VitalSigns

• Vital signs

  • Body temperature
  • Pulse rate
  • Respiratory rate
  • Blood pressure
  • Pain/comfort (5th vital sign)
  • O2 sat
• Vital signs

  Measure vital function
• Importance of accurate assessment of vital signs

  Excellent means of assessing client's status- compare with accepted standards as well as client's baseline
• Recording vital signs

  1. Abnormal findings are reported to the nurse immediately

  2. Assess signs and symptoms: chest pain, vertigo, shortness of breath, flushing, and diaphoresis

  3. Document interventions initiated as a result of vital sign readings, such as tepid bath

  4. Always check baseline and compare

  
• Factors affecting body temperature

  
• Normal body temperature range

  97°F to 98.8°F
• Hypothalamus

  • Maintains a balance between heat lost and heat produced by the body
• Factors affecting body temperature

  • Exercise
  • Hormones (ovulation and menopause)
  • Individual variations
  • Stress (sympathetic nervous system, high stressed or anxious > temp)
  • Circadian rhythms (temp highest 4PM-6PM, lowest 1AM and 4AM)
  • Hot or cold liquids/food
  • Smoking
  • Medication
  • Site of assessment
  • Age (infants, children, elderly)

  
• Core temperature

  Temperature of the deep tissues of the body, remains relatively constant unless exposed to severe extremes in environmental temperature, assessed by using a thermometer (rectum, tympanic membrane, temporal artery)

  
• Surface temperature

  Temperature of the skin, may vary a great deal in response to the environment, assessed by touching the skin (skin, mouth, axillae)

  
• Hyperthermia

  Overheating in extreme weather conditions, heat stroke is a life-threatening form
• Pyrexia, febrile, hyperthermia

  Terms to describe above-normal temperature
• Fever


  A body defense and can destroy invading bacteria
• Types of fever


  • Constant fever (fluctuates minimally, remains elevated)
  • Intermittent fever (body temperature alternates at regular intervals, "spike" in afternoon)
  • Remittent fever (fluctuates but does not return to normal until well)
• Hypothermia


  Untreated leads to complete failure of heart and respiratory system and death, caused by excessive heat loss, inadequate heat production, or impaired hypothalamic temperature regulation
• Preventing hypothermia


  1. Wear a hat (significant loss of body heat from the head)

  2. Layer clothing (warm but breathable layers)

  3. Pay attention to shivering (produces body heat, but if severe, stop exercising and head indoors)

  
• Types of hypothermia


  • Accidental (cold environment, immersion in cold water, inadequate clothing, decreased metabolic rate, drugs)
  • Elderly (worse due to decreased metabolic rate, sedatives)
  • Induced (surgery to decrease oxygen demands, comatose survivors of cardiac arrest to reduce ischemic injury)

  
• Treatment of hypothermia

  1. Rewarm gradually

  2. Hyperthermia blanket

  3. Warm saline stomach lavage, IV fluids, and in extreme case dialysis

  4. Dry clothing

  
• Pulse rate


  Normal 60-100 bpm, S1-S2, dysrhythmia/arrhythmia (irregular pulse rhythm), pulse volume (force of blood in artery with each heartbeat, ranges from absent to bounding)

  
• Factors affecting pulse


  • Pain/anxiety/excitement
  • Age
  • Exercise
  • Fever
  • Hemorrhage
  • Medications
  • Sleep
  • Heart disease
  • Metabolism
  • Gender
  • Time of day
  • Pulmonary conditions
  • Position changes
• Obtaining pulse measurements


  1. Peripheral pulse (taken away from the heart, carotid pulse best to find quickly)

  2. Apical pulse (essential on all cardiac patients, refers to the apex of the heart)

  
• Respiration


  Normal respiratory rate 12-20 respirations per minute, expiration is passive, ventilation is inhalation/inspiration which requires energy, hyperventilation is rapid and deep, hypoventilation is slow and shallow
• Factors affecting respiratory rate

  • Exercise
  • Stress
  • Environment
  • Increased altitude
  • Certain medications
  • Increased ICP
  • Pulmonary disorders
• Blood pressure

  Measure of force exerted by blood as it flows through arteries, measured in mm Hg, systolic pressure is from contraction of ventricles, diastolic pressure is when ventricles are relaxed
• Factors affecting blood pressure

  • Age
  • Exercise
  • Stress
  • Race
  • Obesity
  • Gender
  • Medications
  • Diurnal variations
  • Disease processes
• Hypotension

  BP below 90 mm Hg or lower systolic, if low and no ill effects considered healthy, orthostatic hypotension is BP that drops when client sits or stands
• Factors determining blood pressure

  • Blood volume (quantity of circulating fluid in blood vessels)
  • Peripheral vascular resistance (pressure and compliance in arteries)
• Collection sites for blood pressure measurement
• Blood pressure classification

  • Normal
  • Elevated
  • Hypertension stage 1
  • Hypertension stage 2
  • Hypertensive crisis
• Korotkoff's sounds

  Sounds auscultated during blood pressure measurement
• Blood pressure measurement of lower extremities
• Height and weight


  Helps assess normal growth and development, aids in proper drug dosage calculation, may be used to assess the effectiveness of drug therapy, significant loss of weight may be a sign of an underlying disease
• Popliteal artery


  Used for blood pressure measurement of lower extremities
• Cuff for lower extremity blood pressure


  • Must be wide and long enough to allow for the larger girth of the thigh
  • Positioned with the bladder over the posterior aspect of the mid-thigh
• Height and Weight


  • Helps assess normal growth and development
  • Aids in proper drug dosage calculation
  • May be used to assess the effectiveness of drug therapy, such as diuretics
  • Significant loss of weight may be a sign of an underlying disease
  • Weigh same time everyday with same scale, and in the same type or amount of clothing
  • 1 liter of fluid = 1 kilogram (kg) = 2.2 pounds [lb]
• Comfort


  • May be slightly different based on individual experiences
  • Comfort is reached when each level of Maslow's hierarchy is met
  • Relief/ease from/freedom from pain, emotional distress, spiritual distress, environmental distress
• Types of Pain


  • Acute
  • Chronic
  • Nociceptive
  • Referred
  • Breakthrough
  • Neuropathic pain
  • Phantom
  • Psychogenic
• Nature of Pain


  • Serves as a warning
  • Often occurs where there is actual or potential tissue damage
  • May be a cardinal sign of inflammation
  • Valuable in the diagnosis of many disorders and conditions
  • Pain causes fatigue
  • Decreases ability to cope physically, emotionally, and mentally
  • Pain is subjective
• McCaffery and Pasero's description of pain

  "Whatever the experiencing person says it is, existing whenever he (or she) say it does"
• Types of Pain


  • Mild or severe
  • Chronic or acute
  • Intermittent or intractable
  • Burning, dull, or sharp
  • Precisely or poorly localized
  • Referred (Felt at a site other than the injured or diseased)