Chapter 17: Vital Signs

VITAL SIGNS TEMPERATURE BLOOD PRESSURE PULSE RESPIRATIONS APICAL RADIAL RESPIRATIONS PULSE OXIMETRY PAIN SCALE

VITAL SIGNS ARE PART OF THE PHYSICAL ASSESSMENT Delegation of Duties to UAP Unlicensed Assistive Personnel RN is Responsible to Manage Care Based on Physical Assessment Administering medications Communicating to other members of the health care team Supervising delegated tasks

EQUIPMENT RN is responsible for assuring equipment is functioning properly Appropriate equipment Must be appropriate to patient age size Thermometer Stethoscope: Diaphragm (high-pitched sounds); bell (low-pitched sounds) BP cuff Pulse oximeter

PATIENT HISTORY RN must know patient medical history, including medications These facts can affect vital signs RN is responsible for knowing the patient’s usual vital sign range

FREQUENCY OF VITAL SIGNS Physicians order the frequency of vital signs Could be ordered by protocol or policy The RN can increase the frequency based on his/her assessment VITAL SIGNS can be an early warning sign that complications are developing

INDICATIONS FOR MEDICATION ADMINISTRATION Many medications are administered when the vital signs are within an acceptable range. Accurate VITAL SIGNS are required in order to make treatment decisions.

COMPREHENSIVE ASSESSMENT FINDINGS Compare VITAL SIGNS to assessment findings and laboratory results to accurately interpret the patient status. Discuss your findings with peers and charge RN before deciding on a plan of action. Use the opportunity to teach patient/family about what VS mean, reason for assessing, meaning if appropriate

TEMPERATURE Factors affecting body temp. (36-38°C/96.8-100.4°F) Age Infants: 95.9 – 99.5° F [36.5-37.2C] intolerant of extremes Elderly: Average temp is 96.8° F; Sensitive to temp extremes Exercise Hormone levels Circadian rhythm Stress Environment

TEMPERATURE ALTERATIONS Afebrile Pyrexia [fever] >37.5 Fever of unknown origin (FUO) Malignant hyperthermia: hereditary, occurs during anesthesia Heatstroke: medical emergency Heat exhaustion Hypothermia Frostbite Heat stroke: High mortality rate, very young or very old, CV disease, hypothyroidism, DM, alcoholism S/S: giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, incontinence Temp sometimes as high as 113 with an increase in pulse and decrease in BP Hot, dry skin is important sign Don’t sweat due to severe electrolyte loss and hypothalamic malfunction Can cause permanent neuro damage Hypothermia: May be unintentional or intentional (surgery) S/S: uncontrolled shivering, loss of memory, depression, poor judgment, VS decreased, cyanosis If progresses, develop dysrhythmias, loss of consciousness, and unresponsive to painful stimuli Frostbite: Ice crystals form inside the cell, permanent circulatory and tissue damage occurs Areas of susceptibility include earlobes, tip of nose fingers and toes Area becomes white, waxy and firm to touch

TEMPERATURE Cont’d. Sites Common sites: Core temp is measured in pulmonary artery, esophagus, and urinary bladder Common sites: Mouth, rectum, tympanic membrane, temporal artery, and axilla – use critical thinking to decide! Variety of types available – electronic and disposable Antipyretics = drugs that reduce fever

Using an oral electronic thermometer, the nurse checks the early morning temperature of a client. The client's temperature is 36.1° C (97° F). The client's remaining vital signs are in the normally acceptable range. What should the nurse do next? A) Check the client's temperature history. B) Document the results; temperature is normal. C) Recheck the temperature every 15 minutes until it is normal. D) Get another thermometer; the temperature is obviously an error. Correct answer is A – Know pt’s baseline vitals

PULSE Sites Increases in HR Decreases in HR Temporal, Carotid, Apical, Brachial, Radial, Femoral, Popliteal, Posterior Tibial, Dorsalis Pedis Increases in HR Short-term exercise, fever, heat, pain, anxiety, drugs, loss of blood, standing or sitting, poor oxygenation Decreases in HR Long-term exercise, hypothermia, relaxation, drugs, lying down

PULSE Cont’d. Volume of blood pumped by the heart during 1 minute is the cardiac output When mechanical, neural or chemical factors are unable to alter stroke volume, a change in heart rate will result in change in cardiac output, which affects blood pressure HR ↑, less time for heart to fill, BP ↓ HR ↓, filling time is increased, BP ↑ An abnormally slow, rapid, or irregular pulse alters cardiac output

The nurse decides to take an apical pulse instead of a radial pulse The nurse decides to take an apical pulse instead of a radial pulse. Which of the following client conditions influenced the nurse's decision? A) The client is in shock. B) The client has an arrhythmia. C) The client underwent surgery 18 hours earlier. D) The client showed a response to orthostatic changes. Correct answer is B

RESPIRATIONS Ventilation = the movement of gases in and out of lungs Diffusion = the movement of oxygen and CO2 between the alveoli and RBCs Perfusion = the distribution of RBCs to and from the pulmonary capillaries

Factors Influencing Character of Respirations Exercise Acute Pain Anxiety Acid-Base balance Body Position Medications Neurological injury Hemoglobin function

RESPIRATIONS Cont’d. Tachypnea = rapid breathing Apnea = cessation of breathing Cheyne-Stokes = rate and depth irregular, alternate periods of apnea and hyperventilation Kussmaul’s = abnormally deep, regular, and increased in rate (associated with DM)

PULSE OXIMETER Indirect measurement of oxygen saturation Photodetector detects the amount of oxygen bound to hemoglobin molecules and oximeter calculates the pulse saturation Only reliable when SaO2 is over 70% Certain conditions may give an inaccurate reading The following conditions may give an inaccurate reading Carbon monoxide poisoning Rapid movement by the patient Seizures, tremors, etc. If the patient is suffering from hypothermia or anemia Nail polish on the as it may not allow the infrared light to pass Raynauds

A client is being monitored with pulse oximetry A client is being monitored with pulse oximetry. On review of the following factors, the nurse suspects that the values will be influenced by which of the following? A) The placement of the sensor on the extremity B) A diagnosis of peripheral vascular disease C) A reduced amount of artificial light in the room D) The increased ambient temperature of the client’s room Correct answer is B

BLOOD PRESSURE Force exerted on the walls of an artery by the pulsing blood under pressure from the heart Systolic = maximum pressure when ejection occurs Diastolic = minimum pressure of blood remaining in the arteries after ventricles relax

BLOOD PRESSURE Cont’d. Physiology of arterial blood pressure Cardiac Output, Peripheral resistance, Blood volume, Viscosity, Elasticity Factors influencing BP Age, Stress, Ethnicity, Gender, Daily Variation, Meds, Activity, Weight, Smoking Hypertension Hypotension Orthostatic or postural hypotension Electronic device not always appropriate Irregular HR Peripheral vascular obstruction (clots) Shivering Seizures Excessive tremors Inability to cooperate BP less than 90 systolic

B) The client’s inability to hear the first Korotkoff sound The nurse is assessing a client’s blood pressure during a routine visit. When asked, the client volunteers that when he took his pressure at home yesterday it was 126/72 mmHg. The nurse determines that the client’s pressure today is 134/70 mmHg. The nurse recognizes that the most likely cause of the elevation is due to which of the following? A) The difference between the monitoring equipment being used B) The client’s inability to hear the first Korotkoff sound C) The client may be experiencing mild anxiety regarding the check-up D) The client is not inflating the cuff sufficiently to detect the systolic pressure Correct answer is C

QUESTIONS?