VITAL SIGNS by: DUMDUMA,ALVIN R.N.,R.

Pretest

Question 1
The clients temperature at 8:00 AM using an oral electronic thermometer is 36.1C (97.2F). If the respiration, pulse, and blood pressure are within normal range, what would the nurse do next?
1. 2. 3. 4.

Wait 15 minutes and retake it. Check what the clients temperature was the last time. Retake it using a different thermometer. Chart the temperature; it is normal.

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? A client is in shock The pulse changes with body position changes A client with an arrhythmia It is less than 24 hours since a client's surgical operation

1. 2. 3. 4.

Question 3
It would be appropriate to delegate the taking of vital signs of which of the following clients to a UAP?
1. 2. 3. 4.

A patient being prepared for elective facial surgery with a history of stable hypertension. A patient receiving a blood transfusion with a history of transfusion reactions. A client recently started on a new antiarrhythmic agent. A patient who is admitted frequently with asthma attacks.

Question 4

A nursing diagnosis of Ineffective Peripheral Tissue Perfusion would be validated by which one of the following: Bounding radial pulse Irregular apical pulse Carotid pulse stronger on the left side than the right Absent posterior tibial and pedal pulses

1. 2. 3. 4.

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. 2. 3. 4.

Shallow respirations Wheezing Shortness of breath Coughing up blood

Rationales 1
1. 2.

3.

4.

Depending on that finding, you might want to retake it in a few minutes (no need to wait 15 minutes). Correct. Although the temperature is slightly lower than expected for the morning, it would be best to determine the clients previous temperature range next. This may be a normal range for this client. There is no need to take temperature again with another thermometer to see if the initial thermometer was functioning properly. Chart after determining that the temperature has been measured properly.

Rationales 2
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.
1.

Rationales 3
1.

2. 3.

4.

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

Rationales 4
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.
1.

Rationales 5
1. 2. 3.

4.

Shallow respirations are seen in tachypnea (rapid breathing). Wheezing is a high-pitched breathing sound that may or may not occur with dyspnea. 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. The medical term for coughing up blood is hemoptysis and is unrelated to dyspnea.

Vital Signs

Temperature, Pulse, Respiration, Blood Pressure and Pain Monitor functions of the body Should be a thoughtful, scientific assessment

When to Assess Vital Signs

On admission Change in clients 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

TEMPERATURE

Body Temperature

Represents the balance between heat produced by:

Metabolism Muscular activity Other factors and heat lost through the:
Skin Lungs Body wastes

Maintenance of Body Temperature

Thermoregulatory Center Center

center in the hypothalamus regulates temperature receives messages from cold and warm thermal receptors in the body initiates responses to produce or conserve body heat or increase heat loss

Heat Production
Primary

source is metabolism

Hormones,

muscle movements, and exercise increase metabolism and norepinephrine are released and alter metabolism production decreases and heat production increases

Epinephrine Energy

Sources of Heat Loss

Skin

(primary source) of sweat and humidifying inspired air urine and feces

Evaporation Warming

Eliminating

Transfer of Body Heat to External Environment

Radiation Convection Evaporation Conduction

Radiation
The

diffusion or dissemination of heat by electromagnetic waves.

Ex. The body gives off waves of heat from

uncovered surfaces.

Convection
The

dissemination of heat by motion between areas of unequal density.

Ex. An oscillating fan blows currents of cool

air across the surface of warm body.

Evaporation
The

conversion of liquid to a vapor.

Ex. Body fluid in the form of perspiration

and insensible loss is vaporized from the skin.

Conduction
The

transfer of heat to another object during direct contact.

Ex. The body transfers heat to an ice pack,

causing the ice to melt.

Factors Affecting Body Temperature

Age Diurnal variations (circadian rhythms) Exercise Hormones Stress Environment

Equipment
Electronic digital or infrared thermometer or tympanic thermometer or glass thermometer. Water-soluble lubricant (for rectal temp.) Gloves (for rectal temp) Facial tissue Disposable thermometer sheath or probe Alcohol pad

Sites for Measuring Body Temperature

Oral Rectal Axillary Tympanic membrane Skin/Temporal artery

Types of Thermometers

Range of Human Body Temperature Measured Orally

Temperature: Lifespan Considerations

Infants Unstable Newborns must be kept warm to prevent hypothermia temporal artery Tympanic or sites preferred Elders Tends to be lower than that of middle-aged adults

Children

Normal Temperatures for Healthy Adults

Oral 37.0C, 98.6F Rectal 37.5C, 99.5F Axillary 36.5C, 97.6F Tympanic 37.5C, 99.5F Forehead 34.4C, 94.0F

TC = 5/9(TF 32)

Dos & Donts

Dont

avoid taking an oral temperature when the patient is receiving nasal O2

because O2 administration raises oral temperature by only about 0.3F (0.2C)

STEP-BY-STEP PROCEDURE

PULSE

PULSE
Pulse rate = number of contractions over a peripheral artery in 1 minute

Equipment
Watch

with second hand Stethoscope (for auscultating apical pulse) Doppler ultrasound blood flow detector Alcohol pad

Sites for Assessing Pulse

Palpating

peripheral arteries apical pulse with

Auscultating

stethoscope
Assessing

apical-radial pulse

Sites for Assessing Pulse by Palpation

Front of the ear and lateral to eyebrow Beside the larynx 5th intercostal space just inside the midclavicular line Halfway between the anterior superior iliac spine and the symphysis pubis, below the inguinal ligament

Medial antecubital fossa (hollow in front of elbow) Thumb side of the forearm at wrist

Behind knee in the popliteal fossa Inner side of the ankle slightly below the medial malleolus Dorsum of the foot with the foot plantar flexed

Factors Affecting Pulse

Age Gender Exercise Fever Medications Hypovolemia Stress Position changes Pathology

Pulse: Lifespan Considerations

Infants Children
Newborns may have heart murmurs that are not pathological 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 Often have decreased peripheral circulation

Elders

Pulse Sites
Radial Temporal Carotid Apical
Readily accessible When radial pulse is not accessible During cardiac arrest/shock in adults Determine children up to 3the brain Infants and circulation to years of
age Discrepancies with radial pulse Monitor some medications

Pulse Sites
Brachial Blood pressure Cardiac arrest in infants Cardiac arrest/shock Circulation to a leg; Circulation to lower leg Circulation to the foot Circulation to the foot

Femoral Popliteal Posterior tibial Dorsalis pedis

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

Assessing Peripheral Pulses

Dos & Donts

Dont use your thumb to take the patients pulse.

because you may mistake your thumbs own strong pulse.

STEP-BY-STEP PROCEDURE

RESPIRATION

Respiration
Interchange

of gases between an organism and the medium in which it lives.

External respiration or breathing in is the exchange of O2 and CO2 between the atmosphere and the body. Internal respiration takes place throughout the body at the cellular level.

Respiratory Control Mechanisms

Respiratory centers
Medulla oblongata Pons

Chemoreceptors
Medulla Carotid and aortic bodies

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

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

Blood Circulation

C6H12 O6 + O2 ATP + CO2 + H2O

Factors Affecting Respirations

Exercise Stress Environmental temperature Medications

Respirations: Lifespan Considerations

Infants Some newborns display periodic breathing Diaphragmatic breathers

Children

Elders

Anatomic and physiologic changes cause respiratory system to be less efficient

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

Effectiveness
Uptake and transport

of O2
Transport and

Quality
Effort Sounds

elimination of CO2

Assessing Respirations
Inspection Listening

with stethoscope Monitoring arterial blood gas results Using a pulse oximeter

STEP-BY-STEP PROCEDURE

To be discussed by Prof. Myrna Pares

BLOOD PRESSURE

Physiology of Blood Pressure

Force

of the blood against arterial walls Controlled by a variety of mechanisms to maintain adequate tissue perfusion Pressure rises as ventricle contracts and falls as heart relaxes
Highest pressure is systolic Lowest pressure is diastolic

Factors Affecting Blood Pressure

Age Exercise Stress Race Gender Medications Obesity Diurnal variations Disease process

Blood Pressure: Lifespan Considerations

Infants Arm and thigh pressures are equivalent under 1 year of age Thigh pressure is 10 mm Hg higher than arm Clients medication may affect how pressure is taken

Children

Elders

Systolic and Diastolic Blood Pressure

Systolic
Contraction of the

ventricles

Diastolic

Cardiac Cycle.mpg

Ventricles are at rest Lower pressure

Measured in mm Hg Recorded as a fraction, e.g. 120/80 Systolic = 120 and Diastolic = 80

present at all times

Pulse Pressure = difference between systolic and diastolic pressures

Korotkoffs Sounds

Korotkoffs Sounds

Phase 1
First faint, clear tapping or thumping

sounds Systolic pressure

Phase 2
Muffled, whooshing, or swishing sound

Korotkoffs Sounds

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)

Equipment for Assessing Blood Pressure

Stethoscope

and sphygmomanometer Doppler ultrasound Electronic or automated devices

Assessing Blood Pressure

Listening

for Korotkoff sounds with stethoscope

First sound is systolic pressure Change or cessation of sounds occurs

diastolic pressure

The

brachial artery and popliteal artery are commonly used

For infant, small child, or frail adult

Normal adult-size Measure BP on the leg or arm of an obese adult

Parts of Sphygmomanometer

Figure 29-19 signs.

Blood pressure monitors register systolic and diastolic blood pressures and often other vital

Normal Ranges for Vital Signs for Healthy Adults

Oral

temperature 37.0C, 98.6F Pulse rate 60 to 100 (80 average) Respirations 12 to 20 breaths/minute Blood pressure 130/85

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
1. The proper time frame for waiting to check a temperature for the patient who has just had a drink of water is a. 2 minutes. b. 5 minutes c. 10 minutes d. 15 minutes 2. The best thing to do when you get a reading on a digital thermometer that does not seem quite right is to a. record that temperature b. do nothing c. repeat the temperature measurement d. report the measurement immediately

1.

The best location for taking the apical pulse is

a. b. c. d. Over the base of the heart At the 5th intercostal space just inside the midclavicular line Upper left chest near nipple At the 3rd intercostal space just inside the midclavicular line.

2.

The location for assessing peripheral pulses are

a. Radial, temporal, carotid, clavicular femoral, popliteal, pedal, and posterior tibial b. Radial, temporal, carotid, brachial, femoral, crucial, pedal, and posterior tibial c. Radius, temporal, carotid, brachial, femoral, crucial, pedal, and posterior tibial d. Radial, temporal, carotid, brachial, femoral, popliteal, pedal, and posterior tibial

3.

A patient who is experiencing eupnea is said to be

a. b. c. d. Breathing slowly Breathing rapidly Breathing normally Not breathing

1.

A normal respiratory rate for the adult is

a. b. c. d. 10 12 14 16 to to to to 20 20 20 20 breaths breaths breaths breaths per per per per minute minute minute minute

2.

Which of these factors can affect blood pressure? (Choose all that apply)
a. b. c. d. Age Height Recent activity Position

3.

The point which the heart is beating and exerting its greatest force is called
a. b. c. d. Systolic pressure Diastolic pressure Pulse pressure Basal pressure

Answers
1. 2. 3. 4. 5. 6. 7. 8.

d c b d c b a, c, d a

TOTAL POINTS = 10