VITAL SIGNS

- (also refers to as the CARDINAL SIGNS) are body temperature, pulse, respirations, and blood pressure.

the heat produced by the body and the heat lost from the body 2 Kinds: 1. Core temperature- is the temperature of the deep tissues of the body such as the cranium, thorax, abdominal cavity, and pelvic cavity 2. Surface temperature- rises and falls in response to the environment

BODY TEMPERATURE

is the balance between

Age Variations: AGE AVERAGE TEMPERATURE newborn to ----- 36.1 37.7 C 1 year 97.0 100.0 F 2-4 years ----- 37.2 C 98.9 F 6 years to ----- 37.0 C adult 98.6 F elderly (over ----- 36.0 C 70 years) 96.8 F

Factors affecting the bodys heat production

1.

2. 3.

4.

5.

Basal metabolic rate (BMR) the rate of energy utilization in the body required to maintain essential activities such as breathing. Metabolic rate decreases with age. In general, the younger the person, the higher the BMR. Muscular activities including shivering, increases the metabolic rate. Thyroxine output increased thyroxine output increases the rate of cellular metabolism throughout the body. This effect is called chemical thermogenesis. Epinephrine, norepinephrine, and sympathetic stimulation these hormones immediately increase the rate of cellular metabolism in many body tissues, thereby increasing cell metabolism. Fever increases the cellular metabolic rate and thus increases the bodys temperature further.

Heat is lost from the body through:

1.

2. 3. 4.

Radiation transfer of heat from the surface of one object to the surface of another without the contact between the two objects, mostly in the form of infrared rays. Conduction transfer of heat from one molecule to another Convection dispersion of heat by air currents. Vaporization continuous evaporation of moisture from the respiratory tract and from the mucosa of the mouth and from the skin ( insensible heat losscontinuous and unnoticed water loss).

1. 2. 3. 4. 5. 6.

Factors affecting body temperature:

Age Diurnal variations (circadian rhythms) Exercise Hormones Stress Environment

Alterations in body temperature:

o

o o o

Pyrexia/Hyperthermia/Fever a body temperature above the normal range Hyperpyrexia a very high fever Febrile referred to a client who has a fever Afebrile referred to a client who has no fever

4 Common types of fever:

o

Intermittent the body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperatures. Remittent a wide range of temperature fluctuations occurs over the 24 hour period, all of which are above normal. Relapsing fever short febrile periods of a few days are interspersed with period of 1 or 2 days of normal temperature. Constant fever the body temperature fluctuates minimally but always remains above normal.


1. 2. 3. 4. 5. 6. 7. 8.

Clinical signs of hypothermia

Decreased body temperature Severe shivering (initially), feelings of cold and chills Pale, cool, waxy skin Hypotension Decreased urinary output Lack of muscle coordination Disorientation Drowsiness progressing to coma

Clinical signs of fever

Onset (cold or chill stage) 1. Increased heart rate 2. Increased respiratory rate and depth 3. Shivering due to increased skeletal muscle tension and contractions 4. Pallid, cold skin due to vasoconstriction 5. Complaints of feeling cold 6. Cyanotic nail beds due to vasoconstriction 7. Gooseflesh appearance of the skin due to contraction of the arrectores pilorum muscles 8. Cessation of sweating 9. Rise in body temperature

Course 1. Absence of chills 2. Skin that feels warm 3. Feelings of neither hot or cold 4. Increased pulse and respiratory rates 5. Increased thirst 6. Mild to severe dehydration 7. Simple drowsiness, restlessness, or delirium and convulsions due to irritations of the nerve cells 8. Herpetic lesions of the mouth 9. Loss of appetite (if the fever is prolonged) 10. Malaise, weakness, and aching muscle due to protein catabolism Defervescence (fever abatement) 1. Skin that appears flushed and feels warm 2. Sweating 3. Decreased shivering 4. Possible dehydration

Types of thermometers:
A.

Mercury-in-glass thermometers

1. 2. 3. 4.

Long slender tip Short rounded tip Pear-shaped tip Color coded
B. C.

D. E. F.

Disposable thermometers Electronic thermometers- consists of a battery-operated portable electronic unit, a probe that the nurse attaches to the unit, and a probe cover, which is usually disposable Chemical disposable thermometer- comes in a plastic case Temperature-sensitive tape Infrared thermometers

1. 2.

Temperature scales: Celsius = ( Fahrenheit temperature 32) x 5/9 Fahrenheit = ( Celsius temperature x 9/5) + 32

Advantages and disadvantages of four sites for body temperature measurement

Sites
1.

Advantages Most accessible and convenient

-

Disadvantages Mercury-in-glass thermometers can break if bitten, therefore, they are contraindicated for children under 6years and clients who are confused or who have convulsive disorders - Inaccurate if client has just eaten very hot or cold food or fluid or smoked - Inaccurate if client breathes through the mouth, therefore contraindicated for clients who have nasal surgery - Could injure the mouth following oral surgery

Oral

2.

Axillary

Safe and most noninvasive

-

The thermometer must be left in place a long time to obtain an accurate measurement
-

3.

Tympanic membrane

Readily accessible; reflects the core temperature

-

Equipment is expensive. Can be uncomfortable and involves risk of injuring the membrane if the probe is inserted too far.
-

4.

Rectal

Most reliable -Inconvenient and more unpleasant for measurement clients; difficult for client who cannot turn to the side. - Could injure the rectum following rectal surgery -Placement of the thermometer at different sites within the rectum yields different temperatures, yet placement at the same time each time is difficult - A rectal thermometer does not respond to changes in arterial temperatures as quickly as an oral thermometer, a fact that ay be potentially dangerous for febrile clients, because misleading information may be acquired - Presence of stool may interfere with thermometer placement. If the stool is soft, the thermometer may be embedded in stool rather than against the wall of the rectum. If the stool is impacted, the depth of the thermometer insertion may be insufficient. - In newborns and infants, insertion of the rectal thermometers has resulted in ulceration and rectal perforations.
-

Tympanic thermometer / Digital thermometer

Mercury glass thermometer

Mercury bulb

Infrared thermometer

Different types of glass thermometers

Different types of digital / battery-operated thermometers

Tympanic thermometer

Digital thermometers

Temperature - sensitive tape

PULSE

is a wave of blood created by contraction of the left ventricle of the heart. It can be palpated (felt with the fingers) at sites where an artery passes alongside or over a bone, by placing slight pressure on the artery.

Stroke volume output the amount of blood that enters the arteries with each ventricular contractions. Compliance of the arteries the ability of the arteries to contract and expand. Cardiac output the volume of blood pumped into the arteries by the heart. It is the result of the stroke volume (SV) x the heart rate (HR) per minute. Peripheral pulse located in the periphery of the body (ex. foot, hand, neck). Apical pulse central pulse; located at the apex of the heart.

Factors affecting pulse rate: 1. Age generally, as the age increases, pulse rate gradually decreases. 2. Sex after puberty, the average males pulse rate is slightly lower than the females. 3. Exercise pulse rate normally increases with activity. The rate of increase in the professional athlete is often less than the average person because of greater cardiac size, strength, and efficiency. 4. Fever - pulse rate increases in response to the lowered blood pressure that results from peripheral vasodilation associated with elevated body temperature, because of the increased metabolic rate. 5. Medications some medicines decreases, and others increases. Ex digitalis - decreases, epinephrine - increases
6.

Hemorrhage loss of blood from the vascular system normally increases pulse rate. It results in a temporary adjustment of the heart rate as the body compensates for the lost blood volume.

7.

8.

Stress in response to stress, sympathetic stimulation increases the overall activity of the heart. It increases the rate as well as the force of the heart beat. Ex.. Fear and anxiety Position changes when a person assumes a sitting or standing position, blood usually pools in dependent vessels of the venous system. Pooling results in transient decrease in the venous blood return to the heart and a subsequent reduction of blood pressure and increase in heart rate

1.

Pulse sites:
Temporal where the temporal artery passes over the temporal bone of the head. The site is superior (above) and lateral to (away from the midline of) the eye Carotid at the side of the neck below the lobe of the ear, where the carotid artery runs between the trachea and the sternocleidomastoid muscle Brachial at the inner aspect of the biceps muscle of the arm or medially in the antecubital space Femoral where the femoral artery passes through the inguinal ligament

2.

3.

4.

5.

Apical located at the apex of the heart

ADULT located on the left side of the heart, no more than 8cm (3inches) to the left of the sternum (breastbone) and under the 4th, 5th, or 6th intercostal spaces (area between the ribs) FOR A CHILD 7-9 YEARS OLD located between the 4th and 5th intercostal spaces BEFORE 4 YEARS OF AGE at the left of MCL (midclavicular line) BETWEEN 4-6 YEARS at the MCL
6. 7.

8.

9.

Radial where the radial artery runs along the radial bone, on the thumbside of the aspect of the wrist Popliteal where the popliteal artery passes behind the knee. This point is difficult to find but it can be palpated if the client flexes the knee slightly Posterior tibial - on the medial surface of the ankle where the posterior tibial artery passes the medial malleolus Pedal (dorsalis pedis) where the dorsalis pedis artery passes over the bone of the foot. This artery can be palpated by the dorsum (upper surface) of the foot on an imaginary line drawn from the middle of the ankle to the space between the big and second toes

Assessing apical-radial pulse by 2-nurse technique

Popliteal pulse site


1.

Ways to assess the pulse:

By palpation- using the middle 3 fingers for palpating all pulses except the apical pulse By using stethoscope- for assessing apical pulse and fetal heart tone (FHT) By Doppler UTZ stethoscope (DUS)- for pulses that are difficult to assess. DUS headset has earpieces similar to standard stethoscope but it has a long cord attached to a volume-controlled audio unit and an UTZ transducer (battery operated) By using cardiac monitoring machine- indicating the rate on the screen or readout graph (chestleads are attached on different sites of the body)

2.

3.

4.

When assessing the pulse, the nurse collects the following data: rate, rhythm, volume, arterial wall elasticity and presence or absence of bilateral equality. Tachycardia referred to an excessively fast heart rate (ex. Over 100 beats per minute in adult) Bradycardia referred to an excessively slow heart rate (ex. Less than 60 beats per minute in adult)

Pulse rhythm pattern of the beats and the interval between the beats Dysrhythmia/arrhythmia a pulse with irregular rhythm Pulse volume also called as pulse strength or amplitude, refers to the force of blood with each beat Elasticity of the arterial wall reflects its expandability or its deformities Apical Radial pulse = may need to be assessed for clients with certain cardiovascular disorders. Normally, they are identical. An apical pulse rate greater than the radial pulse rate can indicate that the thrust of the blood from the heart is too feeble for the wave to be felt at the peripheral pulse site, or it can indicate that vascular disease is preventing impulses from being transmitted. Any discrepancy should be reported promptly. There is no instance that radial pulse is greater than the apical pulse. Apical-radial pulse can be taken by 2 nurses or 1 nurse but the 2nurse technique may be more accurate.

Stethoscope an instrument use to listen to the sounds produced by the heart, lungs, and other body organs. Use to take apical pulse and blood pressure. Heartbeat normally sounds like lub-dub. Each lub-dub is counted as 1 beat.

1. 2. 3. 4. 5.

Parts of a stethoscope:
Earpieces Binaurals Rubber or plastic tubing Bell diaphragm

Colored stethoscope

Stethoscopes

Binaurals

BP app kit

Stethoscope with animal cover

Variations of pulse rate at rest/min by age Age Newborn 1 year 2 years 4 years 6 years 8-10years 12 years 14 years Average 125 120 110 100 100 90 Male-85 Female-90 Male-80 Female-85 Male-75 Female-80 Male-70 Female-75 Range 70-190 80-160 80-130 80-120 75-115 70-110 65-105 70-110 60-100 65-105 55-95 60-100 50-90 55-95

16 years
18 years and above

Respiration

- the act of breathing; it includes the intake of oxygen and the output of carbon dioxide. External respiration refers to the interchange of oxygen and carbon dioxide between the alveoli of the lungs and the pulmonary blood. Internal respiration takes place throughout the body; the interchange of same gases between the circulating blood and the cells of the body tissues. Inhalation/Inspiration refers to the intake of air into the lungs. Exhalation/Expiration refers to the breathing out or the movement of gases from the lungs to the atmosphere. Ventilation another word that is used to refer to the movement of air in and out of the lungs.


1.

2 types of breathing that nurses observe:

Costal (thoracic) breathing involves the external intercostal muscle and other accessory muscles such as the sternocleidomastoid muscle. Diaphragmatic (abdominal) breathing involves the contraction and relaxation of the diaphragm, observed by the movement of the abdomen, which occurs as a result of the diaphragms contraction and downward movement. Breathing Patterns:

2.

1.

Rate
Eupnea normal respiration that is quiet, rhythmic, and effortless Tachypnea rapid respiration marked by quick, shallow breaths Bradypnea abnormally slow breathing Apnea cessation of breathing

2.

3. 4.

1.

Volume
Hyperventilation an increase in the amount of air in the lungs, characterized by prolonged and deep breaths; may be associated with anxiety

2.

Hypoventilation a reduction in the amount of air in the lungs; characterized by shallow respirations

1.

Rhythm
Cheyne-stroke breathing rhythmic waxing and waning of respirations, from very deep to very shallow breathing and temporary apnea; often with associated with cardiac failure, increased intracranial pressure, or brain damage

1.

Ease of effort
Dyspnea difficult and labored breathing during which the individual has a persistent, unsatisfied need for air and feel distressed Orthopnea ability to breath only in upright sitting or standing positions Breath Sounds:

2.

1.

Audible without amplification

Stridor a shrill, harsh sound heard during inspiration with laryngeal obstruction Stertor snoring or sonorous respiration, usually due to a partial obstruction of the upper airway Wheeze continuous high-pitched musical squeak or whistling sound occurring on expiration and sometimes on inspiration when air moves through a narrowed or partially obstructed airway

2.

3.

4.

Bubbling gurgling sound heard as air passes through most secretions in the respiratory tract

1.

Audible by stethoscope
Crackles (formerly called rales) dry or wet crackling sounds simulated by rolling a lock of air near the ear. Generally heard on inspiration as air moves through accumulated moist secretions. Fine-to-medium crackles occur when air passes through moisture in small air passages and alveoli. Medium-to-coarse crackles occur when air passes through moisture in bronchioles, bronchi, and the trachea. Gurgles (formerly called rhonchi) coarse, dry, wheezy or whistling sound more audible during expiration as the air moves through tenacious mucus or narrowed bronchi Pleural friction rub coarse, leathery, or grating sound produced by the rubbing together of inflamed pleura

2.

3.

1. 2.

Chest movements
Intercostal retraction indrawing between the ribs Substernal retraction indrawing beneath the breastbone Suprasternal retraction indrawing above the clavicle

3.

4.

5.

Tracheal tug indrawing and downward pull of the trachea during inspiration Flail chest the ballooning out of the chest wall through injured rib spaces; results in paradoxical breathing, during which the chest wall balloons on expiration but is depressed or sucked inward on inspiration

1.
2.

Secretions and coughing

Hemoptysis - the presence of blood in the sputum Productive cough a cough accompanied by expectorated secretions Nonproductive cough a dry, harsh cough without secretions
Major Factors Influencing Respiratory Rate Exercise (increases metabolism) increase RR Stress (readies the body for fight or flight) increase RR Environment (increase temperature) increase RR Increased altitude (lower oxygen concentration) increase RR Certain medications (ex. narcotics, analgesic) decrease RR

3.

1. 2.

3. 4.

5.

VARIATIONS IN RESPIRATION BY AGE Age Respiratory Average 15 30 25 20 18 16 Rate/Minute Range 30-80 20-40 20-30 15-25 15-20 12-20

Newborn 1 year 2 years 8 years 16 years Adult

BLOOD PRESSURE
Arterial blood pressure is a measure of the pressure exerted by the blood as it flows through the arteries. It is measured in millimeters of mercury (mmHg) and recorded as a fraction. It is controlled by: 1. The force of hear contractions (resistance) 2. The amount of blood pump with each heartbeat (volume) 3. How easily the blood flow through the blood vessels (viscosity)
2 Blood Pressure measurements as the blood moves in waves: Systolic pressure the pressure of the blood as a result of contraction of the ventricles, that is, the pressure of the height of the blood wave Diastolic pressure the pressure when the ventricles are at rest; it is the lower pressure

Pulse Pressure the difference between the systolic and diastolic pressure

Cardiac output volume of the blood pumped into the arteries by the heart Hypertension persistent measurement above the normal systolic and diastolic pressure (over 140/90) Hypotension abnormally low blood pressure below 100 mmHg systolic Factors Affecting Blood Pressure Age BP increases as person grows older. It is lowest in infancy and childhood and highest in adulthood. BP continuous to increase with aging. Gender women usually have lower BP than men. BP rises in women after menopause. Blood volume (the amount of blood in the system) severe bleeding lowers blood volume, therefore BP lowers. Rapid administration of IV fluids increases the blood volume, therefore the BP rises. Stress includes anxiety, fear, and emotions. HR and BP increases as part of the bodys response to stress.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

Pain generally increases BP. However, severe pain can cause shock. BP is seriously low in the state of shock. Exercise increases HR and BP; so BP should not be measured right after exercise. Weight BP is higher in overweight persons. BP lowers with weight loss. Race black persons generally have higher BP than white persons do. Diet a high-sodium diet increases the amount of water in the body. Extra fluid volume increases BP. Medications drugs can be given to raise or lower BP. Other drugs have side effects of high or low BP. Position BP is lower when lying down and higher in standing position. Sudden changes in position can cause sudden changes in BP (orthostatic hypotension). A person who stands suddenly may have sudden drop in BP. Dizziness and fainting can occur. Alcohol excessive alcohol intake can raise BP.

13.

14.

15.

Smoking increases BP. Nicotine in cigarettes causes blood vessels to narrow. The heart must work harder to pump blood through narrowed vessels. Diurnal variations BP s usually lowest early in the morning, when the metabolic rate is lowest; then rises throughout the day and peaks in the late afternoon or early evening. Disease process any condition affecting the cardiac output, blood viscosity, and/or compliance of the arteries has a direct effect on the BP.

BP equipment:
1.

Sphygmomanometers

Aneroid Mercury Electronic / Digital Cuff Bulb Valve Tube to sphygmomanometer bladder

2.

BP cuff

Aneroid sphygmomano meter

Digital / Electronic BP app

Aneroid sphygmomanometer

Mercurial sphygmomanometer

Cuff

Different bladder sizes

Arm blood pressure

Thigh blood pressure

Doppler probe on the dorsalis pedis

KOROTKOFFS SOUND ( named after Dr. Nikolai Korotkoff, a Russian Physician,1905) the five phases in the series of sounds heard when taking the blood pressure by using a stethoscope.
1.

2.

3.

4.

5.

PHASE 1 The period initiated by the first faint, clear tapping sounds. These sounds become rapidly more intense. To ensure that they are not extraneous sounds, the nurse should identify at least two consecutive tapping sounds. PHASE 2 the period during which the sounds have a swishing quality. PHASE 3 the period during which the sounds are crisper and more intense. PHASE 4 the period during which the sounds become muffled and have a soft, blowing quality. PHASE 5 the point where the sounds disappear.

VARIATIONS IN BLOOD PRESSURE BY AGE

Age Mean BP (mmHg)

Newborn 1 year 2 years 4 years 6 years 8 years 10 years 12 years 14 years 16 years 18 years Adult Elderly (over 70 years)

78/42 96/65 100/63 97/64 98/65 106/70 110/72 116/74 120/76 123/76 126/79 120/80 120/80

SELECTED SOURCES OF ERROR IN BLOOD PRESSURE ASSESSMENT Too narrow bladder cuff erroneously high Too wide bladder cuff erroneously low Arm unsupported erroneously high Insufficient rest before the assessment erroneously high Repeating assessment too quickly erroneously high systolic or low diastolic readings Cuff wrapped too loosely or unevenly erroneously high Deflating cuff too quickly erroneously slow systolic and high diastolic readings Deflating cuff too slowly erroneously high diastolic reading Failure to use the same arm consistently inconsistent measurements Arm above level of the heart erroneously low Assessing immediately after a meal or while client smokes or has pain erroneously high Failure to identify auscultatory gap erroneously low systolic pressure and erroneously low diastolic pressure

GUIDELINES FOR MEASURING BLOOD PRESSURE

1.
2.

3.

4.

5. 6.

7.

Let the person rest for 10-20 minutes before measuring BP. Do not take BP on an arm with an IV infusion, a cast, or a dialysis access site. F a person has had breast surgery, BP is not taken on that side. Also avoid taking BP on an injured arm. Measure BP with the person sitting or lying. Sometimes the doctor orders measurement of BP in the standing position. Apply the cuff on the bare upper arm. Clothing can affect the measurement. Do not apply the cuff over clothing. Make sure the cuff is snug. Loose cuff can cause inaccurate readings. Place the diaphragm of the stethoscope firmly over the artery. The entire diaphragm must be in contact with the skin. Make sure the room is quiet. Talking, TV, radio, and sounds from the hallway can affect an accurate reading.

8. 9.

10.

11.

12.

Have the sphygmomanometer clearly visible. Locate the radial artery, and then inflate the cuff. When you no longer feel the pulse, inflate the cuff another 30mmHg. This prevent cuff inflation to an unnecessarily high pressure which is painful to the person. (You can deflate the cuff at this time and note the point where you feel a pulse. Wait 30seconds and inflate the cuff 30mmHg above the point. Measure the systolic and diastolic pressure. Expect to hear the 1st BP sound at the point where you felt the radial pulse. The 1st sound is the systolic pressure. The point where the sound disappears is the diastolic pressure. Take the BP again if you are not sure of an accurate measurement. Wait 30-60seconds before repeating the measurement. Notify the nurse in charge if you cannot hear the BP.