Measuring Vital Signs

Measuring Vital Signs

• Vital signs reflect three essential body processes: regulation of body temperature, breathing, and heart function.
• The four vital signs are temperature, pulse, respirations, and blood pressure.
• Pain is sometimes considered the "5th vital sign".

Measuring and Reporting Guidelines

• Vital signs are assessed to detect changes in normal body function, inform treatment response, signal life-threatening events, and as part of the nursing process.
• Factors affecting vital signs include activity, age, anger, anxiety, drugs, eating, exercise, fear, illness, noise, pain, sleep, smoking, stress, and weight.
• Vital signs are measured during physical exams, upon admission to a healthcare agency, as condition requires, and before/after surgery or diagnostic tests.
• Monitoring also occurs after care measures like ambulation, falls/injuries, when medications affect respiratory or circulatory systems, and if one complains of pain, dizziness, or rapid heart rate.
• Vital signs should show even minor changes in a person’s condition.
• Accuracy is essential when measuring, recording, and reporting vital signs.
• If unsure of a measurement, retake it and consult with the nurse.
• Vital signs are recorded in a person's medical record, and are used by medical personnel to adjust current or future care.
• Vital signs should be assessed when at rest.
• Report any vital sign that changes from a prior measurement or is above/below the normal range immediately.

Body Temperature

• Body temperature reflects the balance between heat produced and heat lost by the body.
• Thermometers are used to measure temperature using Fahrenheit (F) or centigrade (C) scales.
• Temperature can be measured at the mouth, rectum, axilla (underarm), tympanic membrane (ear), and temporal artery (forehead).
• Each measurement site has its own normal range.
• Report temperatures above or below the normal range immediately.
• Fever means an elevated body temperature.
• Body temperature is lower in the morning and higher in the afternoon/evening.
• Body temperature is affected by pregnancy and the menstrual cycle.

Types of Thermometers

• Standard electronic thermometers are used today.
• Tympanic membrane thermometers measure temperature in 1-3 seconds.
  • They reduce the risk of spreading infection.
  • Hearing aids and hair can impact accuracy.
• Temporal artery thermometers measure temperature in 3-4 seconds.
  • They measure the temperature of the blood in the temporal artery.
• Glass thermometers are color-coded: blue for oral/axillary and red for rectal use.
• Glass thermometers are problematic due to:
  • Requiring a long time to register (3-10 minutes).
  • The risk of breaking, which can cause mercury poisoning.

Pulse

• A pulse is felt each time the heart beats.
• It is the beat of the heart felt at an artery as a wave of blood passes through.
• Radial pulse is used most often.
• Carotid pulse is taken during CPR and other emergencies.
• The pulse sites include temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis (pedal) arteries.
• The apical pulse is felt over the heart and is taken with a stethoscope.
• A stethoscope is an instrument used to listen to sounds produced by the heart, lungs, and other body organs.
• Stethoscopes are used to take apical pulses and blood pressures.
• To use a stethoscope:
  • Wipe earpieces and diaphragm with antiseptic wipes before and after use.
  • Place the earpiece tips in your ears snugly to block out noises, and the diaphragm firmly over the pulse site.
  • Tap the diaphragm gently to use, and prevent noise which can cause pain or discomfort.
• The pulse rate is the number of heartbeats or pulses felt in 1 minute, and varies for each age group.
• The adult pulse range is typically 60-100 beats per minute.
  • Report abnormal pulses to the nurse at once.
  • Tachycardia is a heart rate of more than 100 beats per minute.
  • Bradycardia is a heart rate of less than 60 beats per minute.
• Pulse rhythm should be regular, and felt in a pattern with the same interval between beats.
• An irregular pulse occurs when the beats are not evenly spaced or beats are skipped.
• Force relates to pulse strength.
  • A forceful pulse is described as strong, full, or bounding.
  • Hard-to-feel pulses are described as weak, thready, or feeble.
• Electronic blood pressure equipment can also count pulses, show if the pulse is regular or irregular, but cannot determine a pulse by force.
• Radial pulses are used in routine vital signs.
  • Count and record the pulse accurately for 1 full minute.

Apical Pulse

• The apical pulse is on the left side of the chest slightly below the nipple.
• It is taken with a stethoscope.
• The apical pulse should be counted for a full minute.
• Each lub-dub is counted as one beat.
• Apical pulses are taken on patients who:
  • Have heart disease or irregular heart rhythms.
  • Are taking medications that affect the heart or are pediatric patients under the age of two.

Apical-Radial Pulse Measurements

• In a healthy patient, the apical and radial pulse rates should be the same.
• To assess their equality, two staff members are needed, with one taking the radial pulse and the other taking the apical pulse simultaneously.
• Apical-radial pulse is called "radial pulse".
• Pulse deficit: the difference between the apical and radial pulse rates.
• Obtained by subtracting the radial rate form the apical rate.

Pedal Pulses

• The pedal (dorsalis pedis) pulse is used to check circulation in the foot.
• If the pedal Pulse cannot be felt you can use Doppler ultrasound stethoscope (DUS).
• Those using DUS should:
  • Recieve the necessary training.
  • Be guided by the nurse's directions. -Follow the manufacturer's instructions.

Respirations

• Respiration means breathing air in (inhalation/inspiration) and air out (exhalation/expiration) of the lungs.
• During respiration:
  • Oxygen enters the lungs during inhalation.
  • Carbon dioxide leaves the lungs during exhalation.
• Each respiration involves one inhalation and one exhalation.
• Chest movement during breathing:
  • The chest rises during inhalation.
  • The chest falls during exhalation.
• The healthy adult respiration range 12 to 20 respirations per minute.
• Normal respirations: quiet, effortless, and regular.
• Heart and respiratory diseases often increase the respiratory rate.
• Count respirations when the person is at rest, and position the subject so you can see the chest rise and fall.
• Both sides of the chest should rise and fall equally.
• The person should not know that you are counting their respirations.
• Count respiration right after taking the pulse, and keep your fingers or stethoscope over pulse site.
• To count respiration, watch the chest rise and fall.

Blood Pressure

• Blood pressure (BP) is the amount of force exerted against the walls of an artery by the blood.
• Blood pressure is controlled by the force of heart contractions, the amount of blood pumped with each heartbeat, and how easily blood flows through the blood vessels.
• Systole is the period of heart muscle contraction.
• Diastole in the period of heart muscle relaxation.
• Systolic pressure is the pressure in the arteries when the heart contracts.
• Diastolic pressure is the pressure in the arteries when the heart is at rest.
• Blood pressure is measured in millimeters (mm) of mercury (Hg).
• Systolic pressure is recorded over the diastolic pressure.
• Normal ranges:
  • Systolic pressure-90 mm Hg or higher, but lower than 120 mm Hg.
  • Diastolic pressure-60 mm Hg or higher, but lower than 80 mm Hg.
• Treatment is indicated for:
  • Hypertension-When the systolic blood pressure is 140 mm Hg or higher (hyper) or the diastolic blood pressure is 90 mm hg or higher.
  • Hypotension-Systolic blood pressure is below (hypo) 90 mm Hg or the diastolic blood pressure is below 60 mm Hg.
• Report any systolic measurement at or above 120 mm Hg.
• Report any diastolic pressure at or above 80 mm Hg.
• Report any systolic pressure below 90 mm Hg. Reporting
• Report a diastolic pressure below 60 mm Hg.
• A stethoscope and a sphygmomanometer are used to measure blood pressure.
• Sphygmomanometers have a cuff and a measuring device.
• Types of sphygmomanometers include Aneroid type, mercury type, electronic type and wrist monitor.
• Blood pressure is normally measured in the brachial artery.

Measuring BP Best Practices

• Do NOT take BP on an arm: * With IV infusion * Cast * With dialysis access site * On the side of breast surgery * That is injured
• Let the person rest 10-20 minutes.
• Apply the cuff to the bare upper arm.
• Make sure cuff is snug and of an appropriate size.
• Make sure the room is quiet.
• Place the entire diaphragm of the stethoscope firmly over the brachial artery.
• Tighten are-release.
• Pump the inflation build to 180mhg.
• Slowly release air-release and listen.
• Measure the systolic and diastolic pressures, the first sound signals systolic, and the last sign signals diastolic

Orthostatic Hypotension

• Abnormally low (hypo) blood pressure upon standing up or sitting down.
• When moving change BP can drop.
• Symptoms can be dizziness, weakness, seeing spots, and syncope (fainting).
• Take patients BP in supine position.
• Then take their BP sitting down to measure again, assist them to stand to check again.
• Prevention is to change positions SLOWLY.
• Report B/P in lying, sitting, and standing positions along with symptoms.

Height and Weight

• People needing monitoring are weighed Daily, Weekly or Monthly.
• Scales include standing, chair, wheelchair, bed, and lift.
• Follow the correct procedure
  • The person wears only a gown or pajamas.
  • The person voids before being weighed.
  • A dry incontinence product is worn (if applicable).
  • Weigh the person at the same time of day, usually in the morning before breakfast
  • Use the same scale for daily, weekly, and monthly weights.
  • Balance the scale at zero (0) before weighing the person

Promoting Leg Circulation

• Circulation must be stimulated for blood flow in the legs to prevent blood clots.
• If blood flow is sluggish, blood clots may form.
• Blood clots (thrombus) can break loose and travel through the bloodstream
• An Embolus is a blood clot that travels through the vascular system until it lodges in a blood vessel.
• Pulmonary embolism is caused by an embolus lodging in the lungs, resulting in the event of severe respiratory problems and possibly death
• Elastic Stockings, Anti-embolism, TED (thrombo-embolic disease) hose will promote venous blood return to the heart.
• This will in turn prevent blood clots (thrombi, DVT) occur.