Vital signs
- 1. I CAN…….I WILL
VITAL SIGNS
Presented by
Fred Cohen, Nursing Instructor
Columbia University School of Nursing
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- 2. Vital Signs
They are called vital signs because they are important.
They include:
Temperature
Pulse
Respirations
Blood pressure
Vital signs and other physiologic measurements can
be part of data base for problem solving.
Many facilities have developed a fifth vital sign pain
level/comfort level.
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- 3. Guidelines for Measuring Vita Signs
The nurse must be able to do all of the following:
Measure vital signs correctly
Ensures that equipment are in proper working
condition
Control environmental factors affecting vital
signs
Understand and interpret the values
Communicate findings appropriately
Begin interventions as needed
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- 4. Factors Affecting Body Temperature
Age
Exercise
Hormonal influences
Diurnal Influences (Happening Daily)
Stress
Environment
Ingestion of hot and cold liquids
Smoking
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- 5. Temperature
Temperature is a relative measure of sensible
heat or cold.
The body strives to maintain a temperature of
98.6° F (37° C), which is considered normal.
Normal range is 97° to 99.6° F (36.1° to 37.5°C).
Many factors can cause body temperature variances.
Environment, time of day, patient’s state of health,
activity levels, and stage of monthly menstrual cycle
The hypothalamus helps maintain a balance between
heat lost and heat produced by the
body.
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- 6. Temperature
Two Types of Body Temperature
Core Temperature
Temperature of the deep tissues of the body
Remains relatively constant unless exposed to severe
extremes in environmental temperature
Assessed by using a thermometer
Surface Temperature
Temperature of the skin
May vary a great deal in response to the environment
Assessed by touching the skin
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- 7. Temperature
Temperature measurements are obtained by several
methods.
Heat-sensitive patches
Patch placed on the skin; color changes on the patch indicate
temperature readings
Electronic thermometers
Consist of a rechargeable battery-powered display unit, a thin
wire cord, and a temperature processing probe
Tympanic thermometer
Special form of electronic thermometer; inserted into
auditory canal
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- 8. Tympanic Thermometers
Advantages – may be more accurate than traditional
thermometers, easy to use, suitable for all ages.
Core temperature readings – shares blood supply with
the hypothalamus
More accurate readings in patients with rapid changes
in temperature.
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- 9. Figure 11-2
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
Disposable, single-use thermometer strip.
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- 10. Figure 11-3
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
Electronic thermometer.
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- 11. Figure 11-4
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
Tympanic thermometer with probe cover inserted into auditory canal.
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- 12. Temperature
Pyrexia, Febrile, or Hyperthermia
When the temperature is above normal
Fever is actually a body defense; it will destroy invading
bacteria.
Classification of Fevers
Constant: remains elevated consistently
Intermittent: rises and falls
Remittent: temperature never returns to normal
until the patient becomes well
Hypothermia
An abnormally low body temperature
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- 13. Signs and Symptoms of Elevated Body Temperature
Thirst
Anorexia
Flushed, warm skin
Irritability
Glassy eyes/photophobia (sensitivity to light)
Headache
Elevated pulse and respiratory rates
Restlessness or excessive sleepiness
Increased perspiration
Disorientation, progressing to convulsions in infants and
children
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- 14. Temperature
Oral temperature is not obtained in the comatose
or disoriented patient or in small infants.
Rectal temperatures are contraindicated for patients
with recent rectal surgery or certain conditions of the
perineum.
Axillary temperature is considered the least accurate
method.
Rectal readings are normally 1° F higher than oral, and
axillary readings are 1° F lower than oral.
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- 15. Stethoscope
An instrument that is placed against the patient’s
chest or back to hear heart and lung sounds
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- 16. Auscultating Using the
Stethoscope
When assessing the apical heart rate, the nurse uses a
stethoscope.
Major Parts of the Stethoscope
Earpieces
Should fit snugly and comfortably in the nurse’s ears
Binaurals
Should be angled and strong enough that the
earpieces remain firmly in the ears without
discomfort
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- 17. Figure 11-6
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St.
Louis: Mosby.)
Parts of a stethoscope.
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- 18. Auscultating Using the
Stethoscope
Tubing
Should be flexible and 12 to 18 inches long
Can have single or dual tubes
Chestpiece
Diaphragm: circular, flat-surfaced portion of the chest
piece covered with a thin plastic disk
Transmits high-pitched sounds created by the high-
velocity movement of air and blood
Bell: bowl-shaped chest piece, usually surrounded by a
rubber ring.
Transmits low-pitched sounds created by the low-
velocity movement of blood.
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- 19. Pulse
Is a rhythmic beating or vibrating movement.
The pulse is the regular, recurrent expansion and
contraction of an artery produced by waves of
pressure caused by the ejection of blood from the left
ventricle of the heart as it contracts.
The nurse notes the rate, rhythm, and volume of the
pulse.
Adult pulse rate is normally between 60 and 100 beats
per minute.
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- 20. Figure 11-7
Pulse sites.
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- 21. Factors Affecting Pulse Rates
Age
Exercise
Fever, heat
Acute pain, anxiety
Unrelieved severe pain, chronic pain
Medications
Hemorrhage
Postural changes
Metabolism
Pulmonary conditions
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- 22. Pulse
Tachycardia
The pulse is faster than 100 beats per minute.
It may result from shock, hemorrhage, exercise, fever,
acute pain, and drugs.
Bradycardia
The pulse is slower than 60 beats per minute.
It may result from unrelieved severe pain, drugs,
resting, and heart block.
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- 23. Pulse
Dysrhythmia
Any disturbance or abnormality in a normal rhythmic
pattern, specifically irregularity in the normal rhythm
of the heart
Any artery can be assessed for pulse rate, but the
radial and carotid arteries are peripheral pulse sites
that are easily palpated.
The radial and apical locations are the most common
sites for pulse rate assessment.
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- 24. Auscultation
Listen to sounds within the body to evaluate the
condition of the heart, lungs, pleura, intestines or
other organs
To listen to fetal heart tones
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- 25. Figure 11-9
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St.
Louis: Mosby.)
A, Point of maximum impulse is at fifth intercostal space. B,
Assessing apical pulse.
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- 26. Pulse
Pulses on both sides of the peripheral vascular system
should be assessed.
Pulses are palpated using the pads of the index and
middle fingers; only slight pressure is applied over the
artery to avoid obliterating the pulse.
Apical pulse represents the actual beating of the
heart.
When auscultated, the “lubb-dubb” heard represents
one cardiac cycle, or heartbeat.
Pulse deficit: difference between the radial and apical
rates; signifies that the pumping action of the heart is
faulty.
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- 27. Pulse
Nursing Interventions for patient with abnormal
pulse
Assess peripheral pulses
Observe s/s of abnormal tissue perfusion
Assess for related data
Observe other signs and symptom
Assess pulse deficit
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- 28. Figure 11-8
(From Sorrentino, S.A. [2004]. Mosby’s textbook for nursing assistants. [6th ed.]. St. Louis: Mosby.)
Taking an apical/radial pulse.
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- 29. Respirations
The taking in of oxygen, its utilization in the
tissues, and the giving off of carbon dioxide; the
act of breathing.
Internal Respirations
The exchange of gas at the alveolar level
External Respirations
Breathing movements that can be observed by
the nurse; inspiration and expiration
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- 30. INSPIRATION AND EXPIRATION
INSPIRATION
Inhaling air with oxygen into the lungs
EXPIRATION
Exhaling air with carbon dioxide out of the
lungs
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- 31. Factors Influencing Respiration
Disease or illness
Stress
Fever
Age
Gender
Body position
Medications
Exercise
Acute Pain
Smoking
Brain Stem Injury
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- 32. Respirations
Assessment includes the rate, depth, rhythm, and
quality.
The normal rate for an adult is between 12 and 20 per
minute.
Tachypnea
Rapid respiratory rate; exercise and fever increase respiratory
rate
Bradypnea
A slow respiratory rate, below 12 per minute
The depth of respiration is determined by the amount
of air taken in with inhalation.
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- 33. Figure 11-10
Patterns of respirations.
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- 34. Respirations
Assessment includes the rate, depth, rhythm, and
quality. (continued)
The rhythm of respiration should be regular and
uninterrupted.
Dyspnea
Breathing with difficulty
Apnea
A lack of spontaneous respirations
Cheyne-Stokes respirations
An abnormal pattern of respiration; alternating
patterns of apnea and deep, rapid breathing.
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- 35. Blood Pressure
The pressure exerted by the circulating volume of
blood on the arterial walls, veins, and chambers of the
heart.
Systolic
The higher number; represents the ventricles
contracting
Diastolic
The second number; represents the pressure within
the artery between beats
Pulse Pressure
Difference between the systolic and diastolic
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- 36. Blood Pressure
Normal blood pressure in the adult is 120/80 mm Hg.
Hypertension
Sustained elevated blood pressure is above 140/90 mm
Hg.
Hypotension
Blood pressure is below normal.
Orthostatic Hypotension
A drop of 25 mm Hg in systolic pressure and a drop of 10
mm Hg in diastolic pressure when moving from lying to
sitting or sitting to standing.
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- 37. Factors Influencing Blood Pressure
Age
Anxiety, fear, pain, emotional stress
Medications
Hormones
Diurnal (happening daily)
Race
Gender
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- 38. Conditions Causing Alterations in Blood Pressure
Hemorrhage
Increased Intracranial Pressure
Acute pain
End-stage renal disease
Primary essential hypertension
General anesthesia
Exercise postural change
Smoking
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- 39. Blood Pressure
Sphygmomanometer
A device for measuring the arterial blood pressure
Consists of an inflatable cuff and a gauge
The cuff is inflated around the patient’s arm to
compress the artery; then it is slowly deflated while the
nurse listens at the brachial artery with a stethoscope
and hears pulsating sounds.
Korotokoff sounds: The first sound heard is the systolic
pressure; the point at which the last sound is heard is the
diastolic pressure.
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- 40. Figure 11-11
(From Sorrentino, S.A. [2004]. Mosby’s textbook for nursing assistants [6th ed.]. St. Louis: Mosby.)
Aneroid manometer and cuff.
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- 41. Figure 11-12
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
Wall-mounted aneroid sphygmomanometer.
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- 42. Figure 11-17
Electronic sphygmomanometer.
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- 43. Figure 11-14
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St.
Louis: Mosby.)
Doppler stethoscope over brachial artery to measure blood pressure.
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- 44. Figure 11-13
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
The sounds during blood pressure measurement can be
differentiated into five Korotkoff phases.
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- 45. Blood Pressure
Assessment of Blood Pressure in the Lower
Extremities
Occasionally, the upper extremities may be
inaccessible, so blood pressure must be measured in the
lower extremities.
The popliteal artery, located behind the knee, is the site
for auscultation.
The cuff must be wide and long enough to allow for the
larger girth of the thigh and is positioned with the
bladder over the posterior aspect of the midthigh.
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- 46. Figure 11-15, A
(A, From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.].
St. Louis: Mosby.)
A, Lower-extremity blood pressure cuff positioned above popliteal
artery at midthigh.
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- 47. Figure 11-15, B
(A, From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.].
St. Louis: Mosby.)
B, Location of the popliteal artery and placement of
the cuff.
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- 48. Blood pressure reading
Do not apply cuff to arm when:
Catheter is in an antecubital fossa and fluids are
infusing
Arteriovenous shunt is in place
Breast or axillary surgery has been performed on that
side
Arm or hand has been traumatized or diseased.
A lower arm cast or bulky bandage is in place.
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- 49. Blood Pressure
Automatic Measurement Devices
Many automatic devices can determine blood pressure
automatically.
Once the cuff is applied, the nurse can program the
device to obtain and record blood pressure readings at
preset intervals.
Self-Measurement
Portable home devices
Stationary automated machines
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- 50. Height and Weight
Helps assess normal growth and development
Aids in proper drug dosage calculation
May be used to assess the effectiveness of drug
therapy, such as diuretics
Significant loss of weight may be a sign of an
underlying disease
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- 51. Figure 11-16
(Photo courtesy Critikon, Inc., Tampa, Fla.)
Automatic blood pressure monitor.
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- 52. Height and Weight
Height
Patient should remove shoes and stand erect.
A measuring stick or tape may be attached vertically to
the weight scales or wall.
Standing scales may have a metal rod, which is attached
to the back of the scale and swings out over the top of
the patient’s head.
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- 53. Height and Weight
Weight
Types of scales
Standing scales
Chair scales; lift scales
Used for patients who cannot stand
Patients should be weighed at the same time of day, on
the same scale, and in the same type of clothing to allow
an objective comparison of subsequent weighing.
Patient should void before weighing.
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- 54. Figure 11-18
(From Sorrentino, S.A. [2004]. Mosby’s textbook for nursing assistants. [6th ed.]. St. Louis: Mosby.)
Types of scales. A, Standing scale. B, Chair scale. C, Lift scales.
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- 55. When Vital Signs Are Assessed
Temperature, pulse, respirations, and blood pressure
are usually assessed at the same time at set intervals.
A set of vital signs is taken when the patient is
admitted to the facility and then as prescribed by the
physician or as policy dictates.
Example: every 4 hours; once a shift; weekly
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- 56. When Vital Signs Are Assessed
The more ill the patient, the more frequently vital
signs are taken.
Vital signs are interrelated.
A rise in temperature of 1° F may cause an increase in
pulse rate of 4 beats per minute.
Respiratory rate and blood pressure readings increase
with a rise in temperature.
Blood pressure falls because of hemorrhage, the pulse
and respirations increase and the temperature usually
decreases.
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- 57. Recording Vital Signs
Graphic Flow Sheet
Used for charting vital signs
R indicates a rectal temperature
Ax indicates an axillary temperature
Blood pressures are always written with the systolic
first and the diastolic beneath.
Example: 120/80
Apical pulse is indicated with an “ap” after next to the
number.
Example: 78 ap
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- 58. Recording Vital Signs
Any abnormal findings are reported to the nurse-
manager or physician immediately.
Any accompanying or precipitating signs and
symptoms such as chest pain, vertigo, shortness of
breath, flushing, and diaphoresis should be recorded
as well.
The nurse documents any interventions initiated as a
result of vital sign measurement, such as tepid
sponging.
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- 59. Pain as the Fifth Vital Sign
Monitor pain along with vital signs
JCAHO requirements for pain control
Assessing and managing pain is a major nursing
responsibility
Collection of subjective and objective data
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- 60. Nursing Process
Assessment
Normal daily fluctuations
Factors likely to interfere with accuracy of vital sign
reading
Medications that may influence vital signs
Factors that influence vital signs
Conditions that precipitate fever, such as infections
Pertinent laboratory values
Previous baseline vital signs from patient’s record
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- 61. Nursing Process
Nursing Process
Fluid volume deficient
Hyperthermia
Hypothermia
Body temperature, risk for imbalance
Gas exchange, impaired
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