VITAL SIGNS Professor Blakey NUR302

Vital Signs Temperature Pulse Respirations Blood Pressure Health Status Changes Accuracy, Responsibility

Vital Signs When are they reported? When are they recorded?

Temperature Sites: Oral- Taken routinely Taken per MD order Taken when fever is suspected

Oral Temperature Contraindicated with Unconscious patient Disorders of mouth Recently had fluids/smoked Wait 15 minutes Receiving nasal oxygen

Temperature Rectal When? Assessing most accurate temp Alternative to oral site

Rectal Temp Contraindicated with: Newborns, small children Diarrhea Rectal surgery Rectal disease Concern re: vagus nerve stimulation Neurological disease

Axillary Temperature When? Unable to use oral or rectal Newborn Contraindications: Axillary/Arm disorders After bathing

Normal Values Average values may vary 1 degree F higher or lower F/ C Oral- 98.6/ 37 Rectal- 99.5/ 37.5 Axillary- 97.6/ 36.5

Factors Affecting Temp Circadian Rhythm (24 hours) Predictable fluctuations- Temp 1-2 degrees lower in early morning Temp peaks late afternoon (4-7 pm)

Factors Affecting Temp Age- very young and old affected Gender- women Progesterone at ovulation increases temp degree Environmental

Factors Affecting Temp Hypothermia- low body temp Hyperthermia- high body temp Fever Loss of appetite, headache, flushed, malaise Severe- dehydration, alt urine output, seizures, lyte imbal

Reducing Fever Cooling the body Increase fluids Monitor intake Monitor labs Antipyretics Antibiotics

Pulse Normal range Tachycardia- more than 100 Causes- Decreased blood pressure Elevated temp Decreased oxygen Heat, Pain, Medicatioins

Pulse Bradycardia- less than 60 Caused by: Slower in men Thin person Sleep Hypothermia Aging Medications

Pulse Strength (Amplitude) 0-Absent 1+- Thready 2+- Weak 3+- Normal 4+- Bounding What would be reported?

Pulse Sites Temporal (Temple) Carotid (Neck) Brachial (Bend of arm) Radial- used frequently/palpate (Wrist) Femoral (Groin) Popliteal (Behind knee) Posterior tibial (Inner ankle) Dorsalis pedis (Top of foot) Apical- used frequently/ auscultate (heart)

Pulse Equipment Hands Doppler Stethoscope

Respirations Ventilation Inspiration Expiration Normal rate- Adults breaths per minute

Respirations Patterns of Respiration Normal- 12/20 per minute Tachypnea- more than 24/min (fever, anxiety, resp disease) Bradypnea- less than 10/min (meds, brain injury)

Respirations Hyperventilation- increased rate and depth (Kussmaul’s) Hypoventilation- decreased rate and depth-narcotics/anesthesia Cheynes-Stokes- alt. deep/rapid with apnea Biot’s- erratic depth and apnea (brain injury)

Respirations Terms Apnea- No breathing Dyspnea- Difficulty breathing Orthopnea- Breathing sitting upright

Factors Affecting Respirations Age- decreases with older age Gender- males- diaphragmatic Exercise- increases respirations Disease- brain injury Anemia- increases respirations Anxiety- increases respirations Medications- narcotics lower; amphetamines- increases Acute pain- increases

Respirations Assessing: Observation (Other monitoring devices)

Blood Pressure Systolic blood pressure- contraction of ventricles (Highest pressure on arterial walls) Diastolic- relaxation (lowest pressure) Pulse pressure (PP)- Systolic- Diastolic= PP

Blood Pressure Values Normal- <120/ <80 Prehypertension / Stage / Stage 2- >160/>100

Blood Pressure Hypertension- Sustained, above normal Primary/essential HTN- no cause Secondary HTN- known etiology Risk factors- Hx, obesity, smoking, sedentary, stress, diet

Blood Pressure Hypotension- below normal B/P Orthostatic hypotension- Postural hypotension; weakness/ fainting when standing (esp when on prolonged bedrest)

Blood Pressure Korotkoff Sounds: Phase I- first faint clear tapping Phase II- Swishing Phase III- Distinct loud sounds Phase IV- Muffling sounds Phase V- Last sound

Blood Pressure Assessment Sites Brachial Artery B/P Do not take in arm with IV, side of mastectomy, AV shunt Popliteal Artery B/P Systolic may be higher Palpating B/P Systolic

Blood Pressure False lows: Releasing valve rapidly Not pumping cuff high enough Using faulty equipment Did not insert earpieces correctly Cuff too wide Looking at meniscus above eye level

Blood Pressure False Highs: Cuff is not calibrated Looking at meniscus below eye level Cuff is too narrow Releasing valve too slowly Reinflating cuff during auscultation

Pain- the 5 th Vital Sign Factors Affecting Pain: It is what the patient says it is Culture Ethnicity Gender Age Support of Others Anxiety Past experiences

Pain JCAHO standards Right to assessment and management Ongoing assessment Recorded Policies and procedures Pain must be managed Education must be provided Discharge planning includes pain mgt Monitor effectiveness of mgt

Pain Assessment Patient’s description Duration Location Quantity/ Intensity Quality Chronology Aggravating factors Alleviating factors Physiologic indicators of pain Behavioral responses Effect on activities and lifestyle

Pain Rating (p. 1384) Simple descriptive Pain Distress Scale Numeric Pain Scale Visual Analog Scale Wong-Baker Faces