Chapter 17: Vital Signs

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Chapter 17 Vital Signs
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VITAL SIGNS

• TEMPERATURE
• BLOOD PRESSURE
• PULSE
• APICAL
• RADIAL
• RESPIRATIONS
• PULSE OXIMETRY
• PAIN SCALE

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VITAL SIGNS ARE PART OF THE PHYSICAL ASSESSMENT

• Delegation of Duties to UAP
• Unlicensed Assistive Personnel
• RN is Responsible to Manage Care Based on
  Physical Assessment
• Administering medications
• Communicating to other members of the health care
  team
• Supervising delegated tasks

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EQUIPMENT

• RN is responsible for assuring equipment is
  functioning properly
• Appropriate equipment
• Must be appropriate to patient age size
• Thermometer
• Stethoscope Diaphragm (high-pitched sounds)
  bell (low-pitched sounds)
• BP cuff
• Pulse oximeter

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PATIENT HISTORY

• RN must know patient medical history, including
  medications
• These facts can affect vital signs
• RN is responsible for knowing the patients usual
  vital sign range

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FREQUENCY OF VITAL SIGNS

• Physicians order the frequency of vital signs
• Could be ordered by protocol or policy
• The RN can increase the frequency based on
  his/her assessment
• VITAL SIGNS can be an early warning sign that
  complications are developing

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INDICATIONS FOR MEDICATION ADMINISTRATION

• Many medications are administered when the vital
  signs are within an acceptable range.
• Accurate VITAL SIGNS are required in order to
  make treatment decisions.

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COMPREHENSIVE ASSESSMENT FINDINGS

• Compare VITAL SIGNS to assessment findings and
  laboratory results to accurately interpret the
  patient status.
• Discuss your findings with peers and charge RN
  before deciding on a plan of action.
• Use the opportunity to teach patient/family about
  what VS mean, reason for assessing, meaning if
  appropriate

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TEMPERATURE

• Factors affecting body temp. (36-38C/96.8-100.4F
  )
• Age
• Infants 95.9 99.5 F 36.5-37.2C intolerant
  of extremes
• Elderly Average temp is 96.8 F Sensitive to
  temp extremes
• Exercise
• Hormone levels
• Circadian rhythm
• Stress
• Environment

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TEMPERATURE ALTERATIONS

• Afebrile
• Pyrexia fever gt37.5
• Fever of unknown origin (FUO)
• Malignant hyperthermia hereditary, occurs during
  anesthesia
• Heatstroke medical emergency
• Heat exhaustion
• Hypothermia
• Frostbite

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TEMPERATURE Contd.

• Sites
• Core temp is measured in pulmonary artery,
  esophagus, and urinary bladder
• Common sites
• Mouth, rectum, tympanic membrane, temporal
  artery, and axilla use critical thinking to
  decide!
• Variety of types available electronic and
  disposable
• Antipyretics drugs that reduce fever

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• Using an oral electronic thermometer, the nurse
  checks the early morning temperature of a client.
  The client's temperature is 36.1 C (97 F). The
  client's remaining vital signs are in the
  normally acceptable range. What should the nurse
  do next?
• A) Check the client's temperature history. B)
  Document the results temperature is normal. C)
  Recheck the temperature every 15 minutes until
  it is normal. D) Get another thermometer the
  temperature is obviously an error.

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PULSE

• Sites
• Temporal, Carotid, Apical, Brachial, Radial,
  Femoral, Popliteal, Posterior Tibial, Dorsalis
  Pedis
• Increases in HR
• Short-term exercise, fever, heat, pain, anxiety,
  drugs, loss of blood, standing or sitting, poor
  oxygenation
• Decreases in HR
• Long-term exercise, hypothermia, relaxation,
  drugs, lying down

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PULSE Contd.

• Volume of blood pumped by the heart during 1
  minute is the cardiac output
• When mechanical, neural or chemical factors are
  unable to alter stroke volume, a change in heart
  rate will result in change in cardiac output,
  which affects blood pressure
• HR ?, less time for heart to fill, BP ?
• HR ?, filling time is increased, BP ?
• An abnormally slow, rapid, or irregular pulse
  alters cardiac output

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• The nurse decides to take an apical pulse instead
  of a radial pulse. Which of the following client
  conditions influenced the nurse's decision?
• A) The client is in shock. B) The client has
  an arrhythmia. C) The client underwent surgery
  18 hours earlier. D) The client showed a
  response to orthostatic changes.

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RESPIRATIONS

• Ventilation the movement of gases in and out of
  lungs
• Diffusion the movement of oxygen and CO2
  between the alveoli and RBCs
• Perfusion the distribution of RBCs to and from
  the pulmonary capillaries

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Factors Influencing Character of Respirations

• Exercise
• Acute Pain
• Anxiety
• Acid-Base balance
• Body Position
• Medications
• Neurological injury
• Hemoglobin function

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RESPIRATIONS Contd.

• Tachypnea rapid breathing
• Apnea cessation of breathing
• Cheyne-Stokes rate and depth irregular,
  alternate periods of apnea and hyperventilation
• Kussmauls abnormally deep, regular, and
  increased in rate (associated with DM)

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PULSE OXIMETER

• Indirect measurement of oxygen saturation
• Photodetector detects the amount of oxygen bound
  to hemoglobin molecules and oximeter calculates
  the pulse saturation
• Only reliable when SaO2 is over 70
• Certain conditions may give an inaccurate reading

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• A client is being monitored with pulse oximetry.
  On review of the following factors, the nurse
  suspects that the values will be influenced by
  which of the following?
• A) The placement of the sensor on the
  extremityB) A diagnosis of peripheral vascular
  diseaseC) A reduced amount of artificial light
  in the roomD) The increased ambient temperature
  of the clients room

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BLOOD PRESSURE

• Force exerted on the walls of an artery by the
  pulsing blood under pressure from the heart
• Systolic maximum pressure when ejection occurs
• Diastolic minimum pressure of blood remaining
  in the arteries after ventricles relax

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BLOOD PRESSURE Contd.

• Physiology of arterial blood pressure
• Cardiac Output, Peripheral resistance, Blood
  volume, Viscosity, Elasticity
• Factors influencing BP
• Age, Stress, Ethnicity, Gender, Daily Variation,
  Meds, Activity, Weight, Smoking
• Hypertension
• Hypotension
• Orthostatic or postural hypotension

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• The nurse is assessing a clients blood pressure
  during a routine visit. When asked, the client
  volunteers that when he took his pressure at home
  yesterday it was 126/72 mmHg. The nurse
  determines that the clients pressure today is
  134/70 mmHg. The nurse recognizes that the most
  likely cause of the elevation is due to which of
  the following?
• A) The difference between the monitoring
  equipment being used
• B) The clients inability to hear the first
  Korotkoff sound
• C) The client may be experiencing mild anxiety
  regarding the check-up
• D) The client is not inflating the cuff
  sufficiently to detect the systolic pressure

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QUESTIONS?