1. VITAL SIGNS
Module C

2. What are Vital Signs? Temperature Pulse Respirations Blood Pressure
Pain (considered the 5th vital sign)

3. When to measure vital signs?
On admission to health care facility
In a hospital on regular hosp schedule or as MD ordered (q8hours, q4 hours, etc)
Before and after procedures (surgery, invasive diagnostic procedures)
Before, during, and after blood transfusions
When patient’s general condition changes (nursing judgment)

4. GUIDELINES FOR ASSESSMENT
Taken by nurse giving care
Equipment should be in good condition
Know baseline VS and normal range for pt and age group
Know pt’s medical history
Minimize environmental factors

5. GUIDELINES CONTINUED Be organized in approach
Increase frequency of VS as condition worsens
Compare VS readings with the whole picture
Record accurately
Describe any abnormal VS

6. VS MUST BE ACCURATE Both measuring and recording
VS vary according to pt’s illness/condition
Compare results with pt’s normal
Results are used to determine treatments, medications, diagnostic work, etc

7. REPORTING ABNORMAL VS
WHEN—grossly abnormal, return to normal, noted change for that pt
WHY—indicates change in metabolism or physiological function within the body
WHO—student reports to instructor, then TL, RN, Dr (follow chain of command)
HOW—orally to appropriate person, then document on chart

8. Body Temperature
Difference between heat produced by body processes and the heat lost to the external environment
Range 96.8 – F (36 – 38 degree C)
Average for healthy young adults 98.6F or 37degrees C
No single temp is normal for all people

9. HEAT IS PRODUCED BY: Metabolism Increased muscle activity
Vasoconstriction
External sources

10. HEAT IS LOST BY: Vasodilation Convection Radiation Conduction
Evaporization

11. TEMP or FEVER? TEMPERATURE—the measurement of heat in the body
FEVER—the measurement of heat in the body that is above normal for the individual

12. TYPES OF THERMOMETERS

13. READING A THERMOMETER

14. Normal Range Throughout Life Cycle
Adults degree F
Adult Avg 98.6 F Oral
Adult Avg 99.5 F Rectal
Adult Avg 97.7 F Ax
Newborn range – F
Infants and children – same as adults
Elderly – Avg 96.8F

15. Frequently used terms:
Pyrexia or fever
Febrile
Hyperthermia
Hypothermia
Afebrile

16. FEVER—A DEFENSE MECHANISM
Indicator of disease in body
Pathogens release toxins
Toxins affect hypothalamus
Temperature is increased
Rest decreases metabolism and heat production by the body

17. PATTERNS OF FEVER SUSTAINED- remains above normal with little change
RELAPSING – periods of febrile episodes interspersed with acceptable temp values
INTERMITTENT—varies from normal to above normal to below normal (may have a fairly predictable pattern)
REMITTENT—fever spikes and falls w/o a return to normal temp values

18. Factors Affecting Body Temp
Age ( newborn- temp control mechanism immature, elderly- sensitive to temp changes)
Exercise
Hormonal level
Circadian rhythm (temp normally changes 0.9 to 1.8 degree F /24hr Lowest 1-4AM Max-6PM )
Stress
Environment

19. ORAL TEMPERATURE
Accessible
Dependable
Accurate
Convenient

20. RECTAL TEMPERATURE
Most reliable
MUST hold thermometer in place

21. AXILLARY TEMPERATURE
Safe
Non-invasive
Least accurate

22. TYMPANIC TEMPERATURE Non-invasive Safe Accurate Disadvantages
Excessive cerumen
Improper technique

23. AXILLARY TEMPERATURE IMPORTANT POINTS
AXILLA MUST HAVE ADEQUATE TISSUE & BE FREE OF PERSPIRATION
Not good method for persons with elevated temp
Used when cannot get oral or tympanic
Leave in place 10 minutes

24. ORAL TEMPERATURES
Wait minutes after eating, drinking, chewing gum or smoking
If mouth breather-do not take orally
Leave in place 2 – 4 minutes with glass thermometer

25. TYMPANIC TEMPERATURES
Oral & tympanic readings will be same/ similar
Must direct probe toward TM (eardrum)
Follow instructions
Keep plugged in and on charger when not in use
Usually preferred method
Adults –pull pinna of ear up & back
Children under 3y/o-pull pinna of ear down & back

26. RECTAL TEMPERATURES MOST accurate MUST hold thermometer in place
Very high temp
Unconscious
Do not take rectal temp on clients with heart conditions
Leave in place 2-3 min with glass thermometer
Lubricate thermometer
DO Not take hand from thermometer while rectal in progress

27. NURSING DIAGNOSIS Hyperthermia> 100.4F Hypothermia <96.8F
Risk for altered body temperature
Ineffective Thermoregulation

28. Temperature Conversion
Temperature can be measured in Fahrenheit (F) or centigrade or Celsius (c)
To convert F to c, subtract 32 from F reading and multiply times 5/9. Ex (104 F – 32) x 5/9 = 40 degree c
To convert c to F, multiply the c reading by 9/5 and add 32 to the product. Example (40 x 9/5) + 32 =104 F

29. Pulse
Pulse- is the palpable bounding of the blood noted at various points on the body. It is an indicator of circulatory status.

30. TERMS RELATED TO PULSE Pulse—Rate, Rhythm, Quality Pulse Deficit
Auscultate
Palpate
Tachycardia, Bradycardia

31. Pulse Sites Temporal Carotid Apical Brachial Dorsalsis Pedis (Pedal)
Radial and Apical are most common pulse sites used!
Radial
Ulnar
Femoral
Popliteal
Posterior Tibial

33. PULSE RANGES AGE RANGE ELDERLY (65+) 60-100 AVERAGE ADULT
(50 or below if extremely athletic)
NEWBORN
0-24 HOURS
INFANT
1 MONTH – 1 YEAR
CHILDREN
(varies with age)

34. TECHNIQUE Feel over BONY area DO NOT use thumb Use 2-3 fingers
DO NOT squeeze
Count 30 seconds if regular x 2
Note Rate, Rhythm, Quality
If irregular, count for 1 full minute or take apical pulse for 1 minute.

35. APICAL-RADIAL PULSE Requires 2 nurses 1 nurse counts apical heart rate
1 nurse counts radial pulse
BOTH count during the same 60 seconds
1 nurse acts as timekeeper for both nurses

36. PULSE DEFICIT Count apical-radial pulse
The difference is the PULSE DEFICIT
Apical pulse will always be the same or higher than the radial pulse if both are counted correctly
If the radial pulse is higher, one or both nurses counted incorrectly

37. Factors Affecting Pulse Rates
Exercise
Temperature
Emotions
Drugs
Hemorrhage
Postural Changes
Pulmonary Conditions

38. Variations of Pulse Rates
Tachycardia – Abnormally elevated pulse rate. (above 100 beats/ min)
Bradycardia – Abnormally slow pulse rate (less than 60 beats / min)

39. Pulse Rhythm
Regular – A regular interval of time occurs between each heartbeat or pulse felt.
Irregular – Interval interrupted by early, late, or missed beat.

40. Strength and Quality of Pulse
Pulse strength may be described as weak, strong, bounding, or thready.
PULSE GRADING (0-4 rating scale)
0 – absent, not palpable
1+ - diminished, barely palpable
2+- easily palpable, normal pulse
3+ - full, increased strength
4+ - bounding, cannot be obliterated

41. Respirations
Mechanism the body uses to exchange gases between the atmosphere, blood, and the cells. Involves three processes:
Ventilation
Diffusion
Perfusion

42. PROCESS OF RESPIRATION
EXTERNAL RESPIRATION
Inhaled air enters lungs, at alveoli O2 crosses over to bloodstream
CO2 and other wastes cross over from bloodstream to alveoli and are exhaled
INTERNAL RESPIRATION
O2 carried in bloodstream crosses over to body cells
CO2 and other wastes from body cells cross over to the bloodstream

43. RESPIRATION Chest Cavity—airtight vacuum with negative pressure
INSPIRATION—diaphragm contracts and pulls down, ribs move up, lungs fill with air
EXPIRATION—diaphragm relaxes and moves up, ribs move down, lungs expel air

44. NORMAL RESPIRATION RANGE
AGE
RANGE
ELDERLY (65+)
12-20
AVERAGE ADULT
NEWBORN
0-24 HOURS
30-60
INFANT
1 MONTH – 6 Months
30-50
CHILDREN
(varies with age)

45. COUNTING RESPIRATIONS
Count pulse first, then count respirations while holding wrist
Note rate, rhythm, quality, and character
Observe a full inspiration and expiration
Respiratory rates below 12 or greater than 20 require further assessment.

46. Counting Respirations cont.
If respirations regular, count respirations for 30 seconds and multiply times 2.
If irregular, less than 12 or greater than 20, count for 1 full minute.
Quality of respirations- assess movement of chest or abdominal wall- deep, normal, shallow
Deep- full expansion of lungs
Normal- normal
Shallow- limited expansion of lungs

47. Factors Influencing Characteristics of Respirations
Exercise
Acute Pain
Anxiety
Smoking
Body position
Medications
Neurological injury
Age
Environmental Temp
Hemoglobin Function

48. Blood Pressure
Force exerted on the walls of the artery. Created by the pulsing blood under pressure of the heart.
Systolic- Peak and maximum pressure of ejection of blood from the heart into the aorta. This is the top number.
Diastolic- The minimal pressure remaining the heart when the heart relaxes. This is the bottom number.
Recorded as a ratio Ex. 120/80
Pulse pressure- Difference between the systolic and diastolic. ( 120/80 – Pulse pressure 40)

49. EQUIPMENT FOR BP

50. “DOPPLER” OR ELECTRONIC BP READINGS

51. ALTERNATIVE SITES

52. MEASURING BP

53. MEASURING BLOOD PRESSURE
Cuff must be appropriate size
Cuff should be snug, not loose
Do not put stethoscope under cuff ( place cuff 1-2 inches above elbow)
Make mental note of systolic and diastolic numbers

54. MEASURING BP CONT’D
If unsure of reading, wait 30 seconds and recheck-if unsure, have someone else check with you
Loosen cuff even if to be checked q 15 minutes
Make sure all air is out cuff before applying

55. MEASURING BP
False high if cuff too small, false low if cuff is too loose
Auscultatory gap-temporary disappearance of sound between first sound and next sound.
Don’t take BP on arm with IV, sling, surgery, mastectomy, renal dialysis shunt, etc.

56. MEASURING BP CONT’D
Pt should be sitting or lying with arm at the level of the heart
Distinguish Korotkoff sounds (sounds heard when taking BP) from artifact

57. ASSESSMENT OF BP IN BOTH ARMS
Heart disease
1st time BP
5-10 mm Hg difference-use reading that is highest
Difference of 10mm Hg should be reported

58. HOW and WHY BP TAKEN BY PALPATION
HOW-apply cuff over brachial artery
Pump up to points above last systolic reading
Feel with 2 fingers for systolic pressure; will not feel diastolic pressure
WHY- unable to hear weak BPs

59. FACTORS AFFECTING BP Exercise-increases
Arteriosclerosis (loss of vessel elasticity) & Atherosclerosis (build up of plaque)-increases
Transfusions- increases
Emotions -increases

60. FACTORS CONT’D
Drugs
Medications
Diurnal variations

61. FACTORS CONT’D PAIN-increases Hemorrhage –decrease Sex/Gender
RACE-Blacks more prone increase
Age
Heredity-increased chance if immediate family history

62. Alterations in Blood Pressure
Hypertension – most common alteration in BP. Most often asymptomatic. Characterized by persistently elevated BP. Noted when diastolic is greater than 90 mm/Hg and systolic is greater than 140mm/Hg. Optimal BP for 18 y/o and older is less than 120/80mm/Hg.

63. Alterations In BP cont
Hypotension- When systolic blood pressure falls to 90 or below.
Orthostatic (Postural) Hypotension- Occurs when a normotensive person develops symptoms and low blood pressure when rising to an upright position.

64. Common Mistakes in Blood Pressure Assessments
Cuff too wide or too narrow
Cuff wrapped too loose or unevenly
Inflating cuff too slowly
Deflating cuff too slowly or too quickly
Arm above or below heart level or not supported
Repeating assessment too quickly
Inaccurate inflation level
Poorly fitting stethoscope
Impairment of examiners hearing

65. Documentation of Vital Signs
Graphic sheets
Flow sheets
Nurses notes
Computerized

66. Pain – Fifth Vital Sign Process of measuring pain:
Verbal and nonverbal
Characteristic of pain- onset, duration, location, quality, intensity, variations
Factors affecting pain – culture, developmental stage, gender, anxiety, previous experience
Pain scale- numerical (0-10), verbal (descriptive), visual analog( faces pain rating scale)