1. Chapter 17: Vital Signs

2. VITAL SIGNS TEMPERATURE BLOOD PRESSURE PULSE RESPIRATIONS
APICAL
RADIAL
RESPIRATIONS
PULSE OXIMETRY
PAIN SCALE

3. VITAL SIGNS ARE PART OF THE PHYSICAL ASSESSMENT
Delegation of Duties to UAP
Unlicensed Assistive Personnel
RN is Responsible to Manage Care Based on Physical Assessment
Administering medications
Communicating to other members of the health care team
Supervising delegated tasks

4. EQUIPMENT
RN is responsible for assuring equipment is functioning properly
Appropriate equipment
Must be appropriate to patient age size
Thermometer
Stethoscope: Diaphragm (high-pitched sounds); bell (low-pitched sounds)
BP cuff
Pulse oximeter

5. PATIENT HISTORY
RN must know patient medical history, including medications
These facts can affect vital signs
RN is responsible for knowing the patient’s usual vital sign range

6. FREQUENCY OF VITAL SIGNS
Physicians order the frequency of vital signs
Could be ordered by protocol or policy
The RN can increase the frequency based on his/her assessment
VITAL SIGNS can be an early warning sign that complications are developing

7. INDICATIONS FOR MEDICATION ADMINISTRATION
Many medications are administered when the vital signs are within an acceptable range.
Accurate VITAL SIGNS are required in order to make treatment decisions.

8. COMPREHENSIVE ASSESSMENT FINDINGS
Compare VITAL SIGNS to assessment findings and laboratory results to accurately interpret the patient status.
Discuss your findings with peers and charge RN before deciding on a plan of action.
Use the opportunity to teach patient/family about what VS mean, reason for assessing, meaning if appropriate

9. TEMPERATURE Factors affecting body temp. (36-38°C/96.8-100.4°F) Age
Infants: 95.9 – 99.5° F [ C] intolerant of extremes
Elderly: Average temp is 96.8° F; Sensitive to temp extremes
Exercise
Hormone levels
Circadian rhythm
Stress
Environment

10. TEMPERATURE ALTERATIONS
Afebrile
Pyrexia [fever] >37.5
Fever of unknown origin (FUO)
Malignant hyperthermia: hereditary, occurs during anesthesia
Heatstroke: medical emergency
Heat exhaustion
Hypothermia
Frostbite
Heat stroke:
High mortality rate, very young or very old, CV disease, hypothyroidism, DM, alcoholism
S/S: giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, incontinence
Temp sometimes as high as 113 with an increase in pulse and decrease in BP
Hot, dry skin is important sign
Don’t sweat due to severe electrolyte loss and hypothalamic malfunction
Can cause permanent neuro damage
Hypothermia:
May be unintentional or intentional (surgery)
S/S: uncontrolled shivering, loss of memory, depression, poor judgment, VS decreased, cyanosis
If progresses, develop dysrhythmias, loss of consciousness, and unresponsive to painful stimuli
Frostbite:
Ice crystals form inside the cell, permanent circulatory and tissue damage occurs
Areas of susceptibility include earlobes, tip of nose fingers and toes
Area becomes white, waxy and firm to touch

11. TEMPERATURE Cont’d. Sites Common sites:
Core temp is measured in pulmonary artery, esophagus, and urinary bladder
Common sites:
Mouth, rectum, tympanic membrane, temporal artery, and axilla – use critical thinking to decide!
Variety of types available – electronic and disposable
Antipyretics = drugs that reduce fever

12. Using an oral electronic thermometer, the nurse checks the early morning temperature of a client. The client's temperature is 36.1° C (97° F). The client's remaining vital signs are in the normally acceptable range. What should the nurse do next?
A) Check the client's temperature history. B) Document the results; temperature is normal. C) Recheck the temperature every 15 minutes until it is normal. D) Get another thermometer; the temperature is obviously an error.
Correct answer is A – Know pt’s baseline vitals

13. PULSE Sites Increases in HR Decreases in HR
Temporal, Carotid, Apical, Brachial, Radial, Femoral, Popliteal, Posterior Tibial, Dorsalis Pedis
Increases in HR
Short-term exercise, fever, heat, pain, anxiety, drugs, loss of blood, standing or sitting, poor oxygenation
Decreases in HR
Long-term exercise, hypothermia, relaxation, drugs, lying down

14. PULSE Cont’d.
Volume of blood pumped by the heart during 1 minute is the cardiac output
When mechanical, neural or chemical factors are unable to alter stroke volume, a change in heart rate will result in change in cardiac output, which affects blood pressure
HR ↑, less time for heart to fill, BP ↓
HR ↓, filling time is increased, BP ↑
An abnormally slow, rapid, or irregular pulse alters cardiac output

15. The nurse decides to take an apical pulse instead of a radial pulse
The nurse decides to take an apical pulse instead of a radial pulse. Which of the following client conditions influenced the nurse's decision?
A) The client is in shock. B) The client has an arrhythmia. C) The client underwent surgery 18 hours earlier. D) The client showed a response to orthostatic changes.
Correct answer is B

16. RESPIRATIONS Ventilation = the movement of gases in and out of lungs
Diffusion = the movement of oxygen and CO2 between the alveoli and RBCs
Perfusion = the distribution of RBCs to and from the pulmonary capillaries

17. Factors Influencing Character of Respirations
Exercise
Acute Pain
Anxiety
Acid-Base balance
Body Position
Medications
Neurological injury
Hemoglobin function

18. RESPIRATIONS Cont’d. Tachypnea = rapid breathing
Apnea = cessation of breathing
Cheyne-Stokes = rate and depth irregular, alternate periods of apnea and hyperventilation
Kussmaul’s = abnormally deep, regular, and increased in rate (associated with DM)

19. PULSE OXIMETER Indirect measurement of oxygen saturation
Photodetector detects the amount of oxygen bound to hemoglobin molecules and oximeter calculates the pulse saturation
Only reliable when SaO2 is over 70%
Certain conditions may give an inaccurate reading
The following conditions may give an inaccurate reading
Carbon monoxide poisoning
Rapid movement by the patient
Seizures, tremors, etc.
If the patient is suffering from hypothermia or anemia
Nail polish on the as it may not allow the infrared light to pass
Raynauds

20. A client is being monitored with pulse oximetry
A client is being monitored with pulse oximetry. On review of the following factors, the nurse suspects that the values will be influenced by which of the following?
A) The placement of the sensor on the extremity B) A diagnosis of peripheral vascular disease C) A reduced amount of artificial light in the room D) The increased ambient temperature of the client’s room
Correct answer is B

21. BLOOD PRESSURE
Force exerted on the walls of an artery by the pulsing blood under pressure from the heart
Systolic = maximum pressure when ejection occurs
Diastolic = minimum pressure of blood remaining in the arteries after ventricles relax

22. BLOOD PRESSURE Cont’d. Physiology of arterial blood pressure
Cardiac Output, Peripheral resistance, Blood volume, Viscosity, Elasticity
Factors influencing BP
Age, Stress, Ethnicity, Gender, Daily Variation, Meds, Activity, Weight, Smoking
Hypertension
Hypotension
Orthostatic or postural hypotension
Electronic device not always appropriate
Irregular HR
Peripheral vascular obstruction (clots)
Shivering
Seizures
Excessive tremors
Inability to cooperate
BP less than 90 systolic

23. B) The client’s inability to hear the first Korotkoff sound
The nurse is assessing a client’s blood pressure during a routine visit. When asked, the client volunteers that when he took his pressure at home yesterday it was 126/72 mmHg. The nurse determines that the client’s pressure today is 134/70 mmHg. The nurse recognizes that the most likely cause of the elevation is due to which of the following?
A) The difference between the monitoring equipment being used
B) The client’s inability to hear the first Korotkoff sound
C) The client may be experiencing mild anxiety regarding the check-up
D) The client is not inflating the cuff sufficiently to detect the systolic pressure
Correct answer is C

24. QUESTIONS?