Chapter 46 Vital Signs

1. Chapter 46Vital Signs

2. Vital Signs • *Vital signs (or cardinal symptoms) • Temperature, pulse, respiration, and blood pressure • Indicators of functions of the body that are necessary, and within normal limits, to maintain life • Pulse oximetry is often included. • Pain is considered to be the fifth vital sign. • Documentation is essential to collecting information regarding the client’s status and well-being.

3. Recording Vital Signs • Graphic record • Documents large amounts of information • Vital signs must be recorded accurately and promptly to provide continuous and current documentation. • Helps providers diagnose and respond to the client’s changing condition • Paper record • Electronic graphic record • Frequent vital signs sheet

4. Regulation of Body Temperature • Body temperature • Measure of core temperature on the Celsius (centigrade—C) or the Fahrenheit (F) scale. • Hypothalamus controls body temperature by controlling blood temperature. • Normal body temperature • Elevated body temperature: Fever or pyrexia

5. Range of Temperatures** • Oral • 35.5-37.5C or 95.9-99.5F • Rectal • 36.6-38C or 97.9-100.4F • Axillary • 34.7-37.3C or 94.5-99.1F • Tympanic • Temporal

6. Fever • Intermittent fever • Alternates between a fever and a normal or subnormal reading • remittent fever • Temp that rises several degrees above normal and return to normal or near normal • constant fever

7. Fever • crisis • Sudden drop form fever to normal • lysis • Elevated temp that gradually returns to normal • relapsing fever • Fever that returns to normal for at least a day and then occurs again

8. Regulation of Body Temperature (cont’d) • Lowered body temperature or hypothermia • A temperature significantly below normal • Clinical hypothermia • Used to perform some surgical procedures • Accidental hypothermia • Life threatening and requires immediate treatment

9. Equipment for Measuring Temperature • Electronic or automatic thermometer • Probes are encased in a new cover for each client. • Discarded according to agency protocol • Disposable single-use thermometer • Made of paper, often used in isolation units*

10. Measuring Body Temperature • Several locations are used to measure body temperature. • Oral (O)—mouth • Rectal (R)—anus • Axillary (Ax)—armpit • Tympanic, aural, or otic • (TM—tympanic membrane)—ear canal • Temporal artery (TA)—forehead

11. Measuring Body Temperature (cont’d) • Oral Temperature: Measures the temperature within the lingual arteries under the tongue (sublingual) • More accurate than axillary and less accurate than rectal measurement • Not used for • Infants and children, clients with active seizure disorder, clients who had oral surgery • Wait 15 minutes before measuring temperature. • If client has had a hot or cold drink or has been smoking

12. Measuring Body Temperature (cont’d) • Rectal temperature • Highly accurate • Contraindicated after rectal surgery (and often after vaginal surgery) and in conditions such as diarrhea, colitis, or cancer of the rectum • Axillary temperature • Least accurate measurement • Used to take temperature of newborns

13. Measuring Body Temperature (cont’d) • Tympanic temperature • Tympanic thermometer is placed snugly into the client’s outer ear canal. • Ideal site for measuring the body’s core temperature • Temporal artery temperature • Quickest, noninvasive* • Temporal artery temperature scanner • Calculates core body temperature or peak body temperature

14. Glass Thermometer • Glass mercury-containing thermometers are illegal in the United States. • Patient education • Properly dispose of any mercury-containing items. • Extended-care facility • May use thermometers containing alcohol

15. The Pulse • Pulse • Every heartbeat produces a wave of blood that causes pulsations through the arteries. • Temporal pulse • Mandibular pulse • Carotid artery pulse • Femoral pulse • Radial pulse

16. Regulation of Pulse • Pulse Rate: The normal adult pulse rate is 60 to 80 beats per minute (bpm). Women have a slightly higher average rate than men* Newborns range from 120-140bpm*, toddlers range 80-140* • Tachycardia • Bradycardia • Pulse volume • Pulse rhythm • Apical-radial pulse

17. Methods and Equipment • Palpation • To assess the radial, temporal, mandibular, carotid, and femoral pulses • Auscultation and counting the apical pulse will usually give the most accurate assessment of pulse rate. For this assessment, use a stethoscope. • An ultrasonic vascular Doppler device is sometimes used to detect peripheral pulses.

18. Measuring the Pulse • Radial pulse • Apical pulse (AP) • More accurate than radial, always used for children younger than 2 years of age** • Apical-radial pulse (A-R) • It is impossible for the apical pulse to be lower than the radial. • If radial is less than apical pulse, a pulse deficit occurs! • Pedal pulse • Popliteal pulse • Carotid pulse • DO NOT reach across the persons neck to obtain!!

19. Respiratory rates at various ages** • Newborn • 30-80 • Early childhood • 20-40 • Late childhood • 15-25 • Adults • 12-18 • 16-20

20. Regulation of Respiration • Respiratory control • Apnea • Rate and depth • Eupnea, tachypnea, bradypnea • Kussmaul’s respirations • Labored breathing, deep and gasping* • Respiration sounds • Snoring • Stertorous breathing • Obstruction near the glottis causes a hissing, crowing sound**

21. Difficult Breathing • Dyspnea: Difficult or painful breathing • Orthopnea: Can breathe only when in an upright position • Asthma: Spasms and edema of the bronchi cause breathing difficultly. • Characteristic signs of breathing difficulty • Heaving of the chest and abdomen, a distressed expression, and cyanosis in the skin • Cheyne-Stokes respirations • Regular pattern with alternating deep and shallow breaths with apnea*

22. Regulation of Blood Pressure • Blood pressure is determined by cardiac output and peripheral resistance. • Cardiac output: • Combination of heart rate and stroke volume • Measured over 1 minute • Systolic blood pressure (SBP) • Diastolic blood pressure (DBP) • AHA says normal BP is 115/75* • Pulse pressure • Difference of systolic pressure minus diastolic pressure

23. Blood Pressure: Methods and Equipment • Measure in both arms • Difference of 5-10 points may exists, but if more than 10 points exist, this indicates and arterial occlusion in the arm with the lower pressure* • Sphygmomanometer • Aneroid manometer • Electronic blood pressure apparatus • Palpation • Doppler ultrasound* • Used when sounds are difficult to hear or indistinct • Amplifies sound

24. Measuring Blood Pressure • Korotkoff’s sounds • Sounds heard in the stethoscope when taking BP* • Physical exertion or emotional stress will affect BP. • Orthostatic blood pressure measurement • Older clients • Those who are taking certain medications • Orthostatic or postural hypotension

25. Pulse Oximetry • Pulse oximetry • Component of baseline vital signs • Noninvasive procedure • Uses a photoelectric impulse to measure the amount of light transmitted or reflected by deoxygenated versus oxygenated hemoglobin • Pulse oximeter or transducer