Vital Signs Assessment in Nursing

• Vital signs are fundamental indicators to evaluate an individual’s health status.
• Necessary nursing practices regard vital signs.
• The ability to perform necessary nursing practices regarding vital signs is necessary.
• Appropriately identify vital signs.
• Normal values of vital signs should be known and evaluated.
• Vital signs are evaluated by measuring.

Contents of Vital Signs Assessment

• Body temperature

• Pulse

• Respiration

• Oxygen saturation

• Blood pressure

• Many factors can lead to changes in vital findings.

• Different times of day can affect vital findings.

• Age, ovulation state, seasons, and physical activity can alter vital sign measurements.

• Dressing type, environmental heat, stress, and presence of disease can result in varied vital signs.

Guidelines on Assessing Vital Signs

• Nurses need to know how to obtain and evaluate vital signs.
• Knowing how to inform team members about vital signs is important.
• Instruments should be reliable.
• Equipment selected must accord with the patient's characteristics and condition.
• Normal ranges for vital signs should be understood.
• Diagnosis, treatments, and medication must be known.
• The patient's medication, medical diagnosis and treatment should be known.
• When assessing vital signs, consider environmental factors.

Vital Sign Measurement Guidelines

• Vital signs should be measured at regular intervals in a systematic way.
• Nurses have to communicate effectively with the patient while vital findings are being measured.
• Nurses should work with physicians.
• After measurement, vital signs should be analyzed.

Frequency of Vital Signs Measurement

• Preparation for patient admission requires measurement.
• Frequency increases before/after surgery.
• Before and following diagnostic procedures.
• Before and after heart or respiratory affecting drugs are administered.
• Measurement is needed during sudden patient condition deterioration.
• Both before and after medical actions that affect life are required.
• In the event of the patient feeling a difference.

Body Temperature

• Body temperature shows the heat produced versus heat consumed balance.
• Heat production minus heat loss results in body temperature.
• Body temperature must be consistent and balanced.
• Heat production must equal heat consumption.
• The body produces heat through food.
• Heat loss passes outwards through the lungs/breathing and skin/sweating.
• Heat is released through excretion of wastes like urine, vomit and blood.

Factors that Affect Body Temperature

• Age
• Exercise
• Hormone Levels
• Stress, environment, emotional state and diseases impacts temperature.
• Basal Metabolic Rate
• Digestion of food
• Nutrition and Sleep
• Induction of the sympathetic nervous system (adrenaline and noradrenaline).

Regulation of Body Temperature

• The thermoregulation center is the hypothalamus.
• The hypothalamus acts as a thermostat.
• Vasodilation causes decrease in heat.
• Sweating cools the body.
• Muscle tremors and piloerection increases heat.

Temperature Changes

• Hypothermia means the body temperature is at or below 35°C.
• Hyperthermia the body temperature is above 38 °C.

Normal Body Temperature Values by Measurement Site

• Oral measurement range: 36.5°C - 37.5°C, average of 37°C
• Ear measurement range: 36.5°C - 37.5°C, average of 37°C
• Axillary and forehead measurement range: 36°C - 37°C, average of 36.5°C
• Rectal measurement range: 37°C - 38°C, average of 37.5°C

Measuring Body Temperature - General Guidelines

• Materials must be prepared.
• Gloves are worn if necessary and hands are washed.
• Full information must be given and consent obtained from the patient, and they should be kept comfortable.

Oral Measurement

• Place thermometer under the tongue, at either the right or left side.
• Average oral measurement range: 36.5 °C - 37.5 °C, 37°C average.

Situations to Avoid Oral Temperature Measurement In

• Patients with dyspnea.
• Children and the elderly.
• Patients who are non-conscious or psychiatrically ill.
• Following surgery.
• In the event of mouth operations or chances of infection.
• Patients on continuous oxygen.

Important Points for Oral Temperature Taking

• The patient needs to have a personal thermometer.
• Consumption of cold or hot food/drink impacts the reading.
• Prior to measurement, patients must not drink or eat anything.
• Place the thermometer under the tongue, and keep mouth closed without squeezing teeth.

Tympanic Measurement

• Measurement occurs in 1–2 seconds.
• The receiver rests in the outer ear's first third.
• Prior to measurement, apply a disposable plastic instrument to the receiver.

Rectal Measurement

• Utilize this approach when temperature readings are unobtainable through oral or axillary means.

Rectal Measurement Procedure

• Close the curtains and the room door.
• The upper leg should be flexed and the patient put in Sim's position.
• Gloves must be worn.
• Lubricate the probe using water-soluble products.
• With one hand, separate the patient's hips and insert the degree into the anus as they deeply and slowly breathe.
• Once the signal sounds, pull out the probe.
• Adults 2.5-3.5 cm, children 2-2.5 cm, and newborns 1.2 cm is the degree advancement.

Situations to Avoid Rectal Temperature Measurement In

• Rectal bleeding
• Following a rectal surgery or birth
• The time of maternity
• Diarrhea cases
• Routine in children

Axillary/Forehead Measurement

• The axillary region is most commonly used.
• Transmission of an Infection is very unlikely.
• The patient should have a personal thermometer.
• Do not measure if the armpit is sweaty.
• A special digital thermometer is used.
• The device rests on the forehead.

Pulse

• Pulse indicates the number of heartbeats each minute.
• The number of heartbeats each minute is the pulse.
• Assess the pulse, focusing on rate, rhythm and volume.
• Pulse for adults is 60-100.
• Pulse for newborns is ~120-160.

Importance of Counting Pulse

• To determine the rate rhythm and contraction of the heart,
• In order to identify peripheral vascular diseases

Pulse Rate

• Pulse rate is the number of heart beats per minute.
• Newborn's pulse rate should be around 120-160/min.
• A child's pulse rate should be around 80-120/min.
• Pulse ranges per minute in adults ought to be 60-100.
• Bradycardia: pulse rate below 60 beats per minute.
• Tachycardia: pulse rate above 100 beats per minute.

Factors Affecting Pulse Rate

• Exercise
• Hyperthermia
• Hypothermia
• Acute pain and anxiety
• Chronic pain
• Drugs
• Age
• Gender
• Metabolism
• Bleeding
• Posture change
• Regular and irregular rhythms refers to arrhythmia.

Pulse Rhythm

• If there is arrhythmia, the difference between apical pulse and radial pulse should be checked.
• In arrhythmia, a deficit (Pulse deficit) develops.
• Pulse deficit shows the apical and peripheral pulse rate difference and may signal an arrhythmia.
• When the heart contracts, the pulse isn't reaching the periphery.
• The radial pulse is lower than the apical rate, and these two pulse rates is called "Pulse Deficit".
• Evaluation is done by 2 people.
• Simultaneously, one person counts the apical pulse with a stethoscope, while the second person counts the radial pulse.
• Apical pulse 90 beats per minute, radial pulse 72 beats per minute shows a pulse deficit of 18.

Pulse Volume

• Pulse volume, or fullness shows the left ventricular contraction strength.
• Normally, the pulse is easily palpated.
• Under normal circumstances the full or bounding pulse is easily found and every beat is felt.
• "Weak Pulse" is difficult to palpate - pressure causes the pulse to disappear, also called «filiform pulse» or «thready pulse».
• Difficult to palpate this pulse means it may evolve into heart failure, bleeding or shock.
• The pulse rate is greater than 130 each minute: Weak pulse= filiform pulse=thready pulse.

Pulse Points

• Temporal
• Carotid
• Apical
• Brachial
• Radial
• Ulnar.
• Femoral
• Popliteal
• Posterior Tibial
• Dorsalis Pedis

Artery Locations

1. Temporal: above the zygomatic arch, in front of the ear's tragus.
2. Carotid: neck
3. Apical: on the midclavicular line, in the fifth intercostal space.
4. Radial: wrist
5. Ulnar: wrist
6. Brachial: the humerus' medial border.
7. Femoral: the groin.
8. Popliteal: behind the knee
9. Dorsalis Pedis: foot
10. Posterior Tibialis: ankle joint, foot

• 0-1 age; apical / brachial/femoral artery are emergency pulse points.
• 1 age; carotid artery is the emergency pulse point.

Peripheral Pulse Taking - Procedure

1. The hands are washed.
2. Authentication is done.
3. Tell the Patient, / inform family about the application.
4. Patient condition and pulse factors should be evaluated.
5. It is imperative that the resting patient be rested, and not standing .
6. Provide the patient with an appropriate position. 7- The sign, middle, and ring finger are placed on the artery without excessive pressure (Two or three finger). 8- If the pulse is measured for the first time and is irregular, it is counted for 1 minute. If the heart rate is regular, it is counted for 30 seconds and multiplied by two to find the heart rate. 9- The findings are recorded.

Respiration

• Organs of the respiratory system include the nose, pharynx, larynx, trachea, bronchi, lungs - alveoli.
• The breathing process involves the organism taking in and using O2 and also releasing CO2.
• There are two different stages:

Stages of Breathing

• External ventilation occurs between the athmosphere and lungs releases O2 turns into the blood, while releasing CO2.

• Internal ventilation, (tissue respiration) is the exchange of O2 and CO2 between cells and blood circulation.

• Three items impact respiration: Ventilation, Diffusion and Perfusion.

• The items of Diffusion and perfusion cause saturation.

• Respiratory rate, depth and rhythm of breathing all impact ventilation.

• Ventilation: inspiration and expiration

• Diffusion means O2 is transferred from the alveoli to the lung circulation, and CO2 is transferred from the lung to the alveoli.

• Perfusion: O2 enters the lung circulation, is carried in the blood and passes to the tissues, and CO2 accumulated in the tissues enters the lungs through circulation.

• Respiratory regulation center is at the medulla oblongata and pons in the brainstem.

• There are three items in respiratory regulation measurement: respiratory rate, depth and type which are very important.

• Respiratory rate for a newborn is 30-60/min, and 12-20/min for adults.

• Respiratory depth is assessed as deep, superficial, and normal.

• Respiratory depth is affected by body position, some medications, exercise, fear, anxiety.

• Normal breathing:diaphragm expands, Costa Extend.

Respiratory Terms & Definitions

• Eupnea is normal breathing.
• Bradypnea is slow breathing.
• Tachypnea is fast breathing.
• Apnea is absent breathing.
• Hyperventilation means increased breathing rhythm and depth.
• Hypoventilation means decreased and irregular breathing rate and depth.
• Anoxia is an absence of oxygen.
• Hypoxia-Cells cannot get oxygen .
• Dyspnea is difficulty breathing.
• Cyanosis is when skin turns blush due to low oxygen reaching cells.
• Cyanosis can be clearly observed from the lips, ear lobes nails and oral mucosa.
• Normal respiration has a regular depth and rhythm.

Assessing Respiration Guideline

• One should never reveal they are counting patient's respiration.
• Respiration should measured after measuring pulse.
• Pulse is measured, and depth and rate of respiration are measured by observing chest wall.
• Measure for one minute, and count each breath cycle.
• Prepare materials such as watch.
• Be sure to wash hands.
• Inform patient prior to examination
• Evaluate their activity, fatigue, and eating
• Place them at a position to see rib cage.
• Evaluate the value is an average.
• Regular:30 secs and multiply by two.
• Regular: Count 1 minute
• Reposition patient comfortably.
• Restock materials after.
• Record and prevent normal findings.

Oxygen Saturation

• Oxygen saturation is measured with pulse oximetry.
• Pulse oximetry : non- invasive, general indicator of oxygen delivery (finger, earlobe, or nose).

Oxygen Values

• Normal pulse oximeter readings range 95–100%.
• Readings below 90% are low.
• Hypoxemia indicates abnormally low oxygen level.
• The finger probe must rest on the light area.

Blood Pressure

• Blood pressure is a measure of the force that heart puts when blood is flowing throughout body.
• Systolic is the pressure exerted when the heart pushes blood out.
• Diastolic is the pressure when heart is resting between beats.
• Ideal blood pressure is between 90/60mmHg and 120/80mmHg.
• 140/90mmHg or higher shows high blood pressure.
• Less than 90/60mmHg is low blood pressure.

Factors that Affect Blood Pressure

• Age
• Stress
• Race
• Gender
• Daily life
• Medicines
• Foods
• Exercise
• The numerical difference between systolic and diastolic blood pressure is called pulse pressure.
• Resting blood pressure = 120/80 millimeters of mercury and that pulse pressure is= 40. Normal =30-50mmHg.
• World Health specifies the limit for 140/90mmHg.
• Hypotension=Systolic blood pressure value is 90mmHg or lower.

Materials to Measure Blood Pressure

• Stethoscope

• Waste container

• Sphygmomanometer

• Disinfectant and pen

• Supine or seated position- elbow should be leved at the heart.

• The arm should be flexed.

• If having previous activity, provide a break to obtain accurate readings.

Guidelines of Taking Proper Blood Pressure

• Place a blood pressure cuff by using the Fowler position.
• 2-3 cm above the area, brachial artery can be closed.
• Make sure pointer starts at zero
• Palpate the brachial artery
• Use the stethoscope ,while putting passive to touch pulse -apply diaphragm to brachial, and hold it together.
• In the absence of a bulb, rapidly inflate to 200–250 mmHg.
• Release at:3mm/sec
• Listen with: diaphragm and reading.
• Take both arm and the first knocking sound when taking to get right numbers.

Recording and First Measurements Blood Pressure

• Repeat to verify the measurements.
• Check blood pressure of both arms.
• Check in higher arm to see is it is not higher to cause problems
• Remember values. If taking the measurements on the other arm. wait for minutes.