpit with arm down at side
  • Wait at least 15 minutes after bathing or exercising

Tympanic (calibrated to oral or rectal scales)

  • Convenient, safe, fast
  • Research inconclusive of accuracy
  • Technique affects reading

Temporal Artery

  • Scans the forehead area for the temporal artery
  • Easy to Use
  • Non-invasive
  • Ideal for all age groups
  • Clinically proven to be more accurate than tympanic thermometry

Assessment of Pulses

May evaluate carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis

Apical pulse

Pulse Characteristics

Rate: Number of beats in 1 minute

  • Influenced by blood pressure, age, gender, activity, emotions, pain, environment, medications, and disease
  • Adult: ______bpm
  • May take for 30 seconds x2
  • Most accurate rate is measured apically using a stethoscope for a 60 second count period
  • Infants –use brachial or apical

Rhythm: Regular vs Irregular

  • Second most important observation

Symmetry: Right vs Left

Amplitude: Pulse strength

  • Absent to bounding
  • If not palpable, try a ______ultrasonic stethoscope
  • Graded

Grading Pulses

Grade Findings

0 Absent pulse

1+ Weak and thready

2+ Normal

3+ Full and bounding

(Some agencies use a four-point scale)

Respirations

One inspiration and one expiration = 1 breath

Adult = ______breaths per minute

In adults, frequently taken with pulse

  • Pulse for 30 sec, Respirations for 30 sec
  • Discreetly observe client’s breathing

In babies, taken with stethoscope

If chief complaint is respiratory, client is an infant, or you have difficulty assessing rate, take for a full 60 seconds

May vary with anxiety, crying, excitement, fever, exercise, medications, altitude, and age

Oxygen Saturation

Oxygen saturation (SO2) measures the percentage of hemoglobin binding sites in the bloodstream occupied by oxygen.

Pulse oximeter = device

Normal = 95% - 100%

Less than 92% = hypoxia

  • Standing order in most facilities is to start ______of oxygen via nasal cannula

Pulse Oximeter

Need to be calibrated

Place probe on tip of finger/toe/ear

  • Reading will vary if:
  • Finger/toenail has polish on it
  • Extremity is cold/decreased circulation
  • Skin is not intact
  • Probe is placed over jewelry

Record number/check orders

Blood Pressure

Force exerted by blood on the arterial walls

Blood pressure is expressed in a ratio of systolic/diastolic (120/80)

Systolic Blood Pressure: pressure exerted on the arterial wall when the heart ventricles are contracting

Diastolic Blood Pressure: pressure exerted on the arterial wall when the ventricles are relaxed

Factors Affecting Blood Pressure

Age

Gender

Race

Diurnal rhythm

Weight

Exercise

Emotions

Stress

Cardiac Output

Peripheral Vascular Resistance

Blood Volume

Viscosity

Elasticity of Walls

American Heart Association recommended blood pressure levels

BP Category Systolic Diastolic

Normal less than 120 less than 80

Prehypertension 120–139 or 80–89

High (HYPERTENSION)

Stage 1 140–159 or ______

Stage 2 160 or higher or 100 or higher

Hypertension

Due to:

  • Thickened arteries, inelastic arteries
  • Smoking
  • Obesity
  • Lack of exercise
  • Hypercholesterolemia
  • Stress

Hypotension

Low blood pressure <______

This is relative…

Orthostatic Hypotension

  • Measured supine, sitting, then standing
  • Wait 1 -3 minutes between positions
  • Decrease in SBP of more than 20 points (this again, is relative)

Equipment

Sphygmomanometer

  • Aneroid: Dial
  • Mercury

Electronic Sphygmomanometers

Stethoscope

  • Bell vs Diaphragm Side
  • Doppler Ultrasound stethoscope

Stethoscopes

Tubing

Eartips

Chestpiece

  • ______– low pitch
  • Diaphragm – High pitch

How to work your stethoscope

If you have a double sided:

If you have a one sided:

Ear Placement

Correct:

  • Hold the headset in front of you with the eartips pointing away
  • Once the eartips are in your ears, they should point forward

Incorrect – Eartips back

Blood pressure cuff

Blood pressure cuff

  • Cuff size important
  • Bladder width should be about ______% of the arm circumference
  • Cuff too narrow: False-high blood pressure
  • Cuff too wide: False-low blood pressure

Korotkoff’s sounds

Phase 1: systolic BP –first sound heard, sharp tapping

Phase 2: swishing/swooshing (can be an absence of sound)

Phase 3: tapping, softer than phase 1

Phase 4: softer blowing muffled, last sound is diastolic BP

Phase 5: silence

Methods

Direct (insertion of catheter into an artery)

Indirect

  • Auscultatory – usual method
  • Palpatory – used to determine initial reading, used when unable to auscultate BP

Site Choice

Either arm, using brachial artery

When not to use a particular limb

  • Use thigh when arms unavailable (burns or injuries to both arms)
  • Use opposite arm in cases of:
  • Mastectomy with lymph node dissection
  • IV infusion
  • Fistula

Do not take over ______

Do not use forearm

Implementation

Position appropriately

  • Have sit quietly for 5 minutes
  • Extend arm and support at heart level, palm up
  • Make sure client does not have legs crossed

Wrap deflated cuff around upper arm – apply center of the bladder directly over the brachial artery - one inch above antecubital space

Determining a Target Pressure

Perform a preliminary palpatory determination of SBP if this is an initial examination

  • Palpate the brachial artery
  • Pump up cuff until you no longer feel the brachial pulse, note pressure on sphygmomanometer
  • Release cuff, wait 1 – 2 minutes (avoids false ______readings)

Implementation

Position stethoscope appropriately

Auscultate the patient’s blood pressure

  • Pump up cuff until sphygmomanometer reads 30 mm Hg above the point where the brachial pulse disappeared
  • Release valve carefully so that the pressure decreases at the rate of 2-3 mmHg per second
  • Try to identify 5 phases
  • Deflate cuff rapidly and completely

Remove cuff

Document data (even numbers)

  • SBP/DBP = 106/68
  • Record RA (right arm) or LA (left arm), RL (right leg) or LL

Erroneously High BP

Bladder cuff too narrow

Arm unsupported

Insufficient rest before the assessment

Repeating assessment too quickly

Cuff wrapped unevenly

Assessing immediately after a meal, smoking, caffeine containing beverage

Assessing when client has pain

Erroneously Low BP

Bladder cuff too wide

Deflating cuff too quickly (low SBP)

Arm above level of heart

Failure to identify auscultatory gap

Sources of Pain

Visceral pain – large interior organs

Deep somatic pain – blood vessels, joints, muscles, bones

Cutaneous pain – skin surface

______pain – Originates from a different location than felt

Types of Pain

Acute pain

  • Short term
  • Self-limiting
  • Follows a predictable trajectory
  • Dissipates after injury heals

Chronic pain

  • Continues for 6 months or longer
  • Types are malignant (cancer-related) and nonmalignant
  • Does not stop when injury heals

Pain Assessment

Pain assessment questions

  • Where is your pain?
  • When did your pain start?
  • What does your pain feel like?
  • How much pain do you have now?
  • What makes the pain better or worse?

Pain Assessment Tools

Initial pain assessment

Brief pain inventory

Short-Form McGill Pain Questionnaire

Pain rating scales

  • Numeric rating scales
  • Descriptor scale

Charting

Vitals:

  • 128/86 LA sitting
  • 37.2°C orally
  • Apical pulse 82 regular, Radial pulses +3, symmetrical and regular at 80
  • O2 sat 98% on room air
  • RR = 16
  • Pain = 0 on 0-10 scale

Can also use a graphing flow sheet