Vital Signs

1. Vital Signs NEO 111 Melanie Jorgenson, RN, BSN

2. Vital Signs • Temperature (T) • Pulse (P) • Respiration (R) • Blood pressure (BP) • Pain (often called the fifth vital sign) • Oxygen Saturation

3. Occasions for Measuring Vital Signs • Upon admission to a healthcare setting • When certain medications are given • Before and after diagnostic and surgical procedures • Before and after certain nursing interventions • In emergency situations

4. Body Temperature • Definition: the heat of the body measured in degrees • The difference between production of heat and loss of heat • Normal temperature: 97.0ºF (36.0ºC) to 99.5ºF (37.5ºC) • Process: heat is generated by metabolic processes in the core tissues of the body, transferred to the skin surface by the circulating blood, and dissipated to the environment

5. Sites for Measurement of Temperatures • Core temperatures • Tympanic and rectal • Esophagus and pulmonary (invasive monitoring devices) • Surface body temperatures • Oral (sublingual) • Axillary

6. Inserting Tympanic Thermometer into Patient’s Ear

7. Contraindications to Temperature Measurement sites • Oral: impaired cognitive functioning, inability to close lips around thermometer, diseases of the oral cavity, and oral or nasal surgery • Rectal: newborns, small children, patients who have had rectal surgery, or have diarrhea or disease of the rectum, and certain heart conditions • Tympanic: earache, ear drainage, and scarred tympanic membrane

8. Characteristics of the Pulse • Pulse rate • Measured in beats per minute • Pulse quality (amplitude) • The quality of the pulse in terms of its fullness • Pulse rhythm • Pattern of the pulsations and the pauses between them • Normally regular

9. Methods of Assessing the Pulse • Palpating the peripheral arteries • Auscultating the apical pulse with a stethoscope • Using a portable Doppler ultrasound

10. Common Pulse Sites • Temporal • Carotid • Brachial • Radial • Femoral • Popliteal • Posterior tibial • Dorsalis pedis

11. Palpating the Radial Pulse

12. Assessing an Apical Pulse • Indications • Patient is receiving medications that alter heart rate and rhythm • A peripheral pulse is difficult to assess accurately because it is irregular, feeble, or extremely rapid • Method • Count the apical rate 1 full minute by listening with a stethoscope over the apex of the heart • Most reliable method for infants and small children; can be palpated with fingertips

13. Assessing Respirations (Normal Findings) • Rate • Adults: 12 to 20 times per minute • Infants and children breathe more rapidly • Depth • Varies from shallow to deep • Rhythm • Regular: each inhalation/exhalation and the pauses between occur at regular intervals

14. Assessing Respiratory Rate, Depth, and Rhythm • Method • Inspection (observing and listening) • Listening with the stethoscope • Counting the number of breaths per minute • Considerations • If respirations are very shallow and difficult to detect visually, observe sternal notch • Patients should be unaware of the respiratory assessment to prevent altered breathing patterns

15. Factors Affecting Respirations • Exercise • Medications • Smoking • Chronic illness or conditions • Neurologic injury • Pain • Anxiety

16. Signs of Respiratory Distress • Retractions • Nasal flaring • Grunting • Orthopnea (breathing more easily in an upright position) • Tachypnea (rapid respirations)

17. Sample Nursing Diagnoses Related to Respiratory Status • Ineffective Breathing Pattern • Impaired Gas Exchange • Risk for Activity Intolerance • Ineffective Airway Clearance • Excess Fluid Volume • Ineffective Tissue Perfusion

18. Blood Pressure • Definition • The force of the blood against arterial walls • Systolic pressure • The highest point of pressure on arterial walls when the ventricles contract • Diastolic pressure • The lowest pressure present on arterial walls during diastole (Taylor, 2007).

19. Measuring Blood Pressure • Blood pressure is measured in millimeters of mercury (mm Hg) • Blood pressure is recorded as a fraction • The numerator is the systolic pressure • The denominator is the diastolic pressure • Pulse pressure • The difference between the systolic and diastolic pressure

20. Blood Pressure Assessment (Methods) • Using a stethoscope and sphygmomanometer • Using a Doppler ultrasound • Estimating by palpation • Assessing with electronic or automated devices

21. Measuring Blood Pressure

22. Ensuring an Accurate Blood Pressure Reading • Use a cuff that is the correct size for the patient • Ensure correct limb placement • Use recommended deflation rate • Correctly interpret the sounds heard

23. Factors Affecting Blood Pressure Reading • Age • Exercise • Position • Weight • Fluid balance • Smoking • Medications

24. Using a Pulse Oximeter • Purpose • Measure the arterial oxyhemoglobin saturation of arterial blood • Method • A sensor or probe, uses a beam of red and infrared light which travels through tissue and blood vessels • The oximeter calculates the amount of light absorbed by arterial blood • Oxygen saturation is determined by the amount of each light absorbed

25. Uses for Pulse Oximetry • Monitoring patients receiving oxygen therapy • Titrating oxygen therapy • Monitoring those at risk for hypoxia • Monitoring postoperative patients

26. Questions?