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
Bodys cells produce heat from foodreleasing
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 Fleast accurate, most safe
Tympanic
98 Favoid 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 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
Low pitched continuous sounds caused by
secretions in large airways
Crackles
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
Korotkoffs sounds
1st
2nd
3rd
4th
5th
1st
2nd
As you deflate the cuff; occurs during systole
Further deflation of the cuff; soft swishing sound
3rd
4th
5th
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
