By Diana Blum MSN
NURS 1510
What are they?
Pulse
Respirations
BP
Temperature
Oxygen Sats
How often?
• As ordered
•
•
•
•
Q1hour
Q2 hours
Q4 hours
Routine (Q8hours)
• Based on client condition
WHY?
• Baseline values establish the
•
norm against which
subsequent measures are
compared
Nurse is
• Responsible for measuring,
•
•
interpreting significance and
making decisions about care
Knowing normal ranges
Knowing history and other
therapies that may affect VS
Temperature
Degree of heat maintained by
the body
Heat produced minus heat lost
equals body temperature
Organs have receptors that
monitor core body
temperature
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
Regulation of Temperature
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
Regulation of temperature
• Vasodilation
–If body temp is above
–
normal, the hypothalamus
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.
–BMR= rate of energy used in
the body to maintain
essential activities
Changes in temperature
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
Factors affecting
Temperature
Age
Exercise
Hormones
Circadian cycle
Stress
Ingestion of food
Smoking
Environment
(Page 529)
Variances in temperature
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
Febrile= has fever
Afebrile= no fever
Intermittent fever:
Remittent fever:
Relapse fever:
Constant fever:
Fever spike: rises rapidly
then normal within a few
hours
Not a true fever @$!?
Heat exhaustion
Heat stroke
• Prolonged exposure to
heat source (Ex. SUN)
• Depression of
hypothalmus
• Emergency
• S/S: hot, dry skin,
confusion, delirium
Serious variations in
temperature
Hypothermia
Below 95 degrees
Uncontrolled shivering, loss of
memory,LOC decreases
Limits: 77-109 degrees F
Physiologic responses
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
Physiologic responses
• Metabolism increases
• O2 consumption increases
• HR and RR increase
• Energy stores are used
• Dehydration and confusion
• When cause is removed, set
point drops
Physiologic responses
• 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
Routes for taking temperatures
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, if hearing aid
Infrared
Temporal
Pulse
The wave begins when the left
ventricle contracts and ends
when the ventricle relaxes
Indirect measure of cardiac
output
Pulse
Each contraction forces blood
into the already filled
aorta, causing increased
pressure within the arterial
system
Systole:
Diastole:
Cardiac Output=SV x HR
Stroke volume
The quantity of blood pumped out by
each contraction of the left
ventricle
Pulse
Measured in beats per minute
(bpm)
Normal
60-100 bpm
Females slightly higher
Average
70-80 bpm
Obtaining pulse rate
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
Common pulse points
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
Variances in pulse rates
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
Factors affecting pulse rate
Exercise
Body
temperature
Anxiety
Position
Age
Gender
Emotions
Medications
Hemorrhage
Pulmonary
condition
Stress
Fluid Volume
Color Change= Circulation problem
Normal: pink
warm dry
Cyanosis
Bluish-grayish
discoloration of
the skin due to
excessive
carbon dioxide
and deficient
oxygen in the
blood
Pallor
Paleness of skin
when compared
with another
part of the body
Respiration=The exchange of oxygen and carbon
dioxide in the body
Mechanical
Chemical
Pulmonary
ventilation;
breathing
Ventilation:
Active movement of air
in and out of the
respiratory system
Conduction:
Movement through
the airways of the
lung
Exchange of
oxygen and
carbon dioxide
Diffusion
Movement of
oxygen and CO2
between alveoli
and RBC
Perfusion
Distribution of
blood through the
pulmonary
capillaries
Mechanics of ventilation
Inspiration
Drawing air into the lung
Involves the ribs, diaphragm
Creates negative pressureallows air into lung
Expiration
Relaxation of the thoracic
muscles and diaphragm
causing air to be expelled
Variations in assessment of respirations
• 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
Variations in assessment findings
Depth
Normal: diaphragm moves ½
inch
Describe as deep or shallow
Rhythm
Assessment of the pattern
Abnormal
Cheyne stokes:
Kussmal's:
Effort
Work of breathing
labored or unlabored
Observe for retractions, nasal
flaring and restlessness
Variations in breath sounds
Wheeze
High pitched continuous musical
sound; heard on expiration
Rhonchi
Low pitched continuous sounds
caused by secretions in large
airways
Crackles
Discontinuous sounds heard on
inspiration; high pitched
popping or low pitched
bubbling
Variations in breath sounds
Stridor
Piercing, high pitched sound
heard during inspiration
Stertor
Labored breathing that
produces a snoring sound
Both may indicate obstruction
Hyperventilation Hypoventilation
Rapid and deep
breathing
resulting in loss
of CO2
(hypocapnea);
light headed
and tingly
Rate and depth
decreased; CO2
is retained
Tools to measure
oxygenation
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= >95-100%
Blood pressure
Force exerted by blood
against arterial walls
Work of the heart
reflected in periphery
via BP
Measured in millimeters
of mercury (mm Hg)
Recorded as systolic over
diastolic
BP regulation
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
Potential Misreads
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
Factors affecting BP
Age
Stress
Gender
Race
Exercise
Diurnal
Medications
Nutrition
Obesity
Disease
Variations in BP
Values
Normal: < 120/80 mm Hg
Hypotension: SBP< 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
Korotkoff’s sounds
Phase 1
As you deflate the cuff; occurs during systole
Phase 2
Further deflation of the cuff; soft swishing
sound
Phase 3
Begins midway through; sharp tapping sound
Phase 4
Similar to 3rd sound but fading
Phase 5
Silence, corresponding with diastole
Auscultatory Gap: occurs in HTN pts
The sound disappears at high cuff pressure
And reappears at low levels
Measurement of BP
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
Other BP issues
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
Nurses can delegate the
activity of VS, but are
responsible for
interpretation, trending
and decisions based on
the findings
Pain
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 to be collected
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?
How does the pain affect…
Energy
Nurse checks for
VS
Appetite
Knowledge of pain
Sleep
Med history
Activity
Side effects of meds
Mood
Use of non
Relationships pharmacological
therapies
Memory
concentration
ANY QUESTIONS????