NURS1100 Week 12 Vital Signs PDF

12 VITAL SIGNS Normal Values for Vital Signs Vital Sign Normal Value Additional Notes - Varies depending on route (oral, rectal, axillary) and core vs. peripheral Temperature 36.7°C–37.5°C...

12 VITAL SIGNS Normal Values for Vital Signs Vital Sign Normal Value Additional Notes - Varies depending on route (oral, rectal, axillary) and core vs. peripheral Temperature 36.7°C–37.5°C measurements. Pulse (Heart Rate) 60–100 bpm - Measure for 30 seconds x2 (if regular) -If irregular: measure apical pulse for full 60 seconds Respiration Rate Adults: 12–20 breaths/min - Observe chest rise discreetly; Assess for rate, rhythm, and depth. (RR) Newborns: 30–60 breaths/min Oxygen Saturation SpO₂: 95–100% - Measured using a pulse oximeter on the finger, toe, or earlobe. - Systolic: Maximum pressure during contraction. Blood Pressure (BP) 120/80 mmHg (dynamic) - Diastolic: Resting pressure between beats. Temperature Aspect Details - Reflects the balance between heat production and loss. Importance - Indicates infection, inflammation, or thermoregulation issues. -Control mechanism: hypothalamus - Oral: Reliable and common; close to core - Axillary: Non-invasive, used for children. Routes - Tympanic: Quick and accessible. - Rectal: Closest to core, used for infants under 2 years when accuracy is critical. Normal - Oral: 35.8–37.3°C Ranges - Axillary: 34.8–36.3°C (Adults) - Tympanic: 36.1–37.9°C - Rectal: 36.8–38.2°C - Diurnal Cycle: Lower in the morning, higher in the evening (1– 1.5°C variation). -Menstrual Cycle: 0.5–1°C increase during ovulation. Factors -Exercise: Raises temperature from increased metabolism. Affecting -Environment: Hot increases, cold decreases temperature. -Stress: Elevates temperature via SNS (Sympathetic Nervous System) activation. -Age: Children have greater variation; elderly have lower temperatures. Temperature Terminology Term Definition Afebrile Without fever; normal body temperature. NURS1100 WEEK 12 VITAL SIGNS 1 Term Definition Febrile Presence of fever (oral temp >38.0°C). Pyrexia Body temperature above the normal range. Hypothermia Core body temperature below the normal lower limit. Hyperthermia Inability of the body to promote heat loss, leading to elevated temperature. Heat Exhaustion Excessive heat and water loss from prolonged sweating (diaphoresis). Heat Stroke Severe condition caused by excessive exercise or heat exposure; life-threatening. Pulse/Heart Rate Aspect Details -Wave of blood flow through arteries -Detected and measured at palpable sites (in peripheral arteries) Importance - Indicates cardiovascular status and rhythm abnormalities. - Assesses stroke volume and circulation. - Radial: Readily accessible. - Carotid: Used in emergencies. Common Sites - Apical: For irregular rhythms or infants. Normal Range - 60–100 beats per minute (bpm). (Adults) - Rate: Bradycardia (100 bpm). Assessed - Rhythm: Regular or irregular. - Strength: Bounding, strong, weak. - Exercise, pain, emotions, Factors medications, and pulmonary Affecting conditions. Methods of Assessing Pulse Pulse Type Method Details Auscultation with a - Located at the 5th intercostal space, Apical Pulse stethoscope midclavicular line (MCL). NURS1100 WEEK 12 VITAL SIGNS 2 Pulse Type Method Details - Commonly used for quick Palpation with Radial Pulse assessments; found on the wrist along three fingers the radial artery. Pulse Characteristics Characteristic Details - Normal adult: 60–100 bpm. Rate (HR) - Bradycardia: Slow (100 bpm). Rhythm - Regularity of beats. - Dysrhythmias indicate irregular rhythms. Strength - Describes force: Bounding, strong, weak, thready, or absent. - Should be equal on both sides of the body for consistent Equality circulation. Factors Affecting Pulse Rate Factor Effect on Pulse Rate Exercise Increases heart rate due to increased oxygen demand. Temperature Fever or heat increases pulse; cold may lower pulse. Emotions Stress, anxiety, or fear elevates pulse due to SNS activation. Pain Acute pain may increase pulse; chronic pain might not have the same effect. Stimulants (e.g., caffeine) raise pulse; depressants (e.g., beta-blockers) Drugs lower it. Hemorrhage Loss of blood volume causes an increased pulse rate as compensation. Body Position Pulse may increase slightly upon standing due to postural adjustments. Pulmonary Conditions Conditions like hypoxia or respiratory distress may increase pulse. NURS1100 WEEK 12 VITAL SIGNS 3 Respiration Rate Aspect Details - Definition: Exchange of O₂ and CO₂ between the body and atmosphere. Importance - Control Center: Regulated by the medulla oblongata. -Drive to Breathe: Determined by blood CO₂ levels. Measurement - Observe chest rise discreetly. Method - Count for 30 seconds (multiply by 2) or 60 seconds if irregular. Normal Range - 12–20 breaths per minute. (Adults) Characteristics - Rate: Eupnea (normal respirations), Tachypnea (>20/min), Bradypnea (20 breaths per minute). Decreased rate and depth of respirations (shallow/slow Hypoventilation breathing). Hyperventilation Increased rate and depth of respirations (deep/fast breathing). Oxygen Saturation Aspect Details - Assesses arterial oxygen saturation by analyzing oxygen (O₂) and carbon Importance dioxide (CO₂) levels. - Detects hypoxia or respiratory distress. NURS1100 WEEK 12 VITAL SIGNS 4 Aspect Details Measurement - Measurement Device: Pulse oximeter placed on finger, toe, or earlobe. Method -Function: Uses light waves to measure the percentage of hemoglobin saturated with oxygen. Normal Range SpO₂ = 95–100% (Adults) - Light Interference: Outside light sources, patient movement, intravascular dyes, jaundice. Factors -Arterial Pulsation Issues: Peripheral vascular disease, hypothermia, Affecting vasoconstrictors, low cardiac output, peripheral edema, tight probe. -Other Factors: Low hemoglobin, physical activity, carbon monoxide poisoning (elevates readings artificially). Blood Pressure Aspect Details - Blood Pressure: Force of blood against artery walls. -Systolic Pressure: Maximum pressure exerted during ventricular Importance contraction -Diastolic Pressure: resting pressure exerted between each ventricular relaxation Measurement - Manual (sphygmomanometer and stethoscope). Methods - Automated devices. Normal Range 120/80 mmHg (dynamic) (Adults) - Age: BP rises with age due to arterial stiffening. - Gender: Men have higher BP until 55; women post-menopause. - Ethno-cultural Background: Some groups (e.g., African descent) have higher hypertension rates. Factors Affecting - Diurnal Rhythm: BP is lower in the morning, higher in the evening. - Weight: Increased weight raises BP - Exercise: Regular activity lowers BP; acute activity temporarily raises it - Emotions: Stress and anger can temporarily increase BP - Stress: Chronic stress leads to sustained BP elevation Steps for Measuring Blood Pressure with Sphygmomanometer Step Procedure Ensure the patient is seated comfortably, legs 1. Position the Patient uncrossed, with the arm supported at heart level. Place the cuff 2.5 cm above the brachial artery, 2. Apply the Cuff wrapping it evenly and snugly around the arm. NURS1100 WEEK 12 VITAL SIGNS 5 Step Procedure Palpate the brachial artery to identify its position 3. Locate Brachial Pulse for stethoscope placement. Inflate the cuff while palpating until the pulse 4. Inflate the Cuff disappears to estimate systolic pressure. Place the stethoscope's bell over the brachial 5. Position the Stethoscope artery site. Inflate 30 mmHg above the point where the pulse 6. Inflate the Cuff Further disappeared. Release the cuff's pressure gradually while 7. Deflate Slowly listening to Korotkoff sounds. Note the first sound (systolic) and disappearance 8. Record Korotkoff Sounds of sound (diastolic). Korotkoff Sounds Phases: 1. Phase I: First sharp tapping sound - systolic pressure. 2. Phase II: Swishing or whooshing sound. 3. Phase III: Thump softer than Phase I tapping. 4. Phase IV: Muffled, softer blowing sound. 5. Phase V: Silence - diastolic pressure. Physiological Factors That Control Blood Pressure: Cardiac Output: Higher cardiac output increases BP. Peripheral Vascular Resistance: Narrower vessels raise BP. Volume of Circulating Blood: More blood volume increases BP. Blood Viscosity: Thicker blood leads to higher BP. Elasticity of Vessel Walls: Stiffer walls elevate BP. Pain Aspect Details - Pain is the 5th vital sign, crucial for assessing physical and emotional well-being. Importance - Indicates underlying conditions or responses to interventions. - Unmanaged pain can activate the sympathetic nervous system, increasing pulse, respiration, and blood pressure. Assessment Methods - Subjective Measurement: Self-reports are the most reliable way to assess pain. NURS1100 WEEK 12 VITAL SIGNS 6 Aspect Details Common tools include: - Numeric Rating Scale (e.g., "Rate your pain from 0–10"). - PQRSTU Mnemonic: - P: Provocative/Palliative (What makes it worse/better?) - Q: Quality/Quantity (Describe the pain: sharp, dull, throbbing). - R: Region/Radiation (Where is it? Does it spread?) - S: Severity (Rate the intensity). - T: Timing (When did it start? Is it constant or intermittent?) - U: Understanding (What do you think is causing it?). - Intensity: Mild, moderate, severe (numeric scale: 0–10). Characteristics - Quality: Sharp, burning, aching, throbbing. Assessed - Location: Specific site or generalized area. - Radiation: Spreading to other areas. - Timing: Acute (short-term) or chronic (lasting >3 months). Factors Affecting Pain - Emotional state, fatigue, cultural background, and individual pain tolerance. Documentation - Record the intensity, location, and response to interventions. - Include subjective reports and observations in the patient’s chart. NURS1100 WEEK 12 VITAL SIGNS 7