Vital Signs in Nursing Practice

• Assist. Prof. Dr. Funda KARAMAN is the lecturer

Aim

• Understand and perform necessary nursing practices regarding vital signs

Purposes

• Vital signs need to be identified appropriately
• Normal values of vital signs must be known and evaluated
• Measuring vital signs must be evaluated

Contents

• Body temperature
• Pulse
• Respiration
• Oxygen saturation
• Blood pressure

Vital Signs Overview

• Basic indicators of an individual's health status
• Affected by different times of day, age, ovulation state, seasons, physical activity, dressing type, environmental heat, stress, disease

Guidelines on Assessing Vital Signs

• The nurse needs to obtain and evaluate vital findings and inform the team
• The equipment needs to be reliable
• Equipment used should be selected according to a patient's condition and characteristics
• Environmental factors should be considered
• Medical diagnosis, treatment, and medication needs to be known
• Normal values of vital signs should be known

Guidelines for Measurement

• Vital signs should be systematically measured at regular intervals
• Nurses need to communicate effectively with the patient when measuring
• The nurse should cooperate with the physician
• When vital signs are measured, they should be analyzed absolutely

Frequency of Vital Signs Measurement

• Vital signs should be checked when preparing a patient for admission
• Before and after surgery, when the frequency increases
• Before and after diagnostic procedures
• Before and after the administration of drugs that affect the heart and respiratory system
• If there is a sudden deterioration in a patient's condition
• Before and after medical interventions that may affect life signs
• When the patient feels a difference

Body Temperature

• A balance between heat produced and heat consumed
• Heat production - heat loss = body temperature
• Body temperature should be consistent and balanced
• Heat production/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 waste elimination (urine/feces/vomiting/blood)

Factors Affecting Body Temperature

• Age
• Exercise
• Hormone level
• Stress
• Environment
• Emotional states
• Basal metabolic rate
• Digestion of food
• Nutrition and sleep
• Diseases
• Induction of the sympathetic nervous system: adrenaline and noradrenaline

Regulation

• Thermoregulation center is the hypothalamus; it acts as a thermostat
• Vasodilation will decrease heat
• Sweating
• Muscle tremors increase heat
• Piloerection (steepening of feathers)

Temperature Changes

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

Normal Values and Measurement Sites

• Oral: 36.5°C - 37.5°C (Average 37°C)
• Ear: 36.5°C - 37.5°C (Average 37°C)
• Axillary/Forehead: 36°C - 37°C (Average 36.5°C )
• Rectal: 37°C - 38°C (Average 37.5°C )

Measurement types

• Oral, ear, axillary, forehead, rectal

Glass Thermometers Containing Mercury

• According to the Environmental Protection Agency (EPA), mercury is toxic and poses a threat to the health of humans, as well as to the environment
• Because of the risk of breaking, should not be used
• Forbidden by the Ministry of Health in 2009

Thermometer Types

• Digital, tympanic, etc.

Measuring Body Temperature

• Before every application, materials are prepared, hands are washed, gloves are worn if necessary, the patient is given information about the application, the patient is made comfortable and permission is obtained from the patient

Oral Measurement

• Degrees are placed right or left under the tongue
• Average temperature range = 36.5°C - 367.5°C
• Should not be taken for patients with dyspnea, children, the elderly, in psychiatric diseases, in non-conscious patients, after surgery, in mouth operations, in case of infection, and in patients on continuous oxygen
• When taking temperature orally, a few key points to remember include; the patient should have a personal thermometer, drinking or eating very hot or cold food can affect temperature measurement when measuring orally, advise patients not to eat or drink anything prior to measurement, the thermometer should be placed under the tongue, mouth should be closed during oral measurement, but the teeth should not be squeezed

Tympanic Measurement

• Measurement is made within 1-2 seconds
• The receiver is placed in the 1/3 of the outer ear
• Before measurement, a disposable plastic cover should be placed over the receiver

Rectal Measurement

• Used when heat cannot be taken by oral or axillary route
• Steps: room door and curtains closed, patient placed in sim's position flex with upper leg, gloves worn, water-soluble lubricant applied to the probe, patient's hips separated with hand, the patient asked to breathe slowly and deeply as degree is inserted into anus, and probe removed when signal sounds
• Should not be used for people that have rectal bleeding, rectum surgeries, birth, period of maternity, continuously as a routine, way in children, and diarrhea cases
• The degree is advanced; 2.5-3.5 cm in adult, 2-2.5 cm in children, 1.2 cm in newborn.

Axillary/Forehead Measurement

• The axillary region is the most commonly used region
• Infection is very unlikely to be transmitted
• The patient should have a personal thermometer
• The armpit should not be sweaty
• After heat is measured, the digital thermometer gives an alarm
• A special digital thermometer is used for this reading
• The device is placed on the forehead

Pulse

• The number of heartbeats per minute

Pulse Assessment

• While assessing the pulse, need to know pulse rate, pulse rhythm, pulse volume; must be assessed
• 60-100 for adults and 120-160 for newborns

Why The Pulse Is Counted

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

Pulse Rate

• The Number Of Heart Beats Per Minute with normal ranges of newborns being 120-160/min, children being 80-120/min, and adults being 60-100/min

Pulse Deviations

• 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

Pulse Rhythm

• Regular rhythm, if irregular the difference between apical pulse and radial pulse should be checked
• In arrhythmia, a deficit (Pulse deficit) develops
• Pulse deficit; the difference between the apical and peripheral pulse rates, and can signal an arrhythmia
• Occurs even when the heart is contracting, the pulse is not reaching the periphery

Pulse Volume

• Reflects the contraction power of the left ventricle
• Palpated easily with every beat being similar in fullness, known as a full or bounding pulse
• "Weak pulse" is difficult to palpate, with slight pressure disappears known as filiform pulse or thready pulse, difficult to palpate and develops in bleeding, shock, heart failure, pulse rate over 130 per minute

Peripheral Pulse Points

• Temporal artery (above the zygomatic arch, above and in front of the tragus of the ear)
• Carotid artery (neck)
• Apical (on the midclavicular line, in the fifth intercostal space)
• Radial artery (wrist)
• Ulnar artery (wrist)
• Brachial artery (medial border of the humerus)
• Femoral artery (at the groin)
• Popliteal artery (behind the knee)
• Dorsalis pedis (on foot)
• Posterior tibial arteries (near the ankle joint) (foot)
• In emergencies can use are apical/brachial/femoral (ages 0-1) Carotid (ages > 1)

Peripheral Pulse Taking Steps:

• Hands must be washed
• Authentication done
• Patient informed on application
• Evaluate conditions that will affect the patient
• Patient should be rested, and not be standing.
• The patient is given the appropriate position.
• The sign, middle, and ring finger are placed on the artery without excessive pressure (Two or three finger)
• If the pulse is measured for the first time, it is measured for 1 minute and is irregular. If the heart rate is regular, it is counted for 30 seconds and multiplied by two to find the heart rate.
• The findings are recorded.

Respiration

• Organs of the respiratory system Nose, pharynx, larynx, trachea, bronchi, lungs-alveoli
• Alveoli: Gas exchange point

Human Respiratory System

• Nose → Pharynx → Larynx → Trachea → Bronchi → Lungs → Alveoli

Inhalation and Exhalation

• When air is drawn in, the ribs move out, and the diaphragm moves down
• When air is forced out, the ribs move back, and the diaphragm moves back

Respiration

• A process that begins with breathing and involves the organism taking in and using O2 and releasing CO2

Stages of Repiration

• Exchange can happen on two levels
• External: O2 is released into the blood and CO2 is released through the respiratory and circulatory systems, between the atmosphere and the lungs
• Internal: O2 and CO2 exchange between cells and blood circulation

Stages of External Repiration

• Ventilation moves air in and out of lungs
• Diffusion describes the gas exchange between the alveoli and the blood
• Perfusion is a the system of blood flow that brings O2 & CO2 to your tissues

Ventilation

• Made of inspiration and expiration of air

Diffusion

• O2 passes from the alveoli to the lung circulation
• CO2 passes from the lung circulation to the alveoli

Perfusion

• O2, enters the lung circulation and is carried in the blood and passes to the tissues as CO2 accumulates in the tissues that enter the lungs through circulation

Repiration Indicators

• Saturation: diffusion and perfusion
• Respiratory rate: ventilation, depth, rhythm of breathing

Regulation

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

Respiratory Measurement

• Respiratory rate, depth, and type are very important

Respiratory Rate

• Normal rate ranges from 30-60/min for newborns and 12-20/min for adults

Respiratory Depth

• Assessed as deep, superficial, and normal
• Affected by body position, some medications, exercise, fear, anxiety
• The diaphragm increases by 1 cm in normal breathing
• The costa extend1.5-2.5 cm forward

Types of Respiration

• Eupnea presents with normal respirations, with equal rate and depth, 12-20 breaths/min
• Bradypnea presents with slow respirations, < 10 breaths/min
• Tachypnea presents with fast respirations, 24 breaths/mm, usually shallow
• Kussmaul's Respirations presents with respirations that are regular but abnormally deep and increased in rate
• Biot's Respirations presents with irregular respirations of variable depth (usually shallow), alternating with periods of apnea (absence of breathing)
• Cheyne-Stokes Respirations presents with gradual increase in depth of respirations, followed by gradual decrease and then a period of apnea
• Apnea presents without breathing
• Hyperventilation presents with increased rate and depth of breathing
• Hypoventilation presents with decreased rate and depth of breathing that is irregular

Respiratory Abnormalities

• Anoxia: Absence of oxygen
• Hypoxia: Cells and tissues can not get enough oxygen
• Dyspnea: Difficult breathing
• Cyanosis: Caused by lack of oxygen

Cyanosis

• Defined as the bluish or purplish discoloration of the skin or mucous membranes due to the tissues near the skin surface having low oxygen saturation
• Observed from the lips, ear lobes, nails, and oral mucosa

Assessing

• The rate rhythm and depth of respiration should be observed when assessing, normal would be regular in depth and rhythmn
• Should be done without saying anything, should never tell the patient, measure after measuring the pulse

Steps

• Materials need to be prepared, hands must be washed, information must be given to the patient, evaluate their condition of exercise, fatigue, and eating status
• The patient has to positioned so that the rib cage is visible
• After checking your watch, be sure to note the numbers as your counting starts
• Inspiration and Expiration is considered one Breath
• Check number of breaths in time allotted.
• If the breathing is normal, count for 30 seconds and multiply by two to find number of breaths per minute.
• Take respiratory rate before depth is looked at, patient must be comfortable, materials put away, hands washed, data recorded, and take steps necessary for taking action on irregular findings

Oxygen Saturation

• Oximetry: used to measure oxygen levels / saturation in blood and indicators of O2 provided to peripheral tissues. painless/ General
• Measured by amount of oxygen-rich hemoglobin through blood vessels

Levels of Normal vs. Abnormal

• Normal levels: 95%-100% normal
• Under 90%: low/ bad
• Hypoxemia: blood oxygen levels

Device

• Check where light source is

Blood Pressure

• Measures the force that the heart uses to pump blood around the body

Types of BP

• Systolic - The pressure when heart pushes blood out (systole of the ventricles)
• Diastolic - The pressure when the heart rests between beats (Diastole of ventricles)
• Systolic is higher number is normally 120, diastolic is lower/ normally 80
• As a guide: ideal blood pressure is considered to be between 90/60mmHg and 120/80mmHg
• High blood pressure is considered to be 140/90mmHg or higher; hypertension means high blood pressure

Pulse Pressure

• Numeric difference between systolic and diastolic blood pressure is called pulse pressure

Range

• The average pulse pressure is between 30-50mmHg

Factors Affecting Blood Pressure

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

Classifications

• Hypertension: World Health Organization states the limit value for hypertension in adults is 140/90mmHg
• Hypotension- Arterial blood pressure is below normal value, called "hypotension", and systolic blood pressure value is 90mmHg or lower

Materials for Taking BP

• Blood Pressure device
• Stethoscope
• Alcohol/ disinfectants
• Pen
• Reporting form
• Where to discard used items

Patients Position

• Must be relaxing, supine, semi fowler-fowler, sit
• When seated, their arm flexed
• Arm at heart level.
• Don't take if they anxious or did anything physical. Have the patient wait a few minutes, before taking BP

Performing Test

• Position patient- supin-fowler
• Place a blood pressure cuff, at 2-3 cm above area of arm and check that brachial area does not constrict
• Check pointer is at 0
• Locate brachial artery. Place the stethoscope at ear
• Feel the brachial pulse with your passive hand and place the diaphragm on the brachial artery and hold it fixed
• Rapidly inflate the cuff to 200-250 mmHg
• Slowly let air out and follow where it reads and listen.

Measurement Steps

• Repeat if the first reading, wait min. 2
• After blood test: arm with greater blood in higher arm is considered the patient blood level
• Note all values
• Clean for the next patient
• Rapidly inflate the cuff to 200-250 mmHg
• Release air from the cuff at a moderate rat and listen
• Know when the blood is reached. Be able to measure accurately by measuring Both arms accurately then repeat Make sure it goes on both sides.