Chapter 19 Learning Objectives

Vital Signs Discuss the physiological processes involved

in regulating body temperature
Discuss expected normal vital signs findings
for various age groups
Recognize client vital signs that should
referred to a primary care provider
Diane Lyons, MSN, RN Define arterial oxygen saturation, hypoxia,
hyperventilation, and secondary hypertension
Define hypotension, hypertension, and
secondary hypertension

Learning Objectives (cont) What are Vital Signs

Select the correct site and equipment for measuring Assessment of vital or critical
temperature, pulse, respiration and blood pressure physiological functions
of patients in various age groups Temperature, pulse, respiration, blood
Demonstrate correct technique and procedures for
pressure & Pain
measuring vital signs
State at least one diagnosis to describe a problem objective data
for each of the vital signs indication of how well or poorly the body
Describe nursing interventions for the client with is Functioning
altered vital signs
measured at intervals to monitor the pt.
Identify important tips to teach clients in managing
their hypertension condition- evaluating in the context of
pt overall assessment
Other Vital signs affect client
WHY ARE V/S MEASURED
care
► MONITOR PHYSICOLOGICAL CONDITTION
Oxygen Saturation
► IDENTIFY NEW PROBLEM

Emotional Distress ► EVALUATE THE EFFECTINESS OF AN

INTERVENTION
Smoking Cessation

Your Responsibility Responsibility and

Measure accurately Delegation
◦ Select and appropriately use equipment
Recognize factors that may interfere with Nurses can delegate the activity of
accuracy of readings
taking vital signs, but the nurse is
understand and interpret the values
Evaluate previous VS, Know pt baseline,
responsible for interpretation of
PMH, medications vital signs, vital sign trends, and
intervene as needed decisions based on abnormal vital
report finding appropriately sign findings.
task delegation when appropriate
Responsibility and Delegation “Obtaining a set of Vital
(cont’d) Signs”
► You will obtain and
As a student nurse, you are report the following
► Temp and route
responsible for functioning ► Pulse rate, rhythm
within your scope of ► Respiratory rate,
rhythm
knowledge. ► Blood pressure
► Pulse oximetry (pulse
ox or 02 sat)
► Assess for pain

When to Measure Vital Signs When to Measure V/S (cont)

On admission Determine a pt Suspect any serious
as ordered baseline condition
before & after Pt. Condition ◦ Stroke CVA
surgery or invasive changes ◦ Heart attack MI
diagnostic tests Pt c/o of feeling ◦ Pulmonary embolus
before & after certain funny, different
Change in LOC
medications (cardiac) Bleeding
before, during & after before & after
Your nursing
blood transfusion & nursing interventions judgment indicates
per hospital policy influencing a vital
sign
 Body Temperature
Degree of heat maintained by the body
Difference between heat produced by the
body and heat lost to the environment
Average normal temp varies among
individuals as a result of different
metabolisms
Temperature/ Routes
Core temp –adults normal internal temp
Rectal & tympanic - core temp (1to 2 F
degrees higher than surface) Normal range
97-100.8 degrees
Oral & axillary surface temp
Degree of temp elevation above normal does
not always correlate with the potential
seriousness of the condition

How does the body cool down

Thermoregulation
or stay cool?
Vasodilation
sweating
Thermoregulation is the process of reduced activity
maintaining stable temp stretched body
position
decreased
metabolism
How does the body warm up
or stay warm?
Thermoregulation = Balance
Vasoconstriction Heat loss and heat
shivering production =
increased activity normal temperature
huddled position Hypothalamus acts
metabolism as the center for
temperature control
Piloerection “goose
bumps” Set point
comfortable core
temperature

Heat Exchange between the Factors Affecting Body

body& environment Temperature
Heat moves from an Developmental level
area of higher ◦ New born/Infants difficulty stabilizing
temperature to temp
lower temperature ◦ Elderly difficulty maintaining temp
Environment
◦ Radiation ◦ Cold environment- lower temp
◦ convection ◦ Warm environment- higher temp
◦ evaporation ◦ Elderly more susceptible to hypothermia
◦ conduction

◦ (pg.424)
 Factors Affecting Body
Temperature
Gender
►Hormone affect temp
► ovulation temp increases
►exercise and activity
►Increases metabolism
► Can Increase Core temp 101 to 104
F
Factors Affecting Body
Temperature
Stress
◦Stimulation of sympathetic nervous
system increased production of
epinephrine & norepinephrine
circadian rhythm
◦24 hour cycle
◦T lowest midnight to dawn
◦T highest late afternoon to early eve
◦1 to 2.0 F variation

Factors Affecting Body Factors Affecting Body

Temperature Temperature
Food Intake ► illness or injury
► tissue injury, infections, inflammatory
diseases, fluid loss, head injury, impaired
◦Hot beverages
circulation
◦Cold beverages
◦Chewing gum ► drugs
◦smoking ► increase or decrease metabolic rate and
energy requirements
Elevated Body Temperature Causes of Fever
Pyrexia (also known as febrile)
◦ Temp above normal Pyrogens
◦ Fever producing substances
● Above 100 oral ,101 rectal
Phagocytes
● “It depends” normal maybe lower (ex
◦ WBC
geriatric) ◦ Bacteria or other foreign substances
◦ afebrile absence of fever Prostaglandins
Hyperpyrexia ◦ Reset hypothalamic thermostat to a higher level
◦ 105.8 excessively high temp. (The reset value called the set point
◦ Requires intervention may cause cell
damage, delirium, seizures

Phases of a Fever Types of Fever

Intermittent
► Initial (febrile or ◦ Fever + periods of normal
onset) Remittent
► Temp rising to new ◦ Wide fluctuations all above normal
set point during a 24 hour period
► Course Constant
► Maximum set point ◦ Fluctuate slightly always above
reached normal
► Resolution, crisis or Relapsing
defervescence ◦ Short periods of fever with periods of
normal temp
► Return to normal
 S&S S&S (cont)
Onset Course
◦increased P & R ◦ Pink, flushed, warm skin
◦Shivering “gooseflesh” ◦ irritability
◦c/o feeling cold ◦ poor appetite - anorexia
◦ glassy eyes and sensitivity to light
◦Pallid, cold skin
◦ photophobia
◦ increased perspiration
◦ headache

Additional symptoms Hyperthermia

convulsion in infants & children Hyperthermia is a temp above normal
fever blisters
Diaphoresis Heat Exhaustion- may occur with core temp
Confusion of 98.6-103- S/S- weakness, N/V, muscle
aches, diaphoresis, increased HR, etc.
Lethargy or drowsiness
Thirst Heat Stroke: When temp progresses greater
Photophobia than 103- (Temp of 106 or higher may
exhist)
 Assessment Sites
Types of Thermometers
see Table 19-3
Temporal artery Glass
electronic
Rectal 99.6F tympanic (infrared)
chemical
Oral 98.6 F automated
Axillary 97.6F ◦ monitoring
Tympanic membrane devices
continuous
◦ monitoring
devices

Rectal site Rectal site

► More reliable when oral temp can
not be obtained
► May lag behind core temp during
rapid temp changes
► Contraindicated
► infants
► Rectal surgery, bleeding tendencies.
Or diarrhea
► Requires repositioning,
embarrassment for client
► Vagal nerve stimulation
► Position pt left lateral or Sims
► Select appropriate probe
► Lubricate probe with water
soluble lubricant
► Ask pt to take in a deep breath
and as he exhales gently insert
probe 1-11/2 inches
► In the direction of the umbilicus
► If resistance is felt remove probe
immediately
► Hold in place until temp registers
► If using glass thermometer hold
in place for 2-3 min
 Key points re: use Oral site (po)
► Accessible, comfortable
► Electronic ► Reflects rapid change in core
thermometer temp
► May have 2 probes ► Affected by ingestion of fluids,
► Blue probe used for food, smoke and oxygen delivery
oral temp wait 30 mins
► Red probe used for ► Contraindications
rectal temp ► Infants & small children, Confused,
unconscious, uncooperative, hx of
(RR red rectal) epilepsy
► Oral surgery or trauma
► Shaking chills

Axillary Tympanic

Safe, easy, if fever suspected use another ► Reflects core body

route tympanic -shares its
Not reflective of core temp blood supply with the
hypothalamus
Sitting or supine position ► Easily accessible site
Remove clothing away from shoulder ► Minimal client
Raise arm away from torso, dry axilla if repositioning
indicated required
► Unaffected by intake
Place (blue) probe into center of axilla,
of food, fluids,
lower arm over thermometer and place smoking
across the pt’s chest
Tympanic procedural
Key points re use
points
Tympanic
Using you right hand take temp in
clients right ear vise-versa Tympanic faulty readings
Remove hearing aide ◦ Ear canal not straightened
Pull pinna back, up and out to
straighten ear canal appropriately
Note presence of cerum (switch to ◦ Contraindicated for children
opposite ear or choose alternate route) younger than 2-3 yrs
Pointing toward client’s nose insert
snugly into the ear canal ◦ Sensor directed at the ear canal
Depress scan button on handheld rather than tympanic
units
Audible signal and display of temp will
membrane
occur when completed ◦ Cerumen or fluid in ear
Gently remove and appropriately
dispose of probe cover

Assessing the patient's

Chemical temperature
Tempa-DOTs
dots change color to reflect temp What do you need
reading usually within 60 sec to consider?
not appropriate for acutely ill clients
or those receiving temp therapies ◦ 97 – 99.6 F
may underestimate oral temperature Thermometer
by 0.4 C or more in 50% of adults selection
used for precaution clients Appropriate route
may use either orally or axillary route
clear plastic covers available to use via Assess client for
rectal route factors which may
affect temp
 Critical thinking Nursing diagnosis
Is the reading accurate?
◦ Did pt just have a hot beverage? Hyperthermia
◦ Is the thermometer working? Body temperature elevated above
◦ Did I use the device correctly? normal
◦ Should I check another site?
Hyperthermia r/t circulating toxins as
What is suggestive of systemic evidenced by temp 101
infection Ineffective thermoregulation above or
◦ Loss of appetite, headache hot, dry skin,
flushed face, thirst general malaise or chills below normal
What are you going to do?
What is suggestive of localized
infection
◦ Site of localized pain, redness, purluent
drainage, unusual warmth

goal planning
Assess causative/contributing factors
The client’s body temperature will be between 96.6
to 99.3 F within 24 hours. Prevent further increase in body
temperature
The client will remain free of complications
associated with hyperthermia. Evaluate the effects/degree of
hyperthermia
The client will identify S&S of fever and strategies
to manage fever such as notifying the physician. To assist with measures to reduce
body temp/restore normal body/organ
function
To promote wellness
 Nursing Actions Nonpharmacological
► Monitor & observe Measures
► For what?
► Obtain ordered tepid sponge bath
specimens ► d’c cooling measures
► Lab values WBC when shivering occurs
► Ice Packs forehead or
► Antipyretics neck; axilla groin
antibiotics ► Remove excess
► limit activity blankets/clothing
► Keep clothing and bed
► encourage fluids & linen dry
calories (3L unless ► Control environmental
contraindicated) temp (fan)
► IV fluids ► Provide mouth care

Point to remember
Subnormal
For each degree of temp elevation there is a Hypothermia less 96.8 or 96 F
10% increase in the client’s metabolic rate
Severe 82.4 - 86 F
 S&S hypothermia Nursing Actions

► Shivering ► Raise room

temperature
► pale skin, puffiness of skin
► remove wet clothing
► impaired muscle coordination ► apply layers of dry
► listlessness clothing
► position arms to
► slow pulse and respiratory rates chest, legs to
► irregular heart rhythm abdomen
► decreased ability to think coherently and ► cover head
► warm fluids
use good judgment &warming devices
► diminished ability to feel pain

Pulse Terms
► Wavelike sensation Systole contraction of heart
produced by the Diastole resting phase of the
movement of blood heart
during the heart’s Stroke volume (SV) quantity of
contraction blood forced out of the left
► Rate- the number of ventricle with each contraction
times the heart (average 70 mL)
beats in a minute Cardiac output (CO) total
► normal 60-100 bpm quantity of blood pumped by the
► Average 70-80 heart in one minute
CO = SV X pulse rate
 What is the cardiac Factors Affecting Pulse
output?
Developmental
◦ Newborns rapid; stabilizes childhood decreases aging
Pulse rate is 77
Gender
◦CO = 70 (SV) X 77 (P) ◦ Women 6-8 bpm than men
◦5,390 mL = 70 x 77 exercise & activity
◦ Increase with activity
Pulse rate is 110 ◦ Training effect heart more efficient lower rate
◦CO = 70 (SV) X 110 (P) circadian rhythm
◦7,700 mL = 70 X 110 ◦ (lower in the am increase during the day
Fluid overload
◦ Full & bounding
◦Normal CO is 4-8 L/min
hypoxia

Factors Affecting Pulse

Assessment
(cont)
► stress and emotions
► Stimulates the sympathetic nervous system Palpation
► Acute pain may result in increased HR ◦ Feeling

► body temp Auscultation

► Every degree F increase of 10 bpm ◦ Listening with a
► Loss of volume causes the rate to increase stethoscope
► Drugs ● Bell low frequency
sounds
► Cardiac drugs may slow, caffeine, nicotine ● Diaphragm high
increase, thyroid medication frequency sound
► Position changes ◦ Place directly on the
► Standing sitting temporary change skin
► Food ◦ Always clean before
► Slight increase for several hours and after use
 Assessing pulse Location of Pulse Sites
Provides an indication of heart
► Peripheral sites
function
► temporal
And tissue perfusion
► carotid
Adults radial site is the routine
site for pulse assessment ► brachial
Pulse should be easily palpable ► radial
Regular in rhythm should not ► femoral
fade in and out when palpated ► popliteal
► posterior tibial
► dorsalis pedis

Sites (cont) Sites

Radial; routine assessment of vital Femoral; circulation to the legs
signs
Brachial; blood pressure (CPR infants)
Carotid; CPR & assessing circulation to
brain NEVER palpate both carotids at
the same time (Why)
Temporal; circulation to the head
Popliteal; circulation to lower leg
Dorsalis pedis (pedal) & posterior
tibial; peripheral circulation to feet and
legs
 Assessment data collected
Pulse Rate
when taking a pulse
Pulse Rate Method palpation or auscultation
◦ Number of beats per minute (bpm)
Count the number of beats for one full
Pulse rhythm
◦ Regular
minute site selection radial method
◦ Irregular palpation
◦ Regular irregular Regular heart beat you can count for
Pulse quality 15 sec multiply by 4
◦ Volume amount of force produced by the blood
pushing through the arteries When you auscultate the apical pulse
you count for 1 minute

Terms Take an apical pulse

Tachycardia heart rate that exceeds 100 bpm Irregular , weak, very fast or slow
count for one full minute
Bradycardia heart rate less than 60 ◦Less than 60 bpm
◦Greater than 100 bpm
◦Prior to cardiac medications
Palpitations awareness of one’s own heart
contraction ◦Infant up to 3 yo
site selection apical
method auscultation
 Auscultation Rhythm
► Pattern of the
Lubb or S1 closing of the tricuspid & pulsations and the
pauses between them
bicuspid valves ► normal regular
► arrhythmia or
Dubb or S2 closing of the semilunar dysrhythmia irregular
pattern of heart beats
valves ► report irregular pulse
◦Ventricles relax ► Irregular or regular
irregular

Rhythm Pulse Volume

     X xxx x xxxx x Quality of pulsations that are felt
Regular xx amount of blood pumped with each
Irregular heartbeat
normal is strong
XXX XX XXX XX
weak, thready, feeble
What do you think??
What would you Regular irregular bounding or full
do??? report a rapid thready pulse not a
good sign
The function of which part of the anatomy is primarily
being assessed when a nurse obtains a pt’s pedal pulse? Apical Heart Rate
A. veins ► Most accurate
B. heart ► When do you use?
C. blood ► Rate <60 or >100
D. arteries ► difficult to palpate
► irregular peripheral
► medication
administration
► Age 3 and less
► Auscultate with a
stethoscope at the
► PMI

PMI Apical-radial pulse

Point of maximal impulse Two people; one counts the apical one
location counts the radial
■ 5th intercostal at the start and stop at the same time
midclavicular line Normal; both number should be the
count for one full minute same or within 2 beats
each “lub-dub” counts as one beat pulse deficit is the difference between
the apical and radial pulse rates
 A nurse takes the pulse of an older
adult. Which pulse is within the
expected range?
A. 50 beats per minute and irregular
B. 70 beats per minute and regular
C. 105 beats per minute and irregular
D. 120 beats per minute and regular
Goals outcomes
Will be developed regarding
normalization of vital signs
Apical pulse will be 60-80- bpm
during rest.
Nursing diagnosis
Ineffective tissue perfusion
Deficient fluid volume
Excess fluid volume
Decreased cardiac output
Interventions
Monitoring VS
Activity tolerance
Collecting & assessing lab reports
Assessing factors related to the dysrhythmia
Administering medications
Providing emotional support
Respiration Respirations
Ventilation Chemical Respiration
Mechanical ◦ External
◦ movement of air in ● exchange of oxygen & carbon dioxide between
(inhalation) and out the alveoli and the pulmonary blood supply
(exhalation) of the ◦ Gas transport
respiratory system ● Transport of these gases throughout the body
(chest, breathing) ◦ Internal
● exchange of these gases between the
capillaries and body tissue cells

Regulation of respiration
Respiratory centers in the brain; medulla Changes in the Thoracic
oblongata & Pons nerve fibers of the ANS
Primary stimulus for breathing is CO2 level &
Cavity
pH concentration
Central chemoreceptors sensitive to CO2 &
pH concentration
Peripheral chemoreceptors sensitive to PaO2
levels normal between 80 and 100
 Factors Influencing resp Factors (cont)
Age newborn 40-90 normal 12-20
Hemoglobin carries oxygen molecules
exercise
Disease brain injury
Pain
Medications
Stress ◦ CNS (central nervous depressants)
Smoking increases ◦ MORPHINE
Fever 1 degree of temp rise may increase Position
resp rate by 4 ◦ Standing
Heart beats ◦ Orthopne
◦ Pulse rate ratio 1breath for every 4 cardiac ◦ Lying flat
contractions

Rate Depth
Number of ventilations per minute Amount of air taken in on inspiration
Tachypnea rapid rate ◦ Tidal volume 300-500mL
Bradypnea slower than normal Normal
women 16-20 Deep
men 14-18 ◦ Taking in a very large volume

Average 12-20 Shallow

◦ Chest barely rises and is difficult to observe
 Rhythm Effort
Normal or abnormal Degree of work required to breath
Normal effortless
Dyspnea labored breathing
Period between each respiratory cycle Orthopnea inability to breath when in
should be even horizontal position

Terms Abnormal breath sounds

► Hyperventilation :rapid or deep
► Hypoventilation: diminished
► Dyspnea: difficult breathing
► Orthopenea: breathing that is facilitated by
sitting up or standing
► Apnea: absence of breathing
► Kussmal : Reg but abnormally deep foundin
DKA
► Cheyne-Stroke: periods of apnea
► Wheezes
► High pitched /musical usually heard on expiration
(ex wheezing)
► Rhonchi (sonorous sound & Gurgling)
► Low pitched wheeze continuous (ex. COPD)
► Clear with coughing
► Crackles : Fluid in the lungs (Crackling
sound) mild, moderate and course (ex CHF,
Fluid Overload)
► May be high pitch popping or low pitch bubbling
 Abnormal Breath Sounds Chest & abdomen
(cont) movement
Stridor: Crowing Sound, (ex Croupe) Intercostal retraction
Diminished: Decrease breath sounds usually ◦ Visible sinking of tissue around and between the
at the base of the lungs (ex. Atelectisis) ribs

Stertor: labored breathing that produces a Substernal retraction

snoring sound ( ex. Death Rattle) ◦ Tissue is drawn beneath the sternum

Pleural Rub: Friction sound on Inspiration Suprasternal retraction

◦ Tissues are drawn in above the clavicle
and Expiration (Ex Pleurisy)

Chest and abdomen Chest and abdomen

Substernal retraction Changes in chest shape Intercostal retraction Suprasternal retraction

Chronic hypoxia Associated signs
Hypoxia inadequate cellular oxygenation
◦ Pallor, cyanosis of the nails, lips or skin,
restlessness. Apprehension, confusion, dizziness,
fatigue, decreased level of consciousness,
tachycardia, tachypnea, changes in BP
Cough
◦ Productive/ non productive, if productive what
color, how long, time of day, what makes it better
or worse

O2 measurements Pain Assessment (5th Vital

procedure 37-2 Sign)
ABG arterial blood Site
gases
Pulse oximeter Characteristics
◦ device that measure
oxygen saturation
Severity
◦ Normal between Effectiveness of interventions
95-100%
◦ COPD 90-92% OK
The nurse is obtaining an oral temp
with an electronic thermometer. What
must the nurse do? Select all that apply

Use the red probe

____
____ take the temperature before
breakfast
____use a new probe cover for
each patient
_____wipe the probe with an
alcohol wipe after each use
_____ assess if the route is
appropriate for the patient