1. Chapter 24
Vital Signs

2. Vital Signs Temperature Pulse Respiration Blood Pressure Pain
Most frequent measurement obtained by health practitioners
Reflect the physiologic status of the body – very important to get accurate measurement.
Assessing VS is a part of nursing care – independent nursing action
Institution, policies, and patient’s status dictate when, where, how, and by whom VS are measured. Admission, routine, pre and post procedures, pre-during-post administration of medication that affects cardiovascular, respiratory and temperature control function. (pt’s condition change, etc.)
May be delegated, but ultimately nurse’s responsibility to ensure accuracy of data and to report abnormal findings.
Always double check findings and further assess the patient when any unexpected changes are noted.
Change may indicate a change in physiological function.
Assessments of VS allow nurse to identify nursing diagnosis, implement interventions, and evaluate success when VS return to acceptable values.
Nurse must know the normal variations in vital signs that occur at various ages.
Compared with accepted normal values and patient’s usual patterns (baseline data).
Take as often as a patient’s condition requires such assessment
Basic techniques of inspection, palpation, and auscultation are used to determine VS.
Essential ingredient when nurses and physicians collaborate to determine the client’s health status.
Use an organized and systematic approach.

3. Temperature Heat Production Heat Loss
Heat of the body measured in degrees.
Difference between production of heat and loss of heat.
Heat is generated by metabolic processes (metabolism) in the core tissues of the body, transferred to the skin surface by the circulating blood, and then dissipated to the environment.
Core body temp of a healthy person is maintained by thermoregulatory center in the hypothalamus.
Receives messages from cold and warm thermal receptors located throughout the body and, in turn, initiates responses to either produce or conserve body heat or to increase heat loss.
Primary source of heat in the body is metabolism
Increased by hormones, muscle movements, and exercise.
Epinephrine and noreinephrine (sympathetic neurotransmitters) are released when addition heat is required and they alter metabolism so that energy production decreases and heat production increases.
Thyroid hormone (thyroid gland) also increases metabolism and heat production.
Shivering increases the production of heat, and is initiated by the hypothalamus and results in muscular tremors.
“Goose Bumps” the contraction of pilomotor muscles of the skin, causing piloerection, reduces the size of the surface to minimize heat loss.
Exercise increases heat production through muscular activity.
Skin primary site.
Circulating blood brings heat to the skin’s surface, where small connections between the arterioles and the venules lie directly below the surface (called arteriovenous shunts) may remain open to allow heat to dissipate to the skin and thus to the external environment, or they may close and retain heat in the body.
Sympathetic nervous system controls the opening and closing of these shunts in response to changes in core body temp and in environmental temp.
Evaporation of sweat, through warming and humidifying of inspired air, and through eliminating urine and feces.
Heat is transferred through radiation, convection, evaporation, and conduction. See Table 24-2, page 526

4. Temperature Core Temperature Surface Temperature
Core: rectum, tympanic membrane, esophagus, pulmonary artery, and urinary bladder. Normally 36.0 C (97.0 F) to 37.5 C (99.5 F)
Lowest in the early morning and highest in the late afternoon.
Surface: skin, oral, axillae
Fluctuates depending on blood flow to the skin and the amount of heat lost to external environment.
Due to fluctuations – acceptable range degrees C (96.8 – degrees F)
Average oral temp 98.6 F

5. Variations in Body Temperature
Factors Affecting Body Temperature
Circadian Rhythms
Age and Sex
Environmental Temperature
Hypothermia – low body temperature
Hyperthermia – high body temperature
Circadian Rhythms:
Usually about 0.6 degrees C (1-2 degrees F) lower in the early morning than in the late afternoon and early evening. Greater in infants and children
Peak elevation 4-7pm
Age and Sex:
Very young and very old more sensitive to changes in environmental temp
Infants and children changes more rapidly in response to both heat and cold air temp
Older adults lose some thermoregulatory control and are at risk for harm from extremes of temp.
Women more fluctuations than men (hormones – increase inprogesterone secretion at ovulation increases body temp as much as ½ to 1 degree.

6. Normal Body Temperature
Varies 0.3 to 0.6 degrees C ( degrees F).
Afebrile – a person with a normal body temperature

7. Increased Body Temperature
Pyrexia (fever) –Febrile – a person with an increased body temperature.
Hyperpyrexia – a high fever, usually above 41 degrees C (105.8 degrees F).
Hyperthermia- differs from pyrexia – hypothalamic set point is not changed, but in extreme heat exposure or excessive heat production, the mechanisms that control body temp are ineffective.
Neurogenic fever – result of damage to the hypothalamus from intracranial trauma, intracranial bleeding, or increased intracranial pressure.
Pyrexia (fever) – increase in body temperature caused by an upward displacement of the hypothalamic thermoregulatory center set point.
Results from bacterial or viral infections, tissue injury (myocardial infarction, pulmonary emboli, cancer, trauma, and surgery)
Febrile – a person with an increased body temperature.
A mild elevation in infants < 3 months of age might indicate a serious infection. They do not have well-developed temp-control mechanisms.
In older adults may be one of the later signs of illness.
When set point is increased, the hypothalamus initiates shivering and vasoconstriction. After new set point, heat-loss mechanisms again keep the body temp from rising to dangerous levels.
Hyperpyrexia – a high fever, usually above 41 degrees C (105.8 degrees F).
Hyperthermia- differs from pyrexia – hypothalamic set point is not changed, but in extreme heat exposure or excessive heat production, the mechanisms that control body temp are ineffective.
Neurogenic fever – result of damage to the hypothalamus from intracranial trauma, intracranial bleeding, or increased intracranial pressure.
Does not respond to antipyretic medications.

8. Physical Effects of Increased Body Temperature
Loss of appetite, headache, hot, dry skin, flushed face, thirst, and general malaise.
Young children may experience delirium or seizures
Assess for potentially dangerous manifestations of a fever, such as dehydration, decreased urinary output, and rapid heart rate.
Methods of reducing
Methods of reducing
Antipyretics
Do not give ASA to children < 2 yrs of age due to possible association with Reye’s syndrome
Cool sponge baths, cool packs, and cooling blankets.

9. Decreased Body Temperature
Hypothermia – body temp below the lower limit of normal.
Death may occur when temp falls below 34 degrees C (93.2 degrees F).

10. Assessing Temperature
Equipment
Electronic and Digital Thermometers
Tympanic Membrane Thermometer
Glass thermometer
Disposable Single-Use Thermometers
Temporal Artery Thermometer
Automated Monitoring Devices

11. Temperature Routes Always record site when recording temperature.
Oral most common
Rectal
Axillary
Tympanic
Always record site when recording temperature.
Routes
Oral most common
npo 30 minutes prior
Deepest part of SL pocket
Hold under tongue with lips and lips closed
Contraindicated: unconscious, irrational, seizure, disease of mouth or surgery of mouth or nose, or O2 mask.
Rectal
Most accurate because it’s a core body temp
Avoid if possible – may stimulate vagus nerve (brady)
Contraindicated: rectal surgery, diarrhea, or disease of rectum
Remember privacy
1 ½” adult, 1” child, ½” infant
Axillary
Deepest part of axilla
Arm held against body
Tympanic
Book states core body Infra red sensor detects heat from tympanic membrane – doesn’t touch it!
temp
My experience inaccurate
Ussually low than normal
Contraindicated , 3 months of age
Always record site when recording temperature.

12. Pulse
Throbbing sensation that can be palpated over a peripheral artery or auscultated (listened to ) over the apex of the heart.
Results as a wave of blood is pumped into the arterial circulation by the contraction of the left ventricle.
Each time LV of the heart contracts to eject blood into an already full aorta, the arterial walls in the cardiovascular system expand to compensate for the increase in pressure of the blood.

13. Pulse Physiology
Pulse regulated by the ANS through the cardiac SA node (pacemaker).
Parasympathetic stimulation via the vagus nerve decreases the HR, and sympathetic stimulation increased the HR and force of contraction.
Pulse rate is the number of pulsations felt over a peripheral artery or heard over the apex of the heart in 1 minute.

14. Variations in Pulse Rate
Normal range 60 – 100
Increased to 100 – 180 Tachycardia
Decreased below 60 Bradycardia

15. Variations in Pulse Amplitude and Quality
Quality of pulse in terms of its fullness and reflects the strength of left ventricular contraction.
Assessed by the feel of the blood flow through the vessel.
Amplitude is normally strong in areas where an artery can be palpated.
Absent (0), Thready (1+), Weak (2+), Normal (3+), Bounding (4+)

16. Variations in Pulse Rhythm
The pattern of the pulsations and the pauses between them.
Normally regular
Irregular pattern of heartbeats - dysrhythmia

17. Assessing the Pulse
Palpating peripheral arteries or by auscultating the apical pulse with a stethoscope.
Equipment
Stethoscope
Acoustical – most common – an amplifying mechanism connected to earpieces by tubing.
Diaphragm – large, flat disk
High-frequency sounds - respiratory
Bell – hollowed, upright, curved appearance.
Low-frequency sounds – heart and the blood
Ear tips – fit comfortably and snugly. Large enough to block out extraneous noises . Fit into the ear cana, not against the ear itself.

18. Sites and Methods of Assessing the Pulse
Peripheral Arterial Pulses – place the middle three fingers over the artery and lightly compress the artery so pulsations can by felt and counted.
Temporal
Carotid – during emergency situations
Brachial – used for infants who have had a cardiac arrest
Radial – most commonly used in children and adults
Femoral
Popliteal
Posterior tibial
Dorsalis pedis

19. Pulse Apical Pulse Apical-Radial Pulse
– rate is counted for 1 full minute by listening with a stethoscope over the apex of the heart (5th & 6th ribs, 3 inches to the left of the median line and slightly below the nipple).
– when radial pulse is irregular, counting the pulse at the apex of the heart and at the radial artery simultaneously is used to assess the apical-radial pulse rate.
The difference between the apical and radial pulse rates – pulse deficit, and signals that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated.

20. Respirations
Pulmonary ventilation (or breathing) is movement of air in and out of the lungs; inspiration (or inhalation) is the act of breathing in, and expiration ( or exhalation) is the act of breathing out.
External respiration is the exchange of oxygen and carbon dioxide between the alveoli of the lungs and the circulating blood through diffusion.
Internal respiration is the exchange of oxygen and carbon dioxide between the circulating blood and tissue cells.

21. Respiration Physiology
Rate and depth of breathing can change in response to body demands.
Increase in carbon dioxide is the most powerful respiratory stimulant, causing an increase in respiratory depth and rate.
The cerebral cortex of the brain allows voluntary control of breathing.
These changes are brought about by the inhibition or stimulation of the respiratory muscles by respiratory centers in the medulla and pons.
Respiratory centers are activated by impulses from chemoreceptors located in the aortic arch and carotid arteries, from stretch and irritant receptors in the lungs, and from receptors in muscles and joints.

22. Variations in Respiratory Rate and Depth
Normally smooth, effortless, and without conscious effort.
Factors Affecting Respiration
Respiratory Rate (12 to 20 times each minute)
Normal – eupnea (1 resp to 4 heartbeats)
Increased – tachypnea – occurs inresponse to the increased metabolic rate during fever (pyrexia).
Decreased – bradypnea – occurs in some pathologic conditions.
Factors Affecting Respiration
Exercise, respiratory and cardiovascular disease, alterations in fluid, electrolyte, and acid-base balances, medications, trauma, infection, pain, and anxiety.
Increased – tachypnea – occurs inresponse to the increased metabolic rate during fever (pyrexia).
Cells require more oxygen and have more carbon dioxide that must be removed.
Decreased – bradypnea – occurs in some pathologic conditions.
Increase in intracranial pressure depresses the respiratory center, resulting in irregular or shallow breathing, slow breathing, or both.
Drugs, such as narcotics (morphine, demerol (meperidine) also depress the respiratory rate.

23. Respiratory Depth and Rhythm
Normally from shallow to deep.
Apnea – no breathing
If lasts longer than 4 to 6 minutes, brain damage and death might occur.
Dyspnea – difficult or labored breathing
Dyspnea – difficult or labored breathing
Person usually has rapid, shallow respirations and appears anxious.
Often breathe easier in an upright position, condition known as orthopnea

24. Assessing Respirations
Rate, Depth, and Rhythm by inspection (observing and listening) or by listening with the stethoscope.
Monitoring arterial blood gas results and using a pulse oximeter to determine oxygenation of blood.
Depth – assessed by observing the degree of excursion or movement in the chest wall.
Rhythm
Depth – assessed by observing the degree of excursion or movement in the chest wall.
Subjectively describes – deep, normal or shallow.
Rhythm
Observe chest or abdomen
Labored – involve accessory muscles and visible in the neck
Longer expiration phase is evident when the outward flow of air is obstructed (asthma)

25. Alterations in Respirations
Bradypnea - <10 rate reg but abn slow.
Tachypnea - > 24 rate reg but abn rapid.
Hyperpnea – resp labored, increase in depth, increase in rate > 20 (occurs normal in exercise).
Apnea – respirations cease for several second. Persistent cessation results in respiratory arrest.

26. Alterations in Respirations
Hyperventilation – increased rate and depth
Hypoventilation – decreased rate and depth; irregular
Cheyne-Stokes Respirations – Alternating periods of deep, rapid breathing followed by periods of apnea.
Kussmauls’s Respirations – abnormally deep; regular and increase in rate.
Biolt’s Respirations – varying depth and rate of breathing, followed by periods of apnea.

27. Oxygen Saturation Measures diffusion and perfusion.
95% - 100% - % of hemoglobin that is bound with oxygen in the arteries is the % of saturation of hemoglobin (SaO2).
Pulse oximeter – indirect measurement
Interferance with Light Transmission
Pulse oximeter – indirect measurement
A probe with a light – emitting diode (LED) and photo detector connected by cable to an oximeter
If O2 < 90% - check position
If accurate, obtain VS and notify appropriate personnel (MD – nurse).
Observe for signs associated with decreased oxygenation.
Verify supplemental O2 is delivered as ordered.
Position client to promote optimal ventilation.
Interferance with Light Transmission
Outside light
Carbon monoxide artificially increases SpO2
Pt motion
Jaundice
Intravascular dyes absorb light

28. Reduction of Arterial Pulsations
PVD
Hypothermia
Pharmocological vasoconstrictors
Decreased Cardiac Output and Hypotension
Peripheral Edema
Tight Probe

29. Blood Pressure The force of the blood against arterial walls.
Maximum blood pressure is exerted on the walls of arteries when the left ventricle of the heart pushes blood through the aortic valve into the aorta at the beginning of systole.
Pressure rises as the ventricle contracts and falls as the heart relaxes.
This continuous contraction and relaxation of the left ventricle creates a pressure wave that is transmitted through the arterial system.
Regulation of BP is controlled by a variety of mechanisms to maintain adequate tissue perfusion.
The arterial blood pressure has constant minor variations from activities of daily living, such as rising from a sitting to a standing position, exercise, or emotions.
Blood circulates through a continuous loop of blood vessels (arteries, arterioles, capillaries, venules, and veins).
Arterioles are very small elastic tubes that can contract or dilate to regulate the distribution of blood to various organs, tissues, or cells.
Arterioles are in a state of partial contraction resulting in Peripheral Resistance and creating a relatively constant level of restraint to blood flow.
Peripheral resistance is one of the main factors affecting blood pressure.

30. Blood Pressure Systolic pressure (numerator) – the highest pressure
Diastolic pressure (denominator) – the lowest pressure
Pulse pressure – the difference between Systolic and Diastolic pressure.
Measured in millimeters of mercury (mm Hg) and recorded as a fraction. (Example 120/80 – systolic 120, diastolic 80, pulse pressure 40)

31. Compliance
Arteries have a considerable quantity of elastic tissue that allows them to stretch and distend.
Constant state of pressure in arteries which offers the resistance.
Elasticity of walls + resistance of the arterioles = maintain normal blood pressure.
With age, walls of arterioles less elastic, decreased ability to stretch and dilate. Ultimately limits adequate blood flow and contributes to rising pressure.

32. Neural and Humoral Mechanisms
ANS mediates control mechanisms that function to maintain short-term regulation of BP
Hormones and humoral mechanisms regulate BP
Renin-angiotensin-aldosterone system controls vasoconstriction to increase peripheral vascular resistance and also increases sodium and water retention bythe kidneys to increase circulatory fluid volume – increased BP
ADH 0 Antidiuretic hormone – vasopressin- is release from the posterior pituitary when stimulated by decreased blood volume and blood pressure, or by an increased osmolarity of the blood – water is retained to increase circulatory fluid volume - increase BP
ANS mediates control mechanisms that function to maintain short-term regulation of BP
Circulatory system baroreflex
Chemoreceptor-mediated reflexes
Other factors outside the circulatory system – pain, cold, etch
BP may change in response to CNS ischemia (decreased blood flow), mood, and emotion.

33. Cardiac Output
Stroke Volume – quantity of blood forced out of the left ventricle with each contraction
Cardiac Output is the amount of blood pumped per minute, and averages from 3.5L to 8.0 L/min in a healthy adult.
CO = SV X HR
Increases during exercise, decreases during sleep.
Varies depending on body size and metabolic needs.
Increased CO – arteries distend more, increased BP.
Decreased CO – BP falls

34. Variations in Blood Pressure
Factors Affection BP
Age
Circadian rhythm
Sex
Food Intake
Exercise
Weight
Emotional state
Body position
Race
Drugs/Medications

35. Increased Blood Pressure
Hypertension – BP is above normal for a sustained period
Most common health problems in adults and the leading cause of cardiovascular disorders.
Primary or essential HTN – without know cause.
Secondary HTN – with know pathology.
Major risk factor for heart disease, and most imp risk factor for stroke.
“Silent Killer”
Few symptoms beyond the HTN; 22 million don’t know
Dysfunction of the neurohormonal system
Overactivation of both angiotensin and aldosterone = HTN
Results in permanent remodeling and thickening of blood vessels which leads to increased peripheral resistance, and back-up of pressure to organs (brain, heart, and kidneys).
Thickening of myocardium, enlargement of the ventricles, CHF, MI, stroke, and kidney damage.

36. Risk Factors for HTN Family history Sedentary lifestyle Obesity
Continual stress

37. HIGH RISK FACTORS Cigarette smoking Alcohol consumption
High salt intake
High-fat, high-calorie diet
Twice as common in African Americans as in Americans of European descent.

38. Treatment of HTN Medications Antihypertensive medication
Diuretics – to decrease fluid volume.
Beta-adrenergic blockers – to block sympathetic stimulation and decrease cardiac output.
Vasodilators and calcium channel blockers – to relax smooth muscles of arterioles and decrease peripheral vascular resistance.
ACE inhibitors – to prevent vasoconstriction by angiotensin II and decrease circulatory fluid volume by reducing aldosterone production.

39. Lifestyle Changes Low-calorie, low-fat diet
Losing excess weight and maintaining weight loss
Limiting alcohol intake
Eliminating smoking
Reducing salt intake
Regular physical activity

40. Decreased Blood Pressure
Hypotension – below-normal BP
Orthostatic hypotension (Postural Hypotension) – low BP
Consistently low BP (systolic 90 – 115 mm Hg)
Pathologic hypotension might result from vasodiation of the arterioles, failure of the heart to function as an effective pump, or loss of blood volume (hemmorrhage).
IMMEDIATELY REPORT ASSESSMENTS OF HYPOTENSION, TACHYCARDIA, PALLOR, INCRASED SWEATING, AND CONFUSION.
Associated with weakness or fainting when one rises to an erect position - Supine to sitting, supine to standing, or sitting to standing.
Result of peripheral vasodilation without a compensatory rise in cardiac output.
At risk – older adults, pt with prolonged BR, dehydrated, or significant blood loss, and drugs.
Arise and move slowly, dangle.

41. Assessing Blood Pressure
Equipment
Sphygmonmanometer
Noninvasive BP monitors
Doppler Ultrasound
Direct Electronic Measurement
Sphygmonmanometer
Need correct size cuff
Direct Electronic Measurement
Arterial line – catheter into an artery that the tip senses the pressure and transmits the information to a machine that displays the systolic and diastolic pressure in a waveform.

42. Assessment Sites and Methods
Korotkoff Sounds
Assessing a Brachial Artery BP
Assessing a Popliteal Artery BP
Palpating the BP
Korotkoff Sounds
Series of sounds – skills lab
Assessing a Brachial Artery BP
Should not be takenon an arm with IV or with an arteriovenous fistula or shunt
Avoid in the arm on the side of an axiillary node dissection or mastectomy – pressure might increase risk of developing lymphedema in the affected arm.
Assessing a Popliteal Artery BP
Use with brachial artery is inaccessible.
Systolic pressure is normally 10 to 40 mm Hg higher, diastolic same.
Palpating the BP
Sensory detection, only use sphygmomanometer. Cuff inflated 30 mm Hg above the point at which pulsation in the artery disappears. As the cuff is released you feel for the return of the pulse. No diastolic pressure is recorded.

43. Blood Pressure Assessment Errors and Contributing Causes
See Table on page 554.