Vital signs including temperature, pulse, blood pressure, respiration rate and oxygen saturation provide important physiological information about the body's major organ systems. Several factors like age, gender, medications and circadian rhythms can influence vital sign measurements. Proper techniques exist for accurately measuring each vital sign to obtain an overall assessment of a patient's condition.
2. Vital signs
Temperature, pulse, blood pressure, respirations and oxygen saturation
are the most frequent measurements obtained by health care practitioners.
These measurements indicate if the circulatory, pulmonary, neurological,
and endocrine body systems are functioning normally.
Because of their importance as indicators of the body’s physiological
status and response to physical, environmental, and psychological
stressors, they are referred to as vital signs
Pain, a subjective symptom, is often referred to as a vital sign along with
the other physiologic signs. Frequently pain is the symptom that leads
patients to seek health care. For this reason assessment of a patient’s pain
status is critical to understanding his or her clinical status and progress
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3. Factors Influencing Vital Signs
+ Age : age influences body temperature. Body temperature varies
from 35.5 C° to 37.5 °C in newborns and 36 C° to 36.8 C° in elderly
+ Gender : Women experience greater temperature fluctuations
than men, probably due to hormonal changes.
+ Race and Heredity : African Americans are more prone to high blood
pressure resulting from increased salt sensitivity or increased blood
cholesterol levels
+ Medications : Some medications can directly or indirectly
alter temperature, pulse, respirations, and blood pressure. For example,
narcotic analgesics can depress the rate and depth of respirations and
lower blood pressure .
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4. + Circadian Rhythms : (pressure is lowest in the morning and
peaks in late afternoon and evening) and temperature (highest
in the evening—8 PM to 12 midnight—and lowest in the early
morning—4 to 6 AM).
+ Pain : Acute pain leads to sympathetic stimulation, which in
turn increases the heart rate, respiratory rate, and blood
pressure.
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Factors Influencing Vital Signs
5. TEMPERATURE
Temperature control of the body is a homeostatic function,
regulated by a complex mechanism involving the hypothalamus
Measuring Body Temperature :
Oral : 36° to 37.5°C
Tympanic Membrane : 0.5° C (0.9° F) lower than oral temperatures
Axilla : 0.5° C (0.9° F) lower than oral temperatures
Rectal : 0.5° C (0.9° F) higher than oral temperatures
Skin
Temporal Artery
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Oral rout
Advantages
Easily accessible—requires no position change
Comfortable for patient
Provides accurate surface temperature reading
Limitations
Causes delay in measurement if patient recently ingested hot/cold fluids or foods,
chewed gum, or smoked
Not used with patients who have had oral surgery or facial trauma or are unable to
position in mouth, shaking chills, or history of seizures
Not used with infants; small children; or confused, unconscious, or uncooperative
patients
Risk for body fluid exposure
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Tympanic Membrane
Advantages
Easily accessible site
Obtained without disturbing, waking, or repositioning patient
Used for patients with tachypnea without affecting breathing
Very rapid measurement (2 to 5 seconds)
Unaffected by oral intake of food or fluids or smoking
Limitations
Requires removal of hearing aids before measurement
distorted with otitis media and cerumen impaction
Not used with patients who have had surgery of the ear or tympanic membrane
Affected by ambient temperature devices such as incubators, radiant warmers, and facial fans
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Rectal Route
Advantages
Argued to be reliable when oral temperature cannot be obtained
Limitations
Not used for patients with diarrhea or those who have had rectal surgery, rectal disorders,
bleeding tendencies, or neutropenia
Requires positioning and is often source of patient embarrassment and anxiety
Risk for body fluid exposure
Requires lubrication
Not used for routine vital signs in newborns
Readings influenced by impacted stool
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Axillary Route
Advantages
Safe and inexpensive
Used with newborns and unconscious patients
Limitations
Long measurement time
Not recommended for detecting fever in infants and young children
Affected by exposure to the environment, including time it takes to place thermometer
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Skin
Advantages
Inexpensive
Provides continuous reading (2 days)
Safe and noninvasive
Used for neonates
Limitations
Impaired adhesion from diaphoresis or sweat
Affected by environmental temperature
Cannot be used for patients with allergy to adhesive
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Temporal Artery
Advantages
Easy to access without position change
Very rapid measurement
Comfortable with no risk of injury to patient or nurse
Eliminates need to disrobe or unbundle
Can be used for premature infants, newborns, and children
Sensor cover not required
Limitations
Inaccurate with head covering or hair on forehead
Affected by skin moisture such as sweating
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Pulse
The pulse is an index of the heart’s rate and rhythm.
Measuring pulse:
A normal adult heart rate is from 60 to 100 beats/min
Rates are slightly faster in women and more rapid in children and infants (90–
140 beats/min
The arterial pulse can be felt over arteries that lie close to the body surface
and over a bone or firm surface that can support the artery when pressure is
applied. In adults and children older than age 3, the radial artery is palpated
most frequently because it is the most accessible. The femoral and carotid
arteries are used in cases of cardiac arrest to determine the adequacy of
perfusion
When peripheral pulses cannot be palpated, a ultrasound stethoscope is used
by the nurse to confirm the presence or absence of the pulse.
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Respiration
Respiration is the process of bringing oxygen to body tissues and removing
carbon dioxide
Measuring Respiration :
Normal breathing, termed eupnea, is almost invisible, effortless, quiet,
automatic, and regular.
The normal rate for a resting adult is 12 to 18 breaths per minute. A rate of 24
or above is considered tachypnea, and a rate of 10 or less is considered
bradypnea.
The rate for infants ranges from 20 to 30 breaths per minute and is often
irregular. Older children average about 20 to 26
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Blood Pressure
The heart generates pressure during the cardiac cycle to perfuse the organs of
the body with blood. Blood flows from the heart to the arteries, into the
capillaries and veins, and then flows back to the heart.
Measuring Blood Pressure:
The indirect method of taking a blood pressure using a recently manometer
and a stethoscope is accurate for most clients.
The direct method is A needle or catheter is inserted into the brachial, radial,
or femoral artery. An oscilloscope displays arterial pressure waveforms
Normal blood pressure in an adult varies between 100 and120 systolic and 60
and 80 diastolic
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Pain
According to The Joint Commission, pain should be considered the fifth vital
sign. Pain must be evaluated every time vital signs are taken, and it should be
documented on the vital sign record
Measuring Blood Pressure:
The indirect method of taking a blood pressure using a recently manometer
and a stethoscope is accurate for most clients.
The direct method is A needle or catheter is inserted into the brachial, radial,
or femoral artery. An oscilloscope displays arterial pressure waveforms
Normal blood pressure in an adult varies between 100 and120 systolic and 60
and 80 diastolic
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Pulse Oximetry SpO2
Arterial blood gas (ABG) analysis has been used for decades to determine a
client’s gas exchange and oxygenation transport ability. Pulse oximetry
technology allows for more cost- and time-efficient continuous monitoring of
arterial oxygen saturation (SaO2). The primary advantages of this method are:
It is cost-effective.
It is a noninvasive evaluation tool.
Minute-to-minute changes in saturation can be assessed and timely
intervention made to meet client needs.
The client’s response to treatment can be evaluated immediately and ongoing.
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Pulse Oximetry SpO2
Normal SpO2 (oxygen saturation) levels is usually between 95–100% for
adults and children
Inaccurate oximetry readings can be found in clients with:
a. Alkalosis, acidosis
b. Fever, hypothermia
c. Poor peripheral blood flow
d. Carbon monoxide poisoning
e. Recent dye injection studies
f. Shivering or excessive movement
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