1. Vital Signs
Teresa V. Hurley. MSN, RN

2. What are vital signs? Blood Pressure Pulse
Respiratory Rate and Oxygen Saturation
Temperature
Abbreviated as T, P, R. Spo2 and B/P

3. Nursing Responsibility
Know range of acceptable values
Client patterns
Frequency of taking based on client’s condition

4. Temperature What is body temperature? How is heat generated?
What is the core body temperature range in degrees C and F?
Which sites are most often used to measure the core temperature?
Which sites are most often used to measure body surface temperatures?

5. Temperature Hypothalamus Range: 36 to 37.5 C or 97-99.5 F
Heat Production
Heat Loss
Radiation
Convection
Evaporation
Conduction

6. Factors Affecting Body Temperature
Circadian Rhythms
Age
Exercise
Sex
Hormone levels
Stress
Environment

7. Body Temperature Afebrile Febrile Fever or Pyrexia
Alteration in in hypothalmic set-point
Increase in cellular metabolism and consumption of o2
Increase in heart and respiratory rates
Prolonged fever leads to cellular, myocardial and or cerebral hypoxia

8. Temperature Alterations
Hyperthermia Hypothermia
Heatstroke -Frostbite
Heat exhaustion

9. Temperature Assessment
Devices
Tympanic: infrared sensors
Rectal: electronic or digital
Oral
Axillary
Temporal Artery
Automated Monitoring

10. Mercury Thermometers: Glass
Toxic hazard effecting CNS via contact with its vapors and by touching it
Clean-up and Disposal

11. Pulse Number of pulsations/minute over a peripheral artery
Rate: Beats per minute
Beat per minute
Bradycardia
Tachycardia
Rhythm: regular or irregular (dysrhythmia)
Amplitude
0 to 4+

12. Apical Pulse Site: PMI at 5th ICS at left MCL
A/R rate correspond usually
Pulse Deficit is the difference between the A/R rate

13. Peripheral Sites Temporal Carotid Brachial Radial Femoral Popliteal
Posterior tibial
Dorsalis pedis

14. Pulse Assessment
Stethoscope for apical pulse using bell side to hear low frequency sounds of heart and blood
Doppler Ultrasound
Cardiac Monitor
Palpation of peripheral arterial pulse

15. Factors Influencing Pulse Rates
Exercise
Temperature
Emotional States
Drugs
Hemorrhage
Postual Changes
Pulmonary Conditions

16. Factors influencing Respirations
Exercise
Acute pain
Anxiety
Smoking
Body Position
Medications
Neurological Injury
Hemoglobin Levels

17. Respirations Passive process regulated by brain stem
Ventilation regulated most importantly by high arterial CO2 (hypercarbia)
COPD regulation is by hypoxemia (low 02 levels) via chemoreceptors in carotid artery and aorta
Respiratory Rate
Eupnea: 12 to 20 breaths/min
Tachypnea
Bradypnea

18. Respiratory Alterations
Apnea
Dyspnea
Hyperventilation
Increase in rate
Decrease in depth
Fear
Hypoventilation
Decrease in rate

19. Respiratory Alterations
Cheyne Stokes
Deep, rapid
Periods of apnea
Biot’s
Severe brain damage
Varying rate and depth

20. Pulse Oximetry Spo2 Spo2 acceptable ranges: 90%-100%
Sp02 85%-89% acceptable for chronic diseases
Spo2 less than 85% is unacceptable

21. Complete Blood Count (CBC)
Measure of RBC’s count, volume of RBC’s. and Hgb concentration which is the capacity to carry O2

22. Blood Pressure What is Blood Pressure? Systolic Diastolic
Pulse Pressure
Difference between systolic and diastolic pressure

23. Blood Pressure Neural and Hormonal B/P Average 120/80 mm Hg
Pulse Pressure difference between systolic and diastolic
Range: mm Hg

24. Hypertension Asymptomatic Diastolic 80-89 mm Hg on 2 subsequent visits
Systolic mm Hg on 2 subsequent visits
HTN greater than 140/90
Greater peripheral vascular resistance with decrease in blood flow to heart, brain and kidneys

25. HTN Factors
What persons are more at risk for developing for HTN?

26. Hypotension Systolic B/P falls below 90 mm Hg Hemorrhage
Pump failure of heart
Pallor
Mottling of skin
Clamminess
Confusion
Increase in HR
Decrease in urinary output

27. Hypotension Orthostatic (Postual) Risk Factors Dehydration Anemia
Prolonged bedrest
Recent blood loss

28. Blood Pressure Variations in B/P Cardiac Output
Peripheral resistance and compliance
Wall elasticity
Neural and humoral mechanisms
Renin-angiotensin-aldosterone
Increase per vascular resitance
Increase Na and H2O retention
Cardiac Output
3.5-8 Liters average

29. Blood Pressure Assessment
Non-invasive Monitoring
Equipment: stethoscope and sphygmomanometer
Select appropriate cuff size
Sites
Brachial artery
Popliteal if brachial artery inaccessible

30. B/P Measurement Kortokoff Sounds Phases I through V
What is the ausculatory gap?
During which phase is there a distinct change in sound?
When does phase V occur?

31. What factors may influence accuracy of B/P measurement?
Exercise
Caffeine
Smoking
Cuff size
Too rapid or too slow release of valve
Release so descent is 2-3mm Hg

32. Korotkoff Sounds Phase I = 1st thump sound Phase II = whooshing sound
Phase III = softer thump than Phase I
Phase IV = soft blowing that fades
Phase V = silence

33. B/P Variation Factors Age Diurnal Rhythms Stress Ethnicity Weight
Gender
Body Position
Exercise
Medications [anti-HTN, cardiac, opiod analgesics, contraceptives]