CHAPTER 11
Vital Signs
1
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
Slide 1
Which needs more assessment?
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
0%
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4%
us
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4.
sin
3.
96%
ar
2.
Regular sinus rhythm
B/P of 120/86
Rectal Temp of 99.8
Respiratory rate of 30
Re
gu
l
1.
Slide 2
What’s most important for an oral
temp just after smoking?
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
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4.
12% 8%
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3.
76%
ns
e
2.
Rinse mouth with
water
Place thermometer
firmly under tongue
Wait 15 minutes to
take temp
Shake down the
thermometer
Ri
1.
Slide 3
Which is the least accurate site
for body temperature?
9%
9%
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
ni
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pa
Ax
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4.
Re
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3.
82%
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2.
Oral
Rectal
Axillary
Tympanic
Or
a
1.
Slide 4
Which statement by the patient
needs further investigation?
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
os
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3.
25%
w
2.
“I will request pain
meds when I can no
longer stand the pain”
Distraction and
imagery techniques
help my pain.
I need to change my
position regularly
“I
1.
36%
39%
Slide 5
Which assessment relates directly
to pain?
25%
1.
Blood Pressure 100/60
25%
2.
Dilated pupils
25%
3.
Pulse 80 beats per minute
25%
4.
Respirations 14 per minute
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Slide 6
The PT is teaching a client to take a core
temperature. Which sites would be used?
1.
Skin
0%
2.
4%
Mouth
3.
4%
Axilla
4.
Rectal
93%
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Slide 7
A client having her B/P taken asks,
“What does B/P actually represent?
1.
It’s
21%the wave of blood created by
contraction of the left ventricle of
the heart.
71%
2.
7%
It’s a measurement of the pressure
exerted by the blood as it pulsates
through the arteries.
3.
It’s a measure of the volume of
blood in the cardiac region.
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Slide 8
Pulse rate of 140 beats per
minute is known as
1.
2.
3.
4.
Bradycardia
Tachycardia
Proxycardia
Extopicardia
4%
12%
4%
81%
Bradycardia
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Tachycardia
Proxycardia
Extopicardia
Slide 9
A pedal pulse site is used to:
Determine discrepancies
with the radial pulse
2. Identify venous thrombus
3. Determine circulation to
the foot.
4. As the primary means of
checking heart rate.
1.
11%
14%
4%
71%
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Determine discrep...
Identify venous t...
Determine circula...
As the primary me...
Slide 10
You arrive at bedside to take vital signs just
after client has had a cup of coffee. What do
you do?
Ask client to rinse mouth
to normalize temp
2. Ask client to not eat,
drink, or smoke for 30
min, then take V/S.
3. Take all the V/S except
temp…do that later
4. Proceed to take the v/s
according to Hospital
routine.
1.
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0%
21%
4%
75%
Ask client to rin...
Ask client to not...
Take all the V/S ...
Proceed to take t...
Slide 11
Which post surgery patient is in
most need of pain meds?
1.
2.
3.
Patient with Pulse
120, R 22 ,b/p
140/92.
“I’m starving and
have a dull ache in
my back
Patient with pulse
of 68, R 18 and
b/p 100/76
11%
7%
81%
Patient with Puls...
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“I’m starving and...
Patient withSlide
puls...
12
Which B/P in an adult is
considered hypertension
1.
2.
3.
4.
110/70
130/80
140/90
160/110
0% 11%
18%
71%
110/70
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130/80
140/90
160/110
Slide 13
Vital Signs
► They
are called vital signs because they are
important.
► They include:




Temperature
Pulse
Respirations
Blood pressure
► Vital
signs and other physiologic measurements
can be the bases for problem solving.
► Many facilities have developed a fifth vital
signpain level/comfort level.
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Slide 14
Guidelines for Obtaining Vital
Signs
► The
Psych Tech must be able to do all of
the following:




Measure vital signs correctly
Understand and interpret the values
Communicate/document findings accurately
Begin interventions as needed
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Slide 15
Oximetry
►A
non-invasive device that measures the
level of oxygenation in the blood.
► An excellent addition to information
received via vital signs.
► Will have a lesson on the operation and
values of oximetry in the nursing lab.
► Peg try to get a picture or example
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Slide 16
Temperature
► Many
factors can cause body temperature
variances.





Environment
Time of day
Patient’s state of health
Activity levels
Stage of monthly menstrual cycle
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Slide 17
Temperature
► Temperature
is a relative measure of
sensible heat or cold.
► The body strives to maintain a
temperature of 98.6° F (37° C), which is
considered normal.
► Normal range is 97° to 99.6° F (36.1° to
37.5° C).
► The hypothalamus helps maintain a
balance between heat lost and heat
produced by the body.
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Slide 18
Temperature
► Two
Types of Body Temperature
 Core Temperature
►Temperature
of the deep tissues of the body
►Remains relatively constant unless exposed to
severe extremes in environmental temperature
►Assessed by using a thermometer device
 Surface Temperature
►Temperature
of the skin
►May vary a great deal in response to the
environment
►Assessed by touching the skin
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Slide 19
Temperature
► Temperature
measurements are obtained
by several methods.
 Heat-sensitive patches
►Patch
placed on the skin; color changes on the patch
indicate temperature readings
 Electronic thermometers
►Consist
of a rechargeable battery-powered display
unit, a thin wire cord, and a temperature processing
probe
 Tympanic thermometer
►Special
form of electronic thermometer; inserted into
auditory canal
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Slide 20
Figure 11-2
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
Disposable, single-use thermometer strip.
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Slide 21
Figure 11-3
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
Electronic thermometer.
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Slide 22
Figure 11-4
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
Tympanic thermometer with probe cover inserted into auditory canal.
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Slide 23
Temperature
Pyrexia, Febrile, or Hyperthermia
 When the temperature is above normal
 Fever is actually a body defense; it will destroy
invading bacteria.
► Classification
of Fevers
 Constant:
remains elevated consistently
 Intermittent: rises and falls
 Remittent:
temperature never returns to
normal until the patient becomes well
► Hypothermia
 An abnormally low body temperature
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Slide 24
Temperature
► Oral
temperature is not obtained in the
comatose or disoriented patient or in small
infants.
► Rectal temperatures are contraindicated
for patients with recent rectal surgery or
certain conditions of the perineum.
► Axillary temperature is considered the
least accurate method.
► Rectal readings are normally 1° F higher
than oral, and axillary readings are 1° F
lower than oral.
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Slide 25
Auscultating Using the
Stethoscope
► When
assessing the apical heart rate, the
PT uses a stethoscope.
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Slide 26
Using a stethoscope
► video
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Slide 27
Figure 11-6
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St.
Louis: Mosby.)
Parts of a stethoscope.
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Slide 28
Auscultating Using the
Stethoscope
► Chestpiece
 Diaphragm: circular, flat-surfaced portion of the
chest piece covered with a thin plastic disk
 Transmits high-pitched sounds created by the
high-velocity movement of air and blood
 Bell: bowl-shaped chestpiece, usually
surrounded by a rubber ring.
Transmits low-pitched sounds created by the
low-velocity movement of blood.
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Slide 29
Pulse
► There
is a rhythmic beating or vibrating
movement.
► The pulse is the regular, recurrent
expansion and contraction of an artery
produced by waves of pressure caused by
the ejection of blood from the left ventricle
of the heart as it contracts.
► The PT notes the rate, rhythm, and
volume of the pulse.
► Adult pulse rate is normally between 60
and 100 beats per minute.
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Slide 30
Figure 11-7
Pulse sites.
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Slide 31
Pulse
► Tachycardia
 The pulse is faster than 100 beats per minute.
 It may result from shock, hemorrhage, exercise,
fever, acute pain, and drugs.
► Bradycardia
 The pulse is slower than 60 beats per minute.
 It may result from unrelieved severe pain,
drugs, resting, and heart block.
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Slide 32
Pulse
► Dysrhythmia
 Any disturbance or abnormality in a normal
rhythmic pattern, specifically irregularity in the
normal rhythm of the heart
► Any
artery can be assessed for pulse rate,
but the radial and carotid arteries are
peripheral pulse sites that are easily
palpated.
► The radial and apical locations are the most
common sites for pulse rate assessment.
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Slide 33
Figure 11-9
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St.
Louis: Mosby.)
A, Point of maximum impulse is at fifth intercostal space. B,
Assessing apical pulse.
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Slide 34
Pulse
► Pulses
on both sides of the peripheral
vascular system should be assessed.
► Pulses are palpated using the pads of the
index and middle fingers; only slight
pressure is applied over the artery to avoid
obliterating the pulse.
► Apical pulse represents the actual beating of
the heart.
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Slide 35
Pulse
► When
auscultated, the “lubb-dubb” heard
represents one cardiac cycle, or heartbeat.
► Pulse deficit: difference between the radial
and apical rates; signifies that the pumping
action of the heart is faulty.
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Slide 36
Figure 11-8
(From Sorrentino, S.A. [2004]. Mosby’s textbook for nursing assistants. [6th ed.]. St. Louis: Mosby.)
Taking an apical/radial pulse.
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Slide 37
Respirations
► The
taking in of oxygen, its utilization in the
tissues, and the giving off of carbon dioxide;
the act of breathing.
 Internal Respirations
►The
exchange of gas at the alveolar level
 External Respirations
►Breathing
movements that can be observed by the
nurse; inspiration and expiration
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Slide 38
Respirations
► Assessment
includes the rate, depth,
rhythm, and quality.
 The normal rate for an adult is between 12
and 20 per minute.
►Tachypnea
 Rapid respiratory rate; exercise and fever increase
respiratory rate
►Bradypnea
 A slow respiratory rate, below 12 per minute
 The depth of respiration is determined by the
amount of air taken in with inhalation.
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Slide 39
Figure 11-10
Patterns of respirations.
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Slide 40
► Assessment
Respirations
includes the rate, depth,
rhythm, and quality. (continued)
 The rhythm of respiration should be regular and
uninterrupted.
► Dyspnea
 Breathing with difficulty
► Apnea
 A lack of spontaneous respirations
► Cheyne-Stokes
respirations
 An abnormal pattern of respiration; alternating
patterns of apnea and deep, rapid breathing.
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Slide 41
Blood Pressure
► The
pressure exerted by the circulating
volume of blood on the arterial walls, veins,
and chambers of the heart.
 Systolic
►The
higher number; represents the ventricles
contracting
 Diastolic
►The
second number; represents the pressure within
the artery between beats
 Pulse Pressure
►Difference
between the systolic and diastolic
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Slide 42
Blood Pressure
► Normal
blood pressure in the adult is
120/80 mm Hg.
► Hypertension
 Sustained elevated blood pressure is above
140/90 mm Hg.
► Hypotension
 Blood pressure is below normal.
► Orthostatic
Hypotension
 A drop of 25 mm Hg in systolic pressure and a
drop of 10 mm Hg in diastolic pressure when
moving from lying to sitting or sitting to
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Slide 43
Blood Pressure
► Sphygmomanometer
 A device for measuring the arterial blood
pressure
 Consists of an inflatable cuff and a gauge
 The cuff is inflated around the patient’s arm to
compress the artery; then it is slowly deflated
while the nurse listens at the brachial artery
with a stethoscope and hears pulsating sounds.
►Korotokoff
sounds: The first sound heard is the
systolic pressure; the point at which the last sound is
heard is the diastolic pressure.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
Slide 44
Figure 11-11
(From Sorrentino, S.A. [2004]. Mosby’s textbook for nursing assistants [6th ed.]. St. Louis: Mosby.)
Aneroid manometer and cuff.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
Slide 45
Figure 11-12
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
Wall-mounted aneroid sphygmomanometer.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
Slide 46
Figure 11-17
Electronic sphygmomanometer.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
Slide 47
Figure 11-14
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St.
Louis: Mosby.)
Doppler stethoscope over brachial artery to measure blood pressure.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
Slide 48
Figure 11-13
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
The sounds during blood pressure measurement can be
differentiated into five Korotkoff phases.
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Slide 49
Blood Pressure
► Assessment
Extremities
of Blood Pressure in the Lower
 Occasionally, the upper extremities may be
inaccessible, so blood pressure must be
measured in the lower extremities.
 The popliteal artery, located behind the knee, is
the site for auscultation.
 The cuff must be wide and long enough to allow
for the larger girth of the thigh and is positioned
with the bladder over the posterior aspect of
the midthigh.
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Slide 50
Figure 11-15, A
(A, From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.].
St. Louis: Mosby.)
A, Lower-extremity blood pressure cuff positioned above popliteal
artery at midthigh.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
Slide 51
Figure 11-15, B
(A, From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.].
St. Louis: Mosby.)
B, Location of the popliteal artery and placement of
the cuff.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
Slide 52
Blood Pressure
► Automatic
Measurement Devices
 Many automatic devices can determine blood
pressure automatically.
 Once the cuff is applied, the nurse can program
the device to obtain and record blood pressure
readings at preset intervals.
► Self-Measurement
 Portable home devices
 Stationary automated machines
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Slide 53
Height and Weight
► Helps
assess normal growth and
development
► Aids
in proper drug dosage calculation
► May
be used to assess the effectiveness of
drug therapy, such as diuretics
► Significant
loss of weight may be a sign of
an underlying disease
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Slide 54
Height and Weight
► Height
 Patient should remove shoes and stand erect.
 A measuring stick or tape may be attached
vertically to the weight scales or wall.
 Standing scales may have a metal rod, which
is attached to the back of the scale and
swings out over the top of the patient’s head.
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Slide 55
Height and Weight
► Weight
 Types of scales
►Standing
scales
►Chair scales; lift scales
 Used for patients who cannot stand
 Patients should be weighed at the same time
of day, on the same scale, and in the same
type of clothing to allow an objective
comparison of subsequent weighing.
 Patient should void before weighing.
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Slide 56
Figure 11-18
(From Sorrentino, S.A. [2004]. Mosby’s textbook for nursing assistants. [6th ed.]. St. Louis: Mosby.)
Types of scales. A, Standing scale. B, Chair scale. C, Lift scales.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
Slide 57
When Vital Signs Are Assessed
► Temperature,
pulse, respirations, and
blood pressure are usually assessed at the
same time at set intervals.
►A
set of vital signs is taken when the
patient is admitted to the facility and then
as prescribed by the physician or as policy
dictates.
► Example:
every 4 hours; once a shift;
weekly
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Slide 58
When Vital Signs Are Assessed
► The
more ill the patient, the more
frequently vital signs are taken.
► Vital signs are interrelated.
 A rise in temperature of 1° F may cause an
increase in pulse rate of 4 beats per minute.
 Respiratory rate and blood pressure readings
increase with a rise in temperature.
 Blood pressure falls because of hemorrhage,
the pulse and respirations increase and the
temperature usually decreases.
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Slide 59
Recording Vital Signs
► Graphic




Flow Sheet
Used for charting vital signs
R indicates a rectal temperature
Ax indicates an axillary temperature
Blood pressures are always written with the
systolic first and the diastolic beneath.
►Example:
120/80
 Apical pulse is indicated with an “ap” after next
to the number.
►Example:
78 ap
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Slide 60
Recording Vital Signs
► Any
abnormal findings are reported to the
nurse-manager or physician immediately.
► Any
accompanying or precipitating signs
and symptoms such as chest pain, vertigo,
shortness of breath, flushing, and
diaphoresis should be recorded as well.
► The
nurse documents any interventions
initiated as a result of vital sign
measurement, such as tepid sponging.
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Slide 61
Nursing Process
► Assessment
 Normal daily fluctuations
 Factors likely to interfere with accuracy of vital
sign reading
 Medications that may influence vital signs
 Factors that influence vital signs
 Conditions that precipitate fever, such as
infections
 Pertinent laboratory values
 Previous baseline vital signs from patient’s
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Slide 62
Nursing Process
► Nursing





Process
Fluid volume deficient
Hyperthermia
Hypothermia
Body temperature, risk for imbalance
Gas exchange, impaired
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Slide 63