VITAL SIGNS ASSESSMENT: TPR
HEAL5026 Introduction to Professional Nursing Practice
Vital Signs Assessment
Lecturer: Mary Hopkinson
Related to: Learning Outcomes 4 & 5
Temperature
Pulse
Respirations
Pulse oximeter
Learning Objectives
1. Define the key terms listed
2. Discuss the purposes, methods and sites for vital sign measurement
3. Describe guidelines for taking vital signs
4. Identify when vital signs should be taken
5. Identify ranges of acceptable vital sign values for various age groups
6. Discuss factors that cause variation in:
body temperature
pulse
respirations
blood pressure (in next lecture)
oxygen saturation
Terminology
afebrile
antipyretics
bradycardia
bradypnoea
cardiac output
conduction
convection
core temperature
diaphoresis
dysrhythmia
eupnoea
febrile
fever
FUO
heatstroke
hypothalamus
hypothermia
hyperthermia
hypoxaemia
pulse deficit
pyrexia
radial pulse
radiation
rigors
shivering
tachycardia
thermoregulation
ventilation
vital signs
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VITAL SIGNS ASSESSMENT: TPR
HEAL5026 Introduction to Professional Nursing Practice
BODY TEMPERATURE
Purposes, Methods and Sites
“hotness” or “coldness” of a substance.” (Crisp & Taylor, 2009, p.546).
heat produced – heat lost = body temperature
thermoregulation: the balance between heat lost and heat
produced
hypothalamus maintains core temperature
PURPOSES
WHY take temperature measurements?
To determine:
basal metabolic rate
potential presence of infection
metabolic response to exercise
Skin temperature
circulatory status
local inflammatory responses
potential periphery nerve injury
METHODS
WHAT to use to take temperature measurements?
Thermometers
electronic
tympanic
mercury
skin
SITES
WHERE to take temperature measurements?
Surface:
oral
axillary
rectal
skin
Core:
1. tympanic membrane
2. intensive care settings:
pulmonary artery
oesophagus
urinary bladder
Average optimal temperature for an adult: 36° C - 38° C
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VITAL SIGNS ASSESSMENT: TPR
HEAL5026 Introduction to Professional Nursing Practice
PULSE (HEART RATE)
Purposes, Methods and Sites
pulse: measurement of heart rate (beats per minute)
basal rate: pulse rate after an extended period of rest
resting heart rate: pulse rate without imposed stress
PURPOSES
Why take pulse measurements?
To determine:
patency
rate
rhythm
strength (amplitude)
equality
METHODS
WHAT to use to take pulse measurements?
manual palpation
auscultation
doppler
pulse oximeter
SITES
WHERE to take pulse measurements?
temporal: over temporal bone of head
carotid: along medial edge of sternocleidomastoid muscle in neck
apical: 4th to 5th intercostal space at left midclavicular line
brachial: groove between biceps and triceps muscles at antecubital fossa
radial: radial or thumb side of forearm at wrist
ulnar: ulnar side of forearm at wrist
femoral: below inguinal ligament, midway between symphysis pubis and anterior superior iliac spine
popliteal: behind knees in popliteal fossa
posterior tibial: inner side of ankle, below medial malleolus
dorsalis pedis: along top of foot, between extension tendons of great and first toe
Reference: Crisp & Taylor, 2009, p. 56.
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VITAL SIGNS ASSESSMENT: TPR
HEAL5026 Introduction to Professional Nursing Practice
Acceptable ranges of heart rate (beats per minute)
AGE
HEART RATE
Infants
120-160/min
Toddlers
90-140/min
Preschoolers
80-110/min
School-agers
75-100/min
Adolescents
60-90/min
Adults
60-100/min
Reference: Crisp & Taylor, 2009, p. 566.
RESPIRATIONS
Ventilation: ‘breathing cycle’
Purposes, Methods and Sites
PURPOSES
Why take respiration measurements?
Rate of respirations (breathing) can be
measured
Each respiratory cycle is one inspiration and
the subsequent expiration
Quality of respirations can be observed
METHODS
WHAT to use to take respiratory measurements?
• observation
• watch with second hand for 1 full
minute
Acceptable range of respiratory rates for age
AGE
RESPIRATORY
RATE
Newborn (3000 g)
30-60
Infant (6 months)
30-50
Toddler (2 years)
25-32
Child
20-30
Adolescent
16-19
Adult
12-20
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VITAL SIGNS ASSESSMENT: TPR
HEAL5026 Introduction to Professional Nursing Practice
Guidelines for taking vital signs
Knowledge
medical history
pattern
trend
therapies
prescribed medications
Responsibility
analysis
interpretation
formulating interventions
Delegation
assistive personnel
Equipment
functional and appropriate
Frequency
collaboration with medical team
nurse judgement
Approaching the patient
calm and proficient
Systematic approach
environmental factors
organised
Communicating findings
verification
documentation
patient education
When to take vital signs?
On admission
Routine schedule
Before and after: surgery or invasive diagnostic procedure, nursing interventions influencing a vital sign
Before, during and after administration of medication: cardiovascular, respiratory, temperature-control
function
Change in physical condition
Non-specific symptoms
Factors affecting body temperature
age
exercise
hormone level
circadian rhythm
stress
environment
temperature alterations
-pyrexia
-pyrogens
-rigors
-febrile
-afebrile
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VITAL SIGNS ASSESSMENT: TPR
HEAL5026 Introduction to Professional Nursing Practice
Factors affecting heart rate
age
exercise
emotions
drugs
haemorrhage
postural changes
pulmonary conditions
Factors affecting character of respirations
exercise
acute pain
anxiety
smoking
body position
medications
neurological injury
haemoglobin function
References
Ackley, B. J., Swan, B. A., Ladwig, G. B., & Tucker, S. J. (2008). Evidence-based nursing care guidelines: MedicalSurgical interventions. St. Louis: Elsevier. Retrieved February 11, 2008, from
http://www.nursingconsult.com/das/book/119817642-4/view/1815
Crisp, J., & Taylor, C. (3rd. ed.). (2009). Potter and Perry’s fundamentals of nursing. Chatswood: Elsevier.
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