Vital Signs
Assessment of Vital Signs
Temperature
Pulse
Respirations
Blood Pressure
The fifth vital sign
Pain
Oxygen Saturation
Temperature
Regulation
hypothalamus
Core body temperature
Set point
Heat Production
Metabolism
Shivering
Exercise
Heat Loss
Radiation Convection
transfer from surface transfer by air
Conduction movement
transfer through Evaporation
direct contact transfer when liquid
changed to a gas
Oral Temperature
97 - 100 F (98.6) Contraindications
36 - 39 C (37) unconscious
must be able to seizures
close mouth infants, young
children
eating or smoking, oral disease/surgery
wait
mouth breathing
oxygen by mask
Rectal Temperature
Reliable Contraindications
Higher than oral by rectal surgery
1o diarrhea
rectal disease
heart disease
Other Methods
Axillary
used when oral or rectal contraindicated
lower than oral by 1o
Tympanic membrane
readily accessible
not affected by eating, smoking cerumen
Elevated Temperature
Pyrexia
Hyperpyrexia
Chill Phase
Signs and Care
Symptoms assessment
shivering blankets
blood vessels fluids
constrict nourishment
absence of sweating Oxygen
Fever Phase
Temp at new set Care
point Comfort
Signs and Hydration
Symptoms Prevent shivering
flushed skin Limit physical activity
warm skin Oral hygiene
weak, muscle aches Environmental
drowsy, restless temperature control
Flush or Crisis Phase
Signs and Care
Symptoms fluids
profuse diaphoresis light clothing
less shivering hypothermia blanket
flushed, warm skin Medications
Oral hygiene
Environmental
temperature control
Subnormal Temperature
Hypothermia
Chemical reactions slowed
Metabolic demands for oxygen
decreased
Assessing Temperature
Glass thermometers
oral = blue, thin bulb
rectal = red, blunt tip
Electronic
oral = blue
rectal = red
Temperature sensitive patches
Pulse
Rate
pulsations per minute
Infant normal = 80 - 180 per minute
Adult normal = 60 - 100 per minute
Slow 100, tachycardia
Slowest at rest, early morning
Tachycardia
pain exercise
stress decrease BP
fear temp
anger low oxygen
anxiety medications
Pulse Rhythm
Pattern of pulsations
Regular
Irregular
dysrhythmia
arrhythmia
Pulse Quality or Amplitude
Description of fullness of pulse
Ratings
0 = Absent
+1 = thready, weak
+2 = normal
+3 = bounding
Assessment Sites
carotid popliteal
brachial posterior tibial
radial dorsal pedis
femoral apical
5th ICS left
use stethoscope
Apical - Radial Pulse
2 nurses
count at same time
differences found with irregular pulses
Respiration
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 minute
Deviations From Normal
rate: rate
illness, fever narcotics
acute pain CNS depressants
stress
exercise
altitude
body position
Respiratory Terms
Apnea Bradypnea
Dyspnea Cheyne - Stokes
Orthopnea
Tachypnea
Blood Pressure
Force of blood against vessel walls
Systolic pressure
Diastolic pressure
Pulse pressure
Factors to Maintain BP
Peripheral Resistance
Pumping action of the heart
Blood volume
Viscosity of the blood
Elasticity of vessel walls
Factors Affecting BP
Age
Time of day
Gender
Eating
Exercise
Emotions
Position
Activity
Smoking/drinking
Terms
Hypertension
Hypotension
Orthostatic
Associated illness
Proper 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 gap
Proper Measurement
Cuff Size
too large - low reading
too small - high reading
Bladder width 40% of limb circumference
Bladder length 80% of limb circumference