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Vital Signs - 2017
1. Nelia B. Perez, RN, MSN
PCU – Mary Johnston College of
Nursing
2. reflects changes in body functions that otherwise
might not be observed
Temperature
Pulse
Respiration
Blood pressure
Pain
3. Vital Signs
One of the most frequent assessments made as a nurse
Nurse is
Responsible for measuring, interpreting significance and
making decisions about care
Knowing normal ranges
Knowing history and other therapies that may affect VS
4. Vital Signs
Nurse must
Know environmental factors that affect vital signs
Exercise, stress, etc.
Use a systematic, organized approach
Verify and communicate changes in vital signs
Monitor VS regularly
Frequency determined by
MD order; nursing judgement, client condition and facility
standards
5. Vital Signs: Facility standards
Hospital:
Every 4-8 hours
Home health:
each visit
Clinic:
Each visit
Skilled facility
Daily and as needed
6. When to Assess Vital Signs
Upon admission to any healthcare agency
Based on agency institutional policy and procedures
Any time 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
7. Special Nursing Interventions:
Wash hands before and after a procedure
to maintain asepsis
Gather equipment needed including
watch with a second hand to maximize
time and reduce effort
Greet client and introduce oneself to
promote client’s sense of well-being
8. Special Nursing Interventions:
Inform client what you will do to elicit cooperation and
allay anxiety
Check for proper lighting and diminish noise when
necessary to obtain accurate baseline data
Assist to a comfortable resting position, for a child, have
the parent remain close by and position the child
comfortably in the parent’s arm to ensure comfort
Record/document appropriately and transfer readings
to TPR sheet
10. Body Temperature
the balance between the heat produced by the body
and the heat lost from the body
Types:
Core Temperature – temperature of the deep
tissues of the body measured by taking oral and
rectal temperature
Surface Temperature – temperature of the skin,
subcutaneous tissue and fat measured by taking
axillary temperature
11. Maintenance of Body Temperature
Thermoregulatory center in the
hypothalamus regulates 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
12. Heat Production
Primary source is metabolism
Hormones, muscle movements, and exercise
increase metabolism
Epinephrine and norepinephrine are
released and alter metabolism
Energy production decreases and heat
production increases
13. Factors affecting Heat Production
Basal metabolic rate (BMR)
Muscle activity
Thyroxine output
Epinephrine, norepinephrine and
sympathetic stimulation
Increased temperature of the body cells
(fever)
14. Sources of Heat Loss
Skin (primary source)
Evaporation of sweat
Warming and humidifying
inspired air
Eliminating urine and feces
15. Processes involved in Heat Loss
Radiation
transfer of heat loss from the surface of one object to the
surface of another without contact between two objects
Convection
dissipation of heat by air currents
Evaporation
continuous vaporization of moisture from the skin, oral mucous,
respiratory tract; insensible heat loss
Conduction
Transfer of heat from one surface to another
transfer of heat from one surface to another, which requires
temperature difference between two surfaces
17. TYPES of FEVER (pyrexia):
Intermittent
temperature fluctuates between periods of fever and periods of
normal/subnormal temperature
Remittent
temperature fluctuates within a wide range over the 24 hour period
but remains above normal range
Relapsing
temperature is elevated for few days, alternated with 1 or 2 days of
normal temperature
Constant
body temperature is consistently high
18. Decline of FEVER (pyrexia):
Crisis/flush/defervescent stage
sudden decline of fever which indicates
impairment of function of the
hypothalamus
Lysis
gradual decline of fever which indicates
that the body is able to maintain
homeostasis
19. Clinical Signs of FEVER (pyrexia):
Onset (cold or chill stage) of fever
Course of fever
Defervescence (fever abatement)
20. TEMPERATURE CONVERSION
To change from Fahrenheit to Celsius:
subtract 32 degrees from the Fahrenheit reading
Multiply by 5/9 or divide by 9/5 (1.8)
oC = (oF – 32) x 5/9
To change from Celsius to Fahrenheit
Multiply the Celsius reading by 9/5 or 1.8
Add 32
oF = (9/5 x oC) + 32 or (oC x 1.8) + 32
21. Special Nursing Interventions:
Remove thermometer from its container and check the
temperature reading. Shake down the mercury as necessary
(until mercury is below 35 C) by holding the thermometer
between the thumb and forefinger at the end farthest from
the bulb. Snap the wrist downward.
Wash/wipe the thermometer in a rotating manner before
use, from the bulb to the stem, after use, from the stem to
the bulb. This practice ensures medical asepsis.
22. Special Nursing Interventions:
Hold the thermometer at
eye level, and rotate it until
the mercury column is
visible
Rinse the thermometer in
tap water, dry it, shake it
down and return to its
container
23. METHODS of Temperature Taking:
ORAL: most accessible and convenient method
Nursing Considerations:
Allow 15 minutes to elapse between client’s intake
of hot or cold food or smoking and the
measurement of oral temperature
24. METHODS of Temperature Taking:
ORAL: most accessible and convenient method
Nursing Consideration:
Place the thermometer under the tongue, directed
towards the side and instruct client to gently close
the lips not the teeth around the thermometer
25. METHODS of Temperature Taking:
ORAL: most accessible and convenient method
Nursing Consideration:
Wash the thermometer before use, from the bulb to
the stem, after use, from the stem to the bulb. This
practice ensures medical asepsis.
26. METHODS of Temperature Taking:
ORAL: most accessible and convenient method
Nursing Consideration:
Take oral temperature for 2 – 3 minutes. This
ensures adequate time for recording of the
temperature
Normal value:
97.6 o – 99.6 oF (36.5 o – 37. 5 oC)
27.
28. METHODS of Temperature Taking:
Contraindications to Oral Temperature Taking:
oral lesions or oral surgery
dyspnea
cough
nausea and vomiting
presence of oro-nasal pack, nasogastric tube
seizure prone
very young children
unconscious
restless, disoriented, confused
30. METHODS of Temperature Taking:
RECTAL: most accurate measurement of temperature
Indications:
When there is respiratory obstruction which prevents closure of the
mouth
When the mouth is dry, parched and inflamed
When there is oral/nasal surgery or disease
For very young, restless and irrational children
For mentally disturbed, unconscious, dyspneic, irrational, restless and
convulsive patients
When a patient is mouth breather and with oxygen
31. METHODS of Temperature Taking:
RECTAL: most accurate measurement of temperature
Nursing Considerations:
Assist client to assume lateral position/sims
position. To expose anal area
Lubricate thermometer about 1 inch above the bulb
with water soluble jelly before insertion. To reduce
friction and prevent trauma to the mucous
membrane in the anus
32. METHODS of Temperature Taking:
RECTAL: most accurate measurement of temperature
Nursing Considerations:
Insert thermometer by 0.5 – 1.5 inches (1.5 – 4 cm) for
adults, 0.9 inch (2.5 cm) for a child and 0.5 inch (1.5 cm) for
an infant or insert beyond the internal anal sphincter
Instruct the client to take a deep breath during the insertion
of the thermometer. To relax the internal anal sphincter
33. METHODS of Temperature Taking:
RECTAL: most accurate measurement of temperature
Nursing Considerations:
Hold the thermometer in place for 2 minutes (for neonates,
5 minutes). To ensure recording of temperature
Do not force the insertion of thermometer. To prevent
trauma in the area
Normal value:
98.6 o – 100.6 oF (37.0 o – 38.1 oC)
34. METHODS of Temperature Taking:
Contraindications to Rectal Temperature
Taking
Anal/rectal conditions or surgeries, e.g. anal
fissure, hemorrhoids, hemorrhoidectomy
Diarrhea
Quadriplegic clients. Vagal stimulation may
occur, causing bradycardia and syncope
36. METHODS of Temperature Taking:
AXILLARY: safest and most non-invasive method
Nursing Considerations:
Pat dry the axilla. Rubbing causes friction and will increase
temperature in the area
Place the thermometer in the client’s axilla
Place the arm tightly across the chest to keep the
thermometer in place for 9 minutes (for infants and children,
5 minutes
Normal value:
96.6 o – 98.6 oF (35.8 o – 37.0 oC)
39. METHODS of Temperature Taking:
Tympanic: readily accessible, reflects the core
temperature, very fast
Nursing Considerations:
Can be very uncomfortable and involve risks of injuring the
membrane if the probe is inserted too far
Repeated measurements may vary (right and left ears may
differ)
Presence of cerumen can affect the reading
Normal value:
98.2 o – 100.2 oF (36.8 o – 37.9 oC)
43. PULSE
wave of blood created by contraction of left ventricle
of the heart
Regulated by the autonomic nervous system through
cardiac sinoatrial node
Parasympathetic stimulation — decrease heart rate
Sympathetic stimulation — increases heart rate
Pulse rate = number of contractions over a peripheral
artery in 1 minute
44. Factors affecting the PULSE rate
Age
Sex/Gender
Exercise
Fever
Medication
Hemorrhage
Stress
Position changes
55. ASSESSMENT of the Pulse:
If pulse is regular, count for 30 seconds and
multiply by 2. If irregular, count for 1
minute. When obtaining baseline date,
count for the pulse for a full minute
Assess pulse rhythm by noting the pattern
and intervals of beat. Dysrhytmia is
irregular rhythm
56. ASSESSMENT of the Pulse:
Asses the pulse volume (amplitude) –
strength of the pulse
Normal pulse ca be felt with moderate
pressure
Full or bounding pulse can be
obliterated only by great pressure
Thready pulse can easily be obliterated
(weak or feeble)
57. ASSESSMENT of the Pulse:
Arterial wall elasticity: the artery feels
straight, smooth, soft and pliable
Presence/absence of bilateral equality:
absence of bilateral equality indicates
cardiovascular disorder
58. ASSESSMENT of the Pulse:
Pulse pressure:
Systolic pressure MINUS diastolic pressure
Pulse deficit
Apical pulse MINUS peripheral pulse
Pulsus paradoxus
Systolic pressure falls by more than 15 mmHg during
inhalation
Pulsus alternans
Alternating strong and weak pulses
59. ASSESSMENT of the Pulse:
Age
Normal Pulse Rate
Newborn to 1 month
80 – 180 beats/min
1 year
80 – 140 beats/min
2 years
80 – 130 beats/min
6 years
75 – 120 beats/min
10 years
60 – 90 beats/min
Adult
60 – 100 beats/min
Tachycardia – pulse rate above 100 beats/min
Bradycardia – pulse rate below 60 beats/min
61. Respiration
the act of breathing
carbon dioxide is the primary chemical stimulus of
breathing; when carbon dioxide level in the blood
is high, there is stimulation for breathing
Pulmonary ventilation — movement of air in and
out of lungs
Inhalation: breathing in
Exhalation: breathing out
62. Respiration
Three processes
Ventilation: movement of gases in and out of
the lungs
Diffusion: exchange of gases from an area of
higher pressure to an area of lower pressure and
occurs in the alveolo-capillary membrane
Perfusion: the availability and movement of
blood for transport of gases, nutrients and
metabolic waste products
63. Respiration
The exchange of oxygen and carbon dioxide in the
body
Two separate process
Mechanical
chemical
64. respiration
Mechanical
Pulmonary ventilation; breathing
Ventilation:
Active movement of air in and out of the respiratory system
Conduction
Movement through the airways of the lung
65. Respiration
Chemical
Exchange of oxygen and carbon dioxide
Diffusion
Movement of oxygen and CO2 between alveoli and RBC
Perfusion
Distribution of blood through the pulmonary capillaries
66. Mechanics of ventilation
Inspiration
Drawing air into the lung
Involves the ribs, diaphragm
Creates negative pressure-allows air into lung
Expiration
Relaxation of the thoracic muscles and diaphragm
causing air to be expelled
67. Variations in assessment of respirations
Rate: regulated by blood levels of O2, CO2 and ph
Chemial receptors detect changes and signal CNS
(medulla)
Normal: 12-20 breaths per minute
Apnea: no breathing
Bradypnea: abnormally slow
Tachypnea: abnormally fast
Observe for one full minute
68. Variations in assessment findings
Depth
Normal: diaphragm moves ½ inch
Deep
Shallow
Rhythm
Assessment of the pattern
Abnormal
Cheyne stokes, Kusmaul,
69. Variations in assessment of respirations
Effort
Work of breathing
Dypsnea: labored breathing
Orthopnea: inability to breath when horizontal
Observe for retractions, nasal flaring and restlessness
70. Variations in breath sounds
Wheeze
High pitched continuous musical sound; heard on
expiration
Rhonchi
Low pitched continuous sounds caused by secretions in
large airways
Crackles
Discontinuous sounds heard on inspiration; high
pitched popping or low pitched bubbling
71. Variations in breath sounds
Stridor
Piercing, high pitched sound heard during inspiration
Stertor
Labored breathing that produces a snoring sound
72. oxygenation
Hyperventilation
Rapid and deep breathing resulting in loss of CO2
(hypocapnea); light headed and tingly
Hypoventilation
Rate and depth decreased; CO2 is retained
Cheyne Stokes
Irregular, alternating periods of apnea and
hyperventilation
73. Tools to measure oxygenation
ABG
directly measures the partial pressures of oxygen,
carbon dioxide and blood ph
normal= paCO2 80-100)
Pulse oximetry
non invasive method for monitoring respiratory status;
measures O2 saturation
normal= >95%
75. Respiratory Centers:
Medulla Oblongata – primary center for respiration
Pons – (1) Pneumotaxic center; responsible for rhythmic
quality of breathing (2) Apneustic center; responsible for
deep, prolonged inspiration
Carotid and aortic bodies – contain peripheral
chemoreceptors, which take up the work of breathing
when central chemoreceptors in the medulla are
damaged, oxygen level concentration is low and respond
to pressure.
Muscle and joints contain proprioreceptors, e.g. exercise
77. Assessment of Respiration:
With fingers still in place, after taking pulse rate,
note the rise and fall of patient’s chest with
respiration. You may place the client’s arm across
the chest and observe chest movement and for
infants, observe the movement of the abdomen,
these observes for depth of respiration
Observe rate. Count for 30 seconds if
respirations are regular and multiply by 2. If
irregular, count for 60 seconds.
78. Assessment of Respiration:
Observe the respiration (inhalations and
exhalations) for regular or irregular rhythm
Observe the character or quality of
respiration – the sound of breathing and
respiratory effort
79. Assessment of Respiration:
Normal rate in adult
12 – 20 breaths/minute
Normal rate in infant
20 – 40 breaths/minute
Normal rate in preschool
20 – 30 breaths/minute
80. Assessment of Respiration:
Types of Breathing
Eupnea
Tachypnea
Bradypnea
Hyperventilation
Hypoventilation
Description
Normal respiration that is quiet, rhythmic and effortless
Rapid respiration, above 20 breaths/min in an adult
Slow breathing, less than 12 breaths/minute in an adult
Deep rapid respiration, carbon dioxide is excessively exhaled (resp. alkalosis)
Slow, shallow respiration, carbon dioxide is excessively retained (resp.
acidosis)
Difficult and labored breathing
Ability to breathe only in an upright position
Absence/cessation of breathing
Quick, shallow inspiration followed by regular or irregular periods of apnea
Very deep and labored breathing; acetone breath (metabolic acidosis)
Dyspnea
Orthopnea
Apnea
Biot’s respiration
Kussmaul
respiration
Apneustic Deep, gasping inspiration with a pause at full inspiration followed by
respiration insufficient release
82. Physiology of Blood Pressure
Force of the blood against arterial walls
Controlled by a variety of mechanism to maintain
adequate tissue perfusion
Sound of Korotkoff
Pressure rises as ventricle contracts and falls as
heart relaxes
Highest pressure is systolic
Lowest pressure is diastolic
83. Physiology of Blood Pressure:
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systolic pressure – pressure of blood as a
result of contractions of the ventricles (100 –
140 mmHg); systole (contraction of the heart);
numerator in BP reading
diastolic pressure – pressure exerted when
the ventricles are at rest (60 – 90 mmHg);
diastole (relaxation of the heart); denominator
in BP reading
84. Physiology of Blood Pressure
pulse pressure – difference between the
systolic and diastolic pressures, normal is 30 –
40 mmHg
hypertension is an abnormally high blood
pressure for at least two consecutive readings
hypotension is an abnormally low blood
pressure, systolic pressure below 100/60
mmHg
85. Determinants of Blood Pressure
Blood volume
Peripheral resistance
Cardiac output
Elasticity or compliance
of blood vessels
Blood viscosity
86. Factors Affecting Blood Pressure:
Age, gender, race
Circadian rhythm
Food intake
Exercise
Weight
Emotional state
Body position
Drugs/medications
Disease process
91. ASSESSING Blood Pressure:
Ensure that the client is rested
Allow 30 minutes to pass if the
client had engaged in exercise or
had smoked or ingested caffeine
before taking the BP (might tend to
increase BP)
Use appropriate size of the BP cuff.
Too narrow cuff causes high false
reading and too wide cuff causes
false low reading.
Position the client in sitting or
supine position
92. ASSESSING Blood Pressure:
Position the arm at the level of the
heart, with the palm of the hand
facing up. The left arm is preferably
used because it is nearer the heart
Apply/warp the deflated cuff snugly
in upper arm, the center of the
bladder directly over the medial
aspect or 1 inch above the
antecubital space or at least 2 – 3
fingers above the elbow
93. ASSESSING Blood Pressure:
Determine palpatory BP before
auscultatory BP to prevent
auscultatory gap
Use the bell of the stethoscope
since the BP is a low frequency
sound
Inflate and deflate BP cuff
slowly, 2 -3 mmHg at a time
Wait 1 -2 minutes before
making further determinations
94. ASSESSING Blood Pressure:
Palpate the brachial artery
with your fingertips
Close the valve on hand pump
by turning the knob
clockwise
Insert the ear attachment of
the stethoscope in your ears
so they tilt slightly forward an
ensure it hangs freely from
the ear to the diaphragm
95. ASSESSING Blood Pressure:
Place the diaphragm of stethoscope
over brachial pulse and hold with the
thumb and index finger
Pump out the cuff until the
sphygmomanometer registers about
30 mmHg above the point where the
brachial pulse disappeared
Release the valve on the cuff carefully
so that the pressure decreases at the
rate of 2 – 3 mmHg per second
96. ASSESSING Blood Pressure:
As the pressure falls, note
the first sound, muffling,
and last sound heard
Deflate the cuff rapidly
and completely after
noting the last sound
97. ASSESSING Blood Pressure:
Read lower meniscus of the
mercury level of the
sphygmomanometer at eye
level to prevent error of parallax
Error of parallax happens if
the eye level is higher than
the lever of the lower
meniscus of the mercury,
this causes false low reading,
if the eye level is lower, this
causes false high reading
99. Korotkoff’s sounds
1st
As you deflate the cuff; occurs during systole
2nd
Further deflation of the cuff; soft swishing sound
3rd
Begins midway through; sharp tapping sound
4th
Similar to 3rd sound but fading
5th
Silence, corresponding with diastole
100. Other BP issues
Orthostatic or postural hypotension
Sudden drop in BP on moving from lying to sitting or
standing position
Primary or essential hypertension
Diagnosed when no known cause for increase
Accounts for at least 90% of all cases of hypertension
101. Vital signs
Combination of skills which provide an indication of
state of health and body functionality
Nurses can delegate the activity of VS, but are
responsible for interpretation, trending and decisions
based on the findings
102. Pain
5th vital sign
It is what the client says it is
Nurse must know
how to assess for it
Establish acceptable comfort levels
Follow up within appropriate time frame after
intervention
103. Pain
Data collection
Location (place and position)
Intensity
1-10
Strength and severity
What is your pain at present? What makes it worse? What is
the best that it gets?
104. Pain data collection
Describe
Aching, stabbing, tender, tiring, numb,……..
Duration
When did it start? Is is always there?
Aggrevate/alleviate
What makes it better/worse?
105. How does the pain affect…
Energy
Appetite
Sleep
Activity
Mood
Relationships
Memory
concentration
Nurse checks for
VS
Knowledge of pain
Med history
Side effects of meds
Use of non
pharmacological
therapies