Vital Signs

Argie Trinidad,RN

• Temperature

• Pulse

• Respirations

• Blood Pressure

• Pain Assessment (Fifth Vital Sign)

• the balance between the amount of heat produced by and heat lost from the body (thermoregulation)

Temperature

types of body temperature

a. core body temperature (CBT)

i. temperature of the deep tissues of the body

ii. fluctuates very little in healthy adults

b. surface temperature (ST)

i. temperature of the surface of the body

ii. fluctuates widely in healthy adults

influencing body temperature factors

a. developmental stateb. diurnal variations

(circadian rhythms)c. hormonesd. stresse. environmentf. nervous system

impairment

g. genetich. circulatory impairmenti. integumentary impairmentj. infectionk. exercisel. altered cognitive statesm. altered nutrition

body temperature regulation

• methods of heat production by the body

physiologic mechanisms

voluntary mechanisms

• methods of heat loss from the body

physiologic mechanisms

behavioral mechanisms

normal temperature ranges at various ages

• a. infant36.1 - 37.7° C (97 - 100° F)

• b. child37 - 37.6° C (98.6 - 99.6° F)

• c. adult37 - 37.6° C (98.6 - 99.6° F)

• d. older adult36 - 36.9° C (96.9 - 98.3° F)

abnormal body temperature

increased body temperature

the state in which an individual's CBT is elevated above his/her normal range

severity of fever

• a. low-grade fever a fever between 37.1° C to 38.2° C (98.8° F to 100.6° F)

• b. high-grade fever a fever between 38.3° C to 40.4° C (100.9° F to 104.7° F)

• c. hyperpyrexia a fever over 41° C (105.8° F)

types of fever

• constant fever

• intermittent fever

• remittent fever

• relapsing fever

phases of fever

a. onset (cold or chill) phase

b. course (fever) phase

c. defervescence (flush or crisis) phase

abnormal body temperature

decreased body temperature (hypothermia)

the state in which an individual's body temperature is reduced below normal range

types of hypothermia

a. induced hypothermia

b. accidental hypothermia

clinical signs of hypothermia

• reduction of body temperature below normal range

• increased respirations, poor judgment, shivering• bradycardia or tachycardia, myocardial

irritability/dysrhythmias, muscle rigidity, shivering, lethargy/confusion, decreased coordination

• hypoventilation, generalized rigidity, coma• no apparent vital signs, heart rate unresponsive

to drug therapy, cyanosis, dilated pupils, areflexia, no shivering, appearance of death

common interventions for hypothermia

• a. remove the patient from the cold• b. apply blankets• c. hyperthermia blankets• d. warmed intravenous solutions• e. remove wet clothing and keep dry• f. keep environment warm• g. apply layers of clothing to trap air between

them to act as insulation• h. warm gradually to prevent vasodilation which

can lead to shock

types of thermometers

• mercury-in-glass

a. oral, approximately 3 - 5 minutesb. rectal, approximately 2 - 3 minutesc. axillary, approximately 10 minutes

• digital electronic

• tympanic membrane

types of thermometers

Pulse

• perceptible throbbing sensation (pulsation) felt over a peripheral artery as a wave of blood is created by contraction of the left ventricle of the heart or auscultated over the apex of the heart with a stethoscope

factors influencing the pulse

• a. developmental state

• developmental state• b. gender• c. exercise

• d. fever• e. medications• f. hemorrhage• g. stress• h. position changes

pulse regulation

• regulated by the autonomic nervous system through the sinoatrial node (pacemaker)

parasympathetic nervous system stimulation decreases the heart rate

sympathetic nervous system stimulation increases the heart rate

pulse rate

the number of perceptible throbbing sensations (pulsations) felt over a peripheral artery as a wave of blood is created by contraction of the left ventricle of the heart, or auscultated over the apex of the heart, in one minute

expressed in beats per minute (bpm)

normal pulse rates per minute at various ages

• i. newborn to 1 monthapproximate range =

120 - 160 bpm

• ii. 1 to 12 monthsapproximate range =

80 - 140 bpm

• iii. 12 months to 2 yrsapproximate range =

80 - 130 bpm

• iv. 2 to 6 yearsapproximate range =

75 - 120 bpm

• v. 6 to 12 yearsapproximate range =

75 - 110 bpm

• vi. adolescence to adultapproximate range =

60 - 100 bpm

abnormal pulse rates per minute

Tachycardia

Bradycardia

Character of pulse

• Rate• Rhythm• Strength

methods of assessing the pulse

• PeripheralPalpation

Compressing a peripheral artery against an underlying bone with the tips of the fingers

Do not use the thumb, which has its own pulse

peripheral pulse sites

• i. temporal• ii. carotid• iii. brachial• iv. radial

• v. femoral• vi. popliteal• vii. posterior tibial• viii. dorsalis pedis

methods of assessing the pulse

Doppler ultrasoundassessing the pulse by auscultating a

peripheral pulse using a device (doppler ultrasound) that detects the movement of blood flow through blood vessels and converts the velocity of the blood flow into sounds

• ApicalAuscultation

assessing the pulse by auscultating the apical pulse located in the 5th intercostal space in the left mid-clavicular line (LMCL) in adults using a device (stethoscope) consisting of two earpieces connected by means of flexible tubing to a diaphragm that amplifies sounds

methods of assessing the pulse

Doppler ultrasound

Doppler ultrasoundelectrocardiogram (EKG or ECG)

assessing the apical pulse by recording the electrical activity of the myocardium by using a device (EKG) to detect transmission of the cardiac impulse through conductive tissue of the muscle

Respiration

the mechanism the body uses to exchange gases between the atmosphere and the cells

a. pulmonary ventilationa. inspiration (inhalation)b. expiration (exhalation)

b. external respiration c. internal respiration

factors influencing respiration

• a. developmental state

• b. exercise

• c. stress

• d. increased altitude

• e. medications

• f. increased intracranial pressure

respiratory rate

• a. the number of full inspirations (inhalations) and expirations (exhalations) observed or palpated in one minute

• b. expressed as breaths per minute (bpm)

• c. should be measured when the patient is at rest and unaware that the measurement is being taken

normal respiratory rates ranges per age

• i. newborna. approximate range =

35 - 40 bpm

• ii. infant (6 months)a. approximate range =

30 - 50 bpm

• iii. toddler ( 2 years)a. approximate range =

25 - 32 bpm

• iv. childa. approximate range =

20 - 30 bpm

• v. adolescenta. approximate range =

16 - 19 bpm

• vi. adulta. approximate range =

16 - 20 bpm

abnormal respiratory rates per minute

• i. tachypnea

• ii. bradypnea

• iii. apnea

respiratory volume

• the volume of air exchanged with each full inspiration (inhalation) and expiration (exhalation) (usually 500 mLs)

normal respiratory volume

• consists of a normal respiratory rate and a moderate amount of chest wall movement and volume of air inspired or expired during each full inspiration (inhalation) and expiration (exhalation)

abnormal respiratory volume

• i. hypoventilation a. consists of a decreased

respiratory rate and an decreased amount of chest wall movement and volume of air inspired or expired during each

full inspiration (inhalation) and expiration (exhalation)

• ii. hyperventilation a. consists of an increased

respiratory rate and an increased amount of chest wall movement and volume of air inspired and expired during each

full inspiration (inhalation) and expiration (exhalation)

respiratory rhythm

• the pattern of, and intervals between, each full inspiration (inhalation) and expiration (exhalation)

normal respiratory rhythm

• has a regular pattern of, and intervals between, each full inspiration (inhalation) and expiration (exhalation)

abnormal respiratory rhythm

• have an irregular pattern of, and intervals between, each full inspiration (inhalation) and expiration (exhalation), e.g.:a. Cheyne-Stokes breathingb. Biot's respirations

respiratory ease or effort

• the amount of effort a patient must exert during each full inspiration (inhalation) and expiration (exhalation)

normal respiratory ease or effort

• the patient does not exert a noticeable amount of effort during each full inspiration (inhalation) and expiration (exhalation)

abnormal respiratory ease or effort

• the patient does exert a noticeable effort during each full inspiration (inhalation) and expiration (exhalation), e.g.:a. dyspneab. orthopnea

methods of assessing respirations

• a. inspection of chest wall movement

• b. palpation of chest wall movement

• c. apnea monitor

• d. auscultation

Blood pressure

• force of the blood against the arterial walls

• a. systolic pressure

• b. diastolic pressure

• c. pulse pressure

factors influencing blood pressure

• a. developmental state

• b. gender• c. stress• d. medication• e. diurnal variation

(circadian rhythms)

• f. race• g. exercise• h. body position• i. body weight• j. blood volume

blood pressure regulation

• i. peripheral resistance

• ii. pumping action of the heart (cardiac output)

• iii. blood volume

• iv. viscosity of blood

• v. elasticity of vessel walls

normal blood pressure at various ages

• a. newborn– i. 40 (mean)

• b. 1 month– i. 85/54

• c. 1 year– i. 95/65

• d. 6 years– i. 105/65

• e. 10 - 13 years– i. 110/65

• f. 14 - 17 years– i. 120/75

• g. middle adult– i. 120/80

• h. older adult– i. 140 - 60/80 -90

abnormal blood pressure

• Hypertensionblood pressure elevated above normal for a

sustained period

types of hypertension

• i. primary or essential

• ii. secondary

blood pressure classifications

• i. normal

• ii. pre-hypertension

• iii. hypertension stage 1

• iv. hypertension stage 2

hypotension

• blood pressure decreased below normal for a sustained period

• type of hypotension– orthostatic (postural)

methods of assessing blood pressure

• directly (invasive)– arterial line

• indirectly (non-invasive)– Auscultation– Palpation– doppler ultrasound– electronic indirect

blood pressure meters

errors when assessing blood pressure

• falsely low readings– i. hearing deficit– ii. noise in the environment– iii. applying too wide a cuff– iv. inserting the eartips of the stethoscope incorrectly– v. using cracked or kinked tubing– vi. releasing the valve too rapidly– vii. misplacing the bell beyond the direct area of the

artery– viii. failing to pump the cuff 20 - 30 mm Hg above the

disappearance of the pulse– ix. viewing the meniscus from above eye level

falsely high readings

– i. using a manometer not calibrated at the zero mark

– ii. assessing the blood pressure immediately after exercise

– iii. applying a cuff that is too narrow– iv. releasing the valve too slowly– v. reinflating the bladder during auscultation– vi. viewing the meniscus from below eye level