1. Vital Signs

2. What are Vital Signs?
Temperature (T)
Pulse (P)
Respiration (R)
Blood pressure (BP)
The VS are an important part of the nursing assessment in any clinical setting, even if they are delegated, because a change in VS might indicate a change in health.

3. How often should vital signs be assessed?
Upon admission to any healthcare agency.
Anytime there is a change in the patient’s condition.
Before and after surgical or invasive diagnostic procedures.
Before and after activity that may increase risk.
Before administering medications that affect cardiovascular or respiratory functioning.

4. Body Temperature
Body temperature is the balance between heat _______in the body and heat ____from the body.

5. Physiology of Body Temperature
What regulates our body temperature?
Center receives messages from cold and warm thermal receptors in the body.
Center initiates responses to produce or conserve body heat or increase heat loss.

6. Heat Production
The primary source of heat production is ________________.
What mechanisms increase a patient’s metabolism and increases heat production?

7. Sources of Heat Loss What is the primary site of heat loss? The skin
Evaporation from sweat
Warm and humidified inspired air
Eliminated urine and feces

8. Mechanisms of Heat Transfer
Radiation
Conduction
Evaporation
Convection
What are nursing implications
that apply to each?

9. How do each of these Factors Affect Temperature?
Age
Activity / Exercise / Sleep
Hormones
Stress
Environment
Medication
Illness

10. Range of Human Body Temperature Measured Orally

11. Normal Temperatures Healthy Adults Oral 98.6°F + or – 10
Axillary °F
Oral °F + or – 10
Rectal/Tympanic °F
Infants – 12 years old - see Pg. 517
Older adult -

12. AGE VARIATIONS IN TEMPERATURE
True or False
Infants & Children – a mild increase could signal a serious infection.
Older adults - have a lower baseline, so “fever” range is lower and may be overlooked early in illness.

13. Assessing
Body Temperature

14. What are the advantages and disadvantages of using each of these devices in assessing temperature?
Electronic Probe
Tympanic Thermometer
Temporal artery scanner
Chemical in glass

15. What are the Sites / Methods used to assess temperature and related Nursing Care? Advantages vs. Disadvantages?
Oral
Rectal
Axillary
Tympanic
Temporal

16. Critical Thinking Question
The nurse is to take an axillary temperature. Which of the following activities are appropriate when preparing to take an axillary temperature?
a. Dry the axilla before inserting the thermometer
b. Lubricate the thermometer before insertion
c. Remove the patients gown or shirt
d. Abduct the arm

17. Types of thermometers used to assess body temperature:
Electronic thermometer – for oral and axillary
Tympanic membrane thermometer
Disposable paper thermometer for taking forehead temperature; the dots change color to indicate temperature.
Temporal artery thermometer

18. Sites & Safety for Assessing Temperature
Oral Temp.- Insert thermometer under the tongue in the posterior sublingual pocket.
Safety Alert
Wait 15 min. if patient has been smoking, eating hot/cold food or fluids, or chewing gum.
Rectal Temp. - Insert thermometer into the rectum.
Not used in newborns, children with diarrhea, rectal disease or rectal surgery.
Can cause HR to decrease by stimulating the vagus nerve so usually not used for patients with heart disease or surgery.

19. Sites for Assessing Temperature
Tympanic Temp.- Place into patient's ear canal with pinna pulled up and back (ear temp.).
The tympanic temp. is the core temp. which is the operating temp. of deep structures i.e. liver.
Children like this because it only takes a few seconds.
Safety Alert
Not used with patients who have drainage from the ear. Ear wax does not effect temp.
Axillary Temp. - Place thermometer in center of axilla.
Used with newborns to avoid perforating the wall of the rectum.

20. Pulse

21. What is a Pulse?
Arterial palpation of the heartbeat by trained fingertips.
Can be palpated in any place that allows an artery to be compressed against a bone, such as at the neck (carotid artery), the wrist (radial artery), behind the knee (popliteal artery), on the inside of the elbow (brachial artery), and near the ankle joint (posterior tibial artery).
Pulse (or the count of arterial pulse per minute) is equivalent to measuring the heart rate (HR).
The Apical Heart Rate can be measured by listening to the heart beat directly (auscultation), using a stethoscope and counting it for a minute.

22. Pulse Physiology
Pulse rate = number of contractions over a peripheral artery in 1 minute.
Regulated by the autonomic nervous system through cardiac sinoatrial (SA) node.
Parasympathetic stimulation—decreases heart rate.
Sympathetic stimulation—increases heart rate.
Normal Ranges

23. Factors that Affect Pulse (P) & Heart Rate (HR)VS
Factors that Increase Pulse
Tachycardia in an adult - >100 beats/min.
Factors that Decrease Pulse
Bradycardia in an adult - <60 beats/min.
Pulse
Bleeding – increase in pulse when there inadequate oxygen delivered to the tissues and organs. By the negative mechanism these receptors send the signals to the brain and thus stimulate heart to pump faster.
Older adults - have a lower baseline pulse rate.
Activity – the heart’s compensatory ability attempts to meet the need for increase blood circulation.
Sleeping
Strong emotions – pain, fear, anger, anxiety, and being surprised.
 Exercise – slower in trained athletes.
Fever – increases 10 beats/min. for each 1° F above normal.

24. Equipment Doppler Ultrasound:
Used to hear pulses that are difficult to palpate or auscultate.

25. Locations of Peripheral Arterial Pulses
These arteries are located near the surface of the body.
The pulse can be detected in any of these sites by light palpation.

26. Sites for Assessing Peripheral Arterial Pulses
Carotid artery - in the neck.
Used –assess this pulse in emergencies.
Safety Alert
Lightly palpate on one side at a time to
prevent a decrease in O2 to the brain which
could cause fainting.
Brachial – inner aspect of the elbow.
Used – most often with infants.
Radial – inner aspect of wrist on thumb side.
Used - most often with children & adults.
Dorsalis pedis –upper surface of the foot.
Used – to assess circulation of the legs & feet.

27. Apical Pulse Location and Rate
Where should the nurse place the stethoscope when assessing an apical pulse?
Between the 5th & 6th ribs (called the “intercostal space”), and midclavicular line (about 3 inches to the left of the mid-sternal line) and slightly below the nipple line
How long should the nurse count the heart beat when auscultating the apical pulse?
15 seconds x 4
30 seconds x 2
60 seconds x 1
Landmarks

28. Question
Which one of the following pulse sites is located on the inside of the elbow?
A. Temporal
B. Radial
C. Femoral
D. Brachial
The temporal site is located ?
The radial site is located?
The femoral site is located?

29. Blood Pressure

30. Factors that Affect Blood PressureVS
Factors that Increase BP
Hypertension – greater than 140/90mm Hg
Factors that decrease BP
Hypotension - less than Systolic of 90mm Hg BP
Older adult – have decreased elasticity of the arteries, which increases peripheral resistance and then increases BP.
Men – more have high BP than women the same age
Women – get high BP after menopause.
Women - lower BP than men of the same age until menopause.
Exercise – Systolic BP rises during periods of exercise.
Exercise – lower in trained athletes.
Weight – BP higher in people who are obese than those who are thin.
Body Position – BP tends to lower in prone or supine position than sitting or standing.
Emotion State - Pain, fear, anger, anxiety and surprise raise BP; BP falls back to normal when the situation passes.
Orthostatic hypotension (postural hypotension) - drop in SBP >20 or DBP >10) within 3 minutes of standing. S&S = dizziness, diaphoresis, blurred vision).
Race – High BP more prevalent and more severe in African American men/women.

31. Equipment Stethoscope
The diaphragm is more useful for hearing high-frequency sounds. (Blood pressure and lung sounds)
The bell is more useful for hearing low-frequency sounds.
(Intestinal sounds and heart
murmurs)
Manual
Digital

32. BP Equipment Sphygmomanometer “sfig-mō-ma-NAW-me-ter”
The width of the blood pressure cuff should cover about 40% of the circumference of the upper arm.
The length of the bladder should cover 2/3 of the circumference of the upper arm.
Safety Alert
Using a blood pressure cuff that's too large or too small can give you inaccurate BP readings (too large = low, too small = high).

33. Assessing Blood Pressure
First sound is the systolic pressure
Change or cessation of sounds occurs is the diastolic pressure
Written as systolic/diastolic: 120/80
Read as: “120 over 80”
Let’s listen and practice

34. BP Equipment Three cuff sizes:
Small cuff for a child or a small or frail adult.
Normal-sized cuff
for teens or adults.
Large cuff, called a
leg cuff, used on a leg or
an obese adult.

35. Blood Pressure Levels
What is normal BP level in an adult as defined by American Heart Association?
Any B/P over 120/80 is considered abnormal.

36. Identify Potential Causes of a BP Error
L = Falsely low assessments
H = Falsely high assessments
___Reflating the bladder during auscultation
___Noise in the environment
___Applying too narrow a cuff
___Releasing the valve too rapidly
___Applying too wide a cuff
___Failing to pump the cuff 30 mmHg
above the disappearance of the pulse
___Releasing the valve too slowly H L

37. Respirations

38. Rate and Depth of Breathing
Unconsciously, breathing is controlled by centers in the brainstem.
The rate & depth of breathing changes in response to tissue demands.
The rate & depth are controlled by respiratory centers in the medulla & the pons which are activated by impulses from chemoreceptors.
Increase in carbon dioxide is the most powerful respiratory stimulant.

39. Factors that Affect RR and DepthVS
Factors that Increase RR
Tachypnea in an adult is a RR > than 24 breaths/min.
Factors that Decrease RR
Bradypnea in an adult is a RR < 10 breaths/min. RR
Age – A newborn RR ranges from breaths/min.
Age – An older adult has a lower baseline RR.
An adult’s normal range of RR is breaths / min.  
Activity – The RR increases due to the increased energy demands placed upon the body. The rate increases to keep up with these energy demands.
Activity – slower in trained athletes.
Anemia – Decrease in hemoglobin, which carries O2, may increase RR.
Medications – Cocaine and amphetamines, known as "uppers," may increase rate and depth.
 Medications – Narcotics, sedatives and general anesthetics slow rate and depth.
Pain – acute pain may increase rate but decrease respiratory depth.
 Pain – acute pain may increase rate but decrease respiratory depth.
Smoking – alters the pulmonary airways causing increased RR, even at rest.

40. Alternative Devices for Assessing Vital Signs
Electronic blood pressure machines
The patient has an IV in her right arm and her right side is closest as you enter the room.
What would the nurse do to assess a B/P?

41. Normal VS Ranges
Place an X on the VS value of an adult that suggests a need for treatment &/or notification of the HCP.
_____ Temp 101F
_____ HR 98
_____ BP 96/54
_____ RR 10
_____ Temp 96.4F
_____ HR 56
_____ BP 146/96
_____ RR 24
__X___ Temp 101 F - Temp 101 or greater call HCP
__X___ RR 10 – rate less than 12
__X___ Temp 96.4 F - less than 97F
__X___ HR 56 - less than 60
__X___ BP 146/96 - diastolic greater than 90
__X___ RR 24 - rate greater than 20