Understanding Vital Signs

Vital Signs

• Vital signs are basic indicators of health status for an individual
• Assessment of vital signs helps to determine ability to perform necessary nursing practice

Purposes

• Assists in the identification of vital signs appropriately
• Assists with recognising and evaluating normal vital sign ranges
• Aids evaluation via measuring vital signs

Contents

• Body Temperature
• Pulse
• Respiration
• Oxygen Saturation
• Blood Pressure

Factors that may affect vital findings

• Different times of the day
• Age
• Ovulation state
• Seasons
• Physical activity and exercise
• Dressing type
• Environmental heat
• Stress
• Disease

Guidelines on assessing Vital Signs

• A nurse should know how to obtain and evaluate vital findings and how to communicate these to team members
• Equipment being used needs to be reliable
• Appropriate equipment must be selected based on the patients condition and characteristics
• Normal values of vital signs should be known
• Patient's medical diagnosis, treatment and medication information should be known
• Environmental factors should be considered when assessing vital signs
• Vital signs should be measured at regular intervals in a systematic manner
• The nurse should be able to communicate effectively with a patient when measuring their vitals
• The nurse should cooperate with the physician
• When vital signs are measured, they should be analyzed absolutely.

Frequency of Vital Signs Measurement

• When preparing a patient for admission to care facility
• Before and after surgery ( frequency of assessment increases)
• Before and after diagnostic procedures are carried out
• Before and after administration of drugs that can affect the heart and respiratory system
• If there is sudden deterioration of the patient's condition
• Before and after medical interventions that may affect life signs
• When the patient reports that they feel a difference or change in condition

Body Temperature

• Body temperature is the balance between heat produced and consumed
• Heat production minus heat loss equals body temperature
• 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(breathing), skin (sweating) and wastes from the body including; urine, features, vomiting, blood
• Factors affecting body temperature include: age, exercise, hormone level , stress, environment, emotional state, basal metabolic rate, digestion of food, nutrition and sleep, diseases and induction of the sympathetic nervous system(adrenaline and noradrenaline)
• Thermoregulation control center is the Hypothalamus
• The hypothalamus acts as a thermostat
• Vaso-dilation reduces body temperature
• Sweating reduces body temperature
• Muscle tremors increase body temperature
• Piloerection (steepening of feathers) increases body temperature

Temperature Changes

• Hypothermia is defined as a body temperature of 35°C or below
• Hyperthermia is defined as a body temperature of 38°C and above

Normal Values for Body Temperature

• Oral: Minimal 36.5°C, Maximal 37.5°C, Average 37°C
• Ear: Minimal 36.5°C, Maximal 37.5°C, Average 37°C
• Axillary: Minimal 36°C, Maximal 37°C, Average 36.5°C
• Forehead: measurement must be possible
• Rectal: Minimal 37°C, Maximal 38°C, Average 37.5°C

Measuring body temperature considerations;

• Before every application, materials should be ready
• Hands must be washed and appropriate gloves worn
• The patient should receive all information about the application
• The patient should be made comfortable and permission should be obtained before process begins

Oral Measurement

• Oral method requires thermometer is placed right or left under the tongue
• Expect an average reading between 36.5°C - 367.5°C
• Do not take oral temperatures for patients with dyspnea, children, the elderly, patients with psychiatric diseases, non-conscious patients, post surgery patients, or those in case of infection or in patients on continuous oxygen
• When taking a temperature orally, confirm the patient has their own thermometer
• Avoid drinking or eating very hot or cold foods can affect temperature measurement when measuring orally and advise patients not to before measurement takes place
• The thermometer should be placed under the tongue
• Mouth should be closed during oral measurement, but the teeth should not be squeezed

Tympanic Measurement

• Using a tympanic thermometer a measurement is made within 1-2 seconds
• During the procedure, the receiver is placed in the 1/3 of the outer ear
• Prior to measurement, a disposable plastic cover should be placed over the receiver

Rectal measurements

• Rectal measurements to obtain body measures when this can’t be done by oral or axillary routes
• A reading of 37 °C - 38 °C is expected using this method
• To conduct measurement successfully, close the room door and curtains
• The patient must be in sims position and flex the upper leg
• Wear gloves
• Apply water-soluble lubricant to the probe
• Separate the patient's hips with your hand
• Ask the patient to breathe slowly and deeply, insert the degree into the anus
• When the signal sounds, remove the probe
• Advance the degree: for adults to 2.5-3.5cm, children to 2-2.5cm and newborns only 1.2cm into the rectum
• Do not take rectal temperatures on patients in rectal bleeding, post rectum surgeries, during birth or in the period of maternity or continuously as a routine way in children or those that have diarrhea

Axillary / Forehead measurement

• Axillary region is most commonly used to obtain a temperature
• Infection is very unlikely to spread using this method
• The patient should have their own / personal thermometer
• The armpit should not be sweaty
• Normal value range 36-37°C
• Special digital thermometer must be used

Pulse

• Pulse is the number of heartbeats per minute
• When assessing pulse, analyse; pulse rate, pulse rhythm and pulse volume

Pulse Rate Values ( in beats per minute)

• Newborn expects 120-160
• Child expects 80-120
• Adult expects 60-100
• Bradycardia means pulse rate is below 60 beats per minute
• Tachycardia means pulse rate is above 100 beats per minute
• Accurate pulse assessment informs decisions on rate, rhythm and contraction

Factors Affecting Pulse Rate

• Exercise
• Hyperthermia
• Hypothermia
• Acute pain and anxiety
• Chronic pain
• Drugs
• Age
• Gender
• Metabolism
• Bleeding
• Posture change

Pulse Rhythm

• With a regular heartbeat, it is called regular rhythm but if it is irregular, it is called irregular rhythm
• When arrhythmia presents, difference between apical pulse and radial pulse should be checked
• Arrhythmia signals that a pulse deficit is developing, defined as the difference between the apical and all peripheral pulse rates
• Pulse deficit; this occurs even as the heart is contracting, but the pulse isn't reaching the periphery resulting in cases where the radial pulse measuring lower than the apical pulse, and those two pulse rates is called " Pulse deficit ".

Pulse Volume

• Pulse Volume, the fullness of the pulse, and the left ventricular reflects the contraction power.
• Normally, when the pulse is palpated, it is easily found and every beat is felt in similar fullness creating a full or bounding pulse.
• In cases where 'weak pulse' is difficult to palpate, despite using finger pressure and then pulse easily disappears, weak pulse is also called «filiform pulse» or «thready pulse»
• This pulse is palpated as very difficult and develops in bleeding, shock and heart failure situations
• Weak pulse, filiform and thready pulses present when rate is over 130 per minute

Sites to Assess Pulse

• Temporal artery: above the zygomatic arch, above and in front of the tragus of the ear
• Carotid artery is located in the neck
• Apical artery is along the midclavicular line, in the fifth intercostal space
• Radial artery is located at the wrist
• Ulnar artery is located along the wrist
• Brachial artery is along the medial border of the humerus
• Femoral artery is located at the groin
• Popliteal artery is found behind the knee
• Dorsalis pedis is found along the foot
• Posterior tibial arteries (near the ankle joint) (foot)
• Emergency pulse points for patients 0-1 years; apical/brachial/femoral artery
• Emergency pulse point from 1 year onward; carotid artery

Process for Peripheral Pulse Taking

• Wash hands
• Complete authentication
• The patient / family is informed about the application
• Evaluate the factors that will affect the patient's condition and pulse rate prior to pulse measurement
• The patient should not be standing but resting
• The patient is given an appropriate position
• Place the sign, middle, and ring finger on the artery without excessive pressure (two or three fingers)
• If the pulse is measured for the first time and is irregular, it is counted for 1 minute, if heart rate is found to be regular, it can be counted for 30 seconds and multiplied by 2 to find rate
• The findings are recorded

Respiration

• Organs involved respiratory system include nose, pharynx, larynx, trachea, bronchi and lungs with alveoli

Respiration Process

• Respiration involves the organism taking in and using O2 and releasing CO2, including two different stages
• Stage one is external and occurs between the atmosphere and the lungs where O2 is released into the blood and CO2 is released through the respiratory and circulatory systems.
• Stage two is internal and signals O2 and CO2 exchange between cells and blood circulation.
• Respiration contains three main processes: ventilation, diffusion and perfusion
• Ventilation contains inspiration and expiration processes
• Diffusion sees O2 pass from the alveoli to the lung circulation and CO2 passing from the lung circulation to the alveoli
• Perfusion is the process by which O2, which enters the lung circulation, is carried in blood and passes to the tissues, and CO2 accumulated in the tissues enters the lungs through circulation.
• Measurement also involves analysing:
  • Saturation - diffusion and perfusion
  • Respiratory rate/depth/rhythm - ventilation
• The respiratory center is located in medulla oblongata and pons in the brainstem

Respiratory Measurement

• Respiratory rate determines breaths per min with newborn range 30-60 and adults 12-20
• Respiratory depth needs consideration with assessment for indications of deep, superficial or normal
• Respiratory depth can be affected by body position, medications, exercise, fear or anxiety.
• The diaphragm increases by 1 cm in normal breathing
• The costa will extend 1.5-2.5 cm forward

Respiratory Types:

• Eupnea: Normal respiration, with equal rate and depth, 12-20 breaths/min
• Bradypnea: Slow respiration, < 10 breaths/min
• Tachypnea: Fast respirations, >24 breaths/min, usually shallow
• Kussmaul's respirations: Regular respirations but abnormally deep and RR increased
• 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 then a period of apnea
• Apnea: Absence of breathing
• Hypoventilation : decreased rate and depth of breathing, will be irregular
• Hyperventilation is recognized by an increased rate and depth of breathing
• Anoxia is the absence of oxygen
• Hypoxia is marked when cells and tissues can not get enough oxygen
• Dyspnea presents when there is difficult breathing
• Cyanosis marks the bluish or purplish discolouration of the skin or mucous membranes where the skin surface indicates there is lower levels of oxygen saturation but it can be clearly observed from the lips, ear lobes tails and oral mucosa

Assessing Respiration

• When doing so, observe the rate, rhythm, and depth of respiration and recognize that normal respiration is regular in depth and rhytm
• After the pulse is counted, the respiratory rate is counted by observing the chest wall

The counting of process includes;

• Number of respirations with chest rising and falling for measurement minute
• Full cycle, indicated by how you define ONE complete respiration
• You should never alert and inform the patient what you are counting
• Measure respiration after measuring taking pulse
• Prepare the materials
• Wash your hands
• Give information/ updates to the patient before procedure
• Evaluate the patient's exercise, fatigue, and eating status
• Position the patient so that the rib cage is visible
• Check timing on watch and remember the value at which you started to count on
• Each complete expiration and inspiration value makes up one full breath
• If breathing is regular, count for 30 seconds and multiply by 2 to find the number of respirations per minute
• If breathing is not regular, count for 1 minute.
• After counting the respiratory rate, the depth of the breathing should also be analyzed
• Position the patient comfortably
• Put away the materials
• Wash your hands
• Record findings and take necessary precautions for abnormal findings.

Oxygen Saturation

• Pulse oximetry measures the oxygen level in the blood (or oxygen saturation) in the blood
• It is a considered to be a noninvasive, painless, general indicator of oxygen delivery to peripheral tissues (such as the finger, earlobe, or nose).
• Pulse Oximetry measures the maximum amount of oxygen-rich hemoglobin pulsating through the blood vessels
• Normal pulse oximeter readings range from 95 to 100%
• Values under 90 %are considered low and point towards hypoxemia( a lower than normal level/saturation of oxygen in your blood)
• During the procedure, the finger probe is placed so that, the light source is on the finger

Blood Pressure

• Blood pressure is a measure of the force that heart uses to push blood round your body
• Systolic pressure is the pressure when heart pushes blood out (systole of the ventricles)
• Diastolic pressure is the pressure when heart is at rests between beats (Diastole of ventricles)
• ideal blood pressure is considered to be between 90/60mmHg and 120/80mmHg
• high blood pressure i (hypertension)s considered to be +140/90mmHg
• low blood pressure (hypotension) is considered to be 90/60mmHg or lower
• Pulse pressure is the numeric difference between systolic and diastolic values in blood pressure
• Resting blood pressure reads as 120/80 millimeters of mercury (mm Hg), pulse pressure is 40
• A normal average pulse pressure is between 30-50mmHg

Factors that Affect Blood Pressure

• Age
• Stress
• Race
• Gender
• Daily life
• Medicines
• Foods and diet
• Exercise

Hypertension and Hypotension

• The World Health Organization cites the limit value for hypertension, in adults, +140/90mmHg
• Arterial blood pressure presenting value that is below normal is recorded and named "hypotension"
• Systolic blood pressure value that reports at 90mmHg or lower, points to hypotension

How to measure blood pressure:

• Blood Pressure Monitor (Sphygmomanometer)
• Stethoscope
• Suitable Disinfectant
• Pen and Registration Form
• Waste Container

Measuring Considerations

• Seat the patient in supine or semi fowler-fowler position
• Subject's arm should be flexed when sitting
• The flexed elbow should be at the level of the heart
• Before procedure begins, if the patient has anxiety or has had an activity wait a few minutes
• When taking blood measure at supine position, ensure patient sits with head upright
• Position yourself close to the seated subject
• Place a blood pressure cuff and report accurate reading
• Blood pressure cuff should be placed 2-3 cm above the antecubital area, brachial artery should not be closed.
• Confirm pointer starts at zero
• Ensure you palpate the brachial artery
• Place your stethoscope ear
• Feel your brachial pulse with your passive hand and place the diaphragm on the brachial artery and hold it fixed.
• Rapidly inflate both the cuff to 200-250 mmHg
• Release air from the cuff at a moderate rate (3mm/sec)
• Listen with the stethoscope and simultaneously observe the dial or mercury gauge.
• The first knocking sound, is the subject's systolic pressure with the knocking sound disappearing as pressure becomes diastolic (reading of 120/80).
• Measure BP from both arms the first time
• If it is the individual's first measurement, repeat procedure for measurement on the other arm, if measuring from the same arm then wait at least 2 minutes.
• After checking the blood pressure in both arms, the blood pressure in the higher arm is considered the patient's blood pressure value.
• Record the values clearly and accurately.
• Finally, wash your hands thoroughly