Vital Signs Teresa V Hurley MSN RN What

Vital Signs Teresa V. Hurley. MSN, RN

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

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

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?

Temperature l l Hypothalamus Range: 36 to 37. 5 C or 97 -99. 5 F Heat Production Heat Loss Radiation Convection Evaporation Conduction

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

Body Temperature l l Afebrile Febrile • • • Fever or Pyrexia Alteration in in hypothalmic set-point Increase in cellular metabolism and consumption of o 2 • Increase in heart and respiratory rates • Prolonged fever leads to cellular, myocardial and or cerebral hypoxia

Temperature Alterations l Hyperthermia • Heatstroke • Heat exhaustion Hypothermia -Frostbite

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

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

Pulse l l Number of pulsations/minute over a peripheral artery Rate: Beats per minute • • • 60 -100 Beat per minute Bradycardia Tachycardia Rhythm: regular or irregular (dysrhythmia) Amplitude • 0 to 4+

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

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

Pulse Assessment l l 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

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

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

Respirations l l Passive process regulated by brain stem Ventilation regulated most importantly by high arterial CO 2 (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

Respiratory Alterations l l Apnea Dyspnea Hyperventilation • • • Increase in rate Decrease in depth Fear Hypoventilation • • Decrease in rate Decrease in depth

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

Pulse Oximetry Spo 2 l l l Spo 2 acceptable ranges: 90%-100% Sp 02 85%-89% acceptable for chronic diseases Spo 2 less than 85% is unacceptable

Complete Blood Count (CBC) l Measure of RBC’s count, volume of RBC’s. and Hgb concentration which is the capacity to carry O 2

Blood Pressure l What is Blood Pressure? l Systolic Diastolic Pulse Pressure l l • Difference between systolic and diastolic pressure

Blood Pressure l l l Neural and Hormonal B/P Average 120/80 mm Hg Pulse Pressure difference between systolic and diastolic • Range: 30 -50 mm Hg

Hypertension l l l Asymptomatic Diastolic 80 -89 mm Hg on 2 subsequent visits Systolic 120 -139 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

HTN Factors l What persons are more at risk for developing for HTN?

Hypotension l l l l l 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

Hypotension l Orthostatic (Postual) • Risk Factors • Dehydration • Anemia • Prolonged bedrest • Recent blood loss

Blood Pressure l Variations in B/P • Peripheral resistance and compliance • Wall elasticity • Neural and humoral mechanisms • Renin-angiotensin-aldosterone l • Increase per vascular resitance • Increase Na and H 2 O retention Cardiac Output • 3. 5 -8 Liters average

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

B/P Measurement l l l 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?

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

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

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