Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Chapter 29 Vital Signs

2Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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

3Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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.

4Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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.

5Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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.

6Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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

7Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Body Temperature Regulation

8Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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.

9Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Factors Affecting Body Temperature AgeExercise Hormonal levelCircadian rhythm EnvironmentTemperature alterations

10Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Temperature Cycle

11Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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

12Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Hypothalamic Temperature Control

13Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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

14Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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

15Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Electronic Thermometer

16Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Temporal Artery Thermometer

17Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Chemical Dot Thermometer

18Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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.

19Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process: Temperature  Diagnosis  Risk for imbalanced body temperature  Hyperthermia  Hypothermia  Ineffective thermoregulation  Planning

20Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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.

21Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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.

22Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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

23Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Parts of a Stethoscope

24Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Use of a Stethoscope

25Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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

26Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process and Pulse Determination Activity intolerance AnxietyFear Decreased cardiac output Deficient/excess fluid volume Impaired gas exchange HyperthermiaHypothermiaAcute pain Ineffective peripheral tissue perfusion

27Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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.

28Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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

29Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Movements During Breathing

30Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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

31Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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.

32Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Factors Influencing Character of Respirations ExerciseAcute pain AnxietySmoking Body positionMedications Neurological injuryHemoglobin function

33Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Alterations in Breathing Pattern  Bradypnea  Tachypnea  Hyperpnea  Apnea  Hyperventilation  Hypoventilation  Cheyne-Stokes respiration  Kussmaul’s respiration  Biot’s respiration

34Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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

35Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Pulse Oximeter

36Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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

37Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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.

38Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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

39Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Physiology of Arterial Blood Pressure Factors affecting arterial blood pressure: Cardiac output Peripheral resistance Blood volume Viscosity Elasticity

40Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Factors Influencing Blood Pressure AgeStress EthnicityGender

41Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Factors Influencing Blood Pressure (cont’d)

42Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Ms. Coburn’s blood pressure is 164/98 mm Hg. Ms. Coburn asks whether this means she is healthy.

43Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Blood Pressure Cuff Size Guidelines

44Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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

45Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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.”

46Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Measurement of Blood Pressure  Equipment  Auscultation  Children  Ultrasonic stethoscope  Palpation  Lower extremity  Electronic blood pressure

47Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Sphygmomanometer

48Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Alternate Methods of Measuring Blood Pressure

49Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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

50Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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.

51Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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.

52Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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.

53Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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.

54Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Health Promotion and Vital Signs  Monitor vital signs.  Include age-related factors.  Include environmental and activity factors.

55Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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?

56Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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.

57Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 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.