Vital Signs Assessment of Vital Signs Temperature

1/20/2011Vital SignsAssessment of Vital Signs• Temperature• Pulse• Respirations• Blood Pressure• The fifth vital sign• Pain• Oxygen SaturationTemperature• Regulation• hypothalamus• Core body temperaturet• Set point1

1/20/2011Heat Production• Metabolism• Shivering• ExerciseHeat Loss• Radiation• transfer from surface• Conduction• transfer throughdirect contact• Convection• transfer by airmovement• Evaporation• transfer when liquidchanged to a gasOral Temperature• 97 - 100 F (98.6)• 36 - 39 C (37)• must be able toclose mouth• eating or smoking,wait• Contraindications• unconscious• seizures• infants, youngchildren• oral disease/surgery• mouth breathing• oxygen by mask2

1/20/2011Rectal Temperature• Reliable• Contraindications• Higher than oral by• rectal surgery1o • diarrhea• rectal disease• heart diseaseOther Methods• Axillary• used when oral or rectal contraindicated• lower than oral by 1 o• Tympanic membrane• readily accessible• not affected by eating, smoking, cerumenElevated Temperature• Pyrexia• Hyperpyrexia3

1/20/2011Chill Phase• Signs andSymptoms• shivering• blood vesselsconstrict• absence of sweating• Care• assessment• blankets• fluids• nourishment• OxygenFever Phase• Temp at new setpoint• Signs andSymptoms• flushed skin• warm skin• weak, muscle aches• drowsy, restless• Care• Comfort• Hydration• Prevent shivering• Limit physical activity• Oral hygiene• Environmentaltemperature controlFlush or Crisis Phase• Signs andSymptoms• profuse diaphoresis• less shivering• flushed, warm skin• Care• fluids• light clothing• hypothermia blanket• Medications• Oral hygiene• Environmentaltemperature control4

1/20/2011Subnormal Temperature• Hypothermia• Chemical reactions slowed• Metabolic demands for oxygendecreasedAssessing Temperature• Glass thermometers• oral = blue, thin bulb• rectal = red, blunt tip• Electronic• oral = blue• rectal = red• Temperature sensitive patches5

1/20/2011Pulse• Rate• pulsations per minute• Infant normal = 80 - 180 per minute• Adult normal = 60 - 100 per minute• Slow < 60, bradycardia• Fast > 100, tachycardia• Slowest at rest, early morningTachycardia• pain• stress• fear• anger• anxiety• exercise• decrease BP• temp• low oxygen• medicationsPulse Rhythm• Pattern of pulsations• Regular• Irregular• dysrhythmia• arrhythmia6

1/20/2011Pulse Quality or Amplitude• Description of fullness of pulse• Ratings• 0 = Absent• +1 = thready, weak• +2 = normal• +3 = boundingAssessment Sites• carotid• brachial• radial• femoral• popliteal• posterior tibial• dorsal pedis• apical• 5th ICS left• use stethoscope7

1/20/2011Apical - Radial Pulse• 2 nurses• count at same time• differences found with irregular pulsesRespiration• Movement of air in and out of lungs• Regulation• carbon dioxide levels• oxygen levels• Normal adult rate: 12 to 20 per minute• Infant rate 30 - 80 per minuteDeviations From Normal• rate:• illness, fever• acute pain• stress• exercise• altitude• body position• rate• narcotics• CNS depressants8

1/20/2011Respiratory Terms• Apnea• Dyspnea• Orthopnea• Tachypnea• Bradypnea• Cheyne - StokesBlood Pressure• Force of blood against vessel walls• Systolic pressure• Diastolic pressure• Pulse pressureFactors to Maintain BP• Peripheral Resistance• Pumping action of the heart• Blood volume• Viscosity of the blood• Elasticity of vessel walls9

1/20/2011Factors Affecting BP• Age• Time of day• Gender• Eating• Exercise• Emotions• Position• Activity• Smoking/drinkingClassification of BloodPressure for AdultsBlood Pressure SBP DBPClassification mmHg mmHgNormal 100Source: The Seventh Report of the National committee on Prevention, Detection, Evaluation, and Treatment of High BloodPressure, US Department of Health and Human Services, National Institutes of Health. 2004.Hypotension• Usually considered less than 90 systolic• The patient’s tolerance is significant indetermining the diagnosis• Orthostatic or postural hypotension10

1/20/2011Proper Measurement• Correct position• arm at heart level• Arm above heart level - low reading• Arm below heart level - high reading• Korotkoff Sounds• first sound = systolic• absence of sounds = diastolic• Auscultatory gapProper Measurement• Cuff Size• too large - low reading• too small - high reading• Bladder width 40% of limb circumference• Bladder length 80% of limb circumference11