Chapter 29 Vital Signs
Vital Signs Temperature, pulse, respiratory rate, blood pressure Pain Oxygen saturation also frequently measured Vital signs are used to: Monitor patient s condition Identify problems Evaluate response to intervention
Guidelines for Measuring Vital Signs Ensure that equipment is functional and is appropriate for the size and age of the patient. Appropriately delegate measurement. Be able to understand and interpret values. Know the patient s usual range of vital signs. Determine the patient s medical history, therapies, and prescribed medications. Control or minimize environmental factors that affect vital signs.
Guidelines for Measuring Vital Signs (cont d) Use an organized, systematic approach when taking vital signs. Know the acceptable ranges for your patients before administering medications, and use vital sign measurements to determine indications for medication administration. Communicate findings. Accurately document findings. Analyze the results of vital sign measurement. Instruct the patient or family caregiver in vital sign assessment and the significance of findings.
Case Study Ms. Coburn is a 26-year-old schoolteacher. Her maternal grandparents immigrated to America from Brazil. She smokes one pack of cigarettes a day and has smoked since she was 16. She is 20 lbs overweight. She made an appointment because she started to have headaches and frequently felt tired.
Body Temperature Physiology Body temperature: Heat produced Heat lost Acceptable temperature range: 98.6 F to 100.4 F or 36 C to 38 C Temperature sites: Oral, rectal, axillary, tympanic membrane, temporal artery, esophageal, pulmonary artery
Body Temperature Regulation Neural and vascular control Heat production Heat loss (radiation, conduction, convection, evaporation) Skin temperature regulation Behavioral control Thermoregulation
Case Study (cont d) Miguel is a 42-year-old Hispanic nurse who works at the clinic Ms. Coburn is visiting. He enjoys providing health-related teaching to the patients and has provided Mrs. Coburn care for 2 years. During the visit, Miguel assesses Ms. Coburn s symptoms. He asks her about her headache and fatigue, then takes her vital signs. Her temperature is 98 Fahrenheit.
Factors Affecting Body Temperature Age Exercise Hormonal level Circadian rhythm Environment Temperature alterations
Temperature Cycle
Temperature Alterations Pyrexia (fever): important defense mechanism Pyrogens Febrile/afebrile Fever of unknown origin (FUO) Hyperthermia Malignant hyperthermia Heatstroke (104 F or higher) Heat exhaustion Hypothermia Frostbite
Hypothalamic Temperature Control
Patterns of Fever Sustained Constant above 38 C (100.4 F) with little fluctuation Intermittent Fever spikes interspersed with usual temperature levels Remittent Fever spikes and falls without a return to normal temperature levels Relapsing Periods of febrile episodes and periods with acceptable temperature values
Nursing Process and Temperature Assessment Sites: advantages and disadvantages Core and surface Thermometers Electronic: oral, axillary, rectal, tympanic membrane, temporal artery Disposable: oral, axillary, rectal Fahrenheit or Celsius scale
Electronic Thermometer
Temporal Artery Thermometer
Chemical Dot Thermometer
Quick Quiz! 1.You have delegated vital signs to assistive personnel. The assistant informs you that the patient has just finished a bowl of hot soup. The nurse s most appropriate advice would be to A. Take a rectal temperature. B. Take the oral temperature as planned. C. Advise the patient to drink a glass of cold water. D. Wait 30 minutes and take an oral temperature.
Nursing Process: Temperature Diagnosis Risk for imbalanced body temperature Hyperthermia Hypothermia Ineffective thermoregulation Planning
Nursing Process: Temperature (cont d) Implementation Health promotion Consider activity, environment, and clothing. Acute care: treat pyrogen, antipyretics Heatstroke Hypothermia Restorative and continuing care Evaluation Get patient s perspective, compare actual with expected outcomes, and determine whether goals were met.
Pulse Physiology and Regulation Pulse = Palpable bounding of blood flow noted at various points on the body The indicator of circulatory status Pulse rate = Number of pulsing sensations in 1 minute Electrical impulses originate from the sinoatrial (SA) node. Cardiac output, heart rate, stroke volume Mechanical, neural, and chemical factors regulate ventricular contraction and stroke volume.
Assessment of Pulse Sites: temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, posterior tibial, and dorsalis pedis Use of stethoscope Character of pulse: rate, rhythm, strength, and equality Nursing process and pulse determination
Parts of a Stethoscope
Use of a Stethoscope
Pulse Character Rate Apical rate: ID S1 and S2, lub + dub = 1 heartbeat Lub-dubs per minute = Rate Bradycardia Tachycardia Pulse deficit = Difference between radial and apical pulse rates Rhythm Dysrhythmia: regularly or irregularly irregular Strength: 4+, 3+, 2+ (normal), 1+, 0 Equality
Nursing Process and Pulse Determination Activity intolerance Anxiety Fear Decreased cardiac output Deficient/excess fluid volume Impaired gas exchange Hyperthermia Hypothermia Acute pain Ineffective peripheral tissue perfusion
Quick Quiz! 2. You notice that a teenager has an irregular pulse. The best action you should take includes A. Reading the history and physical. B. Assessing the apical pulse rate for 1 full minute. C. Auscultating for strength and depth of pulse. D. Asking whether the patient feels any palpitations or faintness of breath.
Respiration Ventilation = Movement of gases into and out of the lung. Diffusion= Movement of oxygen and carbon monoxide between alveoli and red blood cells. Perfusion = Distribution of red blood cells to and from the pulmonary capillaries. Physiological control; hypoxemia Mechanics of breathing; eupnea
Movements During Breathing
Assessment of Ventilation Easy to assess Respiratory rate: breaths/minute Ventilatory depth: deep, normal, shallow Ventilatory rhythm: regular/irregular Diffusion and perfusion Arterial oxygen saturation
Case Study (cont d) Miguel continues to take Ms. Coburn s vital signs. Ms. Coburn s respiratory rate is 14 breaths per minute, and her pulse is 86 beats per minute.
Factors Influencing Character of Respirations Exercise Anxiety Body position Neurological injury Acute pain Smoking Medications Hemoglobin function
Alterations in Breathing Pattern Bradypnea Tachypnea Hyperpnea Apnea Hyperventilation Hypoventilation Cheyne-Stokes respiration Kussmaul s respiration Biot s respiration
Assessment of Diffusion and Perfusion Measurement of arterial oxygen saturation (SaO 2 ), the percent of hemoglobin that is bound with oxygen in the arteries Usually 95% to 100% Pulse oximeter Probes: digit, earlobe, disposable
Pulse Oximeter
Nursing Process and Respiratory Vital Signs Nursing diagnosis Activity intolerance Ineffective airway clearance Anxiety Ineffective breathing pattern Impaired gas exchange Acute pain Ineffective peripheral tissue perfusion Dysfunctional ventilatory weaning response Planning, interventions, evaluation
Quick Quiz! 3. A postoperative patient is breathing rapidly. You should immediately A. Call the physician. B. Count the respirations. C. Assess the oxygen saturation. D. Ask the patient if he feels uncomfortable.
Arterial Blood Pressure Force exerted on the walls of an artery by pulsing blood under pressure from the heart Systolic = Maximum peak pressure during ventricular contraction Diastolic = Minimal pressure during ventricular relaxation Pulse pressure = Difference between systolic and diastolic pressures
Physiology of Arterial Blood Pressure Factors affecting arterial blood pressure: Cardiac output Peripheral resistance Blood volume Viscosity Elasticity
Factors Influencing Blood Pressure Age Stress Ethnicity Gender
Factors Influencing Blood Pressure (cont d) Daily variation Medications Activity, weight Smoking
Case Study (cont d) Ms. Coburn s blood pressure is 164/98 mm Hg. Ms. Coburn asks whether this means she is healthy.
Blood Pressure Cuff Size Guidelines
Hypertension versus Hypotension Hypertension More common than hypotension Thickening of walls Loss of elasticity Family history Risk factors Hypotension Systolic <90 mm Hg Dilation of arteries Loss of blood volume Decrease of blood flow to vital organs Orthostatic/postural
Case Study (cont d) Miguel responds, Ms. Coburn, your blood pressure is pretty high right now. After you see the nurse practitioner today, I am going to take your blood pressure again. We are also going to talk about the changes you can begin to make to help you be healthier and feel better.
Measurement of Blood Pressure Equipment Auscultation Children Ultrasonic stethoscope Palpation Lower extremity Electronic blood pressure
Sphygmomanometer
Alternate Methods of Measuring Blood Pressure
Patient Conditions Not Appropriate for Electronic Blood Pressure Measurement Irregular heart rate Peripheral vascular obstruction (e.g., clots, narrowed vessels) Shivering Seizures Excessive tremors Inability to cooperate Blood pressure less than 90 mm Hg systolic
Patient Measurement of BP Benefits Detection of new problems (prehypertension) Patients with hypertension can provide to their health care provider info about patterns of BP. Self-monitoring helps adherence to therapy. Disadvantages Improper use risks inaccurate readings. Unnecessary alarming of patient Patients may inappropriately adjust medications.
Nursing Process and Blood Pressure Determination Assessment of blood pressure and pulse evaluates the general state of cardiovascular health. Hypertension, hypotension, orthostatic hypotension, and narrow/wide pulse pressures are defining characteristics of certain nursing diagnoses.
Case Study (cont d) After caring for Ms. Coburn, Miguel sees the need to educate Ms. Coburn about the different types of vital signs. Miguel determines that the priority is to focus on hypertension and ways to prevent or control elevated BP. He states, We need to watch your blood pressure closely over the next few weeks. In the meantime, remember, you decided that you are going to walk for at least 15 minutes 3 days a week; you are also going to try to eat foods with less salt and think about not smoking anymore.
Quick Quiz! 4. When assessing the blood pressure of a school-aged child, using an adult cuff of normal size will affect the reading and produce a value that is A. Accurate. B. Indistinct. C. Falsely low. D. Falsely high.
Health Promotion and Vital Signs Monitor vital signs. Include age-related factors. Include environmental and activity factors.
Case Study (cont d) Ms. Coburn has purchased an electronic blood pressure device for home use. What evaluation strategies would you suggest for Miguel to use with Ms. Coburn?
Recording Vital Signs Record values on electronic or paper graphic. Record in nurses notes any accompanying or precipitating symptoms. Document interventions initiated on the basis of vital sign measurement. If a vital sign is outside anticipated outcomes, write a variance note to explain, along with the nursing course of action. In the nurse s variance note, address possible causes of a fever.
Safety Guidelines for Skills Cleaning devices between patients decreases the risk for infection. Rotating sites during repeated measurements of BP and pulse oximetry decreases the risk for skin breakdown. Analyze trends for vital signs, and report abnormal findings. Determine the appropriate frequency of measuring vital signs based on the patient s condition.