Vital Signs Monitoring and Patient Assessment

• Vital signs (VS) are frequently measured data used to monitor vital body functions
• Vital signs are usually the first and the most important indicators that a patient's condition is changing
• Vital signs are usually used to establish a baseline, observe patient trends, and evaluate therapy response

Five Classical Vital Signs

• Temperature
• Pulse Rate (PR)
• Respiration (RR)
• Blood Pressure (BP)
• Pulse Oximetry (SpO2)

Additional Initial Assessments

• Height
• Weight
• Level of consciousness (LOC) and responsiveness
• General clinical impression
• Non-invasive monitoring is becoming part of the standard vital signs in some institutions

Frequency of Vital Signs Measurements

• Vital Signs are taken based on a patient's condition
• Baseline measurements should be taken on: admission, at the beginning of a shift, prior to a treatment or procedure, and when the patient's condition changes
• Routine vital signs recording is commonly done every 4-6 hours
• Respiratory care VS is taken before and after treatments
• Following surgery VS: every 15 minutes x 2 hours, followed by every 30 minutes x 2 hours

Trends in Vital Signs

• A trend constitutes a series of vital signs measurements over time
• An isolated measurement of VS represents static data
• A trend represents dynamic data, deemed more clinically important
• Any abnormal measurement should be compared with previous measurements before new treatment or changes in ongoing therapy
• Graphs over 24 hours facilitate the visual interpretation of VS trends.
• When evaluating, compare VS in relationship to the patient's age, current disease, and external environment

Comparing Vital Signs

• The key with assessing vital signs is to constantly look for change
• Look: at facial expressions, body movements, color/appearance, effort to breathe
• Listen: for sounds, note rhythm, consider feelings, and look for fears
• Touch: for moisture, temperature, assesses pulse quality, muscle tone, and skin tone

Comprehensive Vital Signs Assessment

• Reassess and analyze - compare to previous information; evaluate whether changes make sense
• Look at trend information and compare with all information collected over a period of time
• Consider differential diagnoses (DD), including multiple signs and symptoms to arrive at a patient's diagnosis

Expert Respiratory Therapist Tips for Vital Signs

• Constantly be aware
• Look, listen, and touch as appropriate
• Question and validate findings
• Reassess, analyze, and monitor trends

Clinical Impression

• General appearance will give information about: level of distress, severity of illness, personality, hygiene, culture, and patient reactions to illness.
• If a patient is in distress, the priority is to evaluate the problem quickly and intervene immediately
• If not in distress, perform a head-to-toe inspection
• Information obtained may include: apparent age, posture, motor activity, nutritional status, and mental acuity
• Document everything

Visual Signs of Distress

• Cardiopulmonary: irregular breathing that is fast, shallow, choking, wheezing, cyanosis, and/or chest pain
• Anxiety-restlessness: fidgeting and/or choppy sentences
• Pain-moaning: shallow breathing and inability to take a deep breath associated with coughing
• Bleeding/LOC: Require immediate intervention

Level of Consciousness

• Adequate cerebral oxygenation is necessary to be awake, alert, and oriented
• Orientation is evaluated as to time, place, and person
• Evaluation can focus on person, wife, husband etc.

Levels when Blood Flow is Inadequate

• Restless, confused, disoriented, or comatose
• Lethargic: sleepy, easily aroused, responds appropriately
• Obtunded: difficult to arouse, but responds appropriately
• Stupor: does not wake up completely, responds to pain, and has slow respirations.
• Comatose: unconscious, has loss of reflexes
• Glasgow Coma Scale: Gold standard tool used for assessing a patient's neurologic function following a head injuries

Glasgow Coma Scale (GCS)

• This is key for expert assessments

Glasgow Coma Scale (GCS) Assessment Responses

• Eye-opening response: 4 (Spontaneous opening), 3 (To verbal stimuli), 2 (To pain), 1 (None)
• Most appropriate verbal response: 5 (Oriented), 4 (Confused), 3 (Inappropriate words), 2 (Incoherent), 1 (None)
• Integrated motor response: 6 (Obeys commands), 5 (Localizes pain), 4 (Flexion to pain), 3 (Extension to pain), 1 (None)

Primary Evaluation of Traumatic Brain Injury by Glasgow Coma Scale

• Severe traumatic brain injury: GCS 3-8
• Moderate traumatic brain injury: GCS 9-12
• Slight traumatic brain injury: GCS 13-15

Height and Weight

• Routinely measured as part of the physical exam.
• 1 inch = 2.54 cm / height
• Weight should be recorded in kg (1kg=2.2lb).
• Hospitalized patients are followed-up every 1-2 days
• If dehydration or fluid overload is present, intake and output is added to follow-up until the patient's fluid balance is stable

Body Temperature: Normal

• Normal: 98.6° F = 37°C, Range 97°-99.5° F=(36.5-37.5 °C)
• Normal, afebrile (without fever)
• Normal elevation in body temperature can occur during: Exercise, ovulation, first trimester of pregnancy
• Body temperature is a balance between heat loss and heat production
• The hypothalamus is the regulator and the respiratory system is the heat remover

Hyperthermia (Fever)

• Febrile, with temperature above the normal range
• Hyperthermia can result from diseases, infection, or from normal activity (exercise)
• If temp> 102° F, fever is most likely the result of an infection.
• Increase in body temperature contributes to increase in the metabolic rate, raising O2 consumption and CO2 production
• For every 🌡️1°C elevation, there is a 10% increase of O2 consumption and CO2 production

Hypothermia

• Can occur in severe head injury or exposure to cold environments.
• The hypothalamus initiates shivering to generate energy and vasoconstriction to conserve body heat
• Decreased O₂ consumption and CO2 production
• Patients presents with shallow breathing and bradycardia.

Body Temperature Sites

• Sites: mouth, ear, axilla, or rectum
• Oral temperature: is best for awake adults; avoid for children, intubated or comatose patients; not influenced by O2 administration, wait 10-15 min after liquids or smoking
• Axillary temperature: is best for infants and small children.
• Tympanic thermometry (1986): infrared emissions is detected from tympanic membrane and ear canal in < 3sec.
• Tympanic thermometry is fast, clean, non-invasive.

Heart Rate (HR)

• Evaluate for rate, rhythm, and strength or character synchronicity (symmetry)
• Palpate for vessel wall thickness and radio-femoral delay and peripheral pulse.
• Adult heart rate 60-100 bpm
• HR ≥ 120: tachycardia
• Common causes can be anxiety, fear, exercise, fever, hypotension, anaemia, hypoxemia, medications like adrenaline, and hyperthyroidism

Bradycardia

• HR < 60: bradycardia
• Can be caused by: diseased heart (IHD or athletes, hypothermia), hypothyroidism, and some medications such as atropine

Pulses - Measurement Sites

• Most common non-emergency site: radial artery
• Assess pulse rate for 1 minute
• If hypotension is present, assess centrally
• If radial pulse cannot be felt, go to others (carotid arteries, femoral)
• The best pulse reading location in an emergency is the brachial site
• In infant, assessing the most often used is brachial

Assessing Pulse

• Pulse volume/fullness:
• 0: absent
• 1+: weak, thready
• 2+: slightly reduced
• 3+: normal
• 4+: bounding large look for collapsing pulse

Age related Heart and Respiratory rate

• < 1 year: Heart rate/min = 110-160, Respiratory rate/min = 30-40
• 2-5 years: Heart rate/min = 95-140, Respiratory rate/min = 25-30
• 6-12 years: Heart rate/min = 80-120, Respiratory rate/min = 20-25

• 12 years: Heart rate/min = 60-100, Respiratory rate/min = 15-20

Infant Ranges for HR, RR and BP

• 0-3 months: Respiratory Rate (35-55), Heart Rate (100-150), Blood Pressure (65-85/45-55)
• 3-6 months: Respiratory Rate (30-45), Heart Rate (90-120), Blood Pressure (70-90/50-65)
• 6-12 months: Respiratory Rate (25-40), Heart Rate (80-120), Blood Pressure (80-100/55-65)
• Normal HR, RR, and BP below 1 Year

Pulse Oximetry

• Pulse oximetry measures O2 saturation % & pulse rate (PR)
• Check O2 saturation where possible to: Reduce O2 flow/L at bedside, during short term therapy, during continuous monitoring, when walking or exercising, and for trending
• Does not look at different hemoglobin as dose CO-oximeter
• Normal value: 95%-99%
• Abnormal value: < 92%

Respiratory Rate (RR)

• Varies with age
• Adult normal value is 12-20 breath/min (cycle/min)
• Abnormal rates:
• Tachypnea: RR is above the normal
• Tachypnea: RR is below the normal Other terms for respiration:
• Apnea; cessation of breathing
• Eupnoea; normal rate and depth
• Hypopnea: decrease depth of breathing
• Hyperpnoea: increase depth/may or may not be associated with increase rate
• Intermittent - irregular breathing with periods of apnea

Respiratory Rate Measurement

• By direct visualization of abdominal and thoracic movement
• Diaphragm moves downward, and the chest moves upward
• Watching the movement of the abdomen will determine the diaphragmatic movement
• Must be counted while patient is not aware of that, as can lead to artificial changes in the assessment
• Count for one full minute because there is likely high variation in the depth of breathing and the rhythm

Evaluating Blood Pressure (BP)

• Force to be applied to the wall of the arteries as the blood moves through post ventricular contraction
• Systolic pressure measures peak force during ventricular contraction
• Diastolic pressure measures forces during relaxed phase
• Pulse pressure measures the difference between systolic and diastolic values; normal is between 35-40 mmHg
• BP varies with the age of the patient (Adults; 120/80(90/60- 140/90) mmHg)
• BP should be considered "normal' if the differential between diastolic and systolic is between 35-40 mmHg.

Blood Pressure Measurement

• Use a sphygmomanometer; apply cuff around the arm and apply pressure until the artery stops blood flow completely.
• When pressure is released, pulsation can be felt palpation.
• The partial obstruction of the arterial blood flow + turbulence will produce the Kortokoff sounds, which audible with stethoscope

Korotkoff Sounds

• Phase-1: First appearance of a palpable pulse = systolic
• Phase -11: Sounds are softer and longer
• Phase 111: Sounds become louder
• Phase 1V: Sound become softer
• Phase V: Sound disappears (diastole pressure)

Errors in Blood Pressure Measurement

• High Blood Pressure errors: Due to use of a too-narrow cuff, a too-tight or too-loose cuff, excessive pressure exerted by the cuff, incomplete pressure deflation.
• Low Blood Pressure errors: Often due to cuff being too wide Static electricity, ventilation, and room sounds may cause erroneous readings.

Effects of Respiratory Cycle on Blood Pressure

• Systolic BP decreases slightly during inspiration
• If it drops by more than 10 mmHg, this is pulsus paradoxus - should normally be at least at 10 mHg value
• Caused by severe bronchial asthma, cardiac tamponade

Hypo-tension Causes

Hypotension can be caused by:

• Weak left ventricle
• Blood loss
• Vasodilation
• Some medications such as diuretics
• Administration of sedatives or paralyzing agents, and some anesthetics.

This lesson covers the frequency of vital signs measurements, the role of non-invasive monitoring, and adapting monitoring to patient stability. It also addresses healthcare provider actions during respiratory distress and insights into chronic conditions. The lesson emphasizes adapting monitoring based on stability.