Chapter 17: Vital Chapter 17: Vital SignsSigns

VITAL SIGNSVITAL SIGNS TEMPERATURETEMPERATURE BLOOD PRESSUREBLOOD PRESSURE PULSEPULSE

APICALAPICAL RADIALRADIAL

RESPIRATIONSRESPIRATIONS PULSE OXIMETRYPULSE OXIMETRY PAIN SCALEPAIN SCALE

VITAL SIGNS ARE PART OF VITAL SIGNS ARE PART OF THE PHYSICAL ASSESSMENTTHE PHYSICAL ASSESSMENT

Delegation of Duties to UAPDelegation of Duties to UAP Unlicensed Assistive PersonnelUnlicensed Assistive Personnel

RN is Responsible to Manage Care RN is Responsible to Manage Care Based on Physical AssessmentBased on Physical Assessment Administering medicationsAdministering medications Communicating to other members of Communicating to other members of

the health care teamthe health care team Supervising delegated tasksSupervising delegated tasks

EQUIPMENTEQUIPMENT

RN is responsible for assuring RN is responsible for assuring equipment is functioning properlyequipment is functioning properly Appropriate equipmentAppropriate equipment

Must be appropriate to patient age sizeMust be appropriate to patient age size ThermometerThermometer Stethoscope: Diaphragm (high-pitched Stethoscope: Diaphragm (high-pitched

sounds); bell (low-pitched sounds)sounds); bell (low-pitched sounds) BP cuffBP cuff Pulse oximeterPulse oximeter

PATIENT HISTORYPATIENT HISTORY

RN must know patient medical RN must know patient medical history, including medicationshistory, including medications These facts can affect vital signsThese facts can affect vital signs

RN is responsible for knowing the RN is responsible for knowing the patient’s usual vital sign rangepatient’s usual vital sign range

FREQUENCY OF VITAL FREQUENCY OF VITAL SIGNSSIGNS

Physicians order the frequency of vital Physicians order the frequency of vital signssigns Could be ordered by protocol or policyCould be ordered by protocol or policy

The RN can increase the frequency based The RN can increase the frequency based on his/her assessmenton his/her assessment

VITAL SIGNS can be an early warning VITAL SIGNS can be an early warning sign that complications are developingsign that complications are developing

INDICATIONS FOR INDICATIONS FOR MEDICATION MEDICATION

ADMINISTRATIONADMINISTRATION

Many medications are administered Many medications are administered when the vital signs are within an when the vital signs are within an acceptable range. acceptable range.

Accurate VITAL SIGNS are required Accurate VITAL SIGNS are required in order to make treatment decisions.in order to make treatment decisions.

COMPREHENSIVE COMPREHENSIVE ASSESSMENT FINDINGSASSESSMENT FINDINGS

Compare VITAL SIGNS to assessment Compare VITAL SIGNS to assessment findings and laboratory results to findings and laboratory results to accurately interpret the patient status.accurately interpret the patient status.

Discuss your findings with peers and Discuss your findings with peers and charge RN before deciding on a plan of charge RN before deciding on a plan of action. action.

Use the opportunity to teach Use the opportunity to teach patient/family about what VS mean, patient/family about what VS mean, reason for assessing, meaning if reason for assessing, meaning if appropriateappropriate

TEMPERATURETEMPERATURE Factors affecting body temp. (36-Factors affecting body temp. (36-

3838°C/96.8-100.4°F)°C/96.8-100.4°F) AgeAge

Infants: 95.9 – 99.5Infants: 95.9 – 99.5° F [36.5-37.2C] ° F [36.5-37.2C] intolerant of extremesintolerant of extremes

Elderly: Average temp is 96.8° F; Sensitive Elderly: Average temp is 96.8° F; Sensitive to temp extremesto temp extremes

ExerciseExercise Hormone levelsHormone levels Circadian rhythmCircadian rhythm StressStress EnvironmentEnvironment

TEMPERATURE TEMPERATURE ALTERATIONSALTERATIONS

AfebrileAfebrile Pyrexia [fever] >37.5Pyrexia [fever] >37.5 Fever of unknown origin (FUO)Fever of unknown origin (FUO) Malignant hyperthermia: hereditary, Malignant hyperthermia: hereditary,

occurs during anesthesiaoccurs during anesthesia Heatstroke: medical emergencyHeatstroke: medical emergency Heat exhaustionHeat exhaustion HypothermiaHypothermia FrostbiteFrostbite

TEMPERATURE Cont’d.TEMPERATURE Cont’d.

SitesSites Core temp is measured in pulmonary artery, Core temp is measured in pulmonary artery,

esophagus, and urinary bladderesophagus, and urinary bladder Common sites: Common sites:

Mouth, rectum, tympanic membrane, Mouth, rectum, tympanic membrane, temporal artery, and axilla – use critical temporal artery, and axilla – use critical thinking to decide!thinking to decide!

Variety of types available – electronic and Variety of types available – electronic and disposabledisposable

Antipyretics = drugs that reduce feverAntipyretics = drugs that reduce fever

Using an oral electronic thermometer, the Using an oral electronic thermometer, the nurse checks the early morning temperature of nurse checks the early morning temperature of a client. The client's temperature is 36.1° C a client. The client's temperature is 36.1° C (97° F). The client's remaining vital signs are in (97° F). The client's remaining vital signs are in the normally acceptable range. What should the normally acceptable range. What should the nurse do next?the nurse do next?

A) Check the client's temperature history.A) Check the client's temperature history.B) Document the results; temperature is B) Document the results; temperature is

normal.normal.C) Recheck the temperature every 15 C) Recheck the temperature every 15

minutes until minutes until it is normal. it is normal.D) Get another thermometer; the D) Get another thermometer; the

temperature is temperature is obviously an error. obviously an error.

PULSEPULSE

SitesSites Temporal, Carotid, Apical, Brachial, Radial, Temporal, Carotid, Apical, Brachial, Radial,

Femoral, Popliteal, Posterior Tibial, Dorsalis Femoral, Popliteal, Posterior Tibial, Dorsalis PedisPedis

Increases in HRIncreases in HR Short-term exercise, fever, heat, pain, anxiety, Short-term exercise, fever, heat, pain, anxiety,

drugs, loss of blood, standing or sitting, poor drugs, loss of blood, standing or sitting, poor oxygenationoxygenation

Decreases in HRDecreases in HR Long-term exercise, hypothermia, relaxation, Long-term exercise, hypothermia, relaxation,

drugs, lying downdrugs, lying down

PULSE Cont’d.PULSE Cont’d. Volume of blood pumped by the heart Volume of blood pumped by the heart

during 1 minute is the cardiac outputduring 1 minute is the cardiac output When mechanical, neural or chemical When mechanical, neural or chemical

factors are unable to alter stroke volume, factors are unable to alter stroke volume, a change in heart rate will result in a change in heart rate will result in change in cardiac output, which affects change in cardiac output, which affects blood pressureblood pressure HR HR ↑, less time for heart to fill, BP ↓↑, less time for heart to fill, BP ↓ HR ↓, filling time is increased, BP ↑HR ↓, filling time is increased, BP ↑

An abnormally slow, rapid, or irregular An abnormally slow, rapid, or irregular pulse alters cardiac outputpulse alters cardiac output

The nurse decides to take an apical The nurse decides to take an apical pulse instead of a radial pulse. Which of pulse instead of a radial pulse. Which of the following client conditions the following client conditions influenced the nurse's decision?influenced the nurse's decision?

A) The client is in shock.A) The client is in shock.B) The client has an arrhythmia.B) The client has an arrhythmia.C) The client underwent surgery 18 C) The client underwent surgery 18

hours hours earlier. earlier.D) The client showed a response to D) The client showed a response to orthostatic changes. orthostatic changes.

RESPIRATIONSRESPIRATIONS

Ventilation = the movement of gases Ventilation = the movement of gases in and out of lungsin and out of lungs

Diffusion = the movement of oxygen Diffusion = the movement of oxygen and CO2 between the alveoli and and CO2 between the alveoli and RBCsRBCs

Perfusion = the distribution of RBCs Perfusion = the distribution of RBCs to and from the pulmonary to and from the pulmonary capillariescapillaries

Factors Influencing Factors Influencing Character of RespirationsCharacter of Respirations

ExerciseExercise Acute PainAcute Pain AnxietyAnxiety Acid-Base balanceAcid-Base balance Body PositionBody Position MedicationsMedications Neurological injuryNeurological injury Hemoglobin Hemoglobin

functionfunction

RESPIRATIONS Cont’d.RESPIRATIONS Cont’d.

Tachypnea = rapid breathingTachypnea = rapid breathing Apnea = cessation of breathingApnea = cessation of breathing Cheyne-Stokes = rate and depth Cheyne-Stokes = rate and depth

irregular, alternate periods of apnea irregular, alternate periods of apnea and hyperventilationand hyperventilation

Kussmaul’s = abnormally deep, Kussmaul’s = abnormally deep, regular, and increased in rate regular, and increased in rate (associated with DM)(associated with DM)

PULSE OXIMETERPULSE OXIMETER

Indirect measurement of oxygen Indirect measurement of oxygen saturationsaturation

Photodetector detects the amount of Photodetector detects the amount of oxygen bound to hemoglobin oxygen bound to hemoglobin molecules and oximeter calculates the molecules and oximeter calculates the pulse saturationpulse saturation

Only reliable when SaO2 is over 70%Only reliable when SaO2 is over 70% Certain conditions may give an Certain conditions may give an

inaccurate readinginaccurate reading

A client is being monitored with pulse A client is being monitored with pulse oximetry. On review of the following factors, oximetry. On review of the following factors, the nurse suspects that the values will be the nurse suspects that the values will be influenced by which of the following?influenced by which of the following?

A) The placement of the sensor on the extremityA) The placement of the sensor on the extremityB) A diagnosis of peripheral vascular diseaseB) A diagnosis of peripheral vascular diseaseC) A reduced amount of artificial light in the C) A reduced amount of artificial light in the roomroomD) The increased ambient temperature of the D) The increased ambient temperature of the client’s client’s room room

BLOOD PRESSUREBLOOD PRESSURE

Force exerted on the walls of an Force exerted on the walls of an artery by the pulsing blood under artery by the pulsing blood under pressure from the heartpressure from the heart

Systolic = maximum pressure when Systolic = maximum pressure when ejection occursejection occurs

Diastolic = minimum pressure of Diastolic = minimum pressure of blood remaining in the arteries after blood remaining in the arteries after ventricles relaxventricles relax

BLOOD PRESSURE BLOOD PRESSURE Cont’d.Cont’d.

Physiology of arterial blood pressurePhysiology of arterial blood pressure Cardiac Output, Peripheral resistance, Cardiac Output, Peripheral resistance,

Blood volume, Viscosity, ElasticityBlood volume, Viscosity, Elasticity Factors influencing BPFactors influencing BP

Age, Stress, Ethnicity, Gender, Daily Age, Stress, Ethnicity, Gender, Daily Variation, Meds, Activity, Weight, Variation, Meds, Activity, Weight, SmokingSmoking

HypertensionHypertension HypotensionHypotension Orthostatic or postural hypotensionOrthostatic or postural hypotension

The nurse is assessing a client’s blood pressure during The nurse is assessing a client’s blood pressure during a routine visit. When asked, the client volunteers that a routine visit. When asked, the client volunteers that when he took his pressure at home yesterday it was when he took his pressure at home yesterday it was 126/72 mmHg. The nurse determines that the client’s 126/72 mmHg. The nurse determines that the client’s pressure today is 134/70 mmHg. The nurse pressure today is 134/70 mmHg. The nurse recognizes that the most likely cause of the elevation recognizes that the most likely cause of the elevation is due to which of the following?is due to which of the following?

A) The difference between the monitoring equipment being A) The difference between the monitoring equipment being usedused

B) The client’s inability to hear the first Korotkoff B) The client’s inability to hear the first Korotkoff soundsound

C) The client may be experiencing mild anxiety C) The client may be experiencing mild anxiety regarding the regarding the check-up check-up

D) The client is not inflating the cuff sufficiently to D) The client is not inflating the cuff sufficiently to detect the detect the systolic pressure systolic pressure

QUESTIONS?QUESTIONS?