FUNDAMENTALS OF NURSING
VITAL SIGNS
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VOCABULARY
KNOW VOCABULARY WORDS
GUIDELINES FOR VS MEASUREMENT
VITAL SIGNS INCLUDE:
TEMPERATURE (T)
PULSE (P)
RESPIRATIONS (RR)
BLOOD PRESSURE (BP)
1ST SIGN THAT SOMETHING IS WRONG WITH YOUR PATIENT
ARE INTERRELATED—A CHANGE IN ONE WILL AFFECT ANOTHER
NURSE MUST KNOW NORMAL RANGES OF VITAL SIGNS
PROCEDURE FOR OBTAINING
TEMPERATURE
VARIATIONS WNL 97-99.6 F
– AGE
– EXERCISE
– HORMONES
– LOW IN AM AND PEAKS BETWEEN 4-6PM
– STRESS
– ENVIRONMENT
– INGESTION
– SMOKING
WHEN HEAT LOST = HEAT PRODUCED IT IS CALLED HOMEOSTASIS
T or thermoregulation is controlled by the HYPOTHALAMUS in the brain
**TEMPERATURE IS THE LEAST LIKELY AFFECTED BY PAIN
Figure 11-2
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
Disposable, single-use thermometer strip.
ORAL—BLUE OR CLEAR TIPPED
RECTAL—RED TIPPED
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
Electronic thermometer.
TYMPANIC—FAST AND ACCURATE
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
Tympanic thermometer with probe cover inserted into auditory canal.
TEMPERATURE
TEMPERATURE LOCATIONS /sites
– ORAL—
– Do not use if:
HAD ORAL SURGERY, CANNOT HOLD THERMOMETER PROPERLY, AND IF CHILLING
– RECTAL—
MOST RELIABLE, USUALLY MEASURES 1 DEGREE HIGHER
USED ON NEWBORN TO ENSURE PATENT ANUS
DO NOT USE:
– ON CARDIAC PATIENTS DUE TO VAGAL STIMULATION (DROPS PULSE)
– AXILLARY— (recorded AX)
LEAST ACCURATE BUT NON-INVASIVE. USUALLY 1 DEGREE LOWER
– TYMPANIC—
USE IF ORAL TEMP CONTRAINDICATED
ACCURATE, SAFE, NON INVASIVE
TEMPERATURE RANGES
– HUMAN LIFE CANNOT EXIST OUTSIDE OF 77-113 F NOT COMPATIBLE FOR CELLULAR ACTIVITY <93 OR >105.8
HYPOTHERMIA—ABNORMALLY LOW BODY TEMPERATURE
HYPERTHERMIA—TEMPERATURE ABOVE NORMAL
AFEBRILE—NO TEMPERATURE
HYPERPYREXIA—TEMP >105 F
FEVER
SIGNS OF FEVER
– USUALLY 1ST SIGN OF INFECTION
– THIRST
– ANOREXIA
– FLUSHED SKIN
– GLASSY EYES
– PERSPIRATION
– HEADACHE
– INCREASED PULSE AND RESPIRATION
– RESTLESS, SLEEPY, DISORIENTATION, CONVULSIONS
CLASSIFICATIONS OF FEVER
– CONSTANT
– INTERMITTENT
– REMITTENT
C = 9/5 + 32 F = -32 X 5/9
TEMPERATURE
FACTORS AFFECTING TEMPERATURE
– AGE
– EXERCISE
– HORMONAL INFLUENCE
– DIURNAL VARIATIONS
– STRESS
– ENVIRONMENT
– INGESTION OF HOT OR COLD LIQUIDS
– SMOKING
FACTORS TO ASSESS IN DETERMINING
POTENTIAL ALTERATIONS IN PULSE
PULSE REPRESENTS THE WAVE OF
PRESSURE PRODUCED WHEN THE
HEART CONTRACTS
NURSE NOTES THE
RATE, RHYTHM, AND
VOLUME WHEN TAKING
A PULSE.
FACTORS TO ASSESS IN DETERMINING
POTENTIAL ALTERATIONS IN PULSE
RATE
– NORMAL RATE IS 60-100 BPM
– TACHYCARDIA-->100 BPM
Several causes…
– HYPOVOLEMIA—LOW BLOOD VOLUME
– BRADYCARDIA--<60 BPM
Several causes…
– **ALWAYS ASSESS PULSE BEFORE GIVING CARDIOTONIC MEDS
THEY USUALLY STRENGTHEN AND SLOW THE HEARTBEAT
PULSE
RHYTHM
– TIME BETWEEN BEATS
SHOULD BE EQUAL AND REGULAR
– DYSRHYTHMIA = abnormality
– ARRHYTHMIA = Irregularity
PULSE
VOLUME = amount of blood with every
beat
– 0=ABSENT
– 1+=THREADY (difficult to palpate, disappears
easily with pressure)
– 2+=WEAK (difficult to palpate)
– 3+=NORMAL
– 4+=BOUNDING (felt easily with slight pressure)
PULSE
INFLUENCING FACTORS
– AGE
– EXERCISE
– FEVER, HEAT
– ACUTE PAIN, ANXIETY
– UNRELIEVED SEVERE PAIN, CHRONIC PAIN
– MEDICATIONS
– HEMORRHAGE
– POSTURAL CHANGES
– METABOLISM
– EMOTION
– SIZE
– HEART CONDITION
SITES FOR PULSE MEASUREMENT
TEMPORAL—TEMPORALIS ARTERY (not common)
CAROTID—COMMON FOR MONITORING DURING
EXERCISE
APICAL—DESIRED SITE IF PATIENT HAVING CHEST PAIN
– ALWAYS TAKE FOR 1 MINUTE
BRACHIAL—INSIDE ELBOW (excellent site for newborns,
infants)
RADIAL—THUMB SIDE OF WRIST
SITES FOR PULSE MEASUREMENT
FEMORAL—INNER LEG, BEND OF LEG BY GROIN
POPLITEAL—BEHIND KNEE
PEDAL—
– DORSALIS PEDIS (TOP OF FOOT)
– POSTERIOR TIBIAL (BEHIND MEDIAL MALLEOLUS)
USE PADS OF INDEX FINGERS WITH LIGHT PRESSURE.
DO NOT OCCLUDE BLOOD FLOW
Figure 11-7
PULSE
SITES
Figure 11-9
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St.
Louis: Mosby.)
A, Point of maximum impulse is at fifth intercostal space. B,
Assessing apical pulse.
PROCEDURE FOR DETERMINING
RESPIRATORY STATUS
RESPIRATION IS TAKING IN OXYGEN AND
BREATHING OUT CARBON DIOXIDE
-THE PROCESS OF INHALING AND EXHALING
PROCEDURE FOR DETERMINING
RESPIRATORY STATUS
INTERNAL RESPIRATIONS—EXCHANGE OF GAS AT THE
ALVEOLAR LEVEL
– DIFFUSION—EXCHANGE OF O2 AND CO2 BETWEEN
ALVEOLI AND RBCs
– PERFUSION—DISTRIBUTION OF BLOOD THROUGH
PULMONARY CAPILLARIES
– VENTILATION—MECHANICAL MOVEMENT OF AIR
– ALVEOLAR—TINIEST AIR CELLS OF THE LUNGS
– OXIDATION—O2 CONTENT OF COMPOUND
INCREASED
RESPIRATORY CONTINUED
EXTERNAL RESPIRATIONS
– INSPIRATION—AIR IN
– EXPIRATION—AIR OUT
– EACH RISE AND FALL OF THE CHEST IS ONE RESPIRATION
RATE—CONTROLLED BY MEDULLA OBLONGATA IN THE BRAIN
– EUPNEA—Normal Breathing
NORMAL ADULT RATE IS 12-20 BPM
– TACHYPNEA—Rapid Breathing
RAPID RESPIRATIONS >20 BPM
– BRADYPNEA—Slow Breathing
SLOW RESPIRATIONS <12 BPM
RESPIRATORY CONTINUED
METABOLISM
– ACTIVITY
– DEPTH
– DIAPHRAM
– RHYTHM
– INTERCOSTAL MUSCLES
RESPIRATORY CONTINUED
RESPIRATORY TERMS
– EUPNEA—NORMAL BREATHING
– DYSPNEA—BREATHING WITH DIFFICULTY
SHORTNESS OF BREATH (SOB)
– APNEA—LACK OF RESPIRATION
RESPIRATORY CONTINUED
RESPIRATORY TERMS
– CHEYNE STOKES—ALTERNATING APNEA AND
DEEP, RAPID BREATHING
RESPIRATORY CONTINUED
RESPIRATORY TERMS
– KUSSMAUL—DEEP AND RAPID
PATTERNS OF RESPIRATIONS
RESPIRATORY CONTINUED
RESPIRATORY TERMS
– ORTHOPNEA:
DIFFICULTY
BREATHING
LYING DOWN
MUST SIT UP OR
STAND TO
BREATHE
RESPIRATORY CONTINUED
RESPIRATORY TERMS
– HYPERVENTILATION—RATE EXCEEDS
METABOLIC NEEDS
– HYPOVENTILATION—RATE NOT
ENOUGH FOR METABOLIC NEEDS
RESPIRATORY CONTINUED
RESPIRATORY TERMS
– HYPOXIA—LOW CELLULAR OXYGEN
– ANOXIA—LACK OF OXYGEN AT CELL
LEVEL, NO SYSTEMIC O2
RESPIRATIONS
INFLUENCING FACTORS
– DISEASE OR ILLNESS
– STRESS
– FEVER (HYPERPYREXIA)
– AGE
– GENDER
– BODY POSITION
RESPIRATIONS
INFLUENCING FACTORS
– MEDICATIONS (NARCOTICS DECREASE RR)
– EXERCISE
– ACUTE PAIN
– SMOKING
– BRAIN STEM INJURY
OCCASIONAL SIGHING IS NORMAL—AERATES
ALVEOLI
FACTORS TO ASSESS IN DETERMINING
ALTERATIONS IN BLOOD PRESSURE
BLOOD PRESSURE
– SYSTOLIC PRESSURE: HIGHEST NUMBER
AND PRESSURE (1ST SOUND HEARD)
– DIASTOLIC PRESSURE: LOWEST NUMBER
AND PRESSURE
REPRESENTS PRESSURE BETWEEN
CONTRACTIONS
FACTORS TO ASSESS IN DETERMINING
ALTERATIONS IN BLOOD PRESSURE
BLOOD PRESSURE
– PULSE PRESSURE: DIFFERENCE BETWEEN
SYSTOLIC AND DIASTOLIC
– ESSENTIAL HYPERTENSION: ELEVATED
BLOOD PRESSURE WITH NO KNOWN CAUSE
BLOOD PRESSURE REFLECTS CARDIAC
OUTPUT
– USUALLY 5 QTS OR 5 LITERS
BLOOD PRESSURE
HYPERTENSION: BP ABOVE NORMAL LIMITS—
USUALLY >140/90
– BP INCREASED BY:
– INCREASED ICP
– PAIN
– END STAGE RENAL DISEASE (ESRD)
– EXERCISE
– SMOKING
– VASOCONSTRICTION: NARROWING OF VESSELS
– VASODILATION: WIDENING OF VESSELS
BLOOD PRESSURE
FACTORS AFFECTING BP
– AGE
– ANXIETY, FEAR, PAIN, EMOTIONAL STRESS
– MEDICATIONS
– DIURNAL FACTORS
– RACE—BLACKS HAVE INCREASED RISK FOR
HTN
BLOOD PRESSURE
FACTORS AFFECTING BP
– HORMONES
– SEX: MEN HAVE INCREASED RISK FOR HTN
– OBESITY: DUE TO MORE VESSELS TO PUMP
THROUGH
– FAMILY HISTORY
– HIGH CHOLESTEROL LEVELS
BLOOD PRESSURE
DIAGNOSIS OF HTN
– NOT DIAGNOSED WITH ONE READING
– MOST CONCERNED WITH DIASTOLIC
– FALSE HIGH READINGS CAUSED BY PATIENT
TALKING OR ARM NOT BEING SUPPORTED
HYPOTENSION <90/50 IS NOT HEALTHY
BLOOD PRESSURE
CAUSES OF HYPOTENSION
– SHOCK
– HEMORRHAGE (DECREASED VOLUME, DECREASED
PRESSURE)
– GENERAL ANESTEHESIA—DEPRESSES VASOMOTOR
CENTER IN BRAIN STEM
– ALCOHOL
– POSTURAL CHANGES
ORTHOSTATIC HYPOTENSION: OCCURS WHEN
CHANGING POSITION TOO QUICKLY
ACTIONS NEEDED TO TAKE AN
ACURATE BLOOD PRESSURE
EQUIPMENT
KOROTKOFF SOUNDS
ENVIRONMENTAL CONSIDERATIONS
– QUIET
– CORRECT CUFF SIZE
– GUAGE AT EYE LEVEL
– POSITION OF PATIENT—
LYING OR SITTING WITH FEET FLAT ON FLOOR
LEGS NOT CROSSED
Figure 11-11
(From Sorrentino, S.A. [2004]. Mosby’s textbook for nursing assistants [6th ed.]. St. Louis: Mosby.)
Aneroid manometer and cuff.
Figure 11-17
Electronic sphygmomanometer.
Figure 11-12
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
Wall-mounted aneroid sphygmomanometer.
Figure 11-14
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St.
Louis: Mosby.)
Doppler stethoscope over brachial artery to measure blood pressure.
BLOOD PRESSSURE
NURSING INTERVENTIONS
– AVOID TAKING BPs:
IN ARM WITH IV’S, INJURY OR DISEASE, CAST OR
BANDAGED, OR PARALYZED FROM STROKE
– IF YOU HAVE DIFFICULTY TAKING A BP,
RELEASE CUFF, WAIT 1-2 MINUTES AND TRY
AGAIN
BLOOD PRESSSURE
PLACEMENT
– NEVER ON MASTECTOMY SIDE
– IN LEG, SYSTOLIC & DIASTOLIC 10-40MM HG
HIGHER
HOME DEVICES—NOT ALWAYS ACCURATE
PROCEDURE FOR OBTAINING
ACCURATE HEIGHT AND WEIGHT
DEFINITIONS
– HEIGHT AND WEIGHT ARE A RATIO—YOU NEED
BOTH
PURPOSE
– ASSESS GROWTH AND DEVELOPMENT
– CALCULATE DRUG DOSAGE
– ASSESS EFFECTIVENESS OF DRUG THERAPY
– S/S OF DISEASE
– DETERMINE NUTRITION OR FLUID BALANCE
PROCEDURE FOR OBTAINING
ACCURATE HEIGHT AND WEIGHT
TO GET ACCURATE WEIGHT:
– BALANCE SCALE FIRST.
– SAME TIME, SAME SCALE, SAME CLOTHES
– IDEAL TIME:
AFTER VOIDING & BEFORE BREAKFAST
HEIGHT OBTAINED BY MEASUREMENT
Figure 11-18
(From Sorrentino, S.A. [2004]. Mosby’s textbook for nursing assistants. [6th ed.]. St. Louis: Mosby.)
Types of scales. A, Standing scale. B, Chair scale. C, Lift scales.
FACTORS TO ASSESS IN DETERMINING
POTENTIAL ALTERATIONS IN
OXYGEN SATURATION
KEY TIMES TO ASSESS
PULSE OXIMETRY
– NAILBED—CLOTHESPIN
– MEASURES ARTERIAL OXYGEN SATURATION
(SAO2)
– <70% IS LIFE THREATENING
FREQUENCY OF VS MEASUREMENT
ADMISSION
FACILITY POLICY/PHYSICIAN ORDER
INSTABILITY
BEFORE/AFTER SURGERY/PROCEDURE
BEFORE/AFTER MEDS
ROUTINELY DURING PROCEDURES
WHEN CLIENT REPORTS SX OF DISTRESS
NORMAL LIMITS FOR VARIOUS AGES
DISCUSS PATIENT/FAMILY TEACHING IN
REGARDS TO VITAL SIGNS
THE END!!!
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