Assessing Vital Signs

• Vital signs serve as basic indicators of an individual's overall health status

Factors Influencing Vital Signs

• Vital sign measurements can be affected by factors such as different times of day, age, ovulation state, seasons, physical activity, dressing type, environmental heat, stress, and disease.

Guidelines for Assessing Vital Signs

• Nurses must know how to obtain vital sign readings, evaluate them, and communicate them effectively to the healthcare team
• Ensure equipment used is reliable
• Select equipment based on patient condition and characteristics
• Knowledge of normal vital sign values is essential
• Patient's medical history, treatments, and medications should be considered
• Take environmental factors into account during assessment
• Measure vital signs methodically at consistent intervals
• Nurses should communicate effectively with patients while measuring vital signs
• Nurses should collaborate with the physician
• Vital signs should be thoroughly analyzed once measured

Frequency of Vital Sign Measurement

• When admitting a patient
• Before and after surgical procedures, with increased frequency
• Before and after diagnostic procedures
• Before and after administering medications that affect the heart and respiratory system
• When a patient's condition suddenly deteriorates
• Before and after medical interventions that may impact life signs
• When a patient reports feeling different or unwell

Body Temperature

• Serves as a basic indicator of a person's health
• Core body temperature reflects the balance between heat production and heat loss
• Body temperature should be consistent and balanced
• Heat production must equal heat consumption in the body
• Heat is produced in the body by food
• Heat loss occurs through the lungs via breathing, the skin via sweating, and the elimination of bodily wastes like urine, feces, vomit, and blood.

Factors Influencing Body Temperature

• Age, exercise, hormone levels and stress
• Environmental conditions and emotional state
• Basal metabolic rate and digestion of food
• Nutrition and sleep
• Illness
• The sympathetic nervous system affects temperature via adrenaline and noradrenaline

Regulation of Body Temperature

• The hypothalamus is the thermoregulation center and acts as a thermostat
• Vasodilation assists decreases in heat
• Sweating assists decreases in heat
• Muscle tremors generate heat
• Piloerection helps to generate heat

Temperature Changes

• Hypothermia is a body temperature at or below 35°C
• Hyperthermia is a body temperature above 38°C

Normal Body Temperature Values and Measurement Sites

• Oral: Minimal 36.5°C, Maximal 37.5°C, Average 37°C
• Ear: Minimal 36.5°C, Maximal 37.5°C, Average 37°C
• Axillary/Forehead: Minimal 36°C, Maximal 37°C, Average 36.5°C
• Rectal: Minimal 37°C, Maximal 38°C, Average 37.5°C

Types of Thermometers

• Glass thermometers containing mercury are forbidden by Ministry of Health in 2009, because mercury is toxic
• Use a thermometer with disposable part

Measuring Body Temperature

• Prepare the materials needed
• Wash hands and wear gloves if required
• Give the patient information about the process
• Ensure comfortable and patient permission is granted

Oral Measurement

• Place thermometer on the right or left under the tongue
• Average range: 36.5 °C - 37.5 °C
• Dispose of plastic sheath
• Do not use in patients with dyspnea, children, elderly, and patients with either psychiatric diseases, is non-conscious, after surgery, and/or with mouth infections, or with continuous oxygen
• Use a personal thermometer and avoid drinking or eating hot or cold food prior to measurement

Tympanic Measurement

• Made within 1-2 seconds
• Place receiver in the 1/3 of the outer ear
• Use a disposable plastic cover over the receiver

Rectal Measurement

• Applied when heat cannot be measured orally or via the axillary route
• Temperature range is 37 °C - 38 °C
• Ensure the room door and curtains are closed
• Place the patient in the Sims' position and flex the upper leg
• Apply lubricant to the probe, separate the patient's hips with your hand, and ask the patient to breathe deeply
• The degree gets advanced 2.5-3.5cm in adults, 2-2.5cm in children, and/or 1.2cm in newborns
• Removed when signal occurs
• Not used in patients with rectal bleeding, rectum surgeries, birth, in the period of maternity, and/or with diarrhea

Axillary/Forehead Measurement

• The axillary region is the most commonly used region for measurement
• Ensure the armpit is sweat-free

Pulse

• Pulse shows number of heartbeats per minute
• Assess pulse absolutely, plus volume, pulse rate and and rhythm are key components for diagnosis
• Count pulse to assist with decisions about rate, rhythm and and contraction of heart
• Identifies peripheral vascular diseases

Pulse Rates

• Newborn:120-160/min
• Children : 80-120/min
• Adult: 60-100/min
• Bradycardia indicates pulse rate below 60 beats per minute
• Tachycardia indicates pulse rate above 100 beats per minute

Factors Influencing Pulse Rate

• Exercise and Hyperthermia
• Hypothermia and acute pain and anxiety
• Chronic pain and drug use
• Race and gender

Pulse Rhythm

• Regular rhythm defined as heart beat being regular
• Irregular rhythm defined as arrhythmia
• Pulse deficit, the difference between apical and peripheral pulse rates signals an arrhythmia
• During a pulse deficit, the heart contracts but the pulse is not reaching periphery with the radial being lower than the apical

Pulse Volume

• The pulse volume, the fullness of the pulse, and the left ventricular contraction
• If palpated, its full or bounding
• Weak pulse indicates the pulse is difficult to palpate and disappears easily
• Weak pulse, also called filiform or thready pulse, occurs with bleeding, shock and/or heart failure
• Indicates pulse rate is over 130 per minute

Pulse Points

• Temporal and carotid
• Apical and brachial
• Radial and ulnar
• Femoral and popliteal
• Dorsalis pedis and posterior tibial
• Used brachial/femoral pulse points for 0-1 year olds
• Use carotid artery for 1 year olds

Peripheral Pulse Takings

• Hands are washed
• Authentication is conducted and patient is notified about procedure
• Patient is rested (not standing), and position is confirmed
• Three fingers will be placed on patients artery without excessive pressure for 1 minute
• If pulse is measured and irregular for first time, pulse is measured for 1 minute. If pulse is regular first rate is counted at 30 sec then multiplied by 2 to find the average rate
• Findings then recorded

Respiration

• Respiration involves of the organism taking in and using O2 and releasing CO2
• Includes external respiration which occurs in the lungs,
• Includes internal respiration which occurs between the blood and cells
• Consists of ventilation, diffusion, and perfusion

Regulation

• Respiration is regulated by breathing.

• The medulla oblongata and pons in the brainstem, the respiratory center,

• Respiratory measurements consist of rate, depth and type

Respiratory Rates

• The respiratory rate shows number of breaths a minute
• Newborn rates show 30-60/min
• Adult rates show 12-20/min
• Respiratory depth is assessed as deep, superficial, and normal
• The diaphragm increases by 1 cm in normal breathing
• The costa extend 1.5-2.5 cm forward

Respiratory Types

• Normal Breathing (eupnea)

• Bradypnea (slow)

• Tachypnea (fast)

• Kussmaul’s (abnormally deep)

• Biot's (irregular)

• Cheyne-Stokes (grad increase in depth of respirations)

• Apnea (absence of breathing)

• Hyperventilation (increased rate and depth of breathing)

• Hypoventilation (decreased rate and depth of breathing is irregular),

• Anoxia (absence of oxygen)

• Hypoxia (Cells and tissues cannot get enough oxygen)

• Dyspnea (difficult breathing)

• Cyanosis (bluish or purplish discolorization)

• Defined by lips, ear lobes nails and oral mucosa low oxygen saturation

• Assess respiratory rate after taking someones pulse

• Done by chest rising and falling for ONE minute

• Tell the patient before

• Involves evaluating position, and breathing

• Can check respirations for 30sec then multiplying that number by 2

Oxygen Saturation

• Pulse oximetry helps with assessing oxygen saturation in a patients' blood.
• Involves a finger probe and is noninvasive
• Normal rates are between 95-100, if under 90, the rates are considered low
• This assesses titreşmen

Blood Pressure

• Blood pressure reflects the force of the blood exerting force around the body
• Systolic pressure occurs as blood get transported into the veins
• Diastolic pressure occurs as blood rests
• Normal ideal pressure is 90/60mmHg and 120/80mmHg
• High pressure is considered as 140/90mmHg
• Low pressure was 90/60 mmHg or lower
• Pulse pressure calculated when subtracting systolic from dialostic blood pressure

Factors Affecting Blood Pressure

• Factors include age,gender, stress and diet

Blood Pressure

• Hypertension: limit value in adults stated by WHO as 140/90mmHg
• Hypotension: arterial blood pressure below value

How to take Blood Pressure

• Use sphygmomanometer, stethoscope and disinfectant.
• Patients should also be in position and have patients arm flex
• Position cuffs and align pointers at zero.
• Should also palpate brachial artery and rapidly inflate cuff to 200-250 mmHg, then listen and document
• If this is a first time reading, do some on both, if in different arms, wait 2 mins
• Clean hands and inform the patient about what you will be doing before starting
• Common errors are the position of feet, not resting, talking during reading
• Patient's arms should be flexed