Vital Signs Adapted from: Health and Physical Assessment in Nursing D’amico & Barbarito

Objectives By the end of this lesson, the student will: Compare methods used to measure body temperature. Describe the purpose of and methods for measuring heart rate. Discuss techniques used for measurement of respiratory rate. Describe the purpose of and methods for measuring blood pressure. Recall the normal ranges of vital signs across age groups. Discuss variables that affect the measurement of vital signs.

Vital Signs Vital signs include temperature, pulse, respiratory rate, blood pressure and pain TTUHSC EMS Program

Vital Signs Vital signs are an outward clue to what is going on in the patient’s body TTUHSC EMS Program

Vital Signs Baseline vital signs provide a basis for comparison of later sets of vital signs. This allows the nurse to identify any changes in the patient’s status. TTUHSC EMS Program

Vital Signs It is important to monitor “trends” in vital signs rather than individual sets of vital signs While one set of vital signs will give the nurse a snap shot of the patient’s status, viewing trends over time will allow the nurse to identify any problems. For example, the patient’s temperature might be spiking at particular time of day, so an adjustment in medication might be necessary. This is information which should be reported to the physician for him or her to act upon. TTUHSC EMS Program

Temperature Temperature is the measure of body heat. Heat is lost from the body by respiration, perspiration and excretion. Heat is generated by shivering, vasoconstriction and inhibition of sweating. The balance between the heat produced and the heat lost is the body temperature. Temperature is regulated by sensors in the hypothalamus gland. These sensors decrease or increase the body’s core temperature based on information they receive. TTUHSC EMS Program

Factors Influencing Body Temp Exercise Age Diurnal variations Illness Stress Hormones *Exercise – Can increase T by 0.35 C to 0.5F *The body’s sensitivity to alterations in evironmental temperature chages thoughout a person’s lifespan. Infants are much more susceptible to temperature changes than older children and adolescents. Older adults are more sensitive than middle aged adults. This can be due to severl factors such as decreased subcutaneous tissue, decreased thermoregulatory control , decreased physical activity, inadequate diet or lack of central heating. *Core body temperature flucuates throughout the day. It is higher between 8:00 p.m. and midnight and lower between 4:00 and 6:00 a.m. It can vary as much as 1.0 degrees C or 1.8 degrees F. *Any illness or central nervous system disorder can impact the thermostatic function of the hypothalamus. Hyperthermia (fever) might be a response to a viral or bacterial infection, tissue breakdown from a myocardial infarction, malignancy, surgery or trauma. Hypothermia most often occurs due to prolonged exposure to cold external temperatures. *Epinephrine and norepinephrine released during stress increases metabolic activity and heat productions which can in turn increase body temperature. *Hormones can affect body temperature. A woman’s body temperature can be raised by about 0.35 degrees C or 0.5 degrees F due to progesterone secretion during ovulation. TTUHSC EMS Program

Types of Thermometers Glass (Mercury) – a hollow glass tube with calibration lines on it. Aural (Tympanic) – Sensor measures body temp. Chemically Treated Paper or Plastic – read by noting color it changes to. Electronic/Digital Thermometers – Temp is registered on a screen.

TYPES OF THERMOMETERS GLASS THERMOMETER A SMALL HOLLOW GLASS TUBE THAT CONTAINS MERCURY OR A MERCURY-FREE SUBSTANCE IN A BULB AT ONE END.WHEN HEATED THE MERCURY RISES IN THE TUBE. Pear – shaped tip

ELECTRONIC THERMOMETER BATTERY OPERATED HAVE AN ORAL PROBE AND A RECTAL PROBE DISPOSABLE PROBE COVER IS PLACED ON THE PROBE THE TEMPERATURE REGISTERS IN ABOUT 30 SECONDS

TYMPANIC THERMOMETER MEASURES THE TEMPERATURE IN THE TYMPANIC MEMBRANE (EARDRUM) FAST AND ACCURATE - 1 TO 3 SECONDS INFANTS – PULL THE EAR STRAIGHT BACK ADULTS AND CHILDREN OVER ONE YEAR – PULL THE EAR UP AND BACK

Temporal Thermometer Digital, takes temperature on forehead Press button down and sweep probe across forehead; This is fairly new technology, but seems to be relatively accurate and very quick and easy to use

Temperature Sites Oral – 98.6 or 37 Rectal – 99.6 or 38 Tympanic – 98.6 or 37 Axillary – 97.6 or 36.4 Temporal – 99.6 or 38

Terms Afebrile – temperature is within normal range. Febrile – temperature is elevated Hypothermia – temperature is below normal. Pyrexia – above normal temperature Pyrogenic – any substance that produces fever.

Pulse rate The number of time your heart beats per minute. Also called the heart rate. Usually counted for 30 seconds and multiplied x 2, unless it is irregular. TTUHSC EMS Program

Pulse Carotid Brachial Radial Femoral Popliteal Pulse Points

Pulse Pulse Points Dorsal Pedal Posterior Tibial (Posterior and slightly inferior to medial Malleolus) Pulse Points

Pulse Rate 60-100 bpm Less than 60 bpm is considered a slow pulse rate – bradycardia Over 100 bpm is considered fast – tachycardia. Bradycardia can be normal in athletes and tachycardia is a normal finding for someone who is undergoing stress, is anxious or has just finished exercising. TTUHSC EMS Program

Pulse Rhythm Regular Irregular The nurse must also assess whether or not the pulse is regular or irregular. Pulses should come at regular intervals, without skips or extra beats. TTUHSC EMS Program

Pulse Quality Full (bounding) Weak (Thready) Elasticity The nurse must also assess the quality or stroke volume. This is determined by the amount of pressure that has to be exerted before the pulse is felt. A full pulse is easy to palpate and is not easy to obliterate. This can be due to fear, anxiety or exercise, as well as many other factors. A weak, thready pulse is easy to obliterate. This can be an indication of hemorrhage. The nurse should palpate along an artery in a proximal-to-distal direction to to assess the elasticity of the artery. Normal arteries feel smooth, straight and resilient. TTUHSC EMS Program

Factors Affecting Pulse Rate Age Gender Exercise Stress Fever Hemorrhage Medications Position changes Pulse rates can be affected by a number of factors. Pulse rates decrease as a person ages. Pulse rates begin stabilize around after the age of 16 with the average pulse rate being around 70 bpm in males and 75 bpm in females. Pulse rate increases with exercise, stress and fever. When a persons body temperature increases, you will have peripheral vasodilation. This lowers blood pressure which in turn increases pulse rate. Loss of blood from hemorrhage cause an increase in pulse rate at the body attempts to circulate blood throughout the body. Medications and either increase or decrease pulse rates. When a person sits or stands for long periods of time, the pulse rates lowers TTUHSC EMS Program

Terms Arrythmia – any deviation from the normal heart rate. Bradycardia – abnormally slow heartbeat. Pulsation – rhythmic beat. Tachycardia – abnormally fast heartbeat.

Respiration Respiratory rate is the number of respirations per minute. A respiration is one inhalation in and one exhalation out. The nurse counts the number of respirations for 30 seconds and then multiplies x 2, unless the respirations are irregular or difficult to assess. In either of these situations, the nurse should count the respirations for 60 seconds. TTUHSC EMS Program

Respirations Rate Adult Child 12-20 Resp/min 20-30 Resp/min As in the pulse rate, the respiratory rate decreases with age. TTUHSC EMS Program

Respirations Rate Newborn - 30-80 resp/min 3-9 y.o. – 20-30 resp/min 16-adult – 15-20 resp/min

Respirations Rhythm Regular Irregular

Respiration Quality Full Deep Shallow Labored Noisy

Factors Increasing Respiration Exercise Anxiety Respiratory Disease Medication Pain Heart disease (CHF)

Factors Decreasing Respiration Relaxation Depression Head injury Medication

Terms Dyspnea – Difficulty breathing. Apnea – Absence of respirations. Cheynes-Stokes – Periods of labored respirations followed by apnea. Rales – Bubbling or rattling sounds caused by mucus in the air passages.

Blood Pressure Systolic - Pressure on the arterial wall when the heart contracts Diastolic - Pressure on the arterial wall when the heart is at rest

BLOOD PRESSURE The measurement of the amount of force blood exerts against the arterial walls. Systolic: Pressure exerted when the heart muscle contracts Diastolic: Pressure exerted when the heart muscle relaxes between beats. SYSTOLIC /DIASTOLIC 120/80 BP is measured in mm of Hg Blood pressure is recorded as a fraction with the systolic pressure on top and the diastolic pressure on the bottom. TTUHSC EMS Program

ABNORMAL BLOOD PRESSURE Average adult systolic range is 100 to 140 Average adult diastolic range is 60 to 90 ABNORMAL BLOOD PRESSURE Hypertension Hypotension High blood pressure – measurements above the normal range. Low blood pressure – below normal blood pressure readings TTUHSC EMS Program

GUIDELINES FOR MEASURING BLOOD PRESSURE Do not take blood pressure on an arm with an IV, cast or shunt. Do not take a blood pressure on the side of a mastectomy. Blood pressure should be taken with the person sitting or lying. Cuff should be applied to bare upper arm, should be the correct size and should be snug. The room should be quiet

Blood Pressure Auscultated BP - Listening for both the systolic and diastolic values Palpated BP - Feeling for the systolic pressure

FACTORS THAT AFFECT BLOOD PRESSURE AGE GENDER BLOOD VOLUME STRESS PAIN EXERCISE WEIGHT RACE DIET MEDICATIONS POSITION BLOOD PRESSURE INCREASES AS A PERSON GROWS OLDER WOMEN USUALLY HAVE LOWER BLOOD PRESSURE THAN MEN BLOOD VOLUME – SEVERE BLEEDING LOWERS THE BLOOD PRESSURE STRESS – HEART RATE AND BLOOD PRESSURE INCREASE AS PART OF THE BODY’S RESPONSE TO STRESS PAIN – INCREASES BLOOD PRESSURE EXERCISE – INCREASES HEART RATE AND BLOOD PRESSURE WEIGHT – BLOOD PRESSURE IS HIGHER IN OVERWEIGHT PERSONS RACE – BLACK PERSONS GENERALLY HAVE HIGHER BLOOD PRESSURE THAN WHITE PERSONS DO DIET – A HIGH-SODIUM DIET INCREASES THE FLUID VOLUME IN THE BODY WHICH INCREASES BLOOD PRESSURE MEDICATIONS – CAN BE TAKEN TO RAISE OR LOWER BLOOD PRESSURE POSITION – lower when lying down TTUHSC EMS Program

Terms Diastolic – least force of pressure exerted against the walls of arteries. Hypertension – high BP Hypotension – low BP Stethoscope –instrument used to amplify sound Systolic – greatest force of pressure exerted against the walls of the arteries

Sphygmomanometer Instrument used to measure BP Sphygmo – refers to pulse Mano – refers to pressure Meter – refers to measure

TYPES OF BLOOD PRESSURE CUFFS THE PROPER NAME FOR A BLOOD PRESSURE CUFF IS SPHYGMOMANOMETER MERCURY ANEROID

USING BLOOD PRESSURE EQUIPMENT TTUHSC EMS Program

Korotkoff Sounds First Phase Second Phase Third Phase A clear tapping sound; onset of the sound for two consecutive beats is considered systolic Second Phase The tapping sound followed by a murmur Third Phase A loud crisp tapping sound When measuring blood pressure we are listening for the Korotkoff sounds First Phase A clear tapping sound; onset of the sound for two consecutive beats is considered systolic Second Phase The tapping sound followed by a murmur Third Phase A loud crisp tapping sound Fourth Phase Abrupt, distinct muffling of sound, gradually decreasing in intensity Fifth Phase The disappearance of sound, is considered diastolic blood pressure- two points below the last sound heard

Korotkoff Sounds Cont. Fourth Phase Fifth Phase Abrupt, distinct muffling of sound, gradually decreasing in intensity Fifth Phase The disappearance of sound, is considered diastolic blood pressure- two points below the last sound heard Fourth Phase Abrupt, distinct muffling of sound, gradually decreasing in intensity Fifth Phase The disappearance of sound, is considered diastolic blood pressure- two points below the last sound heard

Steps for Measuring Blood Pressure Seated for 5 minutes Patient Position Expose Upper arm Center of upper arm at heart level Seated for 5 minutes No smoking, caffeine or vigorous exercise for 30 minutes before Patient Position Sit straight, both feet flat on floor, arm at slightly more than 90 degree angle on table with crease in elbow level with heart Expose Upper arm Use the right arm- for accuracy and for consistency Center of upper arm at heart level Elbow slightly flexed, Forearm with the palm facing upwards and supported on flat surface

Steps for measuring cont. Cuff applied 1 inch above crease at elbow Locate brachial artery Palpate radial pulse Inflate cuff until pulse disappears Cuff applied 1 inch above crease at elbow Make sure cuff is correct size Locate brachial artery Palpate radial pulse Inflate cuff until pulse disappears

Steps for measuring cont. Let air out Place stethoscope on brachial artery Pump up cuff to 20-30 above point of obliteration Let air out at 2 mmHg per second Let air out Place stethoscope on brachial artery Pump up cuff to 20-30 above point of obliteration 20 for kids 30 for adults Let air out at 2 mmHg per second

PAIN Pain means to ache, hurt, or be sore. Pain is a warning from the body. Pain is personal. Types of pain Acute pain – felt suddenly from an injury, disease, trauma, or surgery Chronic pain – lasts longer than 6 months. Pain can be constant or occur on and off. Radiating pain – felt at the site of tissue damage and in nearby areas. Phantom pain – felt in a body part that is no longer there. Pain is referred to as the “5th vital sign”. TTUHSC EMS Program

Signs and symptoms Location – Where is the pain? Pattern – When did the pain start? Intensity – Rate the pain on a scale of 1 to 10, with 10 as the most severe Description – Can you use words to describe the pain? Precipitating factors– What were you doing when the pain started? Vital signs – Take the person’s vital signs when they complain of pain. Other signs and symptom Body responses - ↑ vital signs, nausea, pale skin, sweating, vomiting Behaviors – crying, groaning, holding affected body part, irritability, restlessness Patients should be observed for signs of pain. If pain is present, a full pain assessment should be completed. TTUHSC EMS Program

Pain Assessment Scales Pain can be assessed using scales. In adults, a 1-10 scale is usually sufficient to rate pain. In children, the use of pictures often works best. TTUHSC EMS Program