Nursing: Vital Signs

• Vital signs are fundamental indicators of an individual's overall health.
• Mastery of nursing practices related to vital signs is essential.
• Accurately identifying vital signs is crucial.
• Knowledge and assessment of normal vital sign ranges are necessary.
• Proficiency in measuring vital signs is key.
• Key vital signs include body temperature, pulse, respiration, oxygen saturation, and blood pressure.
• Vital signs provide essential information about a patient's condition.
• Changes in vital signs can be influenced by time of day, age, ovulation state, seasons, physical activity, clothing, environmental heat, stress, and disease.
• Nurses should know how to obtain and interpret vital signs, and how to communicate findings to other team members.
• Reliable equipment is a must for accurate vital sign assessment.
• The selection of equipment depends on the patient's condition and characteristics.
• Knowing normal vital sign values is essential for identifying abnormalities.
• A patient's medical history, treatments, and medications should be considered during vital sign assessment.
• Environmental factors can impact vital signs and should be taken into account.
• Vital signs must be measured systematically at regular intervals.
• Nurses must communicate effectively with patients during the measurement process.
• Nurses need to work together with physicians when conducting vital sign measurements.
• Measured vital signs require absolute, precise, and systematic analysis.
• Vital signs should be recorded upon patient admission.
• Vital sign measurement frequency increases before and after surgery.
• Vital signs are taken before and after diagnostic procedures.
• The administration of drugs that impact the heart and respiratory system requires vital sign monitoring.
• Sudden deterioration in a patient's condition needs vital sign assessment.
• Vital signs should be monitored before and after medical interventions that may affect life signs.
• A patient's feeling of a difference warrants vital sign assessment.

Body Temperature

• Thermoregulation depends on the balance between heat production and heat loss.
• Body temperature should be consistent and balanced.
• Body temperature balances the heat produced and the heat consumed.
• Heat production must equal heat consumption in the body.
• The human body generates heat through food metabolism.
• Heat loss happens through the lungs via breathing, the skin via sweating, and wastes including excrement, and blood.
• Factors influencing body temperature includes age, exercise, hormone levels, stress, environment, emotional states, Basal Metabolic Rate, digestion, nutrition and sleep, diseases, and the sympathetic nervous system.
• The hypothalamus is the body's thermoregulation center and acts as a thermostat.
• Vasodilation helps the human body to decrease heat.
• Sweating is a method of thermoregulation.
• Muscle tremors produce heat generation.
• Piloerection, the raising of body hairs, is a thermoregulation method.
• Hypothermia involves a body temperature of 35 °C and below.
• Hyperthermia involves a body temperature above 38 °C.
• Oral measurements typically range from 36.5 °C to 37.5 °C.
• Ear measurements typically range from 36.5 °C to 37.5 °C.
• Axillary measurements typically range from 36 °C to 37 °C and are the most common measurement site.
• Forehead measurements are a possible body temperature site.
• Rectal measurements typically range from 37°C to 38°C, and are not to be routinely used.
• Mercury, a dangerous toxin, led to glass thermometers being forbidden by the Ministry of Health in 2009.
• Before application of taking temperature, materials should be assembled, hands washed, gloves worn if needed, explanation is given to a patient, their comfort is ensured and permission is obtained.
• Oral measurement occurs on either side of the tongue, with an average range of 36,5 °C - 367,5 °C

Oral Measurements

• There are key points to remember when taking temperature orally.
• The subject should have a personal thermometer.
• Consuming hot or cold contents alters the reading.
• Advise patients not to eat or drink anything before measurement.
• There should be thermometer placement under the tongue.
• The mouth should be closed at the time, in which the teeth shouldn't be squeezed.
• Degrees should be position on either the left or right underneath the tongue.

Tympanic Measurements

• The measurement must exist between 1-2 seconds.
• The receiver must be located in the 1/3 of the outer ear.
• A disposable plastic cover should be placed over the reciever.

Rectal Measurements

• Rectal Measurements shall be reserved and only taken when the is no oral or auxillary alternative.
• It's not routinely used.
• Close all blinds and curtains.
• Apply a water-soluble lubricant to the tip.
• Seperate the patient's legs with your hand.
• Instruct the patient to attempt to breath slow and freely.
• When it beeps, take out the probe
• If the rectal approach must be taken, consider this: 2.5-3.5 cm in adult, 2-2.5 cm in children, in newborn, 1.2 cm.
• The device shouldn't perform on rectal bleeding cases, rectum surgeries, birth, maternity cases continuously on childrean or diarrhea
• A temperature-reading application requires: a closed door and curtains.
• A patient should be in sim's position with the upper leg flexed.
• Gloves should be worn, and a water-soluble lubicrant shoud be applied to the probe.
• Seperate the patient's leg, apply instructions to breathe slowly and calmly.
• Push, and remove once a sound occurs.

Axillary Measurements

• Axillary Measurements are the most common approach.
• Transmission of infection is unlikely.
• Personal thermometers are highly encouraged.
• Avoid excess sweat in the armpit.
• Infection unlikely is the axillary region is the correct region used.
• All subjects should benefit from their own personal thermometer.
• Also be sure to have a non-sweaty armpit.
• When measuring make sure device makes an audible when complete.
• Temperature taking devices should be forehead with a special one that rests on the forehead and in-between the eyebrow

Pulse

• The pulse indicates the amount of heartbeats per minute.
• When assessing the pulse, one must assess this absolutely with the rates, rhythm and volume.
• Adult range falls approximately in the range of 60-100, newborn at approximately 120-160
• There must be measurements to decide the rate, rhythm, and contraction of the heat.
• It can be identified that it should be known for identify peripheral vascular diseases

Pulse Rate

• Pulse can vary depending on the age: newborn (120-160/min), children (80-120/min), adult (60-100/min).
• Bradycardia has a pulse rate below 60 beats per minute while tachycardia has a pulse rate above 100 beats per minute.
• Factors that can alter your pulse are, age, gender, metabolism, bleeding, posture change + exercise, hyperthermia and hypothermia + acute and chronic pain coupled with anxiety + drugs.
• Regularity in the heart beat is considered a regular rhythm.
• Difference between apical and radial/peripheral pulses can determine signal an arrhythmia

Pulse Rhythm

• Pulse Deficit is the difference and signal the potential arrhymia
• The heart contracts, but the pulse can be felt in a variety of areas.
• The radial pulse should be felt in the wrist.
• The pulse rates are called pulse deficit, and the pulse isn't effectively reaching the location.
• The volume measures pulse, where fullness reflects contraction in the heart with every beat.
• Normally, the heart has even beats to all regions that must be easy to find and similar.
• The difficult palpated are called weak, they disappear easily.
• It is important to remember in cases of bleeding, heart failure, or shock.
• Volume in pulse rate, if equal to over 130 indicate death or filiformity

Pulse Points

• The temporal artery is on the head.
• The Carotid artery is in the neck.
• The Heart has the Apical The Heart points to the bottom
• The Ulnar
• Anterior Elbow has Radial
• Femoral is high in the thigh.
  • Behind the knee, it is Popliteal
• The Dorsalis Pedis (on foot)
• The foot has the Posterior Tibial
• In emergencies, take at (0–1 age; apical/ branchial/ femoral artery) (1 and up age; Carotid) and be aware,
• There are tips to help take pulse, make sure hands are washed, ask for authentication, inform the subject and family about pulse rate conditions and finally get patient set. The patient should not be moved before they are in position.

Peripheral Pulse Taking

• Wash hands prior to, and have authentication of the patient before beginning.
• Inform the family and the patient
• Evaluate the factors that affect the patient.
• Have the patient not stand, and have them sit or lay down.

Respiration

• Place ring middle and sign finger the artery
• Avoid too much pressure two-three fingers
• Palpate for 1 minute if this for first time and or irregular vs 30 secs if heart has stable rate and has high heart rate.
• Respiration is a process beginning with breathing.
• O2 and CO2 are the most important factors
• 02 - used
• Co2 - released.
• The process has two different stages. It will occur between atmosphere and lungs.

Stages of Respiration

• Oxygen will be launched to blood, carbon is moved through blood by circulating system.
• This consists of three parts
• Ventilation - the ability of the person to get air through their system
• Diffusion - transferring something through liquid to other areas
• Perfusion - is movement of gas through the circulatory system
• Saturation - perfusion and diffusion Respiratory rate, depth and rhythm of breathing - Ventilation and information.
• The respiratory center is located in the medulla oblongata and pons in the brainstem
• The key things to keep in mind are rate, depth and type.

Respiratory Rate

• In Newborns there are approximately 30-60/min
• In Adults there are approximately 12-20/min
• The rate depends on 4 states -deep, superficial, and normal.

Respiratory Types

• It can vary by body position, exercise, or anxiety/fear or medications, but is often affected by position.

• Types are defined by being easy to identify based with a diagram for visual aide,

  • Eupnea
  • Bradrypnea
  • Tachypnea
  • Kussmaul's Respirations
  • Biot's Respirations
  • Cheyne Stokes
  • Sleep Apnea
  • Hyperventilation
  • Hypoventilation

• Anoxia is an absence of oxygen.

• Hypoxia means that you don’t have enough oxygen to the cells and tissues.

• Dyspnea is the the breathing.

• Cyanosis is also is another cause, it’s defined as being blue and/or purple.

• When viewing it observe at rate, rhythm and depth, if they have breathing with a regular rhythm, then you need you need say nothing at all otherwise count for 1 minute and get number for every inspiration.

Guidelines

• When counting, evaluate the respiratory rate while assessing chest wall. Also keep in mind that everything is based on a one breath number.

• Wash face prior to and get details prepare evaluate and position face prior to

• Never tell patient, count face without showing rib cage then take precaution by getting rib case details.

Oxygen Saturation

• It is used to measure the oxygen in the blood
• It is considered to be noninvasive and painless
• Can apply in the following areas
  • Finger
  • Nose
  • Earlobe
• Oxygen rich rich and pulsating by vessels

The Measures

• Readings ranging from 95 to 100% and under normal circumstances are okay otherwise values under 90 are too low.
• Also remember hypoexemia , the description of the lower and normal levels.

Blood Pressure

• Blood flows and puts pressure on arties , measuring them for the form of pumps.

• Systolic measuring during the heart pump by the ventricles are the measurements of the device.

• Diastolic The arteries will relax when the ventricles will

• If the blood pressure is over 100 and sixty, a pulse pressure is made that needs a checkup.

Additional Pressures

• Blood Pressure, that can be checked based on:

  • Age
  • Stress
  • Race
  • Gender
  • Medicines
  • Foods

• World Health Organization , when seeing Hypertension is at the value at which you are,

• The point about Blood Pressure is about arterial pressuring.

Tips

• Position the patient, keep flex at elbow, keep heart at that level and finally make

• Position should be Fowler

• Cup should be located 2-3 cm above the brachial artery

• Always listen for when tapping starts and measure when you hear it

The rapid and the cuff to be able and listen simultionously, make sure the mercury is gauge

If the pulse is measured for the first time and is irregular

• Repeat check by holding the same amount, by waiting 2 mins. If you check. Check for the arm at that position because you need the blood to that arm.
• Remember The values, Remember Your washes

Blood Pressure Errors Include

• Not being upright
• Not having elevated arm
• Un calibrated machine And more and incorrect marker setting.