Vital Signsrevised06

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Vital Signs revised06

• Cardinal signs, reflects bodys physiological
  status
  
• Provides information critical to evaluate
  homeostatic balance
  
• Five critical assessments
• Temperature
• Pulse
• Respiration
• Blood Pressure (B/P)

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• Pain is considered the 5th vital sign
• Now also checking the oxygen saturation
• Vital signs are taken at regular intervals
  depending on unit policy and patient condition.
  These times may be
  
• Every 8hrs
• Every 4 hrs
• Every 2 hrs
• Every hour
• Every 5-30 minutes
• Depending on condition of client or medication
  administration
  

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• Vital signs indicate a positive or negative
  change in clients condition
  
• If vital signs are out of range or different from
  previous recordings, repeat if using mechanical
  equipment find a different machine
  
• Factors influencing Vital Signs
• Age Gender Medications
• Race Heredity Environment
• Pain Stress Metabolism
• Lifestyle Exercise
• Components of Vital Signs
• Temperature- regulated by hypothalamus shows
  balance between heat gained and heat loss
  

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Temperature

• Temperature- measured by thermometer
• Oral, rectal, ,axillary, tympanic, heat sensitive
  tape
  
• Electric probe with disposal cover
• Always designate where temperature is taken as O,
  R, A, T, tape
  
• Register temperature as C (Centigrade) or F
• (Fahrenheit)
• -Mercury thermometers no longer used

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• Temperature-measured by thermometer
• Oral Electronic with disposal cover
• Tympanic- electric probe used in ear
• Oral, rectal, axillary
• Heat sensitive tape
• Temperature variations
• Newborn 36.5-37 C axillary
• No newborn has rectal temp
• Infants 3 mo 99.4F 1 yr 99.7F axillary or
• rectal. After 4-5 yrs old can be taken orally
• or ear based device

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• Convert centigrade to Fahrenheit
• C multiply by 1.8 then add 32
• Convert Fahrenheit to centigrade
• F subtract 32 divided by 1.8
• Temperature varies by the time of day
• Highest between 500 to 700pm, late afternoon
• Lowest between 200 to 600am, early morning
• If possibility of contamination by body fluids
  wear gloves
  
• Most accurate is rectal, least is axillary

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• Temperature variations
• - Newborns 36.5-37oC
• No rectal temperature for newborns
• 1 year 99.7oF temp taken rectal or axillary
• 4-5 year old taken orally or tympanic
• 13 years 97.8oF
• Elderly range between 96.6o to 98.3oF
• Taken orally, axillary it unable to close mouth
  may also use tympanic or heat sensitive tape
  

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• PROCEDURE
• Wash hands
• ID client
• Explain procedure to client
• Don gloves if necessary
• Provide privacy
• Electronic thermometer --Oral
• Wait 20-30 minutes if client was eating,
  drinking, smoking, exercising
  
• Place disposal cover on probe
• Place probe under tongue to sublingual pocket

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• Have client close mouth
• When audible signal occurs (temperature has
• registered) remove from clients mouth
• Remove probe and dispose of probe cover
• Wash hands
• Record temperature with proper notations

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• Electronic Temperature-Rectal Temperature
• Don gloves
• Position client facing away from you,laying in
  Sims position with upper leg flexed
  
• Place disposal cover lubricated with water
  soluble lubricant .
  
• Insert probe ¼ to 1 inch through anal sphincter
• If encounter resistance remove probe immediately
• After audible signal, remove probe
• Discard probe cover, tissue and gloves

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• Wash hands
• Record temperature with proper notation of R
• Digital thermometer
• Clients individual thermometer
• Gloves maybe necessary
• Oral
• Similar to electronic thermometer
• Wait 20-30 minutes if activities require
• Place thermometer in clients mouth under tongue
  (sublinguinal pocket)
  

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• Client holds lips closed
• Leave in for 45-90 seconds
• Temperature displayed
• Record temperature with O
• Axillary
• Same as Oral
• Expose axilla and dry under arm
• Place thermometer in center of axilla and lower
  arm
  
• Wait 1-2 minutes to register
• Record temperature
• Wash hands

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• Tympanic
• Wash hands
• Attach disposal probe
• Turn clients head to one side
• Place probe in ear and must be in contact will
  all sides of canal
  
• When inserting probe into ear use figure 8
  pattern
  
• Adults pinna upward and backward Child down and
  backward
  
• Make sure probe has firm seal in ear

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• Press hold temp switch till light flashes
  (approx. 3 seconds)
  
• Remove thermometer, discard probe cover Wipe lens
  with alcohol swab, dry
  
• Record temperature with Tympanic temperature
• Wash hands

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Pulse

• Pulse an index of the hearts rate and rhythm,
  shows heart action
  
• Need to evaluate
• Rate- number of pulsation in one minute
• Rhythm- pattern, even or regular regular
  irregular irregular irregular
  
• Quality- fullness or strength- reflex stroke
  volume maybe bounding, very strong, weak/
  thready, absent

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• Pulse rate may increase or decrease for various
  reasons (exercise, drugs, lack of oxygen, medical
  conditionsdehydration, hemorrhage, etc)
  
• Tachycardia pulse over 100 BPM.
• Bradycardia pulse below 60 BPM
• Pulse located
• Carotid- avoid pressuring too hard decreases
  blood flow to brain
  
• Apical
• Brachial ( site for auscultation of B/P)

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• Ulnar-near pinky finger
• Radial- easy access near thumb
• Femoral
• Popliteal (behind knee)
• Posterior Tibial-evaluate circulation lower
  extremities
  
• Dorsalis Pedis- evaluate circulation lower
  extremities
  
• Pulses should be felt against bone and using pads
  of 3 middle fingers
  
• DO NOT USE YOUR THUMB
• NEED A WATCH WITH SECOND HAND
• Client should be either in supine or sitting
  position

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• Procedure
• Always wash hands no matter where you take a
  pulse
  
• Always ID patient, provide privacy, explain
  procedure to client
  
• Always check clients activity level of previous
  15 minutes
  
• When regular pulse can count for 30 seconds and
  multiplying by 2
  
• If difficult or irregular, or taking certain
  medication then MUST count for 1 full minute
  
• Record pulse rate, rhythm and strength
• Need watch with second hand

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• Infants and Children
• Newborn 80-180/min
• Toddler80-110/min
• School age 50-90/min
• Adolescent 50-90/min

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• Radial Pulse
• Use pads of the 3 middle fingers, place fingers
  on side of thumb
  
• Count 30 seconds and multiply by 2
• Wash hands and record rate, rhythm, volume
• (strength)
• Apical Pulse
• -Client in supine position, expose chest.
• -Locate apical impulse (palpate the Angle of
  Louis below suprasternal notch, palpate
  down-
  

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• ward to fifth Intercostal space
• -Move to Midclavicular line
• -Warm stethoscope, place diaphragm over apical
  space
  
• -Count clients apical pulse for 1 full minute
• (lub-dub)
• -Wash hand clean stethoscope
• Record rate, rhythm, intensity of apical pulse

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• Apical-Radial Pulse
• Equipment watch with second hand, another nurse
  and stethoscope( warm in your hand)
  
• Beginning procedure by washing hands, ID client,
  provide privacy, explain procedure
  
• Nurse one takes radial pulse and at the same time
  the nurse two auscultates the apical pulse for
  one full minute
  
• Nurse one signals to stop counting.
• Records rate, rhythm, volume.

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• Pulse Deficit- the difference between the radial
  pulse and the apical pulse
  
• Peripheral Pulse
• Palpate peripheral, radial,carotid, brachial,
  femoral, popliteal, dorsalis pedis and posterior
  tibial
  
• Compare bilaterally using pads of middle three
  fingers
  
• If difficult to feel, when located mark locations
  with felt tip pen

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• May need to get Doppler.
• If need to do this get conductive jelly and
  Doppler
  
• Plug in stethoscope, apply gel to clients skin
  at site
  
• Hold probe 90oangle
• Turn on Doppler, and move probe around to hear
  probe, will hear swooshing sound
  
• Mark site
• Wipe skin

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Blood Pressure

• Blood pressure (B/P)- is the force of blood
  against arterial wall
  
• Pulse pressure is the difference between the
  systolic and diastolic pressure (normal 30-50 mm
  HG
  
• Equipment Stethoscope ( bell and diaphragm)
  sphygmomanometer
  
• Make sure B/P cuff size is based on circumference
  of the limb
  
• When unable to take B/P on arm can take on thigh
  ( see pg 527)
  

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• Factors affecting B/P
• Cardiac output
• Peripheral vascular resistance
• Elasticity Distensibility of arteries
• Blood volume
• Blood Viscosity
• Hormones Enzymes
• Chemoreceptors
• Age, sex, weight
• Body position
• Activity

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• Difference between recumbent and standing B/P
  systolic falls 10-15points
  
• diastolic may rise 5 points mmHG
• Adults- normal range is between 100-130/60-85
• No B/P taken on Neonates
• Need to take B/P 2 different times days to
  diagnosis high B/P.
  
• Two types anaeroid mercury manometer
• High B/P immediately after birth, lowest
• 3 hrs later4-6 days later rises and levels off

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• Normal adult B/P ranges below 120(systolic) and
  less than 80(diastolic), varies with different
  people
  
• Hypertensive B/P is defined as 140 mmHG or
  greater systolic and/ or 90mmHG or greater
  diastolic
  
• Systolic pressure- give data about the condition
  of the heart and great arteries
  
• Diastolic pressure- data about the arteriolar or
  peripheral vascular resistance
  
• Allow 1 to 2 minutes between taking B/P again
• Always clean, wipe ear pieces with alcohol

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• Always wash hands
• ID client
• Clean ear piece, and bell/diaphragm with alcohol
• B/P may be taken over brachial artery
• Always explain procedure to client
• Size of cuff vary depending on size of arm
• If client has smoked or exercise wait 15 minute
• DO NOT take B/P on arm of Dialysis or Radial
  Mastectomy client

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• Procedure
• Wash hands, ID client, explain procedure
• Client is sitting or reclining position
• Choose proper cuff size
• Locate palpate brachial artery
• Wipe stethoscope with alcohol
• Close sphygmomanometer
• Inflate cuff to 30points mm HG above level were
  radial pulsation are no longer felt.
  
• Bell or diaphragm on medial antecubital fossa (
  bell is better for auscultation)
  
• Deflate cuff gradually until first Korotkoff
  sound heard (systolic pressure)
  

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• Read pressure on manometer at eye level
• Continue to deflate until Korotkoff sound no
  longer heard (diastolic pressure)
  
• Remove cuff
• Record results and wash hands
• Palpable Systolic Arterial B/P
• This is done when unable to hear B/P readings
• Wash hands, check ID, Explain, wrap cuff on upper
  arm
  
• Locate radial artery
• Inflate cuff to where radial artery pulsation

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• no longer felt
• -Continue to palpate and release pressure on
  cuff
  
• -First palpated beat is systolic pressure ( same
  point of last pulsation during inflation
  
• Remove cuff, wash hands, record
• Monitoring with Noninvasive Device
• Wash hands, ID client, attach B/P cuff to client
• Plug in machine in electrical outlet
• Turn on switch
• Press start
• When reading occurs, record reading

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• Remove cuff and return and re-plug machine into
  electrical outlet
  
• Respirations
• Respiration is the process of bringing oxygen to
  the body tissue ( Inspiration) and removing
  carbon dioxide (expiration)
  
• Normal rate of adult 12-18 breaths/min.
• Newborn 30- (40-60) breaths/min.
• Older children 20-26 breaths/min.
• Tachypnea rate over 24 breaths/min.
• Bradypnea rate less than 10 breaths/min.

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• Apnea absence of breathing
• Dyspnea difficulty breathing
• Need to assess pattern, rate and depth of clients
  breathing
  
• Rhythm- pattern between inspiration and
  expiration
  
• Quality effort required to breathe
• Always wash hand
• ID Client
• Provide privacy
• Explain procedure

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• Factors affecting respiration
• Age
• Drugs
• Stress
• Emotions
• Body position
• Procedure
• Wash hands, ID client, provide privacy, explain
  procedure
  
• While taking pulse check clients respirations

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• Observe clients respirations and count for 30
  seconds and multiply by 2
  
• If unable to accurately visualize clients
  respirations may place hand on clients chest and
  count respirations for 30 second and multiple by
  2
• Wash hands and record noting rate, rhythm and
  depth
  
• Rhythm- can be either regular or irregular
• Depth- can be normal or shallow

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• Respirations
• Newborn- 30-60/min
• Toddler24-32/min
• School age- 18-26/min
• Adolescent- 16-20/min
• Adults- 12-20/min

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Pain

• Pain is a sensation in which a person experiences
  discomfort, distress, or suffering
  
• Types of pain
• Acute- occurs only in a defined period of time (6
  mo or less) and is caused by specific stimuli
  that damages the tissue. Usually recent onset and
  varies in intensity
• Chronic-prolonged, persistent nonmalignant

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• -Pain that occurs over 6 months period or
  longer, varies in intensity and may serve no
  useful function
  
• -Malignant- recurrent, acute episodes which may
• include chronic pain, may vary in intensity
  and have
  
• rapid or slow onset. May last longer than 6
  months
  
• and be intractable
• JCAHO standards assess regularly and manager in
  order to maintain clients hemostasis and quality
  of life.
  
• Rating scale used to rate clients pain on level
  of 1 to 10 or children using different faces.
  (pg135)
  

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• Measurement of pain (Ask client for all this
  information about pain
  
• Location, ( exactly where is the pain, point)
• Intensity, determine strength, power or force of
  pain, using numeric or face picture scale
  
• Quality, features of characteristics the
  distinguish pain as searing, dull, throbbing,
  sharp, burning, etc
  
• Pattern, how pain changes and timing of pain as
  continuous, steady, intermittent, transient

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• Factors associated with pain
• Nausea
• Vomiting
• Bradycardia ,tachycardia
• Hypotensive, hypertensive
• Profuse perspiration
• Apprehension or anxiety
• Precipitating Factors
• -Motion affecting incision area (coughing,
• turning, deep breathing)

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• Fear and emotional distress
• Inflammation or infection
• Trauma
• Disease state
• Aggravating Factors
• Position changes
• Environmental stressors
• Fatigue
• Inadequate pain relief measures

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• Alleviating Factors
• Position change
• Medication
• Biofeedback
• Visualization
• Relaxation techniques
• TENS
• Massage
• Pain Management
• Listen to client

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• Intervention with medication
• Dont allow pain to escalate, anticipate
• What works for client to relieve pain
• Understand various actions of drugs
• Nonpharmacological approach to relieve pain
• PHYSICAL METHOD
• Tens, Stimulation of mild electrical current
• Acupuncture, Chinese form of treatment
• Biofeedback electric monitoring devices shows
  effect of behavior on internal control processes

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• Vibration or massage, manipulation of muscles or
  electrical massage
  
• Cold therapy, cold wraps, gel packs, ice message
• Heat therapy, hot wraps, dry heat, moist heat
• Counterirritants, Mentholated ointments or
  lotions
  
• Acupressure, Chinese method using specific point
  to locate meridians
  
• BEHAVIORAL METHODS
• Relaxation
• Imagery
• Deep breathing
• Hypnosis