1. Chapter 32 Vital Signs NRS 102
Students need to learn how to assess temperature, pulse, blood pressure, respiratory rate, and oxygen saturation. These are referred to as vital signs, since these measurements indicate the effectiveness of the circulatory, respiratory, neural, and endocrine body functions. Pain is also measured as the sixth vital sign. Vital sign measurements help nurses identify and evaluate the client's response to an intervention and provide nurses with physiological measurements used for clinical problem solving.

2. General Survey Physical appearance Age Sex Level of consciousness
Skin color
Facial features

3. General Survey Body structure Mobility Stature Nutrition Symmetry
Posture
Position
Body build, contour
Mobility
Gait
Range of motion

4. General Survey Behavior Facial expression Mood and affect Speech Dress
Personal hygiene

5. Guidelines for Measuring Vital Signs
Establish a baseline for future assessments.
Be able to understand and interpret values.
Appropriately delegate measurement.
Communicate findings.
Ensure equipment is in working order.
Accurately document findings.
Vital sign measurements must be taken in an organized manner. You must be aware of the surroundings and any extraneous factors that might affect the measurements. Changes, both positive and negative, will provide you with valuable information regarding your client’s status.

6. Body Temperature Physiology
Heat produced
Heat lost
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

7. Body Temperature Regulation
Neural and vascular control
Heat production
Heat loss
Skin temperature regulation
Behavioral control
Thermoregulation
A process called thermoregulation controls the physiological and behavioral mechanisms that regulate heat loss and heat production. The relationship is regulated by these six mechanisms.
Neural and vascular control is governed by the hypothalamus, located between the cerebral hemispheres. The hypothalamus works like a thermostat, which establishes a comfortable body “set point.” The anterior hypothalamus controls heat loss, while the posterior hypothalamus controls heat production.
Heat production is a by-product of metabolism, a series of chemical reactions that take place in the body. Food is the primary source of the body’s metabolic process. Heat production occurs through the basal metabolic rate (BMR), as well as through shivering and nonshivering thermogenesis, which occurs in neonates.
Heat loss occurs through the processes of radiation, conduction, convection, and radiation.
Skin temperature is an effect of its role as body insulator, vasoconstriction, and temperature sensation. The skin, subcutaneous tissue, and fat keep heat inside the body.
Behavioral control depends upon a person’s ability to control body temperature through:
The degree of temperature extreme
The ability to sense comfort or discomfort
Through processes or emotions
The person's mobility or ability to add or remove clothing
In summary, thermoregulation constitutes the physiological and behavioral mechanisms that regulate the balance between heat loss and heat production.

8. Factors Affecting Body Temperature
Age
Exercise
Hormonal level
Circadian rhythm
Environment
Temperature alterations
Age has a great effect on body temperature. Newborns’ temperature control mechanisms are immature. They can loose up to 30% of heat through their heads. Until a child reaches puberty, temperature regulation is unstable. Also note that it is not unusual for older adults to reach temperatures no higher than 96.8° F.
Exercise stimulates muscle activity and requires an increased blood supply and increased carbohydrate and fat breakdown. Exercise will increase heat production and body temperature.
Women experience greater fluctuations in body temperature than men. Hormonal variations occur during menstrual cycle and menopause. Women may experience hot flashes due to an inability to control vasodilation and vasoconstriction.
Circadian rhythm changes the body temperature over the 24-hour period. The lowest body temperature occurs between 0100 and 0400 hours. The body reaches maximum temperature at 1800 hours. The circadian rhythm does not change with age, but will change for those who work the night shift. This usually takes up to three weeks.
The environment influences body temperature. When entering a warm room, a person’s body heat will raise. If outside without warm clothing, a person’s body temperature may be low due to radiant and conductive heat loss.
Temperature alterations are related to excess heat production, excessive heat loss, minimal heat production, minimal heat loss, or any combination of these.
Fever or pyrexia occurs because the body is unable to keep pace with a heat production mechanism. This can be a result of the hypothalamus being unable to keep the “set point.” Pyrogens may be the cause. Remember that a fever is an important defense mechanism. But also recall that a fever also increases oxygen demand and can stress the cardiac and respiratory systems.
Hyperthermia is an elevated body temperature resulting from the body’s inability to promote heat loss or reduce heat production.
Heatstroke occurs from prolonged exposure to the sun or high environmental temperatures. This may occur in those who spend time outside, such as athletes and construction workers. Signs and symptoms include giddiness, confusion, delirium, excessive thirst, nausea, muscle cramps, visual disturbances, elevated body temperature, increased heart rate, and lower blood pressure.
Heat exhaustion occurs when profuse diaphoresis results in water and electrolyte loss.
Hypothermia occurs with exposure to cold. The core body temperature drops and the body is unable to compensate.

9. Abnormal Body Temp Hypothermia
Heat loss during prolonged exposure to cold
Classified by core temp (mild-severe)
May be intentional (surgery)
Early signs- uncontrolled shivering, loss of memory, poor judgment
Later signs- Cyanosis, decreased VS, cardiac dysrhythmias, loss of consciousness
Frostbite- body exposure to subnormal temps

10. Abnormal Body Temp Hyperthermia
Elevated body temp related to body’s inability to promote heat loss or reduce heat production
Heatstroke- prolonged exposure to sun or high environmental temp. Heat depresses hypothalamus function
Heat Exhaustion- profuse diaphoresis result in fluid & electrolyte loss

13. Nursing Process and Temperature
Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment is the first step of the nursing process (Chapter 16). Temperature can be measured orally, rectally, axillary, and on the skin. Thermometers use either a Celsius or Fahrenheit scale. Each temperature device has pro’s and con’s. Devices include electronic, chemical dot, or glass. You will practice with the devices used by your health care facility.
Nursing diagnoses will be selected from the NANDA-approved list.
During the planning stage, you will use knowledge gathered from the assessment to write individualized client goals/outcomes.
Implementation will revolve around either raising or lowering the client’s body temperature. In the acute care or restorative care settings, your implementation will be aimed at health promotion.
Finally, you need to evaluate whether clients have achieved their outcomes/goals or whether you need to revise your plan of care.

14. Pulse, Physiology, and Regulation
The indicator of circulatory status
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.
The SA node stimulates cardiac contraction.
The volume of blood pumped by the heart in one minute is cardiac output, which is the product of the heart rate and ventricle's stroke volume. The inability of the blood pressure to respond to increases or decreases in the heart rate indicates a health problem.

15. Assessment of Pulse Sites Use of stethoscope Character of pulse
Nursing process and pulse determination
You will select the most appropriate and age-specific site to measure the pulse. Theses sites include: temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, posterior tibial, or dorsalis pedis. Table 32-2 presents pro’s and con’s for each site. When measuring the apical site, you will need to use a stethoscope. A stethoscope consists of ear pieces, a diaphragm, bell, and tubing. During a skills lab, you will discuss the type most appropriate for you and learn how to use it.
The pulse has various characteristics, including rate, rhythm, strength, and equality. It will be important to establish a baseline for future comparison. Be judicious when delegating the assessment of vital signs to nursing assistive personnel. Table 32-3 presents acceptable ranges of heart rate. Table 32-4 presents factors influencing heart rates. The rhythm should be regular; however, both normal and abnormal variations will occur.
Your nursing diagnosis will relate to disturbances to the general state of the client’s cardiovascular health. Select the most appropriate NANDA-approved nursing diagnosis. The nursing care plan should include interventions designed to help the client alleviate the problem.

18. Knowledge check!
Which patient would be most likely to present with a pulse rate that is lower than normal?
A 70-year-old telephone salesman presenting with dehydration.
A 20-year-old runner who had surgery 4 days ago for a fractured leg.
A 67-year-old who presented with an exacerbation of his COPD

19. Respiration Ventilation Diffusion Perfusion Physiological control
Mechanics of breathing
Respiration includes three processes: ventilation, diffusion, and perfusion. Ventilation is the movement of gases in and out of the lung. Diffusion is the movement of oxygen and carbon monoxide between the alveoli and red blood cells. Perfusion is the distribution of red blood cells to and from the pulmonary capillaries. You will analyze respiratory efficiency and ventilation by assessing respiratory rate, depth, and rhythm.
Breathing is a passive process. The brain stem regulates the involuntary control. The body regulates ventilation through CO2 and O2 and hydrogen ion concentration in arterial blood. If oxygen falls below acceptable parameters, respiratory rate and depth of ventilation will increase.
Breathing is a passive action, as is the muscular activity that moves the air in and out of the lungs. Normally 500 ml of air is inhaled in a breath (this is referred to as tidal volume). Expiration is passive.

20. Assessment of Ventilation
Easy to assess
Respiratory rate
Ventilatory depth
Ventilatory rhythm
Diffusion and perfusion
Arterial oxygen saturation
Respirations are tied to all functions of body systems. A sudden change in respiration may indicate a problem or can be a normal physiological response. Box presents factors that influence respiration.
Respiratory rate is age specific. Respiratory rate can be influenced by activity and age as well as by illness, injury, or disease.
The ventilatory movements are described as deep, normal, or shallow. Table 32-6 presents alterations in breathing patterns. Remember that infants tend to breathe less regularly. Respiration is regular or irregular in rhythm.
You will evaluate respiratory processes of diffusion and perfusion by measuring the oxygen saturation of blood. The percentage of hemoglobin that is bound with oxygen in the arteries is the percent of saturation of hemoglobin or SaO2. This should be between 95% and 100%.
Arterial oxygen saturation is measured through a pulse oximeter. SpO2 is a reliable estimate of SaO2 when it is higher than 70%.

21. Assessing Respirations
Assessing rate- observe full inspiration & expiration
Assess for full minute
Normal adult 12 –20 breaths/minute
Varies with age, rate declines throughout life
Apnea Monitor

22. Normal & Abnormal Respirations
Eupnea- normal respirations
Bradypnea- abnormally slow < 12
Tachypnea- abnormally fast >20
Hyperpnea- labored, after exercise
Hyperventilation/Hypoventilation
Cheyne-Stokes

23. Nursing Process and Respiratory Vital Signs
Measurements include:
Respiratory rate, pattern, depth, SpO2, ventilation, diffusion, perfusion
Nursing diagnosis
Interventions
Planning
Evaluation
Assessment of the respiratory system will be discussed further in Chapter 33. Each measurement will give you data to determine the client’s problem.
You will select the appropriate nursing diagnosis from the NANDA list.
The nursing interventions you select for your client are based on nursing diagnosis and related characteristics.
Planning will help the client meet the outcomes/goals selected.
Evaluate whether the client has met the outcomes and determine if interventions must be changed or discontinued.

24. Arterial Blood Pressure and Physiology
Force exerted on walls of an artery
Systolic and diastolic
Cardiac output
Peripheral resistance
Blood volume
Viscosity
Elasticity
Blood pressure is the force exerted on the arterial wall by pulsing blood under pressure from the heart. Blood moves from higher to lower pressures. The maximum peak pressure is known as systolic blood pressure. When the ventricles relax, a minimal pressure is exerted against the arterial walls, known as diastolic blood pressure. Blood pressure is measured in millimeters of mercury (mmHg).
Blood pressure depends on cardiac output (CO). Cardiac output is the volume of blood ejected by the ventricles of the heart (stroke volume) multiplied by the heart rate.
Blood pressure depends on peripheral resistance. Peripheral resistance is determined by the tone of vasculature and diameter of blood vessels. Blood flows through arteries, arterioles, capillaries, venules, and veins. The size changes to meet the needs of surrounding structures and tissues.
The volume of circulating blood affects blood pressure. Normal circulating volume is 5000 ml. Rapid infusion of volume elevates blood pressure. Decrease in volume, which can be caused by hemorrhage or dehydration, causes blood pressure to fall.
The thickness or viscosity of blood affects the ease of blood flow through small vessels. Hemocrit, or percentage of red blood cells, determines viscosity.
Normal arterial walls are elastic and easily distensible. As blood pressure increases, the diameter of the vessels will increase to accommodate the pressure. Distensibility prevents fluctuations in blood pressure. Systolic pressure is elevated more than diastolic pressure as a result of reduced arterial elasticity.
It is important to remember that each hemodynamic factor significantly affects the others.

25. Factors Influencing Blood Pressure
Age
Stress
Ethnicity
Gender
Daily Variation
Medications
Activity, weight
Smoking
Blood pressure is not a constant. Many factors influence blood pressure.
Table 32-7 presents the “normal” blood pressure levels throughout the lifespan. Blood pressure can be further classified as normal, prehypertension, Stage 1 Hypertension, and Stage 2 Hypertension. See Table 32-8.
Stress created by anxiety, fear, pain, and emotions causes a sympathetic stimulation, which increases heart rate, cardiac output, and vascular resistance.
The incidence of hypertension is higher in African Americans than in European Americans. Genetic and environmental factors are often contributing factors.
There is no clinical differences between boys and girls. However, after puberty, males tend to have higher blood pressure. After menopause, women tend to have higher blood pressure than men of similar age.
Blood pressure will vary during the day, around sleep intervals and activities. Blood pressure is highest between 1000 and 1800 hours. Blood pressure is lowest between hours of sleep and As the person wakes up, the blood pressure will rise.
Medications will directly or indirectly alter blood pressure. Antihypertensives alter blood pressure directly. Indirectly, opioid analgesics will lower blood pressure while volume and vasoconstrictors raise blood pressure. Table 32-9 lists antihypertensive medications.
Activity and weight are directly linked. A period of exercise can reduce blood pressure for several hours. Inadequate exercise contributes to weight gain and perhaps obesity, which can trigger hypertension.
Smoking directly affects vessels, causing vasoconstriction which causes the BP to rise.

26. Hypertension and Hypotension
More common than hypotension
Thickening of walls
Loss of elasticity
Family history
Risk factors
Hypotension
90 mm Hg
Dilation of arteries
Loss of blood volume
Decrease of blood flow to vital organs
Orthostatic/postural
Hypertension is more common than hypotension.
Hypertension is asymptomatic, while hypotension causes pallor, skin mottling, clamminess, confusion, increased heart rate, decreased urine output.
Modifiable risk factors include: obesity, smoking, alcohol consumption, high salt. A person has no control over family history. Higher incidents for high blood pressure exist in those with diabetes, of African American descent.
Orthostatic or postural hypotension occurs when a normotensive person develops symptoms and low blood pressure when rising to an upright position. Clients who are dehydrated, anemic, on prolonged bed rest, or who have had a recent blood loss are at risk for orthostatic hypotension.

27. Factors controlling Blood Pressure

28. Measurement of Blood Pressure

29. Vital Signs Blood pressure Systolic pressure Diastolic pressure
Pulse pressure
Mean arterial pressure

30. Measurement of Blood Pressure
Equipment
Auscultation
Children
Ultrasonic stethoscope
Palpation
Lower extremity
Electronic blood pressure
BP can be measured directly or indirectly. You will practice these methods in the skills lab. Direct and invasive measurement requires a catheter insertion into an artery. Direct, noninvasive will require equipment. A baseline is necessary for comparison. Delegation depends upon the condition of the client.
Equipment consists of sphygmomanometer and stethoscope. Aneroid and mercury manometers are used. You will discuss and practice the type commonly used at your health care facility.
The best environment to auscultate the BP is a quiet environment. The client may sit, stand, or lie. The client should be assessed in the same position so comparisons can be made. You will hear and record both systolic and diastolic readings. Table presents common mistakes in blood pressure assessment.
When assessing a child’s blood pressure, the correct cuff size must be used to prevent a high or low reading.
An ultrasonic stethoscope will help you to hear a weak BP. This will pick up low-frequency sounds.
Palpations indirectly measure BP. They can be used when the BP is weak and the Korotkoff sounds cannot be heard. You will only be able to identify the systolic pressure. This method takes practice.
Lower-extremity BP may need to be assessed if the upper extremities are not available because of dressings, casts, burns, lines, fistulas, or shunts. The proper size is a must. You will need to practice this to acquire competency.
Electronic blood pressure devices come in many styles. You will learn how to take BPs manually and electronically. When taking BP electronically, make sure the device is fully charged and calibrated.

31. Nursing Process and Blood Pressure Determination
Assessment of blood pressure and pulse evaluates the general state of cardiovascular health.
Hypertension, hypotension, orthostatic hypotension, or narrow/wide pulse pressures define nursing diagnoses.
As previously discussed, you will use all steps of the nursing process to assist clients who suffer from problems with blood pressure. Your evaluation will help you to alter or adjust your nursing interventions.

32. Knowledge check!
Significant elevation in blood pressure measurements from one day to the next could be attributed to:
A decrease in cuff size
An increase in cuff size
New onset of pain or anxiety
A and C

33. Measurement of Arterial Oxygen Saturation
Pulse oximeter
Allows indirect measurement of oxygen saturation
SpO2 is a reliable estimate of SaO2
Measurement is affected if extremity is cold, edematous or if nail polish is present (interference with light transmission)

36. Health Promotion and Vital Signs
Monitor vital signs.
Include age-related factors.
Include environmental and activity factors.
When teaching clients regarding their vital signs, it is important to emphasize health promotion and activities that support health. You may need to teach clients and their families to assess and record vital signs. Box presents variations unique to the older adult. Stress that vital signs should be taken at the same time everyday. Food and activity will alter the readings.