Metro Community College

Nursing Program
Nancy Pares, RN, MSN

Objective data that contributes to all other

nursing and medical information
Baseline values establish the norm against
which subsequent measures are compared
Accurate information is essential
Information must be obtained and recorded
accurately.

One of the most frequent assessments made

as a nurse
Nurse is
Responsible for measuring, interpreting
significance and making decisions about care
Knowing normal ranges
Knowing history and other therapies that may affect
VS

Nurse must
Know environmental factors that affect vital signs
Exercise, stress, etc.

Use a systematic, organized approach

Verify and communicate changes in vital signs
Monitor VS regularly
Frequency determined by
MD order; nursing judgement, client condition and
facility standards

Hospital:
Every 4-8 hours

Home health:
each visit

Clinic:
Each visit

Skilled facility
Daily and as needed

Degree of heat maintained by the body

Heat produced minus heat lost equals body
temperature
Organs have receptors that monitor core
body temperature

Core temperature
Normal
96.2 degrees F to 100.4 degrees F
36.2 degrees C to 38 degrees C

Surface temperature
Lower than core temperature
Use oral and axillary method

Neural control
Hypothalmus acts as thermostat

Vascular control
Vasoconstriction ---hypothalmus directs the body
to decrease heat loss and increase heat production
If cold, vasoconstriction will conserve heat
shivering will occur

Vasodilation
If body temp is above normal, the hypothalmus will
direct the body to decrease heat production;
Perspiration and increased respiratory rate

Body heat production

Bodys cells produce heat from foodreleasing
energy.
Kilocalorie= energy value;
BMR= rate of energy used in the body to maintain
essential activities

If metabolism increases, more heat is

produced
More muscle= greater metabolism
Shivering is an early response for
thermoregulation that increases heat
production.

Conduction
Transfer of heat from a warm to cool surface by
direct contact

Convection
Transfer of heat through currents of air or water

Radiation
Loss of heat through electromagnetic waves from
surfaces that are warmer than the surrounding air

Evaporation
Water to vapor lost from skin or breathing

Age
Exercise
Hormones
Circadian cycle
Stress
Ingestion of food
smoking

Fever (pyrexia)
Abnormally high body temperature (>100.4 F)
Occurs in response to pyrogens (bacteria)
Pyrogens induce secretion of prostoglandins that
reset the hypothalmic thermostat to a higher
temperature

Hyperpyrexia
Fever > 105.8

Temp increases:
Immune system stimulates hypothalmus to new set
point
Chills, shivers
Feels cold even though temp increasing
When body temp is reset, chills subside

Metabolism increases
O2 consumption increases
HR and RR increase
Energy stores are used
Dehydration and confusion
When cause is removed, set point drops

Vasodilation
Warm flushed skin and diaphoresis

Benefits

Activates the immune system

Interleukin 1 stimulates antibody production
Fights viruses by stimulating interleukin
Serves as a diagnostic tool

Chill stage:
Temp every 1-4 hours
Reduce activity
Warm blankets

Throughout course
Fluids, tepid baths, limit activity, keep dry
Provide oral hygiene
Provide air circulation

Heat stroke

Prolonged exposure to heat

Depression of hypothalmus
Emergency
S/S: hot, dry skin, confusion, delirium

Hypothermia
Below 95 degrees
Uncontrolled shivering, loss of memory,LOC
decreases

Limits: 77-109 degrees F

Oral
Most accessible and accurate
Do not use if unconscious, confused recent oral or
facial OR

Rectal
99 F
Avoid with MI and after lower GI

Axillary
97 Fleast accurate, most safe

Tympanic
98 Favoid with infection, after exercise, w
hearing aid

The wave begins when the left ventricle

contracts and ends when the ventricle relaxes
Indirect measure of cardiac output

Each contraction forces blood into the already

filled aorta, causing increased pressure within
the arterial system
Systole:
Peak of the wave; contraction of the heart

Diastole
Resting phase of the heart

Rate
Measured in beats per minute (bpm)
Normal
60-100 bpm
Females slightly higher

Average
70-80 bpm

Apical is most accurate

Use a standard stethescope to auscultate the
number of heartbeats at the apex of the heart
A heartbeat is one series of the LUB and DUB
sounds

Apical: at the apex of the heart

Carotid: between midline and side of neck
Brachial: medially in the antecubital space
Radial: laterally on the anterior wrist
Femoral: in the groin fold
Popliteal: behind the knee
Post tibial
Dorsalis pedis
ulnar

Bradycardia: rate < 60 bpm

Tachycardia: rate> 100 bpm
Is the rate regular?
What is the quality?
Bounding?
Thready?

Dysrhythmia (arrhythmia)
Pulse deficit

Difference between radial and apical

Exercise
Body temperature
Anxiety
position

Emotions
Medications
Hemorrhage
Pulmonary
condition

Stroke volume
The quantity of blood pumped out by each
contraction of the left ventricle

Cardiac output
Stroke volume x pulse (heart) rate

Pallor
Paleness of skin when compared with another part
of the body

Cyanosis
Bluish-grayish discoloration of the skin due to
excessive carbon dioxide and deficient oxygen in
the blood

The exchange of oxygen and carbon dioxide

in the body
Two separate process
Mechanical
chemical

Mechanical
Pulmonary ventilation; breathing
Ventilation:
Active movement of air in and out of the respiratory
system

Conduction
Movement through the airways of the lung

Chemical
Exchange of oxygen and carbon dioxide
Diffusion
Movement of oxygen and CO2 between alveoli and RBC

Perfusion
Distribution of blood through the pulmonary
capillaries

Inspiration
Drawing air into the lung
Involves the ribs, diaphragm
Creates negative pressure-allows air into lung

Expiration
Relaxation of the thoracic muscles and diaphragm
causing air to be expelled

Rate: regulated by blood levels of O2, CO2

and ph
Chemial receptors detect changes and signal
CNS (medulla)

Normal: 12-20 breaths per minute

Apnea: no breathing
Bradypnea: abnormally slow
Tachypnea: abnormally fast
Observe for one full minute

Depth
Normal: diaphragm moves inch
Deep
Shallow

Rhythm
Assessment of the pattern
Abnormal
Cheyne stokes, Kusmaul,

Effort

Work of breathing
Dypsnea: labored breathing
Orthopnea: inability to breath when horizontal
Observe for retractions, nasal flaring and
restlessness

Wheeze

High pitched continuous musical sound; heard on

expiration

Rhonchi

Low pitched continuous sounds caused by

secretions in large airways

Crackles

Discontinuous sounds heard on inspiration; high

pitched popping or low pitched bubbling

Stridor
Piercing, high pitched sound heard during
inspiration

Stertor
Labored breathing that produces a snoring sound

Hyperventilation
Rapid and deep breathing resulting in loss of CO2
(hypocapnea); light headed and tingly

Hypoventilation
Rate and depth decreased; CO2 is retained

Cheyne Stokes
Irregular, alternating periods of apnea and
hyperventilation

ABG
directly measures the partial pressures of
oxygen, carbon dioxide and blood ph
normal= paCO2 80-100)
Pulse oximetry
non invasive method for monitoring
respiratory status; measures O2 saturation
normal= >95%

Force exerted by blood against arterial walls

Work of the heart reflected in periphery via BP
Systolic
Peak pressure exerted against arterial walls as the
ventricles contract and eject blood

Diastolic

Minimum pressure exerted against arterial walls

between contraction when the heart is at rest

Measured in millimeters of mercury (mm Hg)

Recorded as systolic over diastolic
Pulse pressure
Difference between systolic and diastolic

The body constantly adjusts arterial pressure

to supply blood to body tissues
Influenced by three factors
Cardiac function
Peripheral vascular resistance
Blood volume

Normal = 5000 ml
Volume increases=BP increases
Volume decreases= BP decreases
Viscosity= reaction same as volume

Elasticity
Less elasticity creates greater resistance to blood
flow= > systolic BP
Decreased in smokers and increased cholesterol

Palpation
Used when BP is too weak to hear

Errors
Wrong size cuff, deflating too rapidly, incorrect
placement

Thigh
Measures 30-40 mm HG less than normal

Age
Stress
Gender
race

Circadian
Medications
nutrition

Values

Normal: < 120/80 mm Hg

Hypotension: < 100mm HG
Pre hypertension: > 120/80 mm Hg
Hypertension: 140/90= Stage 1; 160/100= Stage 2

Persistant increase in BP
Damage to vessels; loss of elasticity; decrease in
blood flow to vital organs

Indirect

Most common, accurate estimate

Direct

In patient setting only

Catheter is threaded into an artery under sterile
conditions
Attached to tubing that is connected to monitoring
system
Displayed as waveform on monitoring screen

Indirect
Equipment
Sphygomanometer and stethescope

Korotkoffs sounds

1st
2nd
3rd
4th
5th

1st

2nd

As you deflate the cuff; occurs during systole

Further deflation of the cuff; soft swishing sound

3rd

4th

5th

Begins midway through; sharp tapping sound

Similar to 3rd sound but fading

Silence, corresponding with diastole

Orthostatic or postural hypotension

Sudden drop in BP on moving from lying to sitting
or standing position

Primary or essential hypertension

Diagnosed when no known cause for increase
Accounts for at least 90% of all cases of
hypertension

Combination of skills which provide an

indication of state of health and body
functionality
Nurses can delegate the activity of VS, but are
responsible for interpretation, trending and
decisions based on the findings

5th vital sign

It is what the client says it is
Nurse must know
how to assess for it
Establish acceptable comfort levels
Follow up within appropriate time frame after
intervention

Data collection
Location (place and position)
Intensity
1-10
Strength and severity
What is your pain at present? What makes it worse? What is
the best that it gets?

Describe
Aching, stabbing, tender, tiring, numb,..

Duration
When did it start? Is is always there?

Aggrevate/alleviate
What makes it better/worse?

Energy
Appetite
Sleep
Activity
Mood
Relationships
Memory
concentration

Nurse checks for

VS
Knowledge of pain
Med history
Side effects of meds
Use of non
pharmacological
therapies