Vital Signs: Nursing Assessment

• Vital signs are essential indicators of an individual's health status.
• Necessary nursing practices related to vital signs include identifying them, knowing their normal values, and evaluating them.

Factors Causing Changes in Vital Signs

• Different times of day can impact vital signs.
• Age can lead to changes in vital signs.
• The ovulation state can affect vital signs.
• Seasons can be a factor in vital sign changes.
• Physical activity can lead to changes in vital signs.
• Dressing type can impact vital signs.
• Environmental heat can cause changes in vital signs.
• Stress can lead to changes in vital signs.
• Disease can be a factor in vital sign change.

Guidelines on Assessing Vital Signs

• Nurses must know how to obtain and evaluate vital signs, and how to inform other team members.
• Equipment used should be reliable.
• Equipment should be chosen based on the patient's characteristics and condition.
• Normal vital sign values should be known.
• The patient's medical history, treatments, and medications should be taken into account.
• Environmental factors should be considered during assessment.
• Vital signs should be measured systematically at regular intervals.
• Effective communication with the patient when measuring vital signs is necessary.
• Nurses must cooperate with physicians.
• When measured, vital signs should be analyzed absolutely.

Frequency of Assessing Vital Signs

• Measurements should be taken when preparing a patient for admission.
• Measurements should be taken Before and after surgery. (frequency increases)
• Before and after diagnostic procedures.
• Before and after the administration of drugs that affect the heart and respiratory system.
• Measurements should be taken if there is sudden deterioration of the patient's condition.
• Before and after medical interventions that may affect life signs.
• When the patient feels a difference.

Body Temperature

• Body temperature is the balance between heat produced and consumed
• Heat production minus heat loss equals body temperature
• Consistent and balanced body temperature is crucial.
• Heat production and consumption in the body should be equal.
• Heat occurs through food consumption.
• Heat loss happens through breathing, sweating, and waste elimination.

Factors That Influence Body Temperature

• Age is a factor that influences body temperature.
• Exercise can affect body temperature.
• Hormone levels can influence body temperature.
• Stress can affect body temperature.
• The environment.
• Emotional states can affect body temperature.
• The basal metabolic rate can affect body temperature.
• The digestion of food can affect body temperatures
• Nutrition and sleep are factors that affect body temperature.
• Diseases are factors that affect body temperature.
• 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 decreases heat.
• Sweating decreases heat.
• Muscle tremor increases heat.
• Piloerection (steepening of feathers) increases heat.

Temperature Changes

• Hypothermy is a body temperature of 35 °C and below.
• Hyperthermia is a body temperature above 38 °C.

Normal Body Temperature Values by Site

• 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, 36.5°C average
• Rectal: 37°C - 38°C; Average 37.5°C

Oral Measurement

• Degrees are placed right or left under the tongue with an average temperature of 36.5°C - 367.5 °C

Contraindications for Oral Temperature Measurement

• Do not take oral temperatures for patients that have dyspnea
• Do not take oral temperatures for children
• Do not take oral temperatures for elderly patients
• Avoid for patients with psychiatric diseases.
• Do not take oral temperatures for non-conscious patients
• Avoid after the surgery
• Do not take oral temperatures for mouth operations
• Avoid in case of infection
• Do not take oral temperatures for patients on continuous oxygen

Key Points for Oral Temperature Measurement

• The patient must have a personal thermometer
• Very hot or cold food affects measurement, advise patient to avoid before and after measurement.
• The thermometer should be placed under the tongue
• The mouth should be closed with teeth unsqueezed

Tympanic Measurement

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

Rectal Measurement

• Rectal measurements should only be performed if heat cannot be taken by oral or axillary route.
• To preform a rectal measurement: close the room door and curtains, Put the patient in sim's position and flex the upper leg Wear gloves, Apply water-soluble lubricant to the probe, Separate the patient's hips with your hand and ask the patient to breathe slowly and deeply, insert the degree into the anus. Remove the probe if there is a signal.
• The degree must be advanced 2.5-3.5 cm in an adult , 2-2.5 cm in children and 1.2 cm in newborn

When not to take temperatures rectally

• Do not take rectal temperatures for rectal bleeding
• Don't take temperatures after Rectum surgeries.
• Do not take temperatures after birth.
• Avoid in the period of maternity
• Do not take temperatures for Continously as a routine
• Avoid the usage with way in children or in diarrhea cases.

Axillary Measurement

• The axillary region is the most commonly used region.
• Infection is very unlikely to be transmitted.
• The patient must have a personal thermometer.
• The armpit should not be sweaty.

Forehead measurement

• Measure using a special digital thermometer.
• The device is placed on the forehead.

Pulse

• Pulse is the number of heartbeats per minute.
• While assessing the pulse measure the 1-Pulse Rate (How Many Pulses Per Minute), Pulse Rhythm (Regular Pulse-arrhythmia), 3-Pulse Volume (Full Pulse) - Weak Pulse (Threaded Pulse)
• Pulse is counted to decide rate, rhythm and contraction of the heart and to identify peripheral vascular diseases

Pulse Rate

• Normal range in newborns is 120-160/min, children is 80-120/min and adults is 60-100/min.
• Bradycardia: Pulse rate is a rate below 60 beats per minute.
• Tachycardia: Pulse rate is above 100 beats per minute.

Factors Affecting Rate

• Affecting factors include exercise, hyperthermia, hypothermia, acute or chronic pain, drugs, age, gender, metabolism, bleeding, and posture change.

Pulse Rhythm

• If the heart beat is not regular, it is called irregular 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 is the difference between the apical and peripheral pulse rates; it can signal an arrhythmia and Occurs even as the heart is contracting, the pulse is not reaching the periphery, The radial pulse is lower than the apical pulse, and these two pulse rates is called Pulse deficit.

Pulse Volume

• Pulse volume is measure of the fullness of the pulse and it reflects power.
• In a normal pulse, it is easily found and every beat is felt in similar fullness.
• When the pulse is 'weak,' it is difficult to palpate and it easily disappears with finger pressure; it can also be called «filiform pulse» or «thready pulse
• Weak pulse is palpated very difficult and develops in bleeding, shock, or heart failure.

Procedure for Peripheral Pulse Taking

• First, the hands must be washed and identify is authentic. Inform the patient about the procedure and Evaluate the factors that will affect the patients condition and pulse, then allow Patient to rest.
• The the index, middle, and ring finger are placed on the artery; If irregular, count for 1 minute . record the the findings.

Emergency pulse points

Emergency pulse points include the apical / brachial/femoral artery, for 0-1 age and carotid artery for 1+ age

Respiration

• Respiration is the process that begins and involves the organism Taking in and using O2 and releasing CO2 There are two stages, it occurs between the atmosphere to the lungs(EXTERNAL), O2 and CO2 within cells and blood within the circulatory system.(Internal)
• There the Ventilation where Inspiration and Expiration, Diffusion where O2 passes fromthe alveoli to the lung circulation and CO2 from lung to alveoli,and Perfusion where O2 enters circulation.

Measure of Respiration

• Saturation measures diffusion and perfusion, and Respiratory rate, depth and rhythm of breathing Ventilation.
• Respiratory Normal rate in newborn is 30-60/min and in Adult is 12-20/min. Factors that influence the depth of Breathing and increase, superficial and normal. body position, some medications, exercise, fear, anxiety

Respiratory Types

• Dyspnea, Apnea, Cyanosis, and other different types and measure based on rate, depth, normal, etc...

How to measure breathign

• After the pulse is counted, Count respirations by chest movement for one minute without saying and one cycle is One Respiration.
• Never let know patients knowing this.
• Then, position the patient record your findings.

O2 levels and measurements

• Pulse Oximetry uses a non-invasive process Oxygen in the blood.
• Measure Pulse: Place probe on finger, earlobe, nose (etc) to measure O2.
• Normal pulse oximeter readings range from 95 to 100 percent and Readings under 90 percent signals a low level of Hypoxemia (oxygen in blood)

Procedure to Measure Oxygen Saturation

When measuring, place finger to where light source is emitted.

Blood Pressure

• Blood pressure is a measure of the force that heart uses to pump blood around your body.

Definitions

• Systolic pressure: pressure when heart pushes blood out .
• Diastolic pressure: pressure when heart rests beetween beats
• Ideal blood pressure: Beetween 90/60mmHg and 120/80mmHg
• High blood pressure: Higher than 140/90mmHg
• Low blood pressure: Lower thant 90/60mmHg

Pulse pressure

• Pulse Pressure is the numeric difference beetwen Systolic and distolic: For example (In millimetters of mercury Hg) 120/80 Pulse pressure is 40 The average pulse pressure is beetwen 30/50mmHg

Factors That Affect Bloos Pressure

Affectinf Factors: Age, Race, excersice,

How to measure blood pressure?

Use: Blood pressure monitor(spygmamometer) Stethoscope suitable desynfecant, pen and registration form and waste container.

• Semi flowler. or other Flex arm level with subjects body. if they have anxious , give them a few minutes

Steps to Measurement :

• Position, Fowler Place a blood pressure cuff, 2-3 cm ahove the antenutibol

• palpate the brachial artery Feel your brachial pulse with your passive hand and place the diaphragm on the brachial artery and hold it fixed Rapydly imflate the cuff (200/25000mg) . Then slowly inflate air and listen, also watch the dial, record systolic/ diastolic if we record for the first time, the Repeat on opposite am. If there isn't another am, Wait 2min

Mistakes and Erros to Avoid

Common mistakes to avoid while measuring blood pressure not have you feet planted firmly, Patient hasn't rested 5 mior , Patient did not sit upright , Patient talking Arm is level, not elevated nor face up Cuff not on direct skinn. too tide and so on. Also make sure. That not too quicly reoeated assessment. That arm it's below, or avobe heart level.