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Vital Signs Assessment Overview

Vital signs include temperature, pulse, respiration, and blood pressure, which provide key information about a patient's general health and should be assessed upon admission, with any change in condition, or as indicated. Normal ranges vary based on factors like age, but changes may indicate issues like fever, abnormal heart rate, respiratory problems, or hypertension. Nurses must be able to properly measure and interpret vital signs using appropriate techniques and equipment to effectively monitor and care for patients.

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Katrina Azeez
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297 views51 pages

Vital Signs Assessment Overview

Vital signs include temperature, pulse, respiration, and blood pressure, which provide key information about a patient's general health and should be assessed upon admission, with any change in condition, or as indicated. Normal ranges vary based on factors like age, but changes may indicate issues like fever, abnormal heart rate, respiratory problems, or hypertension. Nurses must be able to properly measure and interpret vital signs using appropriate techniques and equipment to effectively monitor and care for patients.

Uploaded by

Katrina Azeez
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
  • Vital Signs Overview
  • Temperature Measurement
  • Body Temperature Variations
  • Pulse Assessment
  • Respiration
  • Blood Pressure Basics

Has anyone checked his Vital Signs?

What are Vital Signs?


Temperature

Pulse

Respiration

Blood Pressure
When to assess vital signs?
 Upon admission to any healthcare agency
 Based on agency policy & procedure
 Anytime there is a change in patient’s
condition
 Increased bleeding post-op
 Loss of consciousness
 Before & after surgical or invasive
diagnostic procedures
 Before administering medications that
affect cardiovascular or respiratory
functioning (psych meds)
 When the nurse determines the need
What do they tell you?
 Vital signs are key physiologic
measures of a person’s general
health state.
 When there is a change of vital
signs…
 Double check vital signs & further assess
patient
 There are normal variations in
vital signs related to age.
Temperature
 Cellular metabolism
requires a stable core
temperature of 37°
Celsius or 98.6°
Fahrenheit.
 The hypothalamus-
located in the pituitary
gland in the brain-is the
body’s built in thermostat
 Shivering is a response
which increases heat
production and is initiated
by the hypothalamus.
Factors affecting Temperature
 Physical exercise
 Hormones

 Age*-96.8 nl for older adult

 Environment

 Time of day

 Stress
Equipment for Assessing Temperature
 Electronic& digital
thermometer
 Tympanic membrane
thermometer
 Glass thermometer
 Disposable single-use
thermometer
 Temporal artery thermometer
 Automated monitoring
devices
Sites for Assessing Temperature

Oral

Rectal

Axillary

Tympanic***

Temporal Artery
Site- Oral
 Most common route
 Wait 15-30 minutes after the
ingestion of hot or cold food or
fluid, smoking or chewing gum
 Not good for the elderly,
confused, toddlers, mouth
breathers, agitated, seizure
disorders or for people using
an oxygen mask.
Site- Rectal
 Thought to be most
reliable
 Sims position
 Insert 1-1/2 inches &
HOLD IN PLACE
 Rectal reading is 0.7° to
1° higher than oral
reading
Site- Axillary
 Delay 15-30 minutes after a
bath
 Used on newborns

 Adult at times(unconscious)

 Read: adults 9-10 minutes


children 5 minutes
 Reading usually 1° lower
than oral 97.6° F
Site-Tympanic
 Good for young, confused, or
unconscious patients
 Snugly place probe in the ear-
angle toward patient’s jaw line
 Reading usually in 2 seconds
 Do not use: ear drainage
scars on tympanic membrane
 Reading is usually about 1°
higher than axillary
 Reliability has been
questioned
Body Temperature Variations

 Afebrile:
normal
 Hyperpyrexia: high fever
above 105.8° F
 Hypothermia: decreased
body temperature 95 and
below; death may occur
below 93.2°
Pyrexia
 Referred to as fever,
febrile, hyperthermia
 Signs & symptoms

 Causes

 Treatment
Terms for Types of Fever
 Sustained-temperature consistently
above 38C= 100.4 F
 Intermittent-Temperature alternates
regularly between a period of fever
& a period of normal temp
 Remittent-temperature spikes and
falls without a return to normal
 Relapsing- periods of fever and
periods of normal temperature,
each often> 24 hrs.
Hypothermia
 Signs & symptoms

 Causes

 Treatment
INTERVENTIONS FOR FEVER
 Minimize heat production,rest
 Maximize heat loss-less cover

 Increased BMR- oxygen,


meals, fluids,
 Promote comfort-oral hygiene,
dry linen, damp cloth to face
 Identify onset,duration of fever

 Antipyretic meds

 Hypothermia blanket
Pulse
 Pulse=Heart rate

 Stroke Volume

 Cardiac Output
Regulation of Pulse
 Factors affecting pulse rate
 Rate varies across life span:
adult 60-100
 Bradycardia: pulse < 60
 Tachycardia: pulse > 100
 Pulse rhythm
 Dysrhythmia
 Pulse amplitude
 Pulse deficit
Methods of Assessing the Pulse

 Palpation of pulse sites


with three middle fingers
 Stethoscope on the
apical pulse
 Doppler ultrasound

 Cardiac monitor to
assess the apical pulse
Pulse Sites
 Peripheral
pulse

 Apical pulse

 Apical-radial
pulse
Assessing Respirations
 Pulmonary ventilation
(breathing)-movement of air in
& out of the lungs.
 Inspiration-inhalation-act of
breathing in
 Expiration-exhalation-act of
breathing out
 Respiration-exchange of
gases-O2 & CO2-between an
organism & its environment
Factors Affecting Respirations

 Exercise & Position


 Respiratory &
cardiovascular disease
 Fluid, electrolyte, acid/base
balances
 Medications
 Infection
 Pain & anxiety
Assessing Respirations
 Inspection

 Listeningwith a
stethoscope
 Monitoring arterial
blood gas results
 Using a pulse oximeter
Patterns of Respirations
 Normal

 Tachypnea

 Bradypnea

 Hyperventilation

 Hypoventilation

 Cheyne Stokes
Respiratory Vocabulary
 Orthopnea

 Dyspnea

 Apnea

 Anoxia

 Cyanosis

 Eupnea
Blood Pressure
 Force of blood against arterial
walls
 Pressure rises as ventricle
contracts & falls as heart
relaxes
 Highest pressure=systolic
 Lowest pressure=diastolic
 Measured in millimeters of
mercury (mmHg)
 Normal reading < 120/80
 Pulse pressure
Regulation of Blood Pressure
 Peripheral resistance
 Pain, fear, anxiety,
smoking, exercise
 Blood loss
 Viscosity of blood
 Age, body size
 Normal fluctations
Modifiable Risk Factors
 Obesity

 Smoking

 Alcohol,Caffeine
 Sodium Intake

 Sedentary Lifestyle

 Exposure to Stress
Hypertension (HTN)
 BP reading above
normal for a sustained
period of time
 Primary or essential
hypertension
 Secondary hypertension

 “Silent Killer”
Hypotension
 Consistently low BP
 Orthostatic/Postural
hypotension-associated
with weakness or fainting
when sitting up- due to
vasodilation without
compensatory rise in
cardiac output
Equipment for Assessing
Blood Pressure
 Stethoscope &
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
 Brachial artery & popliteal
artery are commonly used

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