Understanding Vital Signs

Vital Signs Overview

• Vital signs indicate an individuals health status.
• They are basic indicators of an individual's health status.
• Vital signs include body temperature, pulse, respiration, oxygen saturation, and blood pressure.

Factors Affecting Vital Signs

• Many factors can lead to changes in vital signs readings.
• These factors include different times of day, age and ovulation state.
• Other factors are the seasons, physical activity, dressing type, and environmental heat.
• Stress and diseases also can impact vital sign readings.

Guidelines for Assessing Vital Signs

• Nurses should know how to obtain and evaluate vital signs, and how to communicate findings to team members.
• Equipment should be reliable and selected based on the patient's condition and characteristics.
• Normal vital sign values should be known as well as the patient's medical diagnosis, treatment, and medications.
• Environmental factors should be considered during assessment.
• Vital signs should be measured systematically at regular intervals.
• Nurses need to communicate effectively with patients during measurement.
• Nurses should cooperate with the physician.
• Obtained vital signs should be analyzed absolutely.

Frequency of Vital Signs Measurement

• Vital signs should be measured when preparing a patient for admission.
• Measure vital signs before and after surgery, as frequency increases.
• Measurement should occur before and after diagnostic procedures.
• Measurements should be taken before and after administering drugs that affect the heart and respiratory system.
• If there is a sudden deterioration of the patient's condition perform measurements.
• Measurements should be taken before and after medical interventions that may affect life signs.
• Measure when the patient reports feeling a difference.

Body Temperature Basics

• Body temperature represents the balance between heat produced and heat consumed.
• Heat production and heat consumption in the body must be equal.
• Heat is produced in the body through food.
• Heat loss occurs through the lungs via breathing, the skin via sweating, and wastes' elimination from the body.

Factors Influencing Body Temperature

• Factors affecting temperature include age, exercise, and hormone levels.
• Stress, environment, emotional state, and basal metabolic rate also affect temperature.
• Digestion, nutrition, sleep, diseases as well as induction of the sympathetic nervous system can affect temperature.

Regulation of Body Temperature

• The thermoregulation center is the hypothalamus.
• The hypothalamus acts as a thermostat.
• Vasodilation and sweating decrease heat.
• Muscle tremor increases heat generation.
• Piloerection generates heat.

Temperature Changes

• Hypothermia is when body temperature is 35°C and below.
• Hyperthermia is when body temperature is above 38°C.

Normal Body Temperature Values and Measurement Sites

• The average normal oral temperature is 37°C, with a normal range of 36.5°C to 37.5°C.
• The average normal ear temperature is 37°C, with a normal range of 36.5°C to 37.5°C.
• The average normal axillary or forehead temperature is 36.5°C, with a normal range of 36°C to 37°C.
• The average normal rectal temperature is 37.5°C, with a normal range of 37°C to 38°C.

Measuring Body Temperature: General Practices

• Ensure materials are prepared before every application.
• Hands should be washed, and gloves should be worn if necessary.
• The patient is given information about the application.
• The patient needs to be comfortable and give permission to continue.

Oral Measurement

• Degrees are placed right or left under the tongue.
• Normal oral temperature is between 36.5 °C - 367.5 °C.

Cases to Avoid Oral Temperatures

• Do not take oral temperatures for patients with dyspnea, children, or elderly patients.
• Oral measurements should not be taken on patients with psychiatric diseases or non-conscious patients.
• Do not take oral readings for patients after surgery.
• In the case of mouth infections, and patients on continuous oxygen avoid this site.

When Taking Temperature Orally, Key Points Include:

• The patient should have a personal thermometer.
• Avoid drinking or eating anything hot or cold food which affects temperature assessment.
• Patients shouldn't eat or drink anything prior to assessments.
• A thermometer should be placed under the tongue.
• The mouth should be closed for measurement.
• The teeth should not be squeezed.

Tympanic Measurement

• Measurement normally completes within 1-2 seconds.
• The receiver is placed in the 1/3 of the outer ear.
• Use a disposable plastic cover over the receiver, for assessments.

Rectal Measurement Usage

• Rectal measurements should be used when heat cannot be taken via oral or axillary routes.

Rectal Measurements

• Close the curtains and the door.
• Place patients in the Sims' position and align the upper leg.
• Wear gloves, and apply soluble lubrication to the probe.
• Hold the patient's hips and ask them to deeply and slowly breath.
• Insert the device into the anus at the degree that it's advanced.
• Once it sounds remove its probe. The degree is advanced:
  • 2.5-3.5cm in adults.
  • 2-2.5 cm in children.
  • 1.2cm in newborns.

Cases to Avoid Rectal Measurement

• Do not take rectal temperatures on patients with rectal bleeding or rectum surgeries.
• Avoid this measurement on births, and in the case of maternity.
• It should not be undertaken with continuative measure on kids.
• It is not advised for diarrhea cases.

Axillary/Forehead Measurement

• The axillary region is the most commonly used region for temperature measurement.
• Infection is very unlikely to be transmitted this way.
• The patient should have a personal thermometer.
• The armpit should not be sweaty.

Digital Applications

• After heat is measured most digital measurements give an alarm.
• For digital readings a device is placed on the forehead.

Pulse overview

• Pulse is the number of heartbeats per minute.

Pulse Assessment

• Assess the pulse absolutely.
• Assess the pulse rate.
• Assess the pulse rhythm .
• Assess three-pulse volume should be assessed.

Why Assess Pulse?

• The pulse is counted when deciding the rate, rhythm, and contraction of the heart.
• Used during determination of peripheral vascular diseases.

Pulse Rate

• Pulse rate measures the number of heartbeats per minute.
  • For newborns, a normal pulse rate is 120-160/min
  • For children, a normal pulse rate is 80-120/min
  • For adults, a normal pulse rate is 60-100/min.
  • Bradycardia occurs with pulse rates below 60 beats per minute.
  • Tachycardia occurs with pulse rates above 100 beats per minute.

Factors Affecting the Pulse Rate

• Exercise, hyperthermia, and hypothermia affect pulse rate.
• Acute pain, chronic pain, anxiety, and drugs also affect pulse rate.
• Age, gender, metabolism, bleeding, and posture change also affect pulse.

Pulse Rhythm

• If the heartbeat is regular, it is called regular rhythm. If it is irregular, it is called irregular rhythm.
• If there is arrhythmia, the difference between apical pulse and radial pulse should be checked.
• In arrhythmia, a pulse deficit develops.
• Pulse deficit is the difference between the apical and peripheral pulse rates; it signals an arrhythmia.
• Pulse deficits occur with heart contractions which do not reach the periphery.
• In pulse deficits, and the radial pulse is lower than the apical pulse.

Pulse Measurements

• Pulse measurement requires one person counts an apical pulse with a stethoscope.
• Second individual simultaneously counts the radial pulse by hand.
• If the apical pulse is 90 beats per minute and the radial pulse is 72 beats per minute, the pulse deficit is 18.
• This means the 18 heart contractions did not push blood through the body effectively.

Pulse Volume

• Pulse volume and the fullness of the pulse reflect the left ventricular contraction power.
• Normally, when the pulse is palpated, it is easily found, and every beat is felt in similar fullness; this is called a full or bounding pulse.
• A weak pulse is difficult to palpate and easily disappears, even with finger pressure; it is also called a filiform or thready pulse.
• Weak pulses develop in bleeding, shock, and heart failure.

Pulse Points

• The main artery pulse points are temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, dorsalis pedis (on foot) and posterial tibial.
• Emergency pulse points for ages 0-1 are apical, brachial, and femoral arteries.
• For ages above 1 a carotid artery can be used.

Peripheral Pulse Intake Procedure

• Perform hand washing on the patient, family or application is done.
• Evaluate the factors the patient is in regarding the condition and pulse prior to the pulse measurement.
• A patient should not be rested or standing when doing so.
• A measurement should be taken in a proper location.

Peripheral Pulse Measurement

• The index, middle and ring fingers need to be placed on the artery, without added pressure.
• If it is a first irregular time it needs to be assessed for another minute.
• If the heartbeat is normal its is used to be assessed at a 30 sec rate.
• It is then used to find the beats for its correct state.
• Note all assessments taken, and the findings.

Respiration

• Respiration is a process that begins with breathing and involves the organism.
• O2 is taken in and uses and releases CO2. The respiration process has two different stages.
• External respiration occurs between the atmosphere and the lungs.
• O2 is released into the blood and CO2 is released through the respiratory and circulatory systems.
• Internal i=O2 and CO2 exchange is between cells and blood circulation.

Respiratory Functions

• Ventilation: Inspiration and Expiration.
• Diffusion: O2 passes from the alveoli to the lung circulation, and CO2  passes from the lung circulation to the alveoli.
• Perfusion: the process by which O2 which enters the lung circulation, is carried in the blood and passes to the tissues, and CO2accumulated in the tissues enters the lungs through circulation.

Indications to Use Respiratory Assessment

• Respiration rate and saturation indicates to diffusion and perfusion.
• Ventilation indicates respiratory, rhythm and dept.

Regulation of Respiration

• The respiratory center is located in the medulla oblongata and pons in the brainstem.

Assessment of Respiratory Measurement

• Respiratory rate, respiratory depth and respiratory.
• Respiratory type all very important in assessment.

Respiratory Rate Assessment

• Normal newborn respiratory rate = 30-60/min.
• Normal adult respiratory rate = 12-20/min.

Respiratory Depth

• Assess respiratory depth is assessed as deep, superficial, and normal.
• Respiratory depth is affected by body position, medications, exercise, fear, and anxiety.
• The diaphragm increases by 1 cm in normal breathing.
• The costa extend 1.5-2.5 cm forward.

Respiratory Types

• Eupnea: Normal respirations with equal rate and depth (12-20 breaths/min).
• Bradypnea: Slow respirations, less than 10 breaths/min.
• Tachypnea: Fast respirations, more than 24 breaths/min usually shallow.
• Kussmaul's Respirations: Respirations with regular that are abnormally deep and with higher rate.
• Biot's Respirations: Irregular respirations of variable depth, usually shallow, alternating with periods of apnea absence of breathing).
• Cheyne-Stokes Respirations: Gradual increase in depth of respirations, followed by gradual decrease and a period of apnea.
• Apnea: Absence of breathing.
• Hyperventilation: Increased rate and depth of breathing.
• Hypoventilation: Decreased rate and depth of breathing, irregular.

Key Respiratory Terms

• Anoxia: Absence of oxygen.
• Hypoxia: Cells and tissues cannot get enough oxygen.
• Dyspnea: Difficult breathing.
• Cyanosis: Bluish or purplish discoloration of the skin or mucous membranes due to tissues near the skin surface having low oxygen saturation.
• Cyanosis can be clearly observed from the lips, ear lobes, nails, and oral mucosa.

Assessing Respiration Procedure

• After the pulse is counted and observe chest walls.
• Count and follow the rhythm to perform correct analysis.
• Every beat is equal to one respiratory.

Counting Process

• Prepare the materials.
• Wash your hands.
• Give the patient information on the procedure.
• Evaluate the exercise, fatigue, and eating habits on patients.
• Evaluate prior to breathing.

Recording

• Never tell the patients you are counting respirations.
• Ensure it is done a certain amount of time.

Key Respiratory Steps

• Remember its value during its respiration.
• Each expiration and inflation is to be one breath.
• Check to see if it has a normal procedure for 30 second
• When the breathing is not stable ensure it reads it for one minute.

Oxygen Saturation

• Procedure measures oxygen levels or saturation in the blood.
• A procedure indicator used noninvasively with the delivery on the tissues.
• An oximeter measures oxygen through the blood levels, hemoglobin and blood vessels.
• The finger probe should be placed and sourced to light or a finger.

Saturation of Oxymeter

• A meter reads normally 95–100 most times.
• Levels lower than a 90, the process are considered to be lowing.
• Hypoxemia describes a rate below its normal limits.

Blood Pressure Basics

• Blood pressure is a measure of blood pumping force.
• Systolic pressure is pushing heart when you breath (the ventricle of its beats).
• The diastolic pressure is the time heart rates are between resting.

Understanding Pulse Pressure

• The number shows how the blood differs, when pushing systolic or diatonic.
• If rests measure 120.2/80 its shows a pressure rate of 40mmHg.
• Average level comes to: 30-50 mmhg.

Factors That Affect the Pumping

• Stress or Age for instance could make a difference within someone's body.
• Gender, race, daily life in medicines or foods can affect.
• Even exercise is known to measure the output as well.

Hypertension

• The World Health organization states adult level to:
• 140/9/Hg, as a normal balance.

Hypotension

• Its a limit measure for normal arteries.
• Its states and goes if it runs below 900mgHg.

Blood Pressure Measurement Materials:

• Sphygmomanometer with a stethoscope.
• Suitable Disinfectant.
• Pen and Form.
• Waste containers.

Blood Pressure

• Semi Fowler and Supline is good posture when resting.
• When you are set for the procedure please measure and re-assess.
• In the arm the subject can't be flexed.
• This step has to at minimum be completed towards the center of the heart.
• When the subject is ready ensure they rest its pulse.

Equipment Placement

• Use a cuff around 2-3 cm, for the antecubital area.
• All of the brachial vessels will not be included and closed.

Using Pointers

• Ensure you point the cuff in accurate direction to reach all ends in the area.

Applying the Stethoscope

• Find the ear and the rhythm with an artery and ensure it doesn't shift from its point.

Cuff Adjustments

• Add more pressure and wait till its runs above 2/250mmHg.
• Ensure its slowly going down a rate by each second.
• Listen to its heart with the stethoscope and see in its dial.
• When knocking it is the force on a artery at its point.

Blood Pressure Measurements

• Measure prior to two arms and find out a baseline.
• Ensure the repeat is all set between 2/4 min of waiting.
• Ensure its a higher rate from these points.
• Evaluate a new and accurate report form.
• Cleanse all necessary tool for the procedure.

Common Errors in Blood Pressure Measurement

• The base and area must be firm without a flat surface.
• No area of a patient should be working near points of the person.
• In a calm tone a state is ready to test.

In An Area

• Always face upwards from any state and keep its base going face up.
• Avoid all cuffs when you begin tests because all outcomes are different.
• All are not moved and ensure its set when tested.

Important Blood Pressure Reminders

• Check heart, if you get constant checks.
• The tool's settings are made for you.