Understanding Vital Signs Assessment Guidelines

• Vital signs are fundamental indicators of an individual's health status.
• Essential vital signs include body temperature, pulse, respiration, oxygen saturation, and blood pressure.
• Many variables such as time of day, age, ovulation state, seasons, physical activity, clothing, environmental heat, stress, and disease may result in differences in vital signs.

Guidelines for Assessing Vital Signs

• Nurses must understand how to obtain and interpret vital signs and how to communicate this information to other team members.
• Equipment used for assessing vital signs should be dependable.
• The selection of equipment should be based on the patient's condition and specific characteristics.
• A solid understanding of normal vital sign values provides a baseline for identifying deviations.
• The medical history, treatment, and medications of the patient should be known.
• The environment should be considered during vital sign assessments.
• To ensure the patient is comfortable, explain steps before taking vitals
• It is important to consider the patient's comfort and obtain their consent before conducting any procedures.

Measuring and Measuring Vital Signs

• Vital signs should be measured systematically at regular intervals.
• Nurses must communicate effectively with patients during the process.
• Healthcare providers should collaborate with physicians.
• Measured vital signs need to be analyzed to see whether they fall within a healthy range.

Frequency of Taking Vital Signs

• Upon patient admission to a healthcare facility.
• Before and after surgical procedures, with increased frequency post-surgery.
• Prior to and following diagnostic procedures.
• Before and after administering medications affecting the heart and respiratory system.
• In case of sudden deterioration in the patient's condition.
• Before and after medical interventions that might impact life signs.
• Anytime a patient reports feeling different or unwell.

Body Temperature Basics

• Body temperature reflects the balance between heat production and heat consumption.
• Heat production and heat consumption in the body must be equal.
• Heat is generated through food.
• Heat is lost through the lungs when breathing, the skin when sweating, and as waste.

Influences on Temperature

• Factors influencing body temperature include age, exercise, hormone levels, stress, environment, emotional state, basal metabolic rate, digestion, nutrition, sleep, diseases, adrenaline, and noradrenaline production.

Regulation of Body Temperature

• The thermoregulation center is the hypothalamus.
• The hypothalamus functions like a thermostat.
• Vasodilation reduces heat.
• Sweating reduces heat via evaporating the skin.
• Muscle tremors generate heat.
• Piloerection increases heat.

Hypothermia vs. Hyperthermia

• Hypothermia denotes a body temperature of 35°C or lower.
• Hyperthermia indicates a body temperature above 38°C.

Routes for Measurement

• Normal oral temperature ranges from 36.5°C to 37.5°C; the average is 37°C.
• Normal ear temperature ranges from 36.5°C to 37.5°C; the average is 37°C.
• Normal armpit temperature ranges from 36°C to 37°C; the average is 36.5°C.
• Normal rectal temperature ranges from 37°C to 38°C; the average is 37.5°C.

Thermometer Concerns

• Mercury is toxic.
• Mercury-containing glass thermometers not recommended.
• Mercury thermometers were banned by the Ministry of Health in 2009.

Preparation for Measuring body Temperature

• Gather materials beforehand.
• Hands are washed, and wear gloves.
• Give the patient information.
• Make sure the patient is comfortable and has given permission.

Oral Measurements

• Place degree under the tongue.
• Average oral temperature ranges from 36.5°C to 367.5°C.
• Do not take oral temperatures for dyspnea, children, the elderly, psychiatric diseases, non-conscious patients, after surgery, mouth operations, infection risks, or continuous oxygen users.
• Use personal thermometer on patient.
• Advise patients not to eat or drink anything prior to measurement.
• Mouth closed during oral measurement, teeth remain unsqueezed.

Tympanic Measurements

• Tympanic or ear temperature is measured in 1-2 seconds.
• Place the receiver inside the outer third of the ear.
• Before measurement, use a disposable plastic cover over the receiver.

Rectal Measurements

• Use rectal measurements only when heat cannot be measured by oral or axillary routes.
• Normal rectal temperature ranges from 37 °C - 38 °C.
• Privacy is important when taking rectal measurements.
• Close the door and curtains, and put the patient in Sim's position with the upper leg flexed.
• Apply water-soluble lubricant to the degree on probe before taking measurements.
• Ask the patient to breathe slowly and deeply while degree is being inserted.
• Insert the degree in anus, then when the signal sounds, remove the probe.

Rectal Measurement Depth

• Adult: Insert 2.5-3.5 cm
• Children: Insert 2-2.5 cm
• Newborn: Insert 1.2 cm
• Don't perform on patients in rectal bleeding cases, Rectum surgeries, birth, during maternity, continuously as a routine way in children, or Diarrhea cases.

Axillary or Forehead Measurements

• The armpit is the most common region for temperature measurement.
• Infection risk is very low in this reading.
• Ensure measurement is done with a personal thermometer with area dry.
• The arm pit should not be sweaty.
• Normal axillary temperatures range from 36 °C-37 °C.
• Forehead is measured using a special digital thermometer.
• Place the device between the eyebrows and the forehead.

Pulse

• The pulse is the number of heartbeats per minute.
• Assess pulse for 60-100 beat for adult pulse.
• Assess pulse for 120-160 beats for newborn.
• Assess pulse Rate, Rhythm (Regular Pulse-arrhythmia) & Volume (Full Pulse) - Weak Pulse (Threaded Pulse).
• The pulse indicates heart contractions, rate & rhythm
• The pulse can detect peripheral vascular disease

Pulse Rate Metrics

• A pulse for a newborn should read 120-160/min.
• A pulse for a child should read 80-120/min.
• A pulse for an adult should read 60-100/ΜΙΝ.

Irregular Pulses

• Bradycardia: indicates a pulse below 60 bpm.
• Tachycardia indicates pulse rate above 100 bpm.

Factors Affecting Pulse Rate

• Influences include exercise, hyperthermia, hypothermia, acute/chronic pain & anxiety, medications, age, gender, metabolism, bleeding, and changes in posture.

Pulse Rhythm

• Regular rhythm is consistent, while irregular rhythm is variable.
• Arrhythmia merits checking the variation between peripheral and apical pulses.
• Pulse Deficit denotes variance between apical and peripheral pulse measurements, signaling arrhythmia.

Assessing Pulse Deficit

• Evaluation requires two people where one counts apical pulse while the other counts radial pulse.
• For instance: if the apical pulse is 90 bpm and the radial is 72, the pulse deficit (18 bpm) shows poor blood circulation

Pulse Fullness or Volume

• The fullness shows the capacity of left ventricular contractions.
• Easy to identify with every beat in general palpations showing full or bounding pulse
• A weak pulse (thready or filiform) is difficult to palpate and vanishes easily.

Pulse Points on the Body

• Convenient sites for checking vital signs include the temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior tibial arteries.
• In emergency, assess apical, brachial, or femoral artery in 0-1 age patients
• In emergency, assess carotid artery in >1 age patients.

Measuring Peripheral Pulse

• Wash hands before taking peripheral pulse.
• Evaluate factors affecting patients condition and pulse
• Inform patient before touching or measuring their pulse.
• Have the patient rest - don't stand.
• Maintain the proper position

Measuring the Pulse

• Position the sign, middle, and ring fingers on the artery.
• If irregular, count for a minute and find rate; if regular, count for 30 seconds and multiply by two to find the heart rate. Record findings.

Respiration

• Organs of the respiratory system include the nose, pharynx larynx, trachea, bronchi, and lungs and alveoli.
• Respiration is taking in and using oxygen, while releasing carbon dioxide
• Respiration occurs in different stages within the body.

Stages of Respiration

• External: Oxygen is released into the blood.
• External: Carbon Dioxide released through the respiratory and circulatory systems.
• Internal: Oxygen & Carbon Dioxide exchange between cells and blood circulation.
• Respiration has two distinct stages.

Ventilation, Diffusion, and Perfusion

• Ventilation: Inspiration (inhale) and Expiration (exhale)
• Diffusion occurs between the alveoli and lung circulation.
• Perfusion occurs through the blood and tissues.

Key Measurements of Respiration

• Saturation involves diffusion and perfusion to share info about condition.
• Ventilation involves respiratory rate, depth, and rhythm of breathing.
• The respiratory center is in the medulla oblongata and pons regions of the rainstem

Respiratory Assessment

• Respiratory rate, depth, ad type are important.
• Normal respiratory patterns include eupnea, bradypnea, tachypnea, Kussmaul's respirations, Biot's respirations, Cheyene-Stokes respirations, sleep apnea, hyperventilation, and hypoventilation. Decreased sounds show it's irregular.

Respiratory Rate Values

• Normal newborn rate is 30-60/min.
• Normal adult rate is 12-20/min.
• Depth shown with deep or shallow breaths.
• Normal respiration is regulat in depth and rhythm
• The costae extend 1.5-2.5 cm forward during respiration.

Lung Conditions

• Anoxia is an absence of oxygen.
• Hypoxia is when cells/tissues cannot get enough oxygen.
• Dyspnea is difficulty breathing.
• Cyanosis is the blue or purple skin discoloration due to low oxygen.

Finding One's Respiration

• After the pulse is measured, count respirations by watching the chest wall.
• Normal breathing is regular in depth and rhythm
• Each rise & fall of the chest counts as one breath.

Cautions When Measuring Respiration

• Never mention you are counting a patient's respiration.
• We should measure respiration after taking the pulse.
• First, prepare materials and wash hands.
• Evaluate their exercise, fatigue, & eating status
• Make sure they are positioned to rib cage is visible

Process Steps

• Check watch and make sure it started counting respirations
• Each breath (inhale + exhale) is considered one breath.
• If breathing is regular, count for 30 seconds (multiply by two) for number of breaths per minute.
• Otherwise, count for a minute.
• Afterwards, check breathing depth while observing area before recording findings and taking necessary precautions.

Oxygen Saturation

• Pulse oximetry assesses oxygen saturation in the blood.
• The method is noninvasive and painless.
• Assesses oxygen delivery as one of three indicators.
• Readings range 95-100% and are considered normal.
• Readings below 90% are considered low
• Hypoxemia: describes when lower-than-normal level oxygen is found in blood
• The finger probe light source needs to align around a finger, toe, or earlobe.

Blood Pressure

• It measures forced pumped by heart around your body,
• Systolic pressure measures of blood forced when heart contracts in ventricles.
• Diastolic pressure indicates when heart rests between beats.

Blood Pressure Guide

• 90/60mmHg and 120/80mmHg is ideal.
• 140/90mmHg or higher = hypertension
• 90/60mmHg or lower = low blood pressure
• Pulse pressure indicates between systolic & diastolic pressure
• Between 30-50mmHg is average
• Many things impact blood pressure including foods, medicine, exercise, Age, Stress, Race, Gender & Daily life

Hypertension and Hypotension

• Hypertension, as defined by WHO, is systolic blood pressure at/above 140/90mmHg
• Hypotension is arterial blood pressure below normal (read at 90mmHg)

Tools for Measurement

• Materials include blood pressure monitor and sphygmomanometer, stethoscope, disinfectant, registration form, and container to discard liquid waste
• A blood pressure test measures force of blood against artery walls and blood flow resistance.

Factors Measuring BP

• Position: supine/semi Fowler.
• The patients arm should be flexed in seated positions.
• The elbow at heart level.
• Wait a few minutes before measuring from the patient having any form of stress

Measurement Process

• Make sure patient has rested and use the correct cuff positioning
• Put meter so you can see it.
• Make sure to palpate brachial artery, feeling for the pulse.
• Put the ear, in right spot
• Next, rapidly pump it towards 200mmHG and steadily start realizing the pump as listen, The first thump signifies systolic and end signifies diastolic

Taking Accurate Measurements:

• On first time, it may need to be assessed 2 times
• Be sure instrument is at zero
• Brachial pulses are clear
• After checking pressures between both arms, take in the note about that the higher arm is where they are

Common Measurement Problems

• Some problems can occur during this assessment and a number these are feet in the wrong spot, arm not at certain palm (up), wrong-sized instrument, and etcetera

Mistakes to avoid

• Cuff being too tight or wide/Arm not being heart level and Inaccurate inflation levels.