Vital Signs: Indicators and Assessment

Vital Signs: Basic Indicators

• Vital signs serve as fundamental indicators of an individual's overall health status.

Purpose of Vital Sign Assessment

• Vital signs are a necessary ability when conducting nursing practices.
• Vital signs assessment includes identifying vital signs, evaluation normal values, and measuring.
• Recognizing typical values of vital signs allows healthcare providers to evaluate a patient's condition.

Components of Vital Signs

• Key vital signs to monitor are body temperature, pulse rate, respiration rate, blood oxygen saturation, and blood pressure.

Factors Affecting Vital Sign Measurements

• Various factors can influence vital signs.
• Some factors which lead to changes in vital findings are time of day, age, ovulation state, season, physical activity, dressing type, environmental heat, stress, and disease.

Guidelines for Accurate Vital Sign Assessment

• Nurses must know how to obtain and interpret vital sign readings.
• Vital sign equipment should be reliable when used.
• Select equipment based on the patient's condition and particular needs.
• Normal vital sign ranges should be known.
• A patient's medical history including diagnoses, treatments, and current medications is important.
• Environmental factors should be taken into account during vital sign measurement.
• Vital signs should be measured regularly and systematically.
• Nurses should communicate effectively with patients during the process.
• Collaboration with physicians is essential for optimal patient care.
• Measured vital signs need to be analyzed as soon as they are available.

Frequency of Vital Sign Measurement

• Vital signs should be measured when preparing a patient for admission.
• Measurement should be taken before and after surgical procedures, with increased frequency postsurgery.
• Testing is required before and after diagnostic procedures.
• Testing is required before and after the administration of drugs affecting the heart and respiratory system.
• Measurements should be taken if deterioration of a patient's condition is sudden.
• Measurements should be taken before and after medical interventions with potential on life signs.
• When the patient reports feeling different or unwell, vital signs should be checked.

Body Temperature Regulation

• Body temperature is the balance between heat produced and heat consumed.
• Heat production minus heat loss is equal to body temperature.
• Consistent and balanced body temperature is essential.
• Heat production and consumption need to be equal.
• Food consumption generates heat in the body.
• Exhaling, sweating, and eliminating bodily wastes are mechanisms of heat loss.

Factors Influencing Body Temperature

• Age, exercise, hormone levels, stress, environment, emotional state and basal metabolic rate affect body temperature.
• Digestion of food, nutrition/sleep, diseases, and induction of the sympathetic nervous system(adrenaline/noradrenaline) all have an effect.

Thermoregulation Center

• The thermoregulation center is located in the Hypothalamus.
• The hypothalamus regulates body temperature.
• Vasodilation decreases in heat.
• The body cools off by seating,
• Increasing muscle tremors helps generate heat.
• Piloerection will heat the body from increased muscle tremor.

Temperature Changes: Hypothermia and Hyperthermia

• Hypothermia occurs when body temperature drops to 35°C or lower.
• Hyperthermia is when body temperature rises above 38°C.

Normal Body Temperature Values and Measurement Sites

• Normal temperatures vary based on measurement site.
• 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 from 36°C to 37°C, with an average of 36.5°C.
• Rectal temperature ranges from 37°C to 38°C, with an average of 37.5°C.

Glass Thermometers with Mercury

• Mercury is toxic and threatens human and environmental health.
• Glass thermometers with mercury are not to be used.
• The Ministry of Health forbade these thermometers in 2009.

Body Temperature Measurement: Preparation

• Before measuring body temperature, ensure all materials are prepared.
• Hands should be washed, and gloves should be worn if necessary.
• The patient should be informed about the process.
• Ensure patient comfort and obtain permission.

Oral Measurement of Body Temperature

• A thermometer is placed either right or left under the tongue.
• The normal range for the oral temperature measurement is 36.5°C - 367.5°C.

Oral Temperature Measurement: Contraindications

• Oral temperature measurements should be avoided in patients with dyspnea, children, and the elderly.
• Oral temperature measurements should be avoided in patients with psychiatric diseases, non-conscious patients, and after surgery.
• Oral temperature measurements should be avoided in patients with a mouth injury, infection, or on continuous oxygen.

Key Considerations for Oral Temperature Measurement

• Oral temperature measurements should be performed with a personal thermometer.
• Advise patients that 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.
• Ensure the thermometer is placed under the tongue.
• The mouth should be closed but the teeth should not be squeezed.

Tympanic Temperature Measurement

• Tympanic measurement takes 1-2 seconds.
• The receiver is positioned in the outer ear, 1/3 in.
• A disposable plastic covers the receiver tip.

Rectal Temperature Measurement

• Rectal measurement is used in cases where oral or axillary is not possible.

Rectal Measurement Technique

• Close the room door and curtains for privacy.
• Place the patient in the Sim position and flex the upper leg.
• Gloves should be worn.
• Apply a water-soluble lubricant to the probe.
• Separate the patient's hips with your hand.
• Direct the patient to breathe deeply, inserting the degree into the anus.
• Remove the probe when the signal sounds.
• To take the temperature, advance 2.5-3.5 cm in adults, 2-2.5 cm in children, and 1.2 cm in newborns.

Rectal Temperature Measurement: Contraindications

• Rectal temperatures on patients experiencing rectal bleeding.
• Rectal temperatures on patients with rectum surgeries,.
• Rectal temperatures on patients that recently gave birth.
• Rectal temperatures should not be performed continuously, as a routine or with children.
• Avoid rectal temperature measurements with diarrhea patients..

Axillary/Forehead Temperature Measurement

• The Axillary region is the most common location to measure temperature.
• Axillary region temperature taking has low risk of infection transfer.
• Each patient should have their own thermometer.
• Important to keep in mind that the armpit should not get sweaty.

Measurement of Pulse

• Pulse is the count of heartbeats per minute.

Pulse Assessment: Key Factors

• Pulse assessment includes pulse rate, rhythm, and volume.
• Pulse assessment is absolutely a must.
• Feeling/Feeding should be assessed easily or hardly.

Purpose of Pulse Count

• Measuring the pulse determines heart rate, rhythm, and contraction strength.
• Pulse checks are done to identify peripheral vascular diseases.

Pulse Rate Reference Values

• Pulse rate measurement include for each age period new born, children and adults..
• Pulse rate is the number of heartbeats per minute.
• Newborn: 120-160/min.
• Children: 80-120/min.
• Adults: 60-100/min.
• Bradycardia is when Pulse rate falls below 60 beats per minute.
• Tachycardia is when Pulse rate goes above 100 beats per minute.

Factors Affecting Pulse Rate

• Various factors can influence the pulse rate.
• Factors like exercise, hyperthermia, hypothermia, acute pain/anxiety, chronic pain, drugs can influence pulse rate
• Age, age, gender, metabolism, bleeding and posture change all factor into the measurement.

Pulse Rhythm: Regularity and Deficits

• If the heartbeat is consistent, the rhythm is regular; inconsistent heartbeats indicate an irregular rhythm.
• When arrhythmia is present the difference between apical and radial pulse should be checked.
• A pulse deficit develops when there is arrhythmia.
• Pulse deficit is the difference between, apical and radial pulse(peripheral), it signalizes arrhythmia.
• A deficit happens if the heart is contracting however pulse isn't going toward the periphery, in this case radial pulse will read lower.

Pulse Volume: Fullness and Strength

• Pulse volume, the fullness of the pulse, reveals left ventricular contraction strength.
• A normal palpated pulse is strong and full and every beat is felt every time.
• A full and strong pulse is also called a bounding pulse
• A 'weak pulse' is hard to discern, the pulse disappears with pressure, also called «filiform pulse» or «thready pulse».
• If the pulse is palpated with high difficulty may indicate bleeding shock, heart failing, or with pulse rates of over 130 per minute..

Common Pulse Points

• Pulse points include temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior tibial arteries.
• Emergency pulse points for 0-1 age is apical / brachial/femoral artery.
• Emergency pulse point for over 1 age is carotid artery.

Peripheral Pulse Taking Technique

• Before taking Peripherial pulse, hands must be washed.
• Authentication is done.
• The patient and or their family is informed. Evaluate the patient's condition
• Evaluate the patient's condition for anything that can offset the reading.
• Patients should be rested, avoid standing.
• Ensure they are in an acceptable position for reading.
• Position the sign, middle, and ring finger are positioned to feel the artery without excessive pressure (using two or three fingers).
• If the pulse is being measured for the 1st time and its irregular, it takes a minute to find an accurate value.
• For a normal person, with clear consistent rate you can count for 30 seconds and then multiply to giter mine proper heat rate.
• After the reading the findings must be recorded.

Respiratory Assessment

• The respiration process includes taking in and utilizing O2 and releasing CO2, the breathing involved is vital to the organism.
• Respiration has two different types.

Respiratory Stages

• Respiration has two distinct stages: external and internal.
• External respiration involves oxygen and carbon dioxide transfer between the atmosphere and the lungs.
• In internal respiration, there is a transfer, of those same gases but taking place between the cells and the blood circulation.

Ventilation of the Lungs Process

Ventilation will cause Diffusion, which will in turn use the bodies process of Perfusion.

3 Steps for Breathing

• Ventilation involves inspiration (inhaling) and expiration (exhaling).
• The lung circulation, helps O2 to move from alveoli and c02 from the lung.
• The O2 moves through the blood and co2 is released to lungs thanks to perfusion.

Respiratory Measurement types

Respiratory rate, depth and type is used as guidelines. Each action is vital to the assessment.

Regulation of Respiration

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

Respiratory measurement

• The rate and depth gives the best idea of what's going on. To obtain a rate you measure:
• Newborns; 30-60/min.
• Adults; 12-20/min.
• There are 3 options in order from low capacity: Deep, superficial and normal For normal breathing the diaphragm expands by 1cm, the costa then extends to about 1.5/2cm.

Respiratory Types and Conditions

Types of breathing: Eupnea , Bradypnea, Tachypnea and Kussmaul Conditions related to the respiratory system, Anoxia/Hypoxia, cyanosis and dyspnea. Cyanosis is the bluish/purplish color, often on ears lips and mucosa.

Assessing Respiration Rate

After the pulse is counted, the respiratory rate should be found by by what the patient's chest wall does. Each rise and fall should be counted for 1 min to asses the cycle and come up with a reading.

• It is important that they not hear you counting so they don't modify their behavior. Be sure that the patient is not too full as that could alter reading ability. To measure each respiration ensure that you are setting yourself in proper position and that the rib rate can be visual. Be mindful how the patient was sitting, and once complete record and determine if any further action needs to be taken.

Pulse Oximetry

Oximetry's is done with a probe to measure Oxygen as it runs through the vein. The device needs to read normal, anywhere from 95 to 100. Should the numbers dip under 90 it is not good. The method of detection used is through finger.

Blood Pressure : Definition and measurements

1320 Blood pressure is measure of force of the blood pushing against the arteries. The 2 points come from how much heart pressure is used pushing it out with the muscle and how rest has an effect. The former is knows as systolic the latter is known as Diastolic. A guide is anywhere between 90/60mmHG to 120/80mmHG, any reading above 140/90 you have hypertension. If you have 90 mmHG expect potential hypotension The Pulse Pressure reading is always between 30-50mmHG the numeric version on a blood test represents this.

Blood Pressure: influencing factors.

Factors like age, stress, race gender and "daily life" can have an effect. Diet medication and exercise are also of influence. To measure, one can use a machine that will inflate and compress against the measuring area. A good assessment required that the person take a seat , after supine they should be be sitting strait. Next have them flex there arms and let the elbow be at the same level as the heart. Have the test being be clear of clothing as that gives inaccurate measure. Inflate the test to a reading of 200 - 250 mmHg. Then deflate it at about 3mm/sec. Have the measurement repeat and then note any value. Ensure to have your hands cleaned.

Errors in measuring

There are multiple sources of error but many of them correlate to positioning and the lack of care. In short, the patient needs to be comfortable and be sure to record every value possible.