Assessing Vital Signs

• Assessing vital or cardinal signs is a routine medical procedure.
• Vital signs reflect the body's essential functions, offering significant insights into a client’s well-being.
• These signs are physical indications that a person is alive.
• Vital signs can predict normal body functions.

Purposes of Assessing Vital Signs

• To get baseline data on the patient's condition.
• Aids in diagnostic efforts.
• Contributes to therapeutic strategies.

When to Assess Vital Signs

• Upon a patient's admission.
• When a client's health status changes, such as reports of chest pain, feeling hot, or fainting.
• Before and after surgical or invasive procedures.
• Before and after giving medications that could affect the cardiovascular system.
• Before and after nursing interventions that could change vital signs.

Body Temperature

• Body temperature balances heat production and heat loss.
• Heat is measured in degrees.
• Normal body temperature ranges from 36.1°C (97°F) to 37°C (98.6°F).
• Body heat mainly comes from metabolism.
• The brain's hypothalamus regulates body temperature.

Types of Body Temperature

• Core temperature measures deep tissues such as the cranium, thorax, and pelvic cavity, remaining relatively constant.
• Surface temperature refers to the skin, subcutaneous tissue, and fat, changing concerning the environment.

Factors Affecting Body Temperature

• Infants' body temperature is greatly impacted by the surrounding temperature.
• Elderly individuals face a higher risk of hypothermia because of reduced thermoregulatory control.
• Diurnal variation causes body temperature to change throughout the day, with variations up to 1.0°C between early morning and late afternoon.
• Body temperature normally peaks between 8 PM and midnight and is lowest during sleep between 4 AM and 6 AM.
• Exercise raises BMR which leads to increased temperature, potentially reaching 38.3 to 40°C (101 to 104°F) when measured rectally.
• Hormones affect women, progesterone secretion increases body temperature by 0.3 to 0.6°C (0.5 to 1.0°F) over their baseline when ovulating.
• Stress raises epinephrine and norepinephrine, increasing metabolic activity.
• Environment temperatures affect temperature regulation.

Sites for Taking Temperature

• Temperature can be taken, orally, axillary, rectally, tympanic or on forehead.

Oral Temperature

• Wait 15 minutes after eating hot or cold foods or smoking before measurement.
• Place a thermometer under the tongue, toward the side.
• Wash the thermometer, before use (bulb to stem) and after (stem to bulb).
• Oral temperature require 2-3 minutes.

Oral Temperature Contraindications

• Oral surgery
• Dyspnea
• Cough
• Nausea and vomiting
• Presence of oro-nasal contraception such as a nasal pack, NGT, or ET
• Seizure
• Very young children
• Unconsciousness
• Restlessness, disorientation, or confusion

Axillary Temperature

• The axillary method is safe and non-invasive.
• Pat the armpit dry.
• Put the thermometer in the patient's armpit.
• Position the arm close to the chest, holding the thermometer for 1-2 minutes or until it beeps.

Rectal Temperature

• Rectal measurement is the most accurate.
• Help the client to a lie on their side.
• Use lubrication on the thermometer tip before inserting.
• Put the thermometer 0.5-1.5 inches (1.5-4 cm) into the rectum.
• Instruct to a deep breath during insertion to relax the internal sphincter.
• Do not use force when inserting into a newborn.

Rectal Temperature Contraindications

• Anal or rectal problems like fissures or hemorrhoids
• Post-hemorrhoidectomy
• Diarrhea

Tympanic Temperature

• The tympanic membrane in the ear canal can be used for core body temperature measurement.
• This area has an abundant arterial blood supply from branches of the external carotid artery.

Forehead Temperature

• Forehead chemical thermometers are typically for infants and children when invasive wasn't needed.
• Liquid crystal dots, bars, or heat-sensitive tape indicates temperature with a color change.
• The temp is determined by the highest reading of changed color.

Infrared Thermometers

• Infrared thermometers measure body heat emitted as infrared energy with the tympanic membrane usually source in the ear canal.
• They do not make contact with the tympanic membrane.

Temperature Definitions

• Defining hypothermia is a core body temperature below 35°C.
• Hyperthermia defines an abnormally high body temperature.
• Febrile means having or showing fever symptoms.
• Afebrile means without fever.

Pulse

• A pulse represents a wave of blood from the left ventricle's contraction.
• When the left ventricle contracts, blood enters the arterial circulation and applies slight pressure on the artery, which feels like a pulse wave.
• Peripheral pulses are located away from the heart in areas such as the foot, wrist, or neck.
• The apical pulse is at the heart's apex.

Pulse Sites

• The temporal pulse is where the temporal artery passes over the temporal bone, above and to the side of the eye.
• The carotid pulse is located on the side of the neck, between the trachea and sternocleidomastoid muscle, below the ear lobe.
• The apical pulse can be found at the heart's apex on the left midclavicular line, in the 4th, 5th, or 6th intercostal space.
• The radial pulse is on the thumb side of the inner wrist.
• The femoral pulse is alongside the inguinal ligament.
• The popliteal pulse can be found at the back of the knee.
• The posterior tibial pulse is on the ankle's middle side, behind the medial malleolus.
• The pedal, or dorsalis pedis, pulse is on the foot's dorsum, between the big and second toes.

Assessing the Pulse

• Palpation or auscultation are common methods for pulse assessment.
• Use three middle fingers for palpating pulse sites, except for the apical pulse.
• A stethoscope is used for assessing apical pulse.
• A Doppler ultrasound assists in assessing pulses that are difficult to feel.
• A pulse is typically palpated with three fingers applying moderate pressure.
• Fingertips yield the most accurate pulse detection.
• Assessment includes noting rate and rhythm.

Stethoscope in Assessing Apical Pulse

• The nurse uses a stethoscope to assess apical heart rate.
• Earpieces should be snug and comfortable.
• Binaurals should be angled and strong enough to ensure firm placement without discomfort.
• Tubing should be flexible and 12-18 inches in length.
• Chestpiece can have single or dual tubes.
• Diaphragm transmits high-pitched sounds of air and blood movement.
• Bell transmits low-pitched sounds of blood.

Pulse Terms

• Bradycardia= slow heartbeat, less than 60 bpm in adults.
• Tachycardia= rapid heartbeat, more than 100 bpm in adults.

Respiration

• Respiration is the act of breathing, including oxygen intake and carbon dioxide output.
• External respiration interchanges O2 and CO2 between the alveoli and pulmonary blood, involving O2 absorption and CO2 elimination.
• Internal respiration involves gas exchange between circulating blood and the body's cells.

Types of Breathing

• Costal or thoracic breathing uses the external intercostal and other intercostal muscles, which can be observed by the movement of the chest upward and outward or downward
• Diaphragmatic or abdominal breathing involves the contraction and relaxation of the diaphragm, which can be observed by the movement of the abdomen.

Assessing Respirations

• Rate is measured in breaths per minute, with a normal adult range of 16-20. A normal relationship between Heart Rate and Respiratory Rate is 1RR=4HR.
• Depth varies- normal, deep, or shallow.
• Rhythm refers to the consistency of inhalation and exhalation.
• Quality or character relates to effort and sound.

Blood Pressure

• Blood pressure measures the force of blood moving through arteries.
• Blood pressure is measured in mmHg and presented as a fraction.
• The first sound marks the beginning of ventricular diastole and the closing of the tricuspid and mitral valves.
• The second sound indicates the beginning of ventricular diastole and the closing of the aortic and pulmonic valves.

Respiration Terms

• Bradypnea defines an abnormally slow breathing rate of fewer than 12 breaths per minute in adults.
• Tachypnea identifies abnormally rapid breathing, exceeding 25 breaths per minute in adults.
• Eupnea signifies normal respiration.
• Dyspnea describes shortness of breath, or air hunger, along with difficult breathing.
• Kussmaul breathing is categorized as deep, rapid, and labored breathing.
• Cheyne-Stokes respiration involves periods of fast, shallow breathing followed by slow, heavier breathing and episodes of apnea.
• Apnea is the absence of breathing or respiration.

Factors Affecting Blood Pressure

• Blood pressure increases with age because of decreased elasticity of blood vessels.
• Exercise raises cardiac output, which in turn raises blood pressure.
• Blood pressure increases due to sympathetic nervous system stimulation.
• African-American men and women commonly present with higher blood pressure.
• Obesity elevates blood pressure.
• Women usually experience lower blood pressure than men until menopause.
• Some medications can increase or decrease blood pressure.
• Diurnal variations cause blood pressure to be at its lowest in the morning and highest in the late afternoon or early evening.
• Disease processes, like diabetes mellitus, renal failure, hyperthyroidism, and Cushing's Disease, elevate blood pressure.

Types of Blood Pressure Cuffs

• An adult cuff is indicated for large arm or thigh circumference exceeding 34 cm.
• A forearm cuff with radial palpation is indicated if the upper arm circumference is greater than 50 cm.
• A pediatric cuff width should be 2/3 the length of the upper arm.
• The minimum cuff length should nearly encircle the arm.
• Using smaller cuffs increases pressure, while larger cuffs decrease it. At least two cuff sizes should be available.

Preparation for Measuring Blood Pressure

• Refrain from eating, drinking, smoking, and taking drugs that affect blood pressure one hour before the measurement.
• Do not consume coffee or smoke on the measurement day.
• Empty the bladder, as a full bladder affects readings.
• Schedule blood pressure before painful activities or exercise in the past hour.
• Wait for about 5 minutes of quiet sitting before measuring.
• Take blood pressure in a silent, comfortable room.

Assessing Blood Pressure

• Clients should be rested.
• Wait 30 minutes after smoking or caffeine intake.
• Use a properly sized cuff.
• Position the patient sitting or lying down.
• Position the arm at heart level, palm up.
• The patient's arm is slightly bent at the elbow.
• The sleeve should come up, or the cuff can be placed around the bare arm.
• Palpate for a pulse from the artery coursing in the elbow.
• Put the stethoscope head directly over that artery.
• Inflate the cuff until the pulse is no longer detected.
• Deflate slowly at 2-3 mmHg/second to detect a radial pulse again.
• Listen for bump sounds from the artery.
• Avoid moving the stethoscope head, which obscures Korotkoff.
• Allow the cuff to deflate and venous congestion to resolve before repeating a minute or more later.
• If the blood pressure seems too high or low, repeat at the end of the exam.

Blood Pressure Terms

• Defining hypotension is low blood pressure below 90/60 mmHg.
• Hypertension defines high blood pressure.

Oxygen Saturation

• Measuring oxygen saturation gives vital insight into possible cardiopulmonary problems.
• Normal level is 95–100%.