Taking Vital Signs

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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