Vital Signs Chapter 12 Bethann Davis MSN NP

Vital Signs Chapter 12 Bethann Davis MSN, NP PNU Fall 2015

Learning Objectives • List the components measured during assessment of “vital signs” • Name various sites used and differences in measurement when assessing a temperature. • Discuss factors that affect a person’s temperature.

Learning Objectives (cont) • Define following terms about a temperature afebrile antipyretics febrile fever pyrexia hypothermia hyperthermia

Learning Objectives (cont) • List three signs/symptoms that accompany a fever. • Name the sites used for pulse assessment. • Identify three characteristics noted when assessing a pulse.

Learning Objectives (cont) • Define following terms bradycardia palpitation tachycardia

Learning Objectives (cont) • Differentiate between normal and abnormal breathing patterns. apnea bradypnea dyspnea tachypnea

Learning Objectives (cont) • Explain the difference between systolic and diastolic blood pressure. Describe the five phases of Korotkoff blood pressure sounds. • List factors that can affect a person’s blood pressure. • Name the various methods for assessing a blood pressure.

Learning Objectives (cont) • Define the following terms pulse pressure hypertension hypotension postural hypotension

Learning Objectives (cont) • Identify the action and nursing implications for Cardiotonics Antihypertensives Bronchodilator medications

Vital Signs • • • Body temperature Pulse Respiratory rate Blood pressure Pain (5 th sign)

Vital Signs Frequency of assessment: on admission – baseline data post operative change in condition severely ill blood transfusion

Vital Signs Frequency of assessment (cont) medical orders before & after giving cardiac medications nursing judgment

Temperature Definition: warmth of the human body produced from exercise & metabolism of food heat lost through skin, lungs and body waste products

Temperature • Core temperature: warmth in deeper sites of body, brain & heart • Shell temperature: warmth at skin surface

Temperature Normal Adults: range 96. 6° F to 99. 3 ° F Elderly : normally lower than adult readings Newborns & young children: slightly higher than adult readings

Temperature Pyrexia (fever): above 99. 3° F Hyperpyrexia, hyperthermia: high fever, above 106° F interventions: antipyretics, cool baths, cool blankets, cool drinks

Temperature Hypothermia: below normal limits death may occur if below 93. 2 °F chemical reactions & metabolic demands for oxygen are decreased

Temperature Factors affecting temperature age food intake exercise climate illness medications

Temperature Assessment sites: normal temps will vary, depending on site – must record site oral (most often used) - 98. 6° ear (closest to core) - 99. 5°

Temperature rectal temporal artery axillary - 99. 5° - 99. 4° - 97. 5°

Pulse • Produced by the movement of blood during the heart’s contraction • (L) ventricle ejects blood into aorta • Can be felt by palpation

Pulse Assessment of pulse rate rhythm volume (quality of beat)

Pulse Assessment sites heart – apical pulse peripheral – carotid, temporal, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis apical/radial pulse – both at same time

Pulse Terms • tachycardia – rate above 100 bpm • bradycardia – rate below 60 bpm • pulse deficit – difference between apical and radial pulses

Pulse Terms (cont) • Stroke volume – amount of blood pumped from (L) vent. w/ each contraction • Cardiac output – amt. of blood pumped from (L) vent. per min. (stroke volume x heart rate)

Pulse Doppler ultrasound device To be used over a peripheral artery when pulse cannot be palpated

Respirations Definition The act of breathing in (inspiration) and breathing out (expiration) Exchange of oxygen and carbon dioxide

Respirations Assessment assess chest/back according to a pattern rate – normal 14 -20 quality – normal, shallow, deep

Respirations Terms: tachypnea – over 20 per min bradypnea – under 12 per min. apnea – absence of breathing dyspnea – difficulty breathing

Respirations Terms (cont) orthopnea – high Fowlers position for breathing Cheyne Stokes – gradual ↑, then ↓ in resp, then period of apnea; repeating

Respirations Breath sounds normal abnormal (adventitious) crackles gurgles wheezes

Blood Pressure Definition: • The force of blood against the arterial walls • Cuff (sphygmomanometer) • Numbers (manometer)

Blood Pressure Systolic blood pressure (top number): maximum pressure of arteries when (L) vent. contracts & pushes blood into aorta

Blood Pressure Diastolic blood pressure (bottom number): lowest pressure on arterial walls when heart is at rest; refilling w/ blood

Blood Pressure Pulse pressure: difference (in numbers) between systolic and diastolic pressures. 30 – 50 normal 120/80 = 40

Blood Pressure Factors affecting BP elasticity of blood vessels pumping action of heart blood volume, viscosity of blood

Blood Pressure Factors affecting BP (cont) age, exercise pain medications gender, circadian rhythm cuff size

Blood Pressure Assessment sites • Brachial artery • Popliteal artery

Blood Pressure Terms: Korotkoff sounds – 5 sounds heard during taking of BP hypertension - sustained above 130/89 hypotension – sustained below normal range

Blood Pressure Terms (cont) orthostatic or postural hypotension: associated with dizziness or fainting when sitting or standing

Considerations Many older clients have dysrhythmias check P, BP carefully Make sure BP cuff is secure, not too tight or loose - can give false readings Clients talking during BP readings can give false high

Considerations Wait at least 10 min. after a client has had a drink to take temp. Must have 2 people to do apical radial pulse correctly Always document vital signs after taking them.