Vital Signs and Age Considerations

• Vital signs indicate basic body functioning.
• Vital signs include body temperature, pulse, respiration, blood pressure, pain, and pulse oximetry.

When to Assess Vital Signs

• On admission, transfer, and discharge
• Before any procedure
• Before administering affect vital signs medications
• When there is a change in condition
• Routinely

Age Considerations for Older Adults

• Thermoregulation involves body's attempts to adapt to temperature.

• Symptoms of infection may differ in older adults.

• Infection symptoms include decreased heart rate and pulse irregularities.

• Anatomical changes can occur.

• Older adults may experience orthostatic hypotension and a head rush.

• Obtaining a pulse oximetry reading may be difficult.

• Auscultation involves listening.

• Pyrexia, febrile, and hyperthermia all indicate fever.

• Hypothermia is defined as a body temperature of 93.2°F or below.

• Normal oral temperature: 98.6°F

• Normal rectal temperature: 99.6°F

• Normal axillary temperature: 97.6°F

• Temperature can be taken orally (mouth), tympanically (ear), axillary (armpit), rectally (rectum), or temporally (forehead).

• Sublingual temperature is taken under the tongue.

Factors Affecting Body Temp

• Age
• Exercise
• Hormones
• Stress
• Environment
• Food
• Smoking

Pulse Measurement Sites

• The pulse results from the regular expansion and contraction of an artery.
• This action is caused by pressure from the heart ejecting blood.
• The most accurate pulse measurement site is the apical pulse, representing the heart's beat.
• Radial pulse is measured in groove along radial side of forearm, lateral to flexor tendon of wrist
• Pulse deficit refers to differences between radial and apical pulse rates.
• Tachycardia is defined as a heart rate faster than 100 beats per minute.
• Bradycardia is defined as a heart rate slower than 60 beats per minute.

Influences on Pulse Rate

• Pain
• Age
• Exercise
• Fever
• Hemorrhage

Pulse Documentation

• 0: Absent, indicating no pulse felt
• +1: Thready, indicating a pulse that is difficult to feel
• +2: Weak, indicating a pulse that is somewhat stronger
• +3: Normal, indicating a pulse that is easily felt
• +4: Bounding, indicating a pulse that feels full

Respiration Assessment

• Assess the rate, depth, quality, and rhythm observed when assessing respiration.
• Respiration assessment involves observing the movement of the diaphragm and intercostal muscles.
• Dyspnea is breathing with difficulty.
• Inspiration is inhaling air with oxygen.
• Expiration is exhaling air with carbon dioxide.
• Tachypnea is a rapid respiratory rate.
• Bradypnea is a slow respiratory rate below 10 breaths per minute.
• Cheyne-Stokes respiration is characterized by alternating periods of apnea and deep, rapid breathing.
• Systolic pressure (higher range) represents the ventricles contracting.
• Diastolic pressure (lower range) is the second pressure.
• The difference between the two readings is called the pulse pressure

Blood Pressure Ranges

• Healthy: Less than 120 (systolic) and less than 80 (diastolic)
• Elevated: 120-129 (systolic) and less than 80 (diastolic)
• Stage 1 hypertension: 130-139 (systolic) or 80-89 (diastolic)
• Stage 2 hypertension: 140 or higher (systolic) or 90 or higher (diastolic)
• Hypertension crisis: Over 180 (systolic) or over 120 (diastolic)
• If blood pressure is abnormal, re-take on different arm after 15 minutes

Pain Scale

• Used to measure pain
• Ranges from 0-10
• 0 indicates no pain
• 10 indicates worst pain

Pulse Oximetry

• Normal range is 95-100 percent.
• Factors affecting pulse oximetry readings include fake nails, smoking, and cold extremities.

Vital signs are indicators of basic body functions including pulse, respiration, blood pressure and temperature. For older adults, consider anatomical changes, orthostatic hypotension, and potential difficulties in obtaining accurate pulse oximetry readings. Monitoring vital signs is crucial upon admission, before procedures, medication administration, and when condition changes.