Understanding Vital Signs

• Vital signs serve as basic indicators of an individual's overall health condition.
• Accurately identifying vital signs, knowing their normal values, and being able to evaluate them are important.

Factors Affecting Vital Signs

• Vital findings can change due to several factors.
• These factors include different times of day, age, ovulation state, seasons, and physical activity.
• Dressing type, environmental heat, stress, and disease can also influence vital signs.

Guidelines for Assessing Vital Signs

• Nurses should know how to obtain vital findings, evaluate them, and communicate them to the team.
• Reliable equipment is needed, selected according to the patient's condition and characteristics.
• Knowledge of normal vital sign values is essential.
• The patient's medical diagnosis, treatment, and medication should be taken into account.
• Environmental factors should be considered during assessment.
• Vital signs should be measured systematically at regular intervals.
• Nurses should communicate effectively with the patient when taking measurements.
• Cooperation with the physician is important.
• When measured, vital signs require absolute analysis and consideration.

Frequency of Vital Sign Measurement

• Vital signs should be taken when preparing a patient for admission.
• Measurements are needed before and after surgery, with increased frequency.
• Vital signs should be taken before and after diagnostic procedures.
• Measurements are needed before and after administering drugs affecting the heart and respiratory system.
• If sudden deterioration happens in the patient's condition, vital signs should be taken.
• Measurements are needed before and after medical interventions that may affect life signs.
• When the patient exhibits a noticeable change or difference.

Body Temperature

• Body temperature reflects the balance between heat production and consumption.
• Heat production and heat consumption in the body must be equal for consistent body temperature.
• Heat is produced in the body through food.
• Heat is lost through the lungs (breathing), skin (sweating), and bodily wastes (urine, features, vomiting, blood).
• Factors like age, exercise, hormone levels, stress, and environment can affect body temperature.
• Emotional states, basal metabolic rate, digestion of food, nutrition and sleep, diseases, and the sympathetic nervous system all affect the body temperature.
• The thermoregulation center is in the hypothalamus, acting as a thermostat.
• The body regulates temperature through vasodilation (decrease in heat), sweating, muscle tremor (increase in heat), and piloerection.
• Hypothermia is registered when body temperature is below 35°C.
• Hyperthermia is registered when body temperature is above 38°C.

Normal Body Temperature Values

• Oral temperature ranges from 36.5°C to 37.5°C, with an average of 37°C.
• Ear temperature ranges from 36.5°C to 37.5°C, with an average of 37°C.
• Axillary temperature ranges around 36°C to 37°C with an average of 36.5°C.
• Rectal temperature ranges 37°C to 38°C, averaging 37.5°C.

Measuring Body Temperature

• Oral measurements are taken by placing the thermometer right or left under the tongue with an average between 36.5°C - 367.5°C.
• Tympanic sensors measure within 1–2 seconds, placing the receiver in the outer ear with a plastic cover.
• Rectal sensors should only be used when heat cannot be taken by mouth or the armpit.
• The axillary region is the most commonly used region and thermometers should not be sweaty.

Glass Thermometers

• Glass thermometers containing mercury are forbidden by the Ministry of Health since 2009.
• Mercury was found to be toxic, posing a threat to the environment and humans.

Oral Temperature Cautions

• Do not take oral temperatures for patients with dyspnea or psychiatric diseases, children, the elderly, non-conscious patients, or in case of infection.
• Do not take oral temperatures on patients on continuous oxygen or those who have had surgery
• Use a personal thermometer for each patient.
• Avoid drinking or eating very hot or cold foods prior to temperature measurement.
• Ensure the thermometer is placed under the tongue and the mouth is closed, without teeth squeezing.

Rectal Measurement Procedure

• Close the room door and curtains for privacy before administering the procedure.
• Put the patient in Sim's position and flex the upper leg.
• Apply water-soluble lubricant to the probe and wear gloves.
• Separate the patient's hips, ask the patient to breathe slowly/deeply, and insert the degree into the anus.
• Advance the degree 2.5-3.5 cm in adults, 2-2.5 cm in children, and 1.2 cm in newborns.
• When the signal sounds, remove the probe from the patient.

Rectal Measurement Cautions

• Do not take rectal temperatures in cases of rectal bleeding or on patients who have had rectum surgeries, or birth.
• Do not take rectal temperatures on patients in the period of maternity or who have diarrhea cases.
• Do not take rectal temperatures continuously as a routine way in children.

Pulse

• The pulse is the number of heartbeats per minute.
• When assessing the pulse, rate, rhythm, and volume should be assessed.
• Normal pulse rate is measured 60-100 bpm in adults, 120-160 bpm in newborns, and 80-120 bpm in children.
• The pulse is counted to determine the rate, rhythm, and contraction of the heart and to identify peripheral vascular diseases.
• Bradycardia is a pulse rate below 60 beats per minute, an illness for adults.
• Tachycardia is a pulse rate above 100 beats per minute, an illness for adults.
• Exercise, hyperthermia, hypothermia, acute pain/anxiety, chronic pain, drugs, age, gender, metabolism, bleeding, and posture changes all affect the pulse rate.
• A regular heart beat is called regular rhythm, an irregular heart beat is called irregular rhythm.
• Pulse deficit, when the heart is contracting but the pulse is not reaching the periphery, can signal an arrhythmia.
• "Weak pulses", or thready pulses, are often difficult to feel and can stem from bleeding, shock, or heart failure.
• With weak pulses, a nurse will find the pulse hard and the pulse rate is over 130 pulses per minute.

Pulse Points

• Emergency pulse points to be found are the apical, brachial, and femoral in children aged 0-1 and in one aged babies, the carotid artery.
• In performing peripheral pulse taking, the hands are washed.
• Evaluate factors that will affect the patient's condition/pulse rate prior to pulse measurement.
• Place the patient at a resting rate and give them the appropriate posture.
• The signal, middle, and ring fingers are placed on the artery w/o pressure.
• If the pulse is measured for the first time, count it for 1 minute and indicate the findings that are recorded.

Respiration

• Respiration is a process that begins with breathing and involves the organism taking in and using O2 and releasing CO2.
• External respiration occurs between the atmosphere and the lungs.
• Internal respiration (tissue respiration) is the exchange of O2 and CO2 between cells and blood circulation.
• The repiratory center is located in the medulla oblongata and pons in the brainstem.
• In respiratory measurement, rate, depth, and type should be noted.
• Ventilation is measured by respiration and inspiration measurements.
• Diffusion is recorded when oxygen is passed to the lung circulation and when carbon dioxide passes from the lung circulation to the alveoli.
• The process of perfusion takes recordings of oxygen which enters the lung, passing to the tissue with carbon dioxide which accumulates.
• Adult respiratory rate is typically between 12-20/min, whereas newborn respiratory rates are at 30-60/min.
• The diaphragm increases by 1 cm in normal breathing and the costa extend 1.5-2.5 cm forward.

Respiratory Types

• Assess respiratory depth as deep, superficial, and normal levels.
• Take into consideration, body position, anxiety, and medications prior to administering the procedure.
• Various respiratory types include eupnea (normal), bradypnea (slow), tachypnea (fast), Kussmaul’s respirations, Biot’s respirations, Cheyne-Stokes respirations, and apnea as well as hyper and hypo ventilation.
• Anoxia is the absence of oxygen in the body.
• Hypoxia is the state when cells and tissues cannot get enough oxygen.

Symptoms

• Dyspnea is a difficult breathing state.
• Cyanosis is the bluish or purplish discolouration of the skin or mucous membranes from low oxygen saturation and can be observed from nailbeds an oral mucosa.

Assessing Respiration

• The respiratory rate should be counted after monitoring pulse at one minute after the patient’s last reading.
• One complete cycle counts as one respiration where patients should not be told they are being measured.

Oxygen Saturation

• Pulse oximetry is a procedure that measures the level of oxygen saturating someone's blood.
• An easy, general way of telling how well oxygen is being delivered using a finger, ear, or nose.
• Higher readings (between 95-100 percent) under most circumstances shows good ratings.
• Lower readings (under 90 percent) are considered low and a lower than normal level of oxygen in the blood is Hypoxemia.

Blood Pressure

• Blood pressure measures the force the heart uses to pump blood around the body, recording diastolic and systolic measures.
• Systolic pressure measures on how the heart pushes blood, being ideal on average, between 90/60mmHg and 120/80mmHg.
• Diastolic pressure counts beat pressure in the heart when the heart is at rest between beats.
• Blood pressure is considered high, or Hypertension, when the diastolic pressure is at 140/90mmHg.
• Blood is considered low, or Hypotension, when the diastolic pressure value is at 90mmHg.
• Pulse pressure, a combination of the diastolic and systolic values, comes at an average rate between 30-50mmHg
• Factors like age, stress, race, gender, daily life, medicines, foods, and exercise can all affect blood pressure.

Measuring Blood Pressure

• Position the patient in supine, semi fowler-fowler.

• In seated position, the subject's arm should be flexed.

• Position the brachial artery 2-3 cm above the antecubital area.

• Make sure the pointer meter starts at zero and palpate the brachial artery.

• Inflate the cuff to the appropriate pressure, releasing air at the recommended rate.

• Check for sound, observe the knocking rate, monitor where sound starts and stops, and then measure on the other for additional measures.