Metro Community College
Nursing Program
Nancy Pares, RN, MSN




Objective data that contributes to all other
nursing and medical information
Baseline values establish the norm against
which subsequent measures are compared
Accurate information is essential
Information must be obtained and recorded
accurately.


One of the most frequent assessments made
as a nurse
Nurse is
◦ Responsible for measuring, interpreting
significance and making decisions about care
◦ Knowing normal ranges
◦ Knowing history and other therapies that may affect
VS

Nurse must
◦ Know environmental factors that affect vital signs
 Exercise, stress, etc.
◦
◦
◦
◦
Use a systematic, organized approach
Verify and communicate changes in vital signs
Monitor VS regularly
Frequency determined by
 MD order; nursing judgement, client condition and
facility standards

Hospital:
◦ Every 4-8 hours

Home health:
◦ each visit

Clinic:
◦ Each visit

Skilled facility
◦ Daily and as needed



Degree of heat maintained by the body
Heat produced minus heat lost equals body
temperature
Organs have receptors that monitor core
body temperature

Core temperature
◦ Normal
 96.2 degrees F to 100.4 degrees F
 36.2 degrees C to 38 degrees C

Surface temperature
◦ Lower than core temperature
◦ Use oral and axillary method

Neural control
◦ Hypothalmus acts as thermostat

Vascular control
◦ Vasoconstriction ---hypothalmus directs the body
to decrease heat loss and increase heat production
◦ If cold, vasoconstriction will conserve heat—
shivering will occur
•
Vasodilation
– If body temp is above normal, the hypothalmus will
direct the body to decrease heat production;
– Perspiration and increased respiratory rate
•
Body heat production
– Body’s cells produce heat from food—releasing
energy.
– Kilocalorie= energy value;
– BMR= rate of energy used in the body to maintain
essential activities



If metabolism increases, more heat is
produced
More muscle= greater metabolism
Shivering is an early response for
thermoregulation that increases heat
production.

Conduction
◦ Transfer of heat from a warm to cool surface by
direct contact

Convection
◦ Transfer of heat through currents of air or water

Radiation
◦ Loss of heat through electromagnetic waves from
surfaces that are warmer than the surrounding air

Evaporation
◦ Water to vapor lost from skin or breathing







Age
Exercise
Hormones
Circadian cycle
Stress
Ingestion of food
smoking

Fever (pyrexia)
◦ Abnormally high body temperature (>100.4 F)
◦ Occurs in response to pyrogens (bacteria)
◦ Pyrogens induce secretion of prostoglandins that
reset the hypothalmic thermostat to a higher
temperature

Hyperpyrexia
◦ Fever > 105.8

Temp increases:
◦ Immune system stimulates hypothalmus to new set
point
◦ Chills, shivers
 Feels cold even though temp increasing
 When body temp is reset, chills subside






Metabolism increases
O2 consumption increases
HR and RR increase
Energy stores are used
Dehydration and confusion
When cause is removed, set point drops

Vasodilation
◦ Warm flushed skin and diaphoresis

Benefits
◦
◦
◦
◦
Activates the immune system
Interleukin 1 stimulates antibody production
Fights viruses by stimulating interleukin
Serves as a diagnostic tool

Chill stage:
◦ Temp every 1-4 hours
◦ Reduce activity
◦ Warm blankets

Throughout course
◦ Fluids, tepid baths, limit activity, keep dry
◦ Provide oral hygiene
◦ Provide air circulation

Heat stroke
◦
◦
◦
◦

Prolonged exposure to heat
Depression of hypothalmus
Emergency
S/S: hot, dry skin, confusion, delirium
Hypothermia
◦ Below 95 degrees
◦ Uncontrolled shivering, loss of memory,LOC
decreases

Limits: 77-109 degrees F

Oral
◦ Most accessible and accurate
◦ Do not use if unconscious, confused recent oral or
facial OR

Rectal
◦ 99 F
◦ Avoid with MI and after lower GI

Axillary
◦ 97 F—least accurate, most safe

Tympanic
◦ 98 F—avoid with infection, after exercise, w
hearing aid


The wave begins when the left ventricle
contracts and ends when the ventricle relaxes
Indirect measure of cardiac output


Each contraction forces blood into the already
filled aorta, causing increased pressure within
the arterial system
Systole:
◦ Peak of the wave; contraction of the heart

Diastole
◦ Resting phase of the heart

Rate
◦ Measured in beats per minute (bpm)
◦ Normal
 60-100 bpm
 Females slightly higher
◦ Average
 70-80 bpm



Apical is most accurate
Use a standard stethescope to auscultate the
number of heartbeats at the apex of the heart
A heartbeat is one series of the LUB and DUB
sounds









Apical: at the apex of the heart
Carotid: between midline and side of neck
Brachial: medially in the antecubital space
Radial: laterally on the anterior wrist
Femoral: in the groin fold
Popliteal: behind the knee
Post tibial
Dorsalis pedis
ulnar




Bradycardia: rate < 60 bpm
Tachycardia: rate> 100 bpm
Is the rate regular?
What is the quality?
◦ Bounding?
◦ Thready?


Dysrhythmia (arrhythmia)
Pulse deficit
◦ Difference between radial and apical




Exercise
Body temperature
Anxiety
position




Emotions
Medications
Hemorrhage
Pulmonary
condition

Stroke volume
◦ The quantity of blood pumped out by each
contraction of the left ventricle

Cardiac output
◦ Stroke volume x pulse (heart) rate

Pallor
◦ Paleness of skin when compared with another part
of the body

Cyanosis
◦ Bluish-grayish discoloration of the skin due to
excessive carbon dioxide and deficient oxygen in
the blood


The exchange of oxygen and carbon dioxide
in the body
Two separate process
◦ Mechanical
◦ chemical

Mechanical
◦ Pulmonary ventilation; breathing
◦ Ventilation:
 Active movement of air in and out of the respiratory
system
◦ Conduction
 Movement through the airways of the lung

Chemical
◦ Exchange of oxygen and carbon dioxide
◦ Diffusion
 Movement of oxygen and CO2 between alveoli and RBC
◦ Perfusion
 Distribution of blood through the pulmonary
capillaries

Inspiration
◦ Drawing air into the lung
◦ Involves the ribs, diaphragm
◦ Creates negative pressure-allows air into lung

Expiration
◦ Relaxation of the thoracic muscles and diaphragm
causing air to be expelled


Rate: regulated by blood levels of O2, CO2
and ph
Chemial receptors detect changes and signal
CNS (medulla)
◦
◦
◦
◦
◦
Normal: 12-20 breaths per minute
Apnea: no breathing
Bradypnea: abnormally slow
Tachypnea: abnormally fast
Observe for one full minute

Depth
◦ Normal: diaphragm moves ½ inch
◦ Deep
◦ Shallow

Rhythm
◦ Assessment of the pattern
◦ Abnormal
 Cheyne stokes, Kusmaul,

Effort
◦
◦
◦
◦
Work of breathing
Dypsnea: labored breathing
Orthopnea: inability to breath when horizontal
Observe for retractions, nasal flaring and
restlessness

Wheeze
◦ High pitched continuous musical sound; heard on
expiration

Rhonchi

Crackles
◦ Low pitched continuous sounds caused by
secretions in large airways
◦ Discontinuous sounds heard on inspiration; high
pitched popping or low pitched bubbling

Stridor
◦ Piercing, high pitched sound heard during
inspiration

Stertor
◦ Labored breathing that produces a snoring sound

Hyperventilation
◦ Rapid and deep breathing resulting in loss of CO2
(hypocapnea); light headed and tingly

Hypoventilation
◦ Rate and depth decreased; CO2 is retained

Cheyne Stokes
◦ Irregular, alternating periods of apnea and
hyperventilation
ABG
directly measures the partial pressures of
oxygen, carbon dioxide and blood ph
normal= paCO2 80-100)
Pulse oximetry
non invasive method for monitoring
respiratory status; measures O2 saturation
normal= >95%



Force exerted by blood against arterial walls
Work of the heart reflected in periphery via BP
Systolic
◦ Peak pressure exerted against arterial walls as the
ventricles contract and eject blood

Diastolic
◦ Minimum pressure exerted against arterial walls
between contraction when the heart is at rest



Measured in millimeters of mercury (mm Hg)
Recorded as systolic over diastolic
Pulse pressure
◦ Difference between systolic and diastolic


The body constantly adjusts arterial pressure
to supply blood to body tissues
Influenced by three factors
◦ Cardiac function
◦ Peripheral vascular resistance
◦ Blood volume




Normal = 5000 ml
Volume increases=BP increases
Volume decreases= BP decreases
Viscosity= reaction same as volume

Elasticity
◦ Less elasticity creates greater resistance to blood
flow= > systolic BP
◦ Decreased in smokers and increased cholesterol

Palpation
◦ Used when BP is too weak to hear

Errors
◦ Wrong size cuff, deflating too rapidly, incorrect
placement

Thigh
◦ Measures 30-40 mm HG less than normal




Age
Stress
Gender
race



Circadian
Medications
nutrition

Values
◦
◦
◦
◦

Normal: < 120/80 mm Hg
Hypotension: < 100mm HG
Pre hypertension: > 120/80 mm Hg
Hypertension: 140/90= Stage 1; 160/100= Stage 2
Persistant increase in BP
◦ Damage to vessels; loss of elasticity; decrease in
blood flow to vital organs

Indirect
◦ Most common, accurate estimate

Direct
◦ In patient setting only
◦ Catheter is threaded into an artery under sterile
conditions
◦ Attached to tubing that is connected to monitoring
system
◦ Displayed as waveform on monitoring screen

Indirect
◦ Equipment
 Sphygomanometer and stethescope
◦ Korotkoff’s sounds





1st
2nd
3rd
4th
5th

1st

2nd

3rd

4th

5th
◦ As you deflate the cuff; occurs during systole
◦ Further deflation of the cuff; soft swishing sound
◦ Begins midway through; sharp tapping sound
◦ Similar to 3rd sound but fading
◦ Silence, corresponding with diastole

Orthostatic or postural hypotension
◦ Sudden drop in BP on moving from lying to sitting
or standing position

Primary or essential hypertension
◦ Diagnosed when no known cause for increase
◦ Accounts for at least 90% of all cases of
hypertension


Combination of skills which provide an
indication of state of health and body
functionality
Nurses can delegate the activity of VS, but are
responsible for interpretation, trending and
decisions based on the findings



5th vital sign
It is what the client says it is
Nurse must know
◦ how to assess for it
◦ Establish acceptable comfort levels
◦ Follow up within appropriate time frame after
intervention

Data collection
◦ Location (place and position)
◦ Intensity
 1-10
 Strength and severity
 What is your pain at present? What makes it worse? What is
the best that it gets?

Describe
◦ Aching, stabbing, tender, tiring, numb,……..

Duration
◦ When did it start? Is is always there?

Aggrevate/alleviate
◦ What makes it better/worse?








Energy
Appetite
Sleep
Activity
Mood
Relationships
Memory
concentration

Nurse checks for
◦
◦
◦
◦
◦
VS
Knowledge of pain
Med history
Side effects of meds
Use of non
pharmacological
therapies