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Vital Signs

Vital Signs. Teresa V. Hurley. MSN, RN. What are vital signs?. Blood Pressure Pulse Respiratory Rate and Oxygen Saturation Temperature Abbreviated as T, P, R. Spo2 and B/P. Nursing Responsibility. Know range of acceptable values Client patterns

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Vital Signs

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  1. Vital Signs Teresa V. Hurley. MSN, RN

  2. What are vital signs? • Blood Pressure • Pulse • Respiratory Rate and Oxygen Saturation • Temperature • Abbreviated as T, P, R. Spo2 and B/P

  3. Nursing Responsibility • Know range of acceptable values • Client patterns • Frequency of taking based on client’s condition

  4. Temperature What is body temperature? How is heat generated? What is the core body temperature range in degrees C and F? Which sites are most often used to measure the core temperature? Which sites are most often used to measure body surface temperatures?

  5. Temperature • Hypothalamus • Range: 36 to 37.5 C or 97-99.5 F • Heat Production • Heat Loss Radiation Convection Evaporation Conduction

  6. Factors Affecting Body Temperature • Circadian Rhythms • Age • Exercise • Sex • Hormone levels • Stress • Environment

  7. Body Temperature • Afebrile • Febrile • Fever or Pyrexia • Alteration in in hypothalmic set-point • Increase in cellular metabolism and consumption of o2 • Increase in heart and respiratory rates • Prolonged fever leads to cellular, myocardial and or cerebral hypoxia

  8. Temperature Alterations • Hyperthermia Hypothermia • Heatstroke -Frostbite • Heat exhaustion

  9. Temperature Assessment • Devices • Tympanic: infrared sensors • Rectal: electronic or digital • Oral • Axillary • Temporal Artery • Automated Monitoring

  10. Mercury Thermometers: Glass • Toxic hazard effecting CNS via contact with its vapors and by touching it • Clean-up and Disposal

  11. Pulse • Number of pulsations/minute over a peripheral artery • Rate: Beats per minute • 60-100 Beat per minute • Bradycardia • Tachycardia • Rhythm: regular or irregular (dysrhythmia) • Amplitude • 0 to 4+

  12. Apical Pulse • Site: PMI at 5th ICS at left MCL • A/R rate correspond usually • Pulse Deficit is the difference between the A/R rate

  13. Peripheral Sites • Temporal • Carotid • Brachial • Radial • Femoral • Popliteal • Posterior tibial • Dorsalis pedis

  14. Pulse Assessment • Stethoscope for apical pulse using bell side to hear low frequency sounds of heart and blood • Doppler Ultrasound • Cardiac Monitor • Palpation of peripheral arterial pulse

  15. Factors Influencing Pulse Rates • Exercise • Temperature • Emotional States • Drugs • Hemorrhage • Postual Changes • Pulmonary Conditions

  16. Factors influencing Respirations • Exercise • Acute pain • Anxiety • Smoking • Body Position • Medications • Neurological Injury • Hemoglobin Levels

  17. Respirations • Passive process regulated by brain stem • Ventilation regulated most importantly by high arterial CO2 (hypercarbia) • COPD regulation is by hypoxemia (low 02 levels) via chemoreceptors in carotid artery and aorta • Respiratory Rate • Eupnea: 12 to 20 breaths/min • Tachypnea • Bradypnea

  18. Respiratory Alterations • Apnea • Dyspnea • Hyperventilation • Increase in rate • Decrease in depth • Fear • Hypoventilation • Decrease in rate • Decrease in depth

  19. Respiratory Alterations • Cheyne Stokes • Deep, rapid • Periods of apnea • Biot’s • Severe brain damage • Varying rate and depth • Periods of apnea

  20. Pulse Oximetry Spo2 • Spo2 acceptable ranges: 90%-100% • Sp02 85%-89% acceptable for chronic diseases • Spo2 less than 85% is unacceptable

  21. Complete Blood Count (CBC) • Measure of RBC’s count, volume of RBC’s. and Hgb concentration which is the capacity to carry O2

  22. Blood Pressure • What is Blood Pressure? • Systolic • Diastolic • Pulse Pressure • Difference between systolic and diastolic pressure

  23. Blood Pressure • Neural and Hormonal • B/P Average 120/80 mm Hg • Pulse Pressure difference between systolic and diastolic • Range: 30-50 mm Hg

  24. Hypertension • Asymptomatic • Diastolic 80-89 mm Hg on 2 subsequent visits • Systolic 120-139 mm Hg on 2 subsequent visits • HTN greater than 140/90 • Greater peripheral vascular resistance with decrease in blood flow to heart, brain and kidneys

  25. HTN Factors • What persons are more at risk for developing for HTN?

  26. Hypotension • Systolic B/P falls below 90 mm Hg • Hemorrhage • Pump failure of heart • Pallor • Mottling of skin • Clamminess • Confusion • Increase in HR • Decrease in urinary output

  27. Hypotension • Orthostatic (Postual) • Risk Factors • Dehydration • Anemia • Prolonged bedrest • Recent blood loss

  28. Blood Pressure • Variations in B/P • Peripheral resistance and compliance • Wall elasticity • Neural and humoral mechanisms • Renin-angiotensin-aldosterone • Increase per vascular resitance • Increase Na and H2O retention • Cardiac Output • 3.5-8 Liters average

  29. Blood Pressure Assessment Non-invasive Monitoring • Equipment: stethoscope and sphygmomanometer • Select appropriate cuff size • Sites • Brachial artery • Popliteal if brachial artery inaccessible

  30. B/P Measurement • Kortokoff Sounds • Phases I through V • What is the ausculatory gap? • During which phase is there a distinct change in sound? • When does phase V occur?

  31. What factors may influence accuracy of B/P measurement? • Exercise • Caffeine • Smoking • Cuff size • Too rapid or too slow release of valve • Release so descent is 2-3mm Hg

  32. Korotkoff Sounds • Phase I = 1st thump sound • Phase II = whooshing sound • Phase III = softer thump than Phase I • Phase IV = soft blowing that fades • Phase V = silence

  33. B/P Variation Factors • Age • Diurnal Rhythms • Stress • Ethnicity • Weight • Gender • Body Position • Exercise • Medications [anti-HTN, cardiac, opiod analgesics, contraceptives]

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