Vital Signs Taking

Prepared by:

Hayden S. Ganta
Nurse Educator

5 Vital Signs
vPulse vTemperature vRespiration vBlood Pressure vPain

When to take VS?

On the client admission. Before and after surgery. Before and after a diagnostic procedure. Before and after giving certain medications. A complaint of pain. A complaint of loss of consciousness.

Body Temperature
It is the balance between the heat produced by the body and the heat lost from the body.

KINDS: Core Temperature is the temperature of the deep tissues of the body such as the cranium, thorax, abdominal cavity and pelvic cavity. Surface Temperature it rises and falls

Age Variations
Age
Newborn 1 year old 2 4 years old 6 years old to adult Elderly (over 70 years old)

Average Temperature
36.1C to 37.7C (97.0F to 100.0F) 37.2C (98.9F) 37.0C ( 98.6F) 36.0C ( 96.8F)

Factors affecting Heat Production

Basal Metabolic Rate - the rate of energy utilization in the body required to maintain essential activities such as breathing.

Muscular Activities

Thyroxine Output - increased thyroxine output increased thyroxine output increases the rate of cellular metabolism throughout the body. This effect is called chemical thermogenesis.

 Epinephrine, norepinephrine, and sympathetic stimulation.

Fever it increases the cellular metabolic rate and thus increases the bodys temperature further.

Modes of Heat Loss

v Radiation- transfer of heat from the surface of one object to the surface of another without the contact between the two objects, mostly in the form of infrared rays.

v Conduction it is a transfer of heat from one molecule to another.

v Convection dispersion of heat by air currents.

v Vaporization it is the continuous evaporation of moisture from the respiratory tract and from the mucosa of the mouth and from the skin.

Factors affecting Body Temperature

v Age (Infants and Elderly) v Circadian Rhythms v Exercise v Hormones v Stress v Environment

Alterations in Thermoregulation
v Pyrexia/Febrile A temperature that is above the normal range

v Hyperthermia/Hyperpyrexia a very high fever.

v
v Hypothermia a temperature that is below the normal range

Fever is not an illness but a natural reaction to a number of illnesses.

Characteristics of FEVER
v Intermittent a period of fever and a period of normal/subnormal temperature. v Remittent a wide range of temp fluctuation over the 24 hour period, all of which are above normal. v Relapsing short febrile for few days and followed by a day or two of normal temperature. v Constant temperature fluctuates minimally but always remains above normal.

Types of Thermometer
Mercury Electronic Disposable Tympanic

Table of Comparison
Site Oral Advantages Most accessible and convenient Disadvantages Can break if bitten. C/I for kids under 6 years old, with nasal/oral surgery, and clients who are confused or who have convulsive disorder. Inaccurate for patients who just eaten hot/cold

Site Axillary

Advantages Safe and most noninvasive

Disadvantages The thermometer must be left in place a long time to obtain an accurate measurement.

Tympanic

Readily accessible and Equipment is expensive. reflects core Puts risks of injuring the temperature. tympanic membrane if probe is inserted too far. Most reliable measurement Inconvenient and more unpleasant to the patient.

Rectal

Can cause trauma to the area especially for newborns and infants.

Temperature Conversion

To convert from Fahrenheit to Celsius:

C = (F 32) x 5/9

Ex:Convert 98.6F (Normal Body Temperature!) to Celsius First: 98.6 - 32 = 66.6 Then: 66.6 5/9 = 333/9 = 37 C

To convert from Celsius to Fahrenheit:

F = (C x 9/5) + 32 Ex: Convert 26 Celsius (A nice warm day!) to Fahrenheit First: 26 9/5 = 234/5 = 46.8 Then: 46.8 + 32 = 78.8 F

Pulse

It is a wave of blood created by contraction of the left ventricle of the heart. It can be palpated (fingers) at sites where an artery passes alongside or over a bone, by placing slight pressure on the artery.

Stroke Volume - is the amount of blood ejected from the left ventricle of the heart during contraction. Cardiac Output it is the volume of blood pumped into the arteries by the heart.

Factors Affecting Pulse Rate

v AGE v Gender v Exercise v Fever v Medications v Hemorrhage v Stress v Position Changes

Pulse Sites

Apical

Ways to assess pulse:

Palpation with the use of 3 middle fingers. Stethoscope for apical pulse and FHT. Doppler UTZ pulses that are difficult to assess. Cardiac Monitor

Always note for the rate, rhythm, strength and equality.

Age Variations
Age
Newborn 1 3 years old 6 8 years old Adult/Elderly (Healthy)

Range
80 - 180 bpm 80 140 bpm 75 120 bpm 60 100 bpm

Respiration

It is the act of breathing. It involves the intake of oxygen through inhalation and expels carbon dioxide through exhalation.

NURSES MUST OBSERVE FOR:

Costal (Thoracic) Breathing It involves the external intercostal muscles and other accessory muscles such as the sternocleidomastoid muscle.

Diaphragmatic (Abdominal) Breathing

It involves the contraction and relaxation of the diaphragm. It is observed by the rise and fall movement of the abdomen.

Breathing Patterns

Rate

q Eupnea normal respiration that is quiet, rhythmic, and effortless. q Tachypnea rapid respiration marked by quick , shallow breaths. q Bradypnea abnormally slow breathing. q Apnea cessation of breathing.

Volume

qHyperventilation an increase amount of air in the lungs. q qHypoventilation a reduction of air in the lungs.

Rhythm

Age Variation
Age
Newborn 1 3 years old 8 16 years old Adult

Range
30 80 cpm 20 30 cpm 15 25 cpm 12 20 cpm

Blood Pressure

It is the measure of pressure exerted by the blood as it flows through the arteries. It is measured in millimeters of mercury (mmHg) and recorded as a fraction.

Systolic Pressure the pressure of the blood as a result of contraction of the ventricles. Diastolic Pressure the pressure when the ventricles are at rest. Pulse Pressure the difference

Korotkoff Phases
PHASE Phase I Phase II Phase III Phase IV Phase V DESCRIPTION CLINICAL OF SOUND of IMPLICATION Appearance Correlates with clear tapping Sounds become systolic blood No clinical sound and longer pressure softer become significance Sounds No clinical crisper and louder significance Sounds become Correlates as muffleddisappear alternate measure Sounds and softer Correlates with of DBP completely DBP

Factors affecting BP
Age Gender Blood Volume Stress Pain Exercise Weight Race Diet M e d i ti n s ca o Po si o n ti A l h o l co S m o ki g n D i rn a lV a ri ti n s u a o D i a se Pro ce ss se

BP Equipment

Aneroid Sphygmomanometer Mercurial Sphygmomanometer

Age Variation
Age Newborn 1 year 2 years 4 years 6 years 8 years 10 years Teenager Adult Elderly Mean BP (mmHg) 78/42 96/65 100/63 97/64 98/65 106/70 110/72 125/79 120/80 120/80

Common Errors in BP taking

Too narrow bladder cuff- erroneously high Too wide bladder cuff - erroneously low Arm unsupported - erroneously high Insufficient rest before the assessment - erroneously high Repeating assessment too quickly erroneously high or low diastolic readings Cuff wrapped too loosely or unevenly - erroneously high

 Deflating cuff too quickly erroneously slow systolic and high diastolic readings Deflating cuff too slowly - erroneously high diastolic reading Failure to use the same arm consistently inconsistent measurements Arm above level of the heart erroneously low Assessing immediately after a meal or while client smokes or has pain or has pain - erroneously high Failure to identify auscultatory gap erroneously low systolic pressure

Guidelines in BP taking
Let the person rest for 10--20 minutes before measuring BP. Do not take BP on an arm with an IV infusion, a cast, or a dialysis access site. If aperson has had breast surgery, BP is not taken on that side. Also avoid taking BP on an injured arm. Measure BP with the person sitting or lying. Sometimes the doctor orders measurement of BP in the standing position.

 Apply the cuff on the bare upper arm. Clothing can affect the measurement. Do not apply the cuff overclothing. Make sure the cuff is snug. Loose cuff can cause inaccurate readings. Place the diaphragm of the stethoscope firmly over artery. The entire diaphragm must be in contact with the skin. Make sure the room is quiet. Talking, TV, radio, and sounds from the hallway can affect an accurate reading.

 Have the sphygmomanometer clearly visible. Locate the radial artery, and then inflate the cuff. When you no longer feel the pulse, inflate the cuffanother 30mmHg . This prevents cuff inflation to an unnecessarily high pressure which is painful to the person. (You can deflate the cuff at thistime and note the point where you feel a pulse. Wait 30seconds and inflate the cuff 30mmHg above point. Measure the systolic and diastolic pressure. Expect To hear the 1st BP sound at the point where you felt radial pulse. The 1st sound is the systolic pressure. The point where the sounddisappears is the diastolic pressure. Take the BP again if you are not sure of an accurate measurement. Wait 30-

Pain
Whatever the patient says it is, existing whenever when the patient says it exists

Beliefs about pain and how to respond to it differ between cultures.

Pain Assessment
PQRST
P (Provokes) Q (Quality) What provokes the pain? (exertion, spontaneous onset, stress)

Is it dull, achy, sharp, stabbing, pressing, deep, surface, etc.? Similar to pain youve had before? Does it travel anywhere (to the jaw,back, arms, etc.)? What makes it better (position, being still)? What makes it worse (inspiration, movement)?

R (Radiation/Relief)

S(Severity/S&Sx)

Explain the pain scale and have Pt rate pain. Are there any associated signs or symptoms (nausea, vomiting, dizziness, diaphoresis, pallor, shortness of breath [SOB], dyspnea, abnormal vital signs, etc.)? When did it start? Is it constant or intermittent? How long does it last? Sudden or gradual onset? Does it start after youve eaten? Frequency?

T (Time; Onset and Duration)

Wong-Baker Faces Pain Rating Scale

Refer red Pain

Characteristic of different Types of Pain

Acute Pain Onset Duration Current < 6 months Chronic Pain Cancer Pain Continuous or May be acute Intermittent or chronic > 6 months Pain maybe associated with cancer itself or the treatment

Thank You !!!