Chapter 26 Measuring Vital Signs

Vital Signs Vital signs reflect the function of three body processes essential for life. Regulation of body temperature Breathing Heart function The four vital signs of body function are: Temperature Pulse Respirations Blood pressure Some agencies consider “pain” to be a vital sign. Vital signs are often called TPR (temperature, pulse, and respiration) and BP (blood pressure). See Chapter 28 in the Textbook for how to assist with pain assessment.

Measuring and Reporting Vital Signs A person’s vital signs vary within certain limits. Vital signs: Are measured to detect changes in normal body function Tell about treatment response Often signal life-threatening events Are part of the assessment step in the nursing process Vital signs are affected by activity, anger, anxiety, drugs, eating, exercise, fear, illness, noise, pain, sleep, and weather.

Measuring and Reporting Vital Signs (cont’d) Vital signs are measured: During physical exams When the person is admitted to a health care agency As often as the person’s condition requires Before and after surgery, complex procedures, and diagnostic tests After some care measures, such as ambulation (walking) After a fall or other injury When drugs affect the respiratory or circulatory system When the person complains of pain, dizziness, light- headedness, feeling faint, shortness of breath, a rapid heart rate, or not feeling well As stated on the care plan Vital signs are usually taken daily, twice a day, or weekly in nursing centers.

Measuring and Reporting Vital Signs (cont’d) Vital signs show even minor changes in the person’s condition. Accuracy is essential when you measure, record, and report vital signs. Take vital signs with the person at rest—lying or sitting, unless otherwise ordered. Report the following at once: Any vital sign that is changed from a prior measurement Vital signs above the normal range Vital signs below the normal range If unsure of your measurements, promptly ask the nurse to take them again. Vital signs are recorded in the person’s medical record. If vital signs are measured often, a flow sheet is used. The doctor or nurse compares past and current measurements. Review the Focus on Communication: Measuring and Reporting Vital Signs Box on p. 467 in the Textbook. Review the Focus on Children and Older Persons: Measuring and Reporting Vital Signs Box on p. 467 in the Textbook.

Body Temperature Body temperature is a balance between amount of heat produced and amount lost by the body. Thermometers measure temperature. Fahrenheit (F) and centigrade (C) scales are used. Temperature sites include: Mouth, rectum, axilla (underarm), tympanic membrane (ear), and temporal artery (forehead) Each site has a normal range. Always report temperatures that are above or below the normal range. Fever means an elevated body temperature. 100.4 = Fever Heat is produced as cells use food for energy. It is lost through the skin, breathing, urine, and feces. Body temperature is lower in the morning and higher in the afternoon and evening. Body temperature is affected by many factors including pregnancy and the menstrual cycle. Review the contents of Box 26-1 on p. 467 and Table 26-1 on p. 468 in the Textbook. Review the Focus on Communication: Temperature Sites Box on p. 468 in the Textbook. Review the Focus on Children and Older Persons: Temperature Sites Box on p. 468 in the Textbook. Review the Promoting Safety and Comfort: Temperature Sites Box on p. 468 in the Textbook.

Body Temperature (cont’d) Types of thermometers used: Glass thermometers (not used anymore) Standard electronic thermometers Tympanic membrane thermometers Temporal artery thermometers Digital thermometers Disposable oral thermometers Temperature-sensitive tape Pacifier thermometers Taking Temperatures The nurse and care plan tell you when to take the person’s temperature, what site to use, and what thermometer to use. Follow the manufacturer’s instructions and agency procedures to use, clean, and store thermometers. Refer to Figures 26-1 (A-H) on p. 469 in the Textbook. Review the Delegation Guidelines: Taking Temperatures Box on p. 470 in the Textbook. Review the Promoting Safety and Comfort: Taking Temperatures Box on p. 470 in the Textbook.

Body Temperature (cont’d) Electronic thermometers are commonly used. Some have batteries. Others are kept in battery chargers when not in use. Standard electronic thermometers Measures temperature in a few seconds They have oral (blue) and rectal (red) probes. Tympanic membrane thermometers Measures temperature in 1 to 3 seconds Risk of spreading infection is reduced. Temporal artery thermometers Measures temperature in 3 to 4 seconds Measures the temperature of the blood in the temporal artery, which is the same temperature of the blood coming from the heart Probe covers are used to prevent the spread of infection. Tympanic membrane and temporal artery thermometers are comfortable and not invasive like rectal thermometers and probes. Tympanic membrane thermometers are not used if there is ear drainage. Review the Focus on Children and Older Persons: Electronic Thermometers Box on p. 471 in the Textbook. Review the Teamwork and Time Management: Electronic Thermometers Box on p. 471 in the Textbook.

Body Temperature (cont’d) Thermometers are color coded. Blue—oral and axillary Red—rectal Glass thermometers are reusable. However, the following are problems and why they are no longer in use in healthcare: They take a long time to register. They break easily. The person may bite down and break an oral thermometer. Glass thermometers take 3 to 10 minutes to register depending on the site. Broken rectal thermometers can injure the rectum and colon. Cuts in the mouth are risks. If the thermometer contains mercury, swallowed mercury can cause mercury poisoning. Review Box 26-3 on p. 474 in the Textbook for how to use and read glass thermometers. Review the Focus on Long-Term Care and Home Care: Glass Thermometers Box on p. 474 in the Textbook. Review the Promoting Safety and Comfort: Glass Thermometers Box on p. 475 in the Textbook.

Pulse A pulse is felt every time the heart beats. The pulse is the beat of the heart felt at an artery as a wave of blood passes through the artery. Pulse sites: Temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis (pedal) pulses are on each side of the body. Radial pulse is used most often. Carotid pulse is taken during CPR and other emergencies. The apical pulse is felt over the heart. This pulse is taken with a stethoscope. The radial pulse is easy to reach and find, and the person is not exposed. The apex (apical) of the heart is at the tip of the heart, just below the left nipple. See Body Structure and Function Review: The Heart and Blood Vessels on p. 476 in the Textbook. Review the Focus on Children and Older Persons: Pulse Sites Box on p. 477 in the Textbook.

Pulse (cont’d) A stethoscope is an instrument used to listen to the sounds produced by the heart, lungs, and other body organs. It is used to take apical pulses and blood pressures. The device makes sounds louder for easy hearing. To use a stethoscope: Wipe the earpieces and diaphragm with antiseptic wipes before and after use. Place the earpiece tips in your ears. Tap the diaphragm gently. Place the diaphragm over the pulse site. Prevent noise. Ear-pieces should fit snugly to block out noises. They should not cause pain or ear discomfort. Refer to Figures 26-13 and 26-14 on pp. 477 and 478 in the Textbook. Review the Focus on Communication: Using A Stethoscope Box on p. 478 in the Textbook. Review the Safety and Comfort: Using a Stethoscope Box on p. 478 in the Textbook.

Pulse (cont’d) The pulse rate is the number of heart beats or pulses felt in 1 minute. The rate varies for each age-group. The adult pulse rate is between 60 and 100 beats per minute. Report abnormal pulses to the nurse at once. Tachycardia is a heart rate of more than 100 beats per minute. Bradycardia is a heart rate of less than 60 beats per minute. Review the contents of Table 26-2 on p. 478 in the Textbook. Some drugs increase pulse rate and others slow down the pulse. Many factors affect pulse rate. Review Factors Affecting Vital Signs Box 26-1 on p. 467 in the Textbook.

Pulse (cont’d) Rhythm and force of the pulse Pulse rhythm should be regular (felt in a pattern with the same interval between beats). An irregular pulse occurs when the beats are not evenly spaced or beats are skipped. Force relates to pulse strength. A forceful pulse is described as strong, full, or bounding. Hard-to-feel pulses are described as weak, thready, or feeble. Electronic blood pressure equipment can also count pulses. Some show if the pulse is regular or irregular. You need to feel the pulse to determine its force. A forceful pulse is easy to feel. Refer to Figure 26-16 on p. 479 in the Textbook.

Pulse (cont’d) You will take radial, apical, and apical-radial pulses. You must accurately: Count. Report and record. The radial pulse is used for routine vital signs. Count the pulse for 30 seconds and then multiply the number by 2. If the pulse is irregular, count for a full minute AND take an apical pulse! In some agencies, all radial pulses are taken for 1 minute. Follow agency policy. Place the first 2 or 3 fingertips of one hand against the radial artery. The radial artery is on the thumb side of the wrist. Review the Delegation Guidelines: Taking Pulses Box on p. 479 in the Textbook. Review the Promoting Safety and Comfort: Taking Pulses Box on p. 479 in the Textbook.

Pulse (cont’d) The apical pulse is on the left side of the chest slightly below the nipple, 5th intercostal space, mid- clavicular line. It is taken with a stethoscope. Count the apical pulse for 1 minute. Count each lub-dub as one beat. Apical pulses are taken on persons who: Have heart disease. Have irregular heart rhythms. Are taking drugs that affect the heart. The heart normally sounds like a lub-dub. Refer to Figure 26-18 on p. 480 in the Textbook.

Apical Pulse: 5th ICS to the left of the sternum at MCL Apical heart rate: stethoscope placement 5th Intercostal space left of the sternum at the midclavicular line AKA mitral area Why would we want an apical pulse measurement if the radial pulse was irregular? If the peripheral pulse such as the radial pulse was irregular…this could indicate cardiac dysfunction. So we go straight to the source (the heart) to further investigate. Remember assess the apical pulse for one full minute!

Pulse (cont’d) Taking an apical-radial pulse The apical and radial pulse rates should be the same. To see if the apical and radial pulses are equal, two staff members are needed. One takes the radial pulse. The other takes the apical pulse. Doing this at the same time is called the apical- radial pulse. The pulse deficit is the difference between the apical and radial pulse rates. To obtain the pulse deficit, subtract the radial rate from the apical rate. Sometimes heart contractions are not strong enough to create pulses in the radial artery. Then the radial rate is less than the apical rate. Heart disease is a common cause. The radial rate is never greater than the apical rate. Example: Apical rate = 84 beats per minute; Radial rate = 84 beats per minute; Pulse deficit = 0 Apical rate = 90 beats per minute; Radial rate = 86 beats per minute; Pulse deficit = 4

Pulse (cont’d) Checking pedal pulses Pedal (dorsalis pedis) pulse is used to check circulation in the foot. Doppler ultrasound stethoscope (DUS) is used when the pedal pulse cannot be felt. Your role may include using a DUS. Make sure you: Have received the necessary training. Follow the nurse’s directions. Follow the manufacturer’s instructions. The dorsalis pedis artery is over a foot bone. Refer to Figure 26-20 on p. 482 in the Textbook. Often, the nurse will mark the skin with an X where the pulse is found. This is so that all staff use the same site. Blood flowing in an artery creates sound waves. These waves can be heard with a Doppler ultrasound stethoscope. Refer to Figure 26-21 on p. 482 in the Textbook.

Respirations Respiration means breathing air into (inhalation) and out of (exhalation) the lungs. Oxygen enters the lungs during inhalation. Carbon dioxide leaves the lungs during exhalation. Each respiration involves one inhalation and one exhalation. The chest rises during inhalation. The chest falls during exhalation. The healthy adult has 12 to 20 respirations/min. Respirations are normally quiet, effortless, and regular. Review the contents of Box 26-1 on p. 467 in the Textbook. Heart and respiratory diseases often increase the respiratory rate. Both sides of the chest rise and fall equally. See Chapter 36 for abnormal respiratory patterns.

Respirations (cont’d) Count respirations when the person is at rest. Position the person so you can see the chest rise and fall. The person should not know that you are counting respirations. Count respirations right after taking a pulse. Keep your fingers or stethoscope over the pulse site. To count respirations, watch the chest rise and fall. Count respirations for 30 seconds. Multiply the number by 2 for the number of respirations in 1 minute. If an abnormal pattern is noted, count the respirations for 1 minute. Follow agency policy. Review the Focus on Children and Older Persons: Respirations Box on p. 483 in the Textbook. Table 26-3 on p. 483 in the Textbook lists the normal respiratory rates for children. Review the Delegation Guidelines: Respirations Box on p. 484 in the Textbook.

D&S Skill: Vital Signs- Temperature, Pulse & Respiration

Blood Pressure Blood pressure (BP) is the amount of force exerted against the walls of an artery by the blood. Blood pressure is controlled by: The force of heart contractions The amount of blood pumped with each heartbeat How easily the blood flows through the blood vessels Systole is the period of heart muscle contraction. Diastole is the period of heart muscle relaxation. The heart is pumping blood during systole. The heart is at rest during diastole.

Blood Pressure (cont’d) Systolic pressure—the pressure in the arteries when the heart contracts Diastolic pressure—the pressure in the arteries when the heart is at rest Blood pressure is measured in millimeters (mm) of mercury (Hg). Written as mmHG The systolic pressure is recorded over the diastolic pressure. Blood pressure has normal ranges. Systolic pressure—90 mmHg or higher but lower than 120 mm Hg Diastolic pressure—60 mmHg or higher but lower than 80 mm Hg You measure systolic and diastolic pressures. The systolic pressure is the higher pressure. The diastolic pressure is the lower pressure. A systolic pressure of 120 mm Hg and a diastolic pressure of 80 mm Hg is written 120/80 mm Hg. Blood pressure can change from minute to minute. Factors affecting blood pressure are listed in Box 26-4 on p. 485 in the Textbook.

Blood Pressure (cont’d) Treatment is indicated for: Hypertension—When the systolic blood pressure is 140 mm Hg or higher (hyper), or the diastolic blood pressure is 90 mm Hg or higher Report any systolic measurement at or above 120 mm Hg. Report any diastolic pressure at or above 80 mm Hg. Hypotension—Systolic blood pressure is below (hypo) 90 mm Hg, or the diastolic blood pressure is below 60 mm Hg Report a systolic pressure below 90 mm Hg. Report a diastolic pressure below 60 mm Hg. Some people normally have low blood pressures. However, hypotension can signal a life-threatening problem. Review the Focus on Communication: Normal and Abnormal Blood Pressures Box on p. 485 in the Textbook. Review the Focus on Children and Older Persons: Normal and Abnormal Blood Pressures Box on p. 485 in the Textbook.

Blood Pressure (cont’d) A stethoscope and a sphygmomanometer are used to measure blood pressure. The sphygmomanometer has a cuff and a measuring device. These types of sphygmomanometers are used (follow the manufacturer’s instructions): Aneroid type Mercury type Electronic type Wrist monitor Blood pressure is normally measured in the brachial artery. Refer to Figure 26-23, A, B, C, and D on p. 486 in the Textbook. Stethoscopes are not needed with electronic manometers or wrist monitors. A wrist monitor measures blood pressure at the wrist and is very sensitive to body position. This type is sometimes used for persons with bariatric needs. Review the Focus on Children and Older Persons: Equipment Box on p. 486 in the Textbook. Review the Promoting Safety and Comfort: Equipment Box on p. 486 in the Textbook. Review the guidelines in Box 26-5 on p. 487 in the Textbook. Review the Delegation Guidelines: Measuring Blood Pressure Box on p. 486 in the Textbook.

Two-Step Method http://www.atitesting.com/ati_next_gen/skillsmodules/content/vital-signs/equipment/bldpressure.html

D&S Skill: Blood Pressure

Pain Pain is a warning sign from the body: Pain can signal tissue damage. Many agencies consider pain to be a vital sign. Is considered the 5th vital sign. See “Pain” in Chapter 28.