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5 vital signs

blood pressure
pain (considered the 5th vital sign)
(sometimes oxygen saturation is considered)


vital signs

-provides baseline assessment data of health status
-may be compared with later findings
-in the hospital, the physician may order minimum schedule for assessment but the nurse uses clinical judgement to determine if more frequent readings are needed
-nurses use vital sign data to implement prescribed treatment and notifies physician of significant changes
-taken in a step by step manner to ensure accuracy
-documentation is often done on a graphic chart to demonstrate trends
-taken on admission, before and after invasive or diagnostic procedures, with blood transfusions and medications, if condition changes or patient reports specific or nonspecific symptoms, when performing nursing interventions that may affect vital signs (ambulation following bed rest), and as ordered by the health care provider or agency policy



-body temperature =heat produced minus heat lost
-acceptable temperatures for humans:
-96.8-100.4 degrees F (36-38 degrees C): Body functions best at this temperature
-average temp for elderly is 96.8 degrees C
- core temperature is in the deep tissues and remains stable
-surface temperature is of the skin and varies greatly depending on blood flow
-physiological and behavioral mechanisms affect temperature
- no single temperature is normal for everyone: Monitored to detect infection and response to treatment



regulation of body temperature, done by balancing heat lost and heat produced



- the body's "thermostat"-responsible for controlling the body's heat temperature.
-sends messages to blood vessels to help conserve heat by vasoconstriction or to release heat by vasodilation and sweating
-shivering is an involuntary response to create heat
- muscular activity increases heat production in the body


basal metabolic rate

-heat produced by the body at absolute rest, is affected by thyroid hormones that control metabolism
-men have higher BMR than women


heat loss

lost from the skin surface by radiation, conduction (contact), evaporation, convection (air movement), diaphoresis


factors that influence body temperature

1. age- unstable in infants and children until puberty as control mechanisms are immature or may be impaired. Older adults are sensitive to extremes since their control mechanisms may deteriorate... especially cardiovascular vasoconstriction and vasodilation
2. exercise- muscle activity increases metabolism
3. hormone level- primarily affects women due to hormonal changes in cycle
4. stress- physical and emotional stress changes physiology and increases temperature through hormone and nervous stimulation
5. environment- cold or extreme heat may affect temperature
6. temperature altercations- due to disease (example: fever from infection)
7. circadian rhythm- varies over the 24 hour period with lowest temp 1am-4am, highest at 6pm. Tales 1 to 3 weeks to change with change of work and sleep pattern


types of thermometers

-glass (still may be used in homes)
-electronic (most often in health care agencies)
-disposable (eliminate cross contamination with heat sensing tape or inexpensive digital thermometers)
-chemical dot
-continuous measurement probe
-temporal arty scanner (detects temperature of cutaneous blood flow)
-Infrared Scanners


Core Body Temperature Sites

-rectal, tympanic, pulmonary, urinary bladder, esophagus
-deep inside of us


Surface Body Temperature Sites

-oral, skin, axillae
-affected by outside surface


Oral: Temperature Measurement

-accessible and comfortable
- affected by food, drinks or smoking
- not for infants or young children
-mercury thermometers are dangerous and slow (3minutes)
-electronic thermometers 20-50 seconds to display temp


Rectal: Temperature Measurement

-about 1 degree higher than oral
-used when cannot take oral temperature
-uncomfortable, requires lubrication
-not used with rectal problems, diarrhea, or bleeding problems
-mercury thermometers are dangers and slow


Axillary: Temperature Measurement

-about 1 degree lower than oral
-not as reliable
-must be held in place for infants and children
-mercury thermometers are slow


Tympanic: Temperature Measurement

-can be accurate core temperature
-unaffected by fluids or food
-expensive and often unreliable due to techniques
-use with caution for infants or toddlers
-ear problems will distort temperature


Temporal: Temperature Measurement

-rapid, easy to access, comfortable, safe for all ages, including newborns
-must be used correctly with scanner flat on skin
-affected by skin moisture or hair


Fever (pyrexia, febrile episode)

-not harmful usually under 102.2 degrees F
-Pyrogens (bacteria, viruses) cause a rise in body temperature by triggering an immune response. This causes the hypothalamus to raise the set point temperature of the body
-important defense mechanism, works to enhance the immune system below 102
- Chills: body's attempt to increase body temperature to attain new "set point" temperature set by hypothalamus affected by pyrogens. Client feels cold even though body temperature is rising
-Diaphoresis: sweating to release heat and decrease body temperature when fever is resolving. Afebrile- fever has "broke"



body's attempt to increase body temperature to attain new "set point" temperature set by hypothalamus affected by pyrogens. Client feels cold even though body temperature is rising



sweating to release heat and decrease body temperature when fever is resolving. Afebrile- fever has "broke"


negative effects of fever

-increased cardiovascular workload
-increased oxygen needs due to increased metabolism
-weakness from depleting energy stores


treatment of fever

-antipyretics: drugs to reduce fever, including Tylenol and Motrin (increase heat loss)
-Do not use ice packs or tepid sponge baths- will promote shivering
-caution with hypothermia blankets- shivering, and risk of injury to skin


Hyperthermia: Heat exhaustion

-excessive perspiration leads to fluid and electrolyte imbalances
-usually due to environmental conditions
-move client to cooler environment and replace fluids
-can lead to heatstroke if not treated


Hyperthermia: Heatstroke

-emergency situation caused by prolonged exposure to sun or heat
-hypothalamus malfunctions due to extreme temperatures, and does not cause sweating
-symptoms include cramps, confusion, visual disturbances, and hot, dry skin
-temperature of 105 degrees F can cause brain and tissue damage-brain is first organ affected
-treatment: cool client to increase heat loss and replace fluids by IV route


Hypothermia: prolonged exposure to cold

-danger point is at 95 degrees F when uncontrollable shivering occurs. Vital signs fail at 94 degrees F
-treatment: slowly increase the temperature with blankets, warming devices and warm fluids
-Hypothermia may be induced to decrease the body's need for heat and oxygen


Hypothermia: Frostbite

-ice crystals form in cells
-areas with decreased blood flow are affected first, such as toes, fingers, earlobes and nose
-Hypothermia may be induced to decrease the body's need for heat and oxygen


blood pressure

-the force of the blood against the arterial walls at all times
- it is measured in millimeters of mercury (mmHg) and is record as a fraction such as 120/80



-period of contraction of the heart during which blood is forced into the aorta and the pulmonary artery
-the maximum blood pressure is when the left ventricle of the heart pushes blood through the aortic valve into the aorta


Systolic pressure

the peak of maximum pressure when ejection of blood occurs



-the phase of the cardiac cycle in which the heart relaxes between contractions;
- specifically, the period when the two ventricles are dilated by the blood flowing into them


diastolic pressure

the minimum pressure against the arteries when the ventricles relax


pulse pressure

-difference between systolic and diastolic BP
-BP 120/80 =PP 40



an abnormally elevated heart rate, above 100 beats per minute in an adult



respirations that are regular in rhythm but slower than normal in rate, less than 12 breaths per minute



-it is the clinical sign for hypoxia and manifests as breathlessness
- it is the subjective sensation of difficult or abnormal breathing



respirations that cease for several minutes, persistent cessation results in respiratory arrest


pulse deficit

-an inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse sites
- thus, a deficit may exist between the apical pulse and peripheral pulses



-generally when systolic pressure falls below 90 mm Hg
-due to dilation of vascular system, loss of blood volume, failure of heart to pump due to a myocardial infarction also known as a heart attack
-signs: pallor, clamminess, confusion, increases heart rate and decreased urine output


orthostatic hypotension

-postural hypotensions
-low BP occurs when a person changes to a rising position... lying to sitting to standing
- attributed to meds, dehydration, anemia, prolonged bedrest
-underlying factor is constriction of vessels already being present due to decrease blood volume



-persistently elevated BP
-multiple measurements on at least 2 occasions are higher than 140mm mercury systolic or 90mm Hg diastolic
- categories of hypertension includes: normal (S less than 120, D less than 80), Prehypertension (S 120-139, D 80-89), Stage 1 (S140-159, D 90-99), Stage 2 (S greater or equal to 160, D is greater or equal to 100)
-Risk factors: family history, smoking, alcohol consumption, obesity, high sodium intake, older persons, african-americans, diabetes
-treatment: meds and alter lifestyle factors


Korotkoff sounds

-sounds heard during assessment of blood pressure, thought to be produced by vibratory motion of the arterial wall as the artery suddenly distends when compressed by a pneumatic blood pressure cuff


ausculatory gap

-temporary disappearance of sound when cuff pressure is reduced
-it occurs during the first and second Korotkoff sounds
-most often occurs in hypertensive clients
-the cuff must be inflated high enough to hear the true systolic sound before the ausculatory gap
-record the gap after recording the BP using the first and last sound


5 major physiologic factors that control blood pressure:
1. cardiac output

-the volume of blood pumped by the heart (SV) during one minute (HR)
-increased volume in an enclosed space exerts more pressure on arterial walls, thus increased BP (this might come from excessive fluids from physiologic causes or from excessive IV fluids)
-if there is a decrease in volume, BP will decrease (hemorrhage, dehydration, dysrhythmias


5 major physiologic factors that control BP:
2. Peripheral Resistance

-the resistance to blood flow determined by the tone of the vascular musculature and diameter of blood vessels
-affected by vasodilation (decrease BP) and vasoconstriction (increase BP)


5 major physiologic factors that control BP:
3. blood volume

- normal adult blood volume is 5000 mL
-increase vol=increase BP; decrease vol=decrease BP


5 major physiologic factors that control BP:
4. Viscosity of Blood

- the thickness of the blood
-percentage of red blood cells in the blood determines blood viscosity
-Check Hematocrit
-Increased Ht slows blood flow and BP increases as heart works harder


5 major physiologic factors that control BP:
5. elasticity of Arteries

-normally elastic, but disease processes may affect this process
-arteriosclerosis leads to fibrous tissue and decreased elasticity with a resulting increase in BP


factors that influence blood pressure

1. age: Child: increase during childhood and larger body size and weight. Range 65-117/42-80
Adult: increases with aging. Optimal pressure is below 120/80
-systolic pressure generally rises related to decreased elasticity of arteries
2. Stress: Increases heart rate, cardiac output, and peripheral resistance
-Sympathetic stimulation increases BP
3. Race: Higher BP among African Americans males
- Potentially related to genetic and environmental factors
4. Gender: No difference in children
-After puberty, males are higher until women reach menopause, then females increase
-female hormones during adulthood appear to protect
5. medications: Narcotics and analgesics decrease BP
-Cardiac meds may increase or decrease
6. Time of Day (Diurnal Variation): lower in am, peaks in late afternoon to evening
7. Exercise
8. Muscle Tension: (including supported back, unsupported arm and crossing of legs) that may raise BP as much as 8 mm Hg
9. Activity: initial increase with demand for oxygen, then may decrease afterwards
11. Nicotine consumption: vasoconstriction when smoking, returns to baseline in 15min, increase BP
12. positioning of the arm, cuff size, and clothing under the cuff
13. medications


Blood pressure: direct measurement

-invasive catheter insertion: ICU only


Blood pressure: indirect measurement

-use auscultation with a stethoscope, or palpation and an aneroid or mercury spygmomanometer
-electronic sphygmomanometers often used in clinical settings
-calibration of equipment must be checked frequently


equipment for indirect measurement: Sphygmomanometer (BP cuff)

- working order
- "miscuffing" is the most frequent error in BP measurement with "undercuffing" (too small for arm accounting for the majority of the errors
- width of cuff should be 40% circumference of arm, but ideal is now set at 46%
-bladder should encircle 80% of the arm of an adult or the whole arm on a child
-cuff too wide= false low reading
-cuff too narrow= false high reading
-poorly wrapped= false high reading
-stethoscope and alcohol wipes


Position when checking BP

-client may stand, sit or be lying down
-sitting is preferred
- if the client is laying down, the arm will fall below heart level, thus raise with pillow
- arm at LEVEL OF HEART; arm below heart= false reading, arm above heart= low reading
-SUPPORT ARM: if not supported =false high reading


Prepare for Auscultation when checking BP

-quiet environment
-neither the nurse or the client should talk
-Korotkoff sounds
-first sound/phase = systolic blood pressure
-it corresponds to the pulse rate of the constricted artery. sharp thump sound
-second sound/ phase= blowing or whooshing as the cuff deflates. this is turbulence in blood flow as the artery distends
-third sound/ phase = soft thumo
-fourth sound/ phase = soft, fading blowing sound as the cuff pressure falls below the BP. (occasionally used this as diastolic for hypertensive clients)
-fifth sound/ phase is silence. Diastolic pressure


an artery can be assessed for....

a pulse rate


a pulse is the result of

the wave of blood being pumped from the left ventricle


apical pulse

-site is 4th or 5th intercostal space at mid-clavicular line
-this pulse provides the most accurate assessment of heart rate, especially with patients who have irregular heartbeats called "dysrthmias"
-also called the PMI (point of maximum impulse) and auscultate with the diaphragm of the stethoscope (60seconds)


carotid pulse

-along the medial edge of sternocleidomastoid muscle in neck
-the best site for quickly finding a pulse
- the heart will continue delivering blood through the carotid artery to the brain as long as possible
-when the cardiac output declines significantly, peripheral pulses weaken and may be difficult to palpate


radial pulse

-radial or thumb side of forearm or wrist
-radial pulses are generally east to locate on adults, sometimes more difficult with children because they can be deep
-they are easily assessable and used by persons learning to monitor their own heart rates


brachial pulse

-groove between biceps and triceps muscles at antecubital fossa used most often in infants and young children
-the other sites are not used routinely for obtaining vital signs, but can be assessed when a complete physical is conducted, when surgery or a treatment has impaired blood flow to a specific body part or when there are clinical indications of impaired peripheral blood flow


ulnar pulse

-ulnar side of little finger side of forearm or wrist
-site used to assess status or circulation o hand
-also used to perform Allen's test


femoral pulse

-below inguinal ligament, midway between sympysis pubis and anterior superior iliac spine
-site used to assess character of pulse during physiological shock or cardiac arrest when other pulses are not palpable: used to assess status of circulation in leg


temporal pulse

over temporal bone of head, above and lateral to eye. Easily accessible site used to assess pulse in children


popliteal pulse

behind knee in popliteal fossa
-site used to assess status of circulation to lower leg


posterior tibial pulse

-inner side or ankle below medial malleolus
-used to access circulation to foot


dorsalis pedis pulse

- along top of foot between extension tendons or great and first toe
-used to assess status of circulation in foot


factors that influence pulse rate

1. exercise: short-term exercise increases pulse rate
-a conditioned athlete who participated in long-term exercise will have a lower resting heart rate
2. temperature: fever and heat will increase pulse ate
-cold temperature "hypothermia" will slow heart rate
3. emotions: acute pain, anxiety, or fear will increases parasympathetic stimulation thus lowering heart rate
-shock may result with low heart rate
4. drugs: Chronotropic means heart rate, so if a drug has a positive chronotropic property, it speeds up the heart rate, such as epinephrine or tobacco, OR negative chronotropic, it slows down the heart rate, such as beta blockers or digitalis
5. hemorrhage: loss of blood increases sympathetic stimulation, the circulatory system attempts to compensate for lack of volume by increasing heart rate
6. postural changes: standing or sitting raises heart rate, laying down lowers heart rate
7. pulmonary conditions: diseases causing poor oxygenation such as acute asthma, emphysema, COPD
-Compensation mechanism: heart speeds up in attempt to supply the body with enough oxygen


identify indications for assessing apical and apical-radial pulse: Dysrhythmia

-irregular pulse caused by early, late or missed beats
-generally these types of beats that can produce pulse deficits


identify indications for assessing apical and apical-radial pulse: Dehydration

- hemorrhage, trauma, burns situations which produce a reduced fluid volume can cause peripheral pulses to be weak and thready


identify indications for assessing apical and apical-radial pulse: Compromised cardiac condition

-Heart Disease, MI, Congenital Anomalies, CHF, cardiomyopathy, invasive cardiac diagnostic tests and procedures that later heart function


identify indications for assessing apical and apical-radial pulse: Certain Medications

- related to cardiac and vascular conditions


Character of the Pulse

-objective and qualitative date is all information used to describe pulse
- Rate: number of pulsations counted over 1 min
-Rhythm: Regular or irregular, specific pattern, can be regularly irregular or irregularly irregular. May note the irregularity in response to something specific. Example: Children often have irregular heartbeat that speeds up with inspiration and slows with expiration. When the child holds their breath, the heart rate becomes regular
-Strength, Quality and Amplitude: strength or amplitude of a pulse reflects the volume of blood ejected against the arterial wall with each heart contractional. Strength is bonding (4+), full or strong (3+), normal and expected (2+), diminished, thready (1+), absent (0)
-equality: should assess pulse on both sides of the body to compare characteristics of each. All pulsed can be measured simultaneously EXCEPT carotid pulses because excessive pressure may occlude blood supply to the brain. Disease states that could produce unequal pulses are blood clot formation, aberrant blood vessels and aortic dissection



-mechanism that is used by the body to transport gases
-3 processes are involved: ventilation, diffusion and perfusion


Respirations: ventilation

-ventilation is assessed by assessing the respiratory rate, depth and rhythm
-Rate: Observe a full inspiration and expiration and count for 1 min. Rate varies with age, newborns 35-40, children 20-30 and adult 12-20
-Depth: this is assessed by observing the degree of movement (excursion) in the chest wall. Generally described as deep, normal or shallow
-Rhythm- breathing patterns. They are either regular or irregular. Determine by observing the chest or abdomen. Diaphragmatic breathing is seen in healthy men and children. Women tend to use thoracic muscles to breather; movements are in the upper chest. Labored respirations usually involve accessory muscles that are visible in the neck. when there is an obstruction, one may see the intercostal spaces (between ribs) retract during inspiration
-Interval: generally a regular interval between respirations. Infants and children tend to breathe less regularly: may breathe slowly for a few seconds and then suddenly breathe more rapidly. Abnormal breathing patterns: Bradypnea (slow, less than 12), tachypnea (fast more then 20), apnea (cease), Cheyne-Stokes (irregular), hyperventilation (rate and depth increased), hypoventilation (rate and depth low), and Kussmaul's respiration (deep and increased)


factors influencing respiratory rate

- position: straight erect posture promotes chest expansion. lying flat inhibits expansion
-medications: narcotics depress, amphetamines and cocaine increase
-neurological injury of the brain stem inhibits respiration
-decreased hemoglobin: carries O2. The body compensates by increasing respirations
- anxiety: sympathetic stimulation increases respirations
-exercise: respirations increase to meet body need for O2
-smoking: alters lungs and airway resulting in increased respiratory rate
-pain: may alter either by increasing or decreasing. there may be sympathetic response as in anxiety or a decrease if expansion of the chest wall is inhibited when patient feels that breathing "hurts"


assessment of color of skin and mucous membranes in white and brown-skinned patients

-normal skin can be a plethora of color: white, rosy, deep pink, brown, red, olive green, yellow, blue skin tones and all shades in between
1. ask the patient if they have noted any changes in skin color
2. determine if the patient works outside or spends excess time outside. Exposed areas of body such as face and arms will be more pigmented than rest of body; therefore assessment of color first involves areas not exposed to the sun
3. inspect color of skin surface yo want to compare color to symmetrical body parts



-bluish color caused by increased amount of deoxygenated hemoglobin associated with hypoxia
-causes are heart or lung disease, cold temperatures
-observe for cyanosis in the nail beds, lips, mouth and the generalized skin can become cyanotic in extreme cases



-decrease in color caused by reduced amounts of oxyhemglobin such as anemia or reduced visibility or oxyhemoglobin resulting from decreased blood flow such as shock: observe for pallor in the face, lips, conjunctivae, nail beds, palms, or soles



-yellow orange color caused by increased deposit of bilirubin in tissues caused by liver disease, hepatitis, newborns have jaundice due to the destruction of red blood cells
-look for jaundice in the sclera, mucous membranes and skin



-red color caused by increased visibility of oxyhemoglobin caused by dilatation or increased blood flow
-causes include fever, direct trauma, blushing and alcohol intake
-look for erythema on face, areas or trauma, sacrum, shoulders or other common sites for pressure ulcers


Dark Skin

-it is more difficult to note changes such as pallor or cyanosis in patients with dark skin
- pallor is more easily seen in the face, buccal mucosa, conjunctiva and nail beds
-in recognizing pallor in the dark-skinned client, normal brown skin appears to be yellow-brown and normal black appears to be ashen gray
-the lips, nail beds and mucous membranes should be assessed for generalized pallor, if pallor is present the mucous membranes will be ashen gray
-Cyanosis is best observed in areas where pigmentation occurs the least such as the lips, tongue, conjunctiva, palms, soles and nail beds
-erythema is not easily observed, so the nurse should palpate the area for heat and warmth to see if inflammation is present


Pulse Oximetry

-measurement of the arterial oxygen saturation with a device named the pulse oximeter
-through light waves, the oximeter measures the SpO2 (pulse saturation) in hemoglobin. Used on body surfaces that has capillaries near the surface for best readings (nail beds, earlobes, and bridge of nose). Opaque materials such as nail polish will interfere with accurate readings as will hypothermia that causes vasoconstriction
-the percent of saturation (SaO2) is measured with normal range 95% to 100%
-venous saturation (SvO2) may be assessed, a usual value is 70%, as oxygen has been removed from the hemoglobin