Vital Signs

1. Vital Signs

2. Assessment of Vital Signs • Temperature • Pulse • Respirations • Blood Pressure • The fifth vital sign • Pain • Oxygen Saturation

3. Temperature • Regulation • hypothalamus • Core body temperature • Set point

4. Heat Production • Metabolism • Shivering • Exercise

5. Radiation transfer from surface Conduction transfer through direct contact Convection transfer by air movement Evaporation transfer when liquid changed to a gas Heat Loss

6. 97 - 100 F (98.6) 36 - 39 C (37) must be able to close mouth eating or smoking, wait Contraindications unconscious seizures infants, young children oral disease/surgery mouth breathing oxygen by mask Oral Temperature

7. Reliable Higher than oral by 1o Contraindications rectal surgery diarrhea rectal disease heart disease Rectal Temperature

8. Other Methods • Axillary • used when oral or rectal contraindicated • lower than oral by 1o • Tympanic membrane • readily accessible • not affected by eating, smoking, cerumen

9. Elevated Temperature • Pyrexia • Hyperpyrexia

10. Signs and Symptoms shivering blood vessels constrict absence of sweating Care assessment blankets fluids nourishment Oxygen Chill Phase

11. Temp at new set point Signs and Symptoms flushed skin warm skin weak, muscle aches drowsy, restless Care Comfort Hydration Prevent shivering Limit physical activity Oral hygiene Environmental temperature control Fever Phase

12. Signs and Symptoms profuse diaphoresis less shivering flushed, warm skin Care fluids light clothing hypothermia blanket Medications Oral hygiene Environmental temperature control Flush or Crisis Phase

13. Subnormal Temperature • Hypothermia • Chemical reactions slowed • Metabolic demands for oxygen decreased

14. Assessing Temperature • Glass thermometers • oral = blue, thin bulb • rectal = red, blunt tip • Electronic • oral = blue • rectal = red • Temperature sensitive patches

16. Pulse • Rate • pulsations per minute • Infant normal = 80 - 180 per minute • Adult normal = 60 - 100 per minute • Slow < 60, bradycardia • Fast > 100, tachycardia • Slowest at rest, early morning

17. pain stress fear anger anxiety exercise decrease BP temp low oxygen medications Tachycardia

18. Pulse Rhythm • Pattern of pulsations • Regular • Irregular • dysrhythmia • arrhythmia

19. Pulse Quality or Amplitude • Description of fullness of pulse • Ratings • 0 = Absent • +1 = thready, weak • +2 = normal • +3 = bounding

20. carotid brachial radial femoral popliteal posterior tibial dorsal pedis apical 5th ICS left use stethoscope Assessment Sites

22. Apical - Radial Pulse • 2 nurses • count at same time • differences found with irregular pulses

23. Respiration • Movement of air in and out of lungs • Regulation • carbon dioxide levels • oxygen levels • Normal adult rate: 12 to 20 per minute • Infant rate 30 - 80 per minute

24. rate: illness, fever acute pain stress exercise altitude body position rate narcotics CNS depressants Deviations From Normal

25. Apnea Dyspnea Orthopnea Tachypnea Bradypnea Cheyne - Stokes Respiratory Terms

26. Blood Pressure • Force of blood against vessel walls • Systolic pressure • Diastolic pressure • Pulse pressure

27. Factors to Maintain BP • Peripheral Resistance • Pumping action of the heart • Blood volume • Viscosity of the blood • Elasticity of vessel walls

28. Factors Affecting BP • Age • Time of day • Gender • Eating • Exercise • Emotions • Position • Activity • Smoking/drinking

29. Classification of Blood Pressure for Adults

30. Hypotension • Usually considered less than 90 systolic • The patient’s tolerance is significant in determining the diagnosis • Orthostatic or postural hypotension

31. Proper Measurement • Correct position • arm at heart level • Arm above heart level - low reading • Arm below heart level - high reading • Korotkoff Sounds • first sound = systolic • absence of sounds = diastolic • Auscultatory gap

33. Proper Measurement • Cuff Size • too large - low reading • too small - high reading • Bladder width 40% of limb circumference • Bladder length 80% of limb circumference