vital signs

Kozier & Erb's Fundamentals of Nursing, 8eBerman, Snyder, Kozier, ErbCopyright 2008 by Pearson Education, Inc.

Chapter 29

Vital Signs

Copyright 2008 by Pearson Education, Inc.

Learning Outcomes

1. Describe factors that affect the vital signs and accurate measurement of them.

2. Identify the variations in normal body temperature, pulse, respirations, and blood pressure that occur from infancy to old age.

3. Compare methods of measuring body temperature.4. Describe appropriate nursing care for alterations in body

temperature.5. Identify nine sites used to assess the pulse and state the

reasons for their use.6. List the characteristics that should be included when

assessing pulses.7. Explain how to measure the apical pulse and the apical-

radial pulse.


Learning Outcomes8. Describe the mechanics of breathing and the

mechanisms that control respirations.9. Identify the components of a respiratory assessment.10. Differentiate systolic from diastolic blood pressure.11. Describe five phases of Korotkoff’s sounds.12. Describe methods and sites used to measure blood

pressure.13. Discuss measurement of blood oxygenation using

pulse oximetry.14. Identify when it is appropriate to delegate

measurement of vital signs to unlicensed assistive personnel.


Pretest

• Use your clickers to complete the following pretest.


Question 1

The client’s temperature at 8:00 AM using an oral electronic thermometer is 36.1°C (97.2°F). If the respiration, pulse, and blood pressure are within normal range, what would the nurse do next?

1. Wait 15 minutes and retake it.2. Check what the client’s temperature was

the last time.3. Retake it using a different thermometer.4. Chart the temperature; it is normal.


Rationales 1

1. Depending on that finding, you might want to retake it in a few minutes (no need to wait 15 minutes).

2. Correct. Although the temperature is slightly lower than expected for the morning, it would be best to determine the client’s previous temperature range next. This may be a normal range for this client.

3. There is no need to take temperature again with another thermometer to see if the initial thermometer was functioning properly.

4. Chart after determining that the temperature has been measured properly.


Question 2

Which of the following clients meets the criteria for selection of the apical site for assessment of the pulse rather than a radial pulse?

1. A client is in shock2. The pulse changes with body position changes3. A client with an arrhythmia4. It is less than 24 hours since a client's surgical

operation


Rationales 2

1. For clients in shock, use the carotid or femoral pulse.

2. The radial pulse is adequate for determining change in orthostatic heart rate.

3. Correct. The apical rate would confirm the rate and determine the actual cardiac rhythm for a client with an abnormal rhythm; a radial pulse would only reveal the heart rate and suggest an arrhythmia.

4. The radial pulse is appropriate for routine postoperative vital sign checks for clients with regular pulses.


Question 3

It would be appropriate to delegate the taking of vital signs of which of the following clients to a UAP?

1. A patient being prepared for elective facial surgery with a history of stable hypertension.

2. A patient receiving a blood transfusion with a history of transfusion reactions.

3. A client recently started on a new antiarrhythmic agent.

4. A patient who is admitted frequently with asthma attacks.


Rationales 31. Correct. Vital signs measurement may be

delegated to UAP if the client is in stable condition, the findings are expected to be predictable, and the technique requires no modification. Only the preoperative client meets these requirements.

2. This client is unstable and vital signs measurement cannot be delegated.

3. In addition to the client being unstable, UAP are not delegated to take apical pulse measurements for the client with an irregular pulse as would be the case with the client newly started on antiarrhythmic medication.



Question 4

A nursing diagnosis of Ineffective Peripheral Tissue Perfusion would be validated by which one of the following:

1. Bounding radial pulse2. Irregular apical pulse3. Carotid pulse stronger on the left side

than the right4. Absent posterior tibial and pedal pulses


Rationales 4

1. Abounding radial pulse is more indicative that perfusion exists.

2. Apical pulses are central and not peripheral.

3. Carotid pulses are central and not peripheral.

4. Correct. The posterior tibial and pedal pulses in the foot are considered peripheral and at least one of them should be palpable in normal individuals.


Question 5

The nurse reports that the client has dyspnea when ambulating. The nurse is most likely to have assessed which of the following?

1. Shallow respirations2. Wheezing3. Shortness of breath4. Coughing up blood


Rationales 5

1. Shallow respirations are seen in tachypnea (rapid breathing).

2. Wheezing is a high-pitched breathing sound that may or may not occur with dyspnea.

3. Correct. Dyspnea, difficult or labored breathing, is commonly related to inadequate oxygenation. Therefore, the client is likely to experience shortness of breath, that is, a sense that none of the breaths provide enough oxygen and an immediate second breath is needed.

4. The medical term for coughing up blood is hemoptysis and is unrelated to dyspnea.


Vital Signs

• Monitor functions of the body• Should be a thoughtful, scientific

assessment


When to Assess Vital Signs

• On admission• Change in client’s health status• Client reports symptoms such as chest

pain, feeling hot, or faint• Pre and post surgery/invasive procedure• Pre and post medication administration

that could affect CV system• Pre and post nursing intervention that

could affect vital signs


Factors Affecting Body Temperature

• Age• Diurnal variations (circadian rhythms)• Exercise• Hormones• Stress• Environment


Factors Affecting Pulse

• Age• Gender• Exercise• Fever• Medications• Hypovolemia• Stress• Position changes• Pathology


Factors Affecting Respirations

• Exercise• Stress• Environmental temperature• Medications


Factors Affecting Blood Pressure

• Age• Exercise• Stress• Race• Gender• Medications• Obesity• Diurnal variations• Disease process


Temperature: Lifespan Considerations

Infants UnstableNewborns must be kept warm to prevent hypothermia

Children Tympanic or temporal artery sites preferred

Elders Tends to be lower than that of middle-aged adults


Pulse: LifespanConsiderations

Infants Newborns may have heart murmurs that are not pathological

Children The apex of the heart is normally located in the fourth intercostal space in young children; fifth intercostal space in children 7 years old and older

Elders Often have decreased peripheral circulation


Respirations:Lifespan Considerations

Infants Some newborns display “periodic breathing”

Children Diaphragmatic breathers

Elders Anatomic and physiologic changes cause respiratory system to be less efficient


Blood Pressure:Lifespan Considerations

Infants Arm and thigh pressures are equivalent under 1 year of age

Children Thigh pressure is 10 mm Hg higher than arm

Elders Client’s medication may affect how pressure is taken


Sites for Measuring Body Temperature

• Oral• Rectal• Axillary• Tympanic membrane • Skin/Temporal artery


Types of Thermometers

• Electronic• Chemical disposable• Infrared (tympanic)• Scanning infrared (temporal artery)• Temperature-sensitive tape• Glass mercury


Nursing Care for Fever

• Monitor vital signs• Assess skin color and

temperature• Monitor laboratory

results for signs of dehydration or infection

• Remove excess blankets when the client feels warm

• Provide adequate nutrition and fluid

• Measure intake and output

• Reduce physical activity

• Administer antipyretic as ordered

• Provide oral hygiene • Provide a tepid sponge

bath • Provide dry clothing

and bed linens


Nursing Care for Hypothermia

• Provide warm environment• Provide dry clothing• Apply warm blankets• Keep limbs close to body• Cover the client’s scalp • Supply warm oral or intravenous

fluids• Apply warming pads


Pulse Sites

Radial Readily accessible

Temporal When radial pulse is not accessible

Carotid During cardiac arrest/shock in adultsDetermine circulation to the brain

Apical Infants and children up to 3 years of ageDiscrepancies with radial pulseMonitor some medications


Pulse Sites

Brachial Blood pressureCardiac arrest in infants

Femoral Cardiac arrest/shockCirculation to a leg;

Popliteal Circulation to lower leg

Posterior tibial

Circulation to the foot

Dorsalis pedis

Circulation to the foot


Characteristics of the Pulse

• Rate• Rhythm• Volume• Arterial wall elasticity• Bilateral equality


Pulse Rate and Rhythm

• Rate– Beats per minute– Tachycardia– Bradycardia

• Rhythm– Equality of beats

and intervals between beats

– Dysrhythmias– Arrhythmia


Characteristics of the Pulse

• Volume– Strength or amplitude– Absent to bounding

• Arterial wall elasticity– Expansibility or deformity

• Presence or absence of bilateral equality – Compare corresponding artery


Measuring Apical Pulse


Apical-Radial Pulse• Locate apical and radial sites• Two nurse method:

– Decide on starting time– Nurse counting radial says “start”– Both count for 60 seconds – Nurse counting radial says “stop”– Radial can never be greater than apical


Inhalation

• Diaphragm contracts (flattens)

• Ribs move upward and outward

• Sternum moves outward

• Enlarging the size of the thorax


Exhalation

• Diaphragm relaxes• Ribs move

downward and inward

• Sternum moves inward

• Decreasing the size of the thorax


Respiratory Control Mechanisms

• Respiratory centers– Medulla oblongata– Pons

• Chemoreceptors– Medulla– Carotid and aortic bodies

• Both respond to O2, CO2, H+ in arterial blood


Components of Respiratory Assessment

• Rate• Depth• Rhythm• Quality• Effectiveness


Respiratory Rate and Depth

• Rate– Breaths per minute– Eupnea– Bradypnea– Tachypnea

• Depth– Normal– Deep– Shallow


Components of Respiratory Assessment

• Rhythm– Regular– Irregular

• Quality – Effort– Sounds

• Effectiveness– Uptake and

transport of O2

– Transport and elimination of CO2


Systolic and Diastolic Blood Pressure

• Systolic – Contraction of the

ventricles

• Diastolic – Ventricles are at rest– Lower pressure

present at all times

• Pulse Pressure = difference between systolic and diastolic pressures

• Measured in mm Hg

• Recorded as a fraction, e.g. 120/80

• Systolic = 120 and Diastolic = 80


Korotkoff’s Sounds



• Phase 1– First faint, clear tapping or thumping

sounds– Systolic pressure

• Phase 2– Muffled, whooshing, or swishing sound



• Phase 3– Blood flows freely – Crisper and more intense sound– Thumping quality but softer than in phase 1

• Phase 4– Muffled and have a soft, blowing sound

• Phase 5– Pressure level when the last sound is heard– Period of silence – Diastolic pressure


Measuring Blood Pressure

• Direct (Invasive Monitoring)

• Indirect– Auscultatory – Palpatory

• Sites– Upper arm (brachial

artery)– Thigh (popliteal artery)


Pulse Oximetry


Pulse Oximetry

• Noninvasive• Estimates arterial blood oxygen

saturation (SpO2)

• Normal SpO2 85-100%; < 70% life threatening

• Detects hypoxemia before clinical signs and symptoms

• Sensor, photodetector, pulse oximeter unit


Pulse Oximetry

• Factors that affect accuracy include:– Hemoglobin level– Circulation– Activity– Carbon monoxide poisoning


Pulse Oximetry

• See Skill 29-7• Prepare site• Align LED and photodetector• Connect and set alarms• Ensure client safety• Ensure accuracy


Delegation of Measurement of Vital Signs

• General considerations prior to delegation– Nurse assesses to determine stability of

client– Measurement is considered to be routine– Interpretation rests with the nurse


Delegating to UAP

• Body temperature– Routine measurement may be delegated

to UAP – UAP reports abnormal temperatures– Nurse interprets abnormal temperature

and determines response


Delegation to UAP

• Pulse– Radial or brachial pulse may be

delegated to UAP– Nurse interprets abnormal rates or

rhythms and determines response– UAP are generally not responsible for

assessing apical or one person apical-radial pulses


Delegating to UAP

• Respirations– Counting and observing respirations

may be delegated to UAP– Nurse interprets abnormal respirations

and determines response


Delegation to UAP

• Blood pressure– May be delegated to UAP– Nurse interprets abnormal readings and

determines response

• Oxygen saturation– Application of the pulse oximeter sensor

and recording the Sp02 may be delegated to UAP

– Nurse interprets oxygen saturation value and determines response


Post Test

• Use your clickers to complete the following post test.


Question 1

The client’s temperature at 8:00 AM using an oral electronic thermometer is 36.1°C (97.2°F). If the respiration, pulse, and blood pressure are within normal range, what would the nurse do next?

1. Wait 15 minutes and retake it.2. Check what the client’s temperature was

the last time.3. Retake it using a different thermometer.4. Chart the temperature; it is normal.


Rationales 1

1. Depending on that finding, you might want to retake it in a few minutes (no need to wait 15 minutes).

2. Correct. Although the temperature is slightly lower than expected for the morning, it would be best to determine the client’s previous temperature range next. This may be a normal range for this client.

3. There is no need to take temperature again with another thermometer to see if the initial thermometer was functioning properly.

4. Chart after determining that the temperature has been measured properly.


Question 2

Which of the following clients meets the criteria for selection of the apical site for assessment of the pulse rather than a radial pulse?

1. A client is in shock2. The pulse changes with body position changes3. A client with an arrhythmia4. It is less than 24 hours since a client's surgical

operation


Rationales 2

1. For clients in shock, use the carotid or femoral pulse.

2. The radial pulse is adequate for determining change in orthostatic heart rate.

3. Correct. The apical rate would confirm the rate and determine the actual cardiac rhythm for a client with an abnormal rhythm; a radial pulse would only reveal the heart rate and suggest an arrhythmia.

4. The radial pulse is appropriate for routine postoperative vital sign checks for clients with regular pulses.


Question 3

It would be appropriate to delegate the taking of vital signs of which of the following clients to a UAP?

1. A patient being prepared for elective facial surgery with a history of stable hypertension.

2. A patient receiving a blood transfusion with a history of transfusion reactions.

3. A client recently started on a new antiarrhythmic agent.

4. A patient who is admitted frequently with asthma attacks.


Rationales 31. Correct. Vital signs measurement may be

delegated to UAP if the client is in stable condition, the findings are expected to be predictable, and the technique requires no modification. Only the preoperative client meets these requirements.


3. In addition to the client being unstable, UAP are not delegated to take apical pulse measurements for the client with an irregular pulse as would be the case with the client newly started on antiarrhythmic medication.



Question 4

A nursing diagnosis of Ineffective Peripheral Tissue Perfusion would be validated by which one of the following:

1. Bounding radial pulse2. Irregular apical pulse3. Carotid pulse stronger on the left side

than the right4. Absent posterior tibial and pedal pulses


Rationales 4

1. Abounding radial pulse is more indicative that perfusion exists.

2. Apical pulses are central and not peripheral.

3. Carotid pulses are central and not peripheral.

4. Correct. The posterior tibial and pedal pulses in the foot are considered peripheral and at least one of them should be palpable in normal individuals.


Question 5

The nurse reports that the client has dyspnea when ambulating. The nurse is most likely to have assessed which of the following?

1. Shallow respirations2. Wheezing3. Shortness of breath4. Coughing up blood


Rationales 5

1. Shallow respirations are seen in tachypnea (rapid breathing).

2. Wheezing is a high-pitched breathing sound that may or may not occur with dyspnea.

3. Correct. Dyspnea, difficult or labored breathing, is commonly related to inadequate oxygenation. Therefore, the client is likely to experience shortness of breath, that is, a sense that none of the breaths provide enough oxygen and an immediate second breath is needed.

4. The medical term for coughing up blood is hemoptysis and is unrelated to dyspnea.


Resources

• Audio Glossary• HyperHEART

Shows the heart pumping and talks about diastolic and systolic cycles. Has tutorials for atrial systole and others. Very fun site.

• Best Practice--Vital SignsReviews research studies related to vital signs. Covers all aspects of vital signs and even gives implications for practice and recommendations.

• The Medical Center--Vital SignsProvides an overview of vital signs. Nicely done.

http://wps.prenhall.com/chet_kozier_fundamentals_8/0,13044,4013707-content,00.html

http://library.med.utah.edu/kw/pharm/index.html

http://www.joannabriggs.edu.au/best_practice/bp8.php

http://www.mccg.org/adulthealth/content.asp?PageID=P00846


Resources

• The National Women's Health Information CenterGood overview of blood pressure, especially high blood pressure, and its effects on women.

• MEDLINEplus--Blood PressureDescribes blood pressure in detail

• MEDLINEplus--PulseDescribes pulse in detail

• MEDLINEplus--Temperature measurementsDescribes temperatures in detail

• A Practical Guide to Clinical Medicine--Vital SignsAn in-depth look at vital signs. Has graphic pictures to explain vital signs.

http://www.4woman.org/faq/bloodpress.htm

http://www.nlm.nih.gov/medlineplus/ency/article/003398.htm



http://medicine.ucsd.edu/clinicalmed/vital.htm

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