Vital Signs: Nursing Procedures and Assessment

• Vital signs provide basic insights into a person's health.
• Necessary nursing practices are performed regarding vital signs.

Purposes

• Identify vital signs appropriately.
• Evaluate normal values of vital signs.
• Measure vital signs accurately.

Contents

• Key vital signs include body temperature, pulse, respiration, oxygen saturation, and blood pressure.
• Changes in different times of the day affect vital signs.
• Age, ovulation state, and seasons can alter vital signs.
• Physical activity and dressing type affects vital signs.
• External factors like environmental heat and the presence of stress or disease influence vital signs.

Guidelines on Assessing Vital Signs

• Nurses should know how to obtain and evaluate vital signs, and how to communicate findings to team members.
• Reliable equipment is essential.
• Select equipment based on the patient's condition and characteristics.
• Normal vital sign values, the patient’s medical history, treatments, and medications should be considered.
• Assess environmental factors.

Measuring Vital Signs

• Vital signs should be measured systematically at regular intervals.
• The nurse should communicate with patients effectively when measuring vital signs.
• The nurse should work with the doctor.
• When measurements are taken they must be analyzed.

Frequency of Vital Signs Measurement

• Measure when preparing patients for admission. Surgical frequency may increase.
• Measure both before and after diagnostic procedures, or after administering drugs that affect the heart and respiration.
• Take measurements when there is sudden deterioration of the patient's condition or medical interventions that may affect life signs.
• Measure when the patient expresses that they feel a difference.

Body Temperature

• Body temperature reflects the balance between heat produced and consumed.
• Heat production minus heat loss equals body temperature.
• Body temperature should remain consistent and balanced.
• Heat production and consumption within the body must be equal.
• Heat is produced through food, while heat loss occurs through the lungs through breathing, skin via sweating, and the elimination of wastes.
• Age, exercise, and hormone levels affect body temperature.
• Stress, environment, emotional state, and basal metabolic rate affects body temperature.
• Digestion, nutrition/sleep, diseases, and the induction of the sympathetic nervous system impact body temperature.
• Thermoregulation occurs in the hypothalamus.
• The hypothalamus regulates temperature like a thermostat.
• Vasodilation, sweating, muscle tremors, and piloerection regulate body temperature.
• Vasodilation causes a decrease in heat, muscle tremors cause an increase in heat.
• Hypothermia is qualified by a body temperature of 35°C or below.
• Hyperthermia is classified by a body temperature above 38°C.
• Normal oral temperature typically averages at 37°C, ranging from 36.5°C to 37.5°C.
• For the ear the average is typically 37°C with ranges 36.5°C to 37.5°C.
• The average temperature of the armpit is 36.5°C, with minimal values at 36°C, and maximal at 37°C.
• Rectal temperature is on average 37.5°C, ranging from 37°C to 38°C.

Measuring Body Temperature Guidelines

• All materials are prepared prior to application.
• Wash and sanitize hands and wear gloves when appropriate.
• Give the patient 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: 36,5 °C - 367,5 °C.
• Do not take oral temperatures for patients with dyspnea, children, the elderly, or those with psychiatric diseases.
• Oral readings should also be avoided for non-conscious patients, post-surgery, when there is infection, when the mouth underwent operations, and those who are receiving continuous oxygen.
• Patients should have their own when taking temperature orally.
• Consuming very hot or cold food/drink impacts measurement. Patients advised to not eat or drink anything before measurement.
• The thermometer should be under the tongue with the mouth closed, but teeth should not be squeezing the device.

Tympanic Measurement

• The measurement is made within one to two seconds
• Before measurement, a disposable plastic cover should be placed over the receiver.
• The receiver is placed in a third of the outer ear.

Rectal

• The application of this procedure is used when heat cannot be taken by oral or axillary route.
• Averages ranging from 37 °C - 38 °C.
• Close the room door and curtains, and put the patient in Sim’s position, flexing the upper leg.
• Apply water-soluble lubricant to the probe.
• Ask the patient to breathe slowly and deeply while inserting.
• Separate the patient’s hips with your hand.
• Insert the thermometer between 2.5-3.5cm for adults, 2-2.5cm for children, and 1.2cm for newborns.
• Do not rectal temperatures on those with rectal bleeding, rectum surgeries, or during birth.
• Avoid application during the period of maternity, or continuously.
• It is also inadvisable for children and diarrhea cases.

Axillary/Forehead, and General Tips

• The armpit is the most regularly used area/region.
• Infection is very unlikely to be transmitted.
• The patient should have a personal thermometer.
• The armpit should not be sweaty.
• There is a digital thermometer under the patient's arm or on the forehead of the patient. After heat is measured, the digital thermometer gives an alarm.
• Special digital thermometers are used for reading. The device is placed on the forehead.

Pulse

• Pulse is the count of heartbeats per minute, with assessment emphasizing, 1-Pulse Rate, 2-Pulse Rhythm, 3-Pulse Volume.

• Pulse rate should be between 60 - 100 heartbeats but will vary based on each subject.

• Newborns should be between 120-160, with adults at 60-100 bpm

• Pulse is counted to decide the rate rhythm and contraction of the heart. It is also counted in order to identify peripheral vascular diseases.

• Factors affecting pulse rate include exercise, hyperthermia, hypothermia, acute pain/anxiety, and chronic pain. Other affections include drugs, age, gender, metabolism, bleeding, and posture changes.

• With each patient, measure pulse deficit, or the difference between apical and peripheral pulse rates, as this can signal arrhythmia. Apical pulse: Apical (on the midclavicular line in the fifth intercostal space.

• Pulse deficit measures the difference between apical and peripheral pulses. This signals arrhythmia. • 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 ".

• Peripheral pulse taking steps include the washing of hands, performing authentication protocols, communication to patient, checking vital for a minute, and recording findings. The patient should not be standing, for accuracy. Emergency pulse points: 1 age; carotid artery 0–1 age; apical / brachial/femoral artery.

Sites to Palpate Pulse

• Temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, dorsalis pedis (on foot), and posterior tibial arteries (near the ankle).

Respiration

• Respiration involves exchange between O2 and CO2.

Organs of the Respiratory System

• Main organs include the nose, pharynx, larynx, trachea, bronchi, and lungs (alveoli).
• Inhalation and exhalation involves the lungs. During inhalation and exhalation, air is drawn in, and air is forced out. The diaphragms moves down, ribs move out during inhalation. Diaphragms move back and ribs move back during exhalation.
• Respiration is a process that includes breathing and using O2, while releasing CO2. It has two different stages; external respiration and internal respiration.
• External respiration occurs between the atmosphere and the lungs; O2 is released into blood while CO2 is released from the respiratory and circulatory systems.
• Internal respiration is the exchange of O2 and CO2 between cells and blood circulation.
• Ventilation, diffusion, and perfusion assist respiration.
• Ventilation involves inspiration and expiration.
• Diffusion sees O2 passing from the alveoli into lung circulation, while CO2 separates from the lungs for the alveoli.
• Perfusion is a process in which O2 which enters the lungs, is carried in blood and passed to the tissue and CO2 accumulated in the tissues enters the lungs for circulation.

Measurements and Regulation

• The respiratory center for this process is in the medulla oblongata and pons of the brainstem.
• Respiratory depth affects body function.
• The costa extend 1.5-2.5 centimeters forward.

Measurements

• The types of respiratory rate, depth, and measurement are very important.
• The normal respiratory rate is 30-60/min.
• Respiratory depth is assessed. Medication, anxiety, and exercise affects depth. The diaphragm increases by typically 1cm.
• Respiratory rates include: eupnea, bradypnea, trachypnea, kussmaul’s respirations, Biot’s respirations, Cheyne-Stokes respirations, apnea, hyper/hypoventilation.
• Anoxia is the absence of oxygen and hypoxia states that tissues cannot get enough oxygen. Dyspnea describes any breathing difficutly.
• Cyanosis is when the skin is purplish or bluish because of low oxygen saturation. It can be shown and recognized in the lips, ear lobes, nails, and oral mucosa.
• The respiratory rate is determined by the observation of the chest wall. For a normal finding, observe the rate, rhythm and depth of the respiration.
• Each complete cycles is one respiration.
• Prepare all materials before measuring the pulse accurately.

Oxygen Saturation (SpO2)

• Pulse oximetry measures the oxygen level in the blood. •It is a noninvasive, painless way by being a general indicator of oxygen delivery by pulsating maximum light and with a finger.
• Normal pulse oximeter readings are in the range 90-100 percent under most circumstances. Values under 90 are considered low, leading to patient with hypoxemia.

Blood Pressure

• Blood pressure measures the force that the heart exerts to pump blood throughout the body.
• The "systolic pressure" is defined as the pressure when the heart pushes blood out. The "Diastolic pressure" describes/defines the pressure when the heart resets.
• As a guide, ideal blood pressure typically ranges between 90/60mmHg and 120/80mmHg. Systolic Pressure to Diaastolic Pressure
• High blood pressure, or hypertension, is measured when there is a registration 140/90mHg or higher.
• Low pressure is when below at 90/60mHg or lower Numeric difference between systolic and diastolic blood pressure is called pulse pressure. pulse pressure between 30 - 50mHg.

For example, if your resting blood pressure is 120/80 millimeters of murcury, pulse pressure is 40.

Factors Affecting Blood Pressure

• Many factors such as age, stress, race, gender, daily life, medicine, food, and exercise affect blood pressure.
• Hypertension is qualified by when the WHO states that the adults must be measured with 140/90mmHG.

Procedures for Measurement

• Necessary materials or instruments Blood Pressure Monitor (Sphygmomanometer), Stethoscope, Suitable Disinfectant, Pen, Registration Form and a place for Waste Container.

• Blood pressure is measured.

• While placing the patient, the body position is supine, semi or fowler-fowler. The patient should be flexed, and they have to make sure by measuring the blood pressure. and has to be placed in a comfortable spot.

• The technician will evaluate for a few minutes before taking any numbers.

• The blood pressure cuff should be placed 2-3cm above the antecubital region ensuring as to not close it. Then the brachial artery should be palpated. The pointer has to start at zero.

• Technicians feel the brachial pulse. Placing it at the same position

• Pump at 200 - 250mHg. listen with your stethoscope.

• Air should be released at 3mm/sec. The first knocking sound represents systolic with the last the diastolic. (such as 120/80)

• Always measure it for a first time and repeat it with 2 minutes of rest.

• With the findings on both arms, the highest is recorded. The values are recorded after this and the instruments are sanitized.

• Be sure to not place the cuff on clothing, not talk to patient, let the patient flex.