VITAL SIGNS
Professor Blakey
NUR302
Vital Signs
• Temperature
• Pulse
• Respirations
• Blood Pressure
• Health Status
• Changes
• Accuracy, Responsibility
Vital Signs
• When are they reported?
• When are they recorded?
Temperature
Sites:
Oral-
Taken routinely
Taken per MD order
Taken when fever is
suspected
Oral Temperature
• Contraindicated with
• Unconscious patient
• Disorders of mouth
• Recently had fluids/smoked
• Wait 15 minutes
• Receiving nasal oxygen
Temperature
• Rectal
• When?
• Assessing most accurate temp
• Alternative to oral site
Rectal Temp
• Contraindicated with:
• Newborns, small children
• Diarrhea
• Rectal surgery
• Rectal disease
• Concern re: vagus nerve
stimulation
• Neurological disease
Axillary Temperature
• When?
• Unable to use oral or rectal
• Newborn
• Contraindications:
• Axillary/Arm disorders
• After bathing
Normal Values
• Average values may vary 1
degree F higher or lower
F/ C
• Oral- 98.6/ 37
• Rectal- 99.5/ 37.5
• Axillary- 97.6/ 36.5
Factors Affecting Temp
• Circadian Rhythm (24 hours)
Predictable fluctuations-
Temp 1-2 degrees lower in
early morning
Temp peaks late afternoon (4-7
pm)
Factors Affecting Temp
• Age- very young and old
affected
• Gender- women
Progesterone at ovulation
increases temp 0.5-1 degree
Environmental
Factors Affecting Temp
• Hypothermia- low body temp
• Hyperthermia- high body temp
• Fever
Loss of appetite, headache,
flushed, malaise
Severe- dehydration, alt urine
output, seizures, lyte imbal
Reducing Fever
• Cooling the body
• Increase fluids
• Monitor intake
• Monitor labs
• Antipyretics
• Antibiotics
Pulse
• Normal range- 60-100
• Tachycardia- more than 100
• Causes-
• Decreased blood pressure
• Elevated temp
• Decreased oxygen
• Heat, Pain, Medicatioins
Pulse
• Bradycardia- less than 60
• Caused by:
• Slower in men
• Thin person
• Sleep
• Hypothermia
• Aging
• Medications
Pulse Strength
(Amplitude)
• 0- Absent
• 1+- Thready
• 2+- Weak
• 3+- Normal
• 4+- Bounding
• What would be reported?
Pulse Sites
• Temporal (Temple)
• Carotid (Neck)
• Brachial (Bend of arm)
• Radial- used frequently/palpate (Wrist)
• Femoral (Groin)
• Popliteal (Behind knee)
• Posterior tibial (Inner ankle)
• Dorsalis pedis (Top of foot)
• Apical- used frequently/ auscultate (heart)
Pulse
Equipment
• Hands
• Doppler
• Stethoscope
Respirations
• Ventilation
• Inspiration
• Expiration
• Normal rate- Adults 12-20
breaths per minute
Respirations
• Patterns of Respiration
• Normal- 12/20 per minute
• Tachypnea- more than 24/min
(fever, anxiety, resp disease)
• Bradypnea- less than 10/min
(meds, brain injury)
Respirations
• Hyperventilation- increased rate
and depth (Kussmaul’s)
• Hypoventilation- decreased rate
and depth-narcotics/anesthesia
• Cheynes-Stokes- alt. deep/rapid
with apnea
• Biot’s- erratic depth and apnea
(brain injury)
Respirations
Terms
• Apnea- No breathing
• Dyspnea- Difficulty breathing
• Orthopnea- Breathing sitting
upright
Factors Affecting
Respirations
• Age- decreases with older age
• Gender- males- diaphragmatic
• Exercise- increases respirations
• Disease- brain injury
• Anemia- increases respirations
• Anxiety- increases respirations
• Medications- narcotics lower;
amphetamines- increases
• Acute pain- increases
Respirations
• Assessing:
Observation
(Other monitoring devices)
Blood Pressure
• Systolic blood pressure-
contraction of ventricles
(Highest pressure on arterial
walls)
• Diastolic- relaxation (lowest
pressure)
• Pulse pressure (PP)-
Systolic- Diastolic= PP
Blood Pressure
Values
• Normal- 160/>100
Blood Pressure
• Hypertension-
Sustained, above normal
Primary/essential HTN- no cause
Secondary HTN- known etiology
Risk factors- Hx, obesity,
smoking, sedentary, stress, diet
Blood Pressure
• Hypotension- below normal B/P
• Orthostatic hypotension-
Postural hypotension;
weakness/ fainting when
standing (esp when on
prolonged bedrest)
Blood Pressure
• Korotkoff Sounds:
Phase I- first faint clear tapping
Phase II- Swishing
Phase III- Distinct loud sounds
Phase IV- Muffling sounds
Phase V- Last sound
Blood Pressure
Assessment Sites
• Brachial Artery B/P
Do not take in arm with IV, side
of mastectomy, AV shunt
Popliteal Artery B/P
Systolic may be higher
Palpating B/P
Systolic
Blood Pressure
• False lows:
• Releasing valve rapidly
• Not pumping cuff high enough
• Using faulty equipment
• Did not insert earpieces correctly
• Cuff too wide
• Looking at meniscus above eye
level
Blood Pressure
• False Highs:
• Cuff is not calibrated
• Looking at meniscus below eye
level
• Cuff is too narrow
• Releasing valve too slowly
• Reinflating cuff during
auscultation
Pain- the 5th
Vital Sign
• Factors Affecting Pain:
• It is what the patient says it is
• Culture
• Ethnicity
• Gender
• Age
• Support of Others
• Anxiety
• Past experiences
Pain
• JCAHO standards
• Right to assessment and management
• Ongoing assessment
• Recorded
• Policies and procedures
• Pain must be managed
• Education must be provided
• Discharge planning includes pain mgt
• Monitor effectiveness of mgt
Pain Assessment
• Patient’s description
• Duration
• Location
• Quantity/ Intensity
• Quality
• Chronology
• Aggravating factors
• Alleviating factors
• Physiologic indicators of pain
• Behavioral responses
• Effect on activities and lifestyle
Pain
Rating (p. 1384)
• Simple descriptive Pain Distress
Scale
• Numeric Pain Scale
• Visual Analog Scale
• Wong-Baker Faces