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    @ 29 vital signs LEARNING OUTCOMES After completing this chapter, you will be able to: 1. Describe factors that affect the vital signs and accurate ‘measurement of them. 2. Identity the variations in normal body temperature, pulse, respi- rations, and blood pressure that occur from infancy to old age. 3. Verbalize the steps used in: a. Assessing body temperature. bb. Assessing a peripheral pulse. ©. Assessing the apical pulse and the apical-radial pulse. . Assessing respirations. €. Assessing blood pressure. {. Assessing blood oxygenation using pulse oximetry. KEY TERMS afebrile, 505 diaphragmatic (abdominal) apical pulse, 519 breathing, 522 apical-radial pulse, 520 dastokc pressure, 525 apnea, 523 dysthythmia, 515, arrhythmia, 515 evaporation, 504 arterial blood prossure, 525 ‘exhalation, 622 arteriosclerosis, 526 expiration, 522 auscuttatory gap, 529 febrile, 505 ‘basal metabolic rate (BMA), 504 fever, 505 ‘body temperature, 504 fover spike, 505 bradycardia, 515 heat balance, S04 bbradypnea, 523 heat exhaustion, 505 carcise output, 513 heat stroke, 506 compliance, 513 hematocrit, 526 ‘conduction, 504 hyperpyrexia, 505 constant fever, 505 hypertension, 526 convection, 504 hyperthermia, 505 core temperature, S04 hyperventiation, 529 costal thoracic) breathing, 522 hypotension, 527 4. Describe appropriate nursing care for alterations. vital signs. 6. Identify nine sites used to assess the pulse and state the reasons for their use. 6. List the characteristics that should be included when assess- ing pulses. 7. Describe the mechanics of breathing and the mechanisms that control respirations. 'B. Recognize when it is appropriate to delegate measurement of vital signs to unlicensed assistive personnel 8. Demonstrate appropriate documentation and reporting of vital signs. hypothermia, 506 pulse volume, 515) hhypoventiation, 523 Pyrex, 505 inhalation, 522 radiation, 504 incensible heat loss, 504 relapsing fever, 505 insensible water loss, 504 remittent fever, 505 inspiration, 622 respiration, 522 intermittent fever, 505 respiratory character, 523, Korotkot’s sounds, 529 respiratory quality, 523 ‘mean arterial pressure (MAP), 525 orthostatic hypotension, 527 ‘oxygen saturation (S20) 533 respiratory rythm, 523 sphygmomanometer, 527 surface temperature, 504 peripheral pulse, 573 systolic pressure, 525, paint of maximal tachycardia, 515 impulse (PM). 513 tachypnea, 523 pulse, 513 tidal volume, 623, pulse deft, 520 ventiation, 622 pulse oximeter, 533 vital signs, 509 pulse pressure, 525, pulse rhythm, 575 INTRODUCTION ‘The traditional vital signs are body temperature, pulse, respi rations, and blood pressure. Many agencies such as the Veterans Administration, American Pain Society, and The Joint Commis- sion have designated pain asa fifth vital sign, to be assessed at the same time as each of the other four. Pain assessment is covered in Chapter 46 cc Oxygen saturation is also commonly measured at thesame timeasthe traditional vitalsigns. Vital signs, which should be looked at in total, are checked to monitor the functions of the body. The signs reflect changes in function that otherwise might not be observed. Monitoring a clients vital signs should not be an automatic or routine procedure; it should be a thoughtful, scien- tific assessment. Vital signs should be evaluated with reference to clients’ present and prior health status, their usual vital sign re- sults (if known), and accepted normal standards, When and how ofien to assess a specific dient vital signs are chiefly nursing judgments, depending on the clients health sta- tus. Some agencies have policies about when to take clients vital signs, The primary care provider may specifically onder a vital sign (eg, "Blood pressure q2hi). Ordered vital sign measurements, how- ‘ever, should be considered the minimum; a nurse should assess vital ‘signs more ofien ifthe clients health status requires it. Examples of times to assess vial signsare listed in Box 29-1 Often, someone other than the nurse measures the client’ vital signs, The nurse must recall, however, that prior to delegating this task to unlicensed assistive personnel (UAP), the nurse must have assessed the individual client and determined that the client is medi- «ally stable or ina chronic condition and not fragile and that the vital sign measurement is considered routine for this client. Under those circumstances, the UAP may measure, record, and report vital signs 503 Regulation of Body Temperature ‘The system that regulates body temperature has three main parts: sensors in the periphery and in the core, an integrator in the hypo: thalamus, and an effector system that adjusts the production and loss of heat, Most sensors or sensory receptors are in the skin. The skin has more receptors for cold than warmth. Therefore, skin sensorsde tect cold more efficiently than warmath ‘When the skin becomes chilled over the entire body. three phys- iological processes to increase the body temperature take place 1. Shivering increases heat production. 2, Sweating inhibited to decrease heat los. 3. Vasoconstriction decreases heat loss. ‘Thehypothalamicintegratoris the center that controls the core tem perature. When the integrator dotectsheat,tsendsoutsignalsintended to reduce the temperature, that is, to decrease heat production and increase Ihat los. In contrast, when the cold sensors are stimulated, the integrator sends out signals to increase heat production and decrease heat loss. “The signals from the cold-sensitive receptors of the hypothala- ‘mas initiate effectors, such as vasoconstriction, shivering, and the re lease of epinephrine, which increases cellular metabolism and hence heat production. When the warmth: sensitive receptors in the hypo thalamus are stimulated, the effector system sends out signals that initiate sweating and peripheral vasodilation. Also, when this system is stimulated, the person consciously makes appropriate adjustments, such as putting on additional dothing in response to cold or turning con a fan in response to heat Factors Affecting Body Temperature Nurses should be aware of the factors that can affect a cient’ body temperature so that they can recognize normal temperature varia- tions and understand the significance of body temperature measure ‘ments that deviate from normal, Among the factors that affect body temperature are the following: 1. Age. Infantsare greatly influenced by the temperature ofthe env ronment and must be protected from extreme changes. Childrens temperatures vary more than those of adults do until puberty ‘Many older people, particularly those over 75 years, reat risk of hypothermia (temperatures below 36°C, or 96°F) for a variety (of reasons, such as inadequate diet, loss of subcutancous fat, lack of activity. and reduced thermoregulatory elfcieney- Older adults are also particularly sensitive to extremes in the environmental temperature due to decreased thermoregulatory controls. 2. Diurnal variations (circadian rhythms). Body temperatures ‘normally change throughout the day. varying as much as 1.0°C (18°F) between the early morning and the late afternoon. The point of highest body temperature is usually reached between 1600 and 1800 hours (400 Pat and 600 Pm), and the lowest point is reached during sleep between 0400 and 0600 hours (4:00 Ax. and 600 aw) (Figure 29-3 Ml). Older adults temperatures may vary less than those of younger persons due to the changes in autonomic functioning common in aging (Marigold, Arias, Vassallo, Allen, & Kwan, 2011) 3. Exercise. Hard work or strenuous exercise can increase body temperature to as high as 38.3°C to 40°C (101°F to 104°F) mea- sured rectally. 4. Hormones. Women usually experience more hormone fluctua- tions than men. In women, progesterone secretion atthe time Chapter 29 © Vital Signs 505 ‘ == Awake =~ = <—Asioop Oral temperature (°C) 8 8 ees ‘0400 | 0800 1200 1600 2000 2400 0400 4am Baw 12Noon 4PM BPM 12 menigh 4 AML Time (hours) Figure 29-3 Range of oral temporatures during 24 hours for a heathy young adult of ovulation raises body temperature by about 0.3°C to 06°C (05°F to L0°F) above basal temperature 5. Stress, Stimulation of the sympathetic nervous system can in- crease the production of epinephrine and norepinephrine, thereby increasing metabolic activity and heat production, [Nurses should anticipate that a highly stressed or anxious client, ‘could have an elevated body temperature for that reason, 6. Environment. Extremes in environmental temperatures can af fect a personis temperature regulatory systems. Ifthe tempera ture is assessed in a very warm room and the body temperature cannot be modified by convection, conduction, or radiation, the temperature will be elevated. Similarly ifthe client has been ‘outside in cold weather without suitable clothing. or ifa medical condition prevents the client from controlling the temperature in the environment (eg. the client has altered mental status or «cannot dress self), the body temperature may below. Alterations in Body Temperature ‘The normal range for adults is considered to be between 36°C and 375°C (96.8°F to 9.5"F). There are two primary alterations in body temperature: pyrexia and hypothermia PYREXIA ‘A body temperature above the usual range is called pyrexia, hyperthermia, or (inlay terms) fever. Avery high fever, suchas 41°C (105 8°F),iscalled hyperpyrexia (Figure 291M). Theclient who has afeveris referred to as febrile the one who docs nots afebrile. Four common types of fevers are intermittent, remittent, re- lapsing. and constant. During an intermittent fever, the body tem- perature alternates at regular intervals between periods of fever and petiods of normal or subnormal temperatures. An example is with the disease malaria. During a remittent fever. such as with a cold or influenza, a wide range of temperature fluctuations (more than 2°C [3.6°F)) occurs aver a 24-hour period, all of which are above ‘normal Ina relapsing fever, short febrile periods of few daysare interspersed with periods of | or 2 days of normal temperature. Dur: ing a constant fever, the body temperature fluctuates minimally but always remains above normal. This can occur with typhoid fe- ver A temperature that rises to fever level rapidly followinga normal temperature and then returns to normal within a few hours is called afever spike. Bacterial blood infections often cause fever spikes. In some conditions. an elevated temperature is nota true fever. Tiwo examplesare heat exhaustion and heat stroke: Heat exhaustion {sa result of excessive heat and dehydration. Signs of heat exhaustion include paleness, dizziness, nausea, vomiting, fainting, and a mod: ctately increased temperature (38.3°C to 38.9°C [101°F to 102°F)). 506 Unit 7 © Assessing Health = ‘c Figure 29-4 Mt Tors used to describe alterations in body temperature (oral measurements) and ranges in Fabrenhet and Calsius (centigrade) scales. Persons experiencing heat stroke generally have been exercising in hot weather, have warm, fished skin, and often do not sweat, They usually have a temperature of 411°C (106°F) or higher. and may be delirious, unconscious, or having seizures. ‘The clinical signs of fever vary with the onset, course, and abate iment stages of the fever (see Clinical Manifestations). These signs ‘occur as a result of changes inthe set point ofthe temperature con: ‘rol mechanism regulated by the hypothalamus. Under normal con: ditions, whenever the core temperature rises, the rate of heat loss is ‘increased, resulting ina fal in temperature toward the set-point level. ‘Conversely, when the core temperature fall, the rate of heat produc: tion isinereased, resultingina ise in temperature toward the set point In fever, however, the set point of the hypothalamic thermostat changes suddenly from the normal level toa higher than normal value (eg. 395°C [103.1°F}) as a result of the effects of tissue destruction, ppytogenic substances, or dehydration on the hypothalamus. Although the set point changes rapidly, the core body temperature (i.e, the blood {emperature) reachesthis new set point only after severalhours. During this interval the usual heat production responses that cause elevation ‘of the body temperature occur: chills. feeling of cokiness, cold skin due to vasoconstrction, and shivering Thisis refered to asthe chill phase. When the core temperature reaches the new set point, the person fees neither cold nor hot and no longer experiences chills {the plateau phase). Depending on the degree of temperature eleva- tion, other signs may occur during the course ofthe fever. Very high Aemperatures, such as 41°C to 42*C (106°F to 108°F), damage the parenchyma of cells throughout the body. particularly in the brain ‘where destruction of neuronal cells is irreversible. Damage to the liver, kidneys, and other bady organs can also be great enough to dis rupt functioning and eventually cause death. ‘When the cause of the high temperature is suddenly removed, the set point of the hypothalamic thermostat is suddenly reduced to CLINICAL MANIFESTATIONS Fever ‘ONSET (COLD OR CHILL PHASE) Increased heart rate Increased respiratory rate and depth Shivering Palid, cold skin Complains of feeling cold Cyanotic nail beds “Gooseflesh” appearance ofthe skin Cessation of sweating Loss of appetite (f the fever is protongec) Malaise, weakness, and aching muscles DEFERVESCENCE (FEVER ABATEMENT/FLUSH PHASE) + Skin that appears fished and feels warm + Sweating + Decreased shivering + Possible dehydration a lower value, perhaps even back to the original normal level. In this instance, the hypothalamus now attempts to lower the temperature, and the usual heat loss responses that cause a reduction of the body temperature occur: excessive sweating and hot, flushed skin due to suxiden vasodilation, This is referred to asthe flush phase. Nursing interventions for a client who hasa fever are designed to support the bodys normal physiological processes, provide comfort, and prevent ‘complications. During the course ofa fever, the nurse needs to moni- torthe clients vital signs closely. Nursing interventions during the chill phase are designed to help the client decrease heat loss. At this time, the body's physiologi cal processes are attempting to raise the core temperature to the new set-point temperature. During the flush or crisis phase, the body pro- ‘cesses are attempting to lower the core temperature to the reduced or normal set-point temperature. At this time, the nurse takes measures toincrease heat oss and decrease heat production, Nursing interven- tions fora client with fever are shown in Box 29-2. HYPOTHERMIA Hypothermia is a core body temperature below the lower limit of normal. ‘The three physiological mechanisms of hypothermia are (a) excessive heat loss, (b) inadequate heat production to counteract heat loss, and (c) impaired hypothalamic thermoregulation. The clin ical signs of hypothermia ae listed in the Clinical Manifestationsbox. ‘Hypothermia may be induced or accidental. Induced hypother- mia isthe deliberate lowering of the body temperature to decrease the nnced for oxygen by the body tissues such as during certain surgeries. Accidental hypothermia can occur asa result ofa) exposure toacold ‘environment, (b) immersion in cold water, and (c) lack of adequate clothing, shelter, or heat. In older adults the problem can be com- pounded by a decreased metabolic rate and the use of sedative medi- ‘cations. Ifskin and underlying tissues are damaged by freezing cold, SPREE Nursing Interventions for Clients Box 29-2 Bue Monitor vital signs. ‘Assess skin color and temperature. Monitor write blood cell court, hematocrit value, and other pertinent laboratory rept for indcatios of infection or dehryration. emave excess blankets when the cient fels warm, but provide extra warmth when the clent fees child. Provide adequate nutrtion and fuids (e.g, 2,500-3,000 mL/ day) to moet the increased metabolic: demands and prevent dehiycration. Measure intake and output RRecivos physical acti to limit heat production, especialy during the fush stage. ‘Administor antipyretics (drugs that recuce the level of fever) as ordered. Provide oral hygiene to keep the mucous membranes moist Provide a tepid sponge bath to increase heat loss through ‘conduction. Provide dry clothing and bed inens. CLINICAL MANIFESTATIONS LS Hypothermia + Decreased body temperature, pulse, and respirations ‘Severe shivering (nial) Feelings of cold and chil ale, cool, waxy skin Frostbite (iscobred, bistered nose, fingers, toes) + Drowsiness progressing to coma this results in frostbite, Frostbite most commonly occurs in hands, feet, nose, and ears, Managing hypothermia involves removing the cient from the cold and rewarming the clients body: For the client with mild hypo- thermia, the body is rewarmed by applying blankets; for the client Chapter 29 © Vital Sons 507 ‘Cover the clients scalp with a cap or turban. ‘Supply warm oral or intravenous fui. Apply warming pads. with severe hypothermia, a hyperthermia blanket (an electronically controlled blanket that provides a specified temperature) is applied, and warm intravenous fluidsare given. Wet clothing, which increases heat lossbecause ofthe high conductivity of water should be replaced with dry clothing See Box 29-3 for nursing interventions for clients ‘who have hypothermia. Assessing Body Temperature The most common sites for measuring body temperature are oral rectal, axillary, tympanic membrane, and skin/temporal artery. Fach ofthe sites has advantagesand disadvantages (Table 29-1). The body temperature may be measured oraly. Ifa client has been taking cold or hot food or fluids or smoking, the nurse should ‘wait 30 minutes before taking the temperature orally to ensure that the temperature of the mouth is not affected by the temperature of the food. fluid or warm smoke. ‘Rectal temperature readings are considered to be very accurate. Rectal temperatures are contraindicated for clients who are undergo ingrectal surgery have diarrhea or discases ofthe rectum, areimmuno- suppressed. have a clotting disorder. or have significant hemorthoids. ‘The alla is often the prefered site for measuring temperature in newborns because itis accessible and safe. Axillary temperatures are lower than rectal temperatures. Some clinicians recommend re~ checking an elevated axillary temperature with one taken from an- other site to confirm the degree of elevation. Nurses should check agency protocol when taking the temperature of newborns, infants, toddlers, and children. Adult clients for whom the axillary method of temperature assessment is appropriate include those for whom other temperature sites are contraindicated Advantages and Disadvantages of Sites Used for Body Temperature Measurements Site ‘Advantages Disadvantages Oral ‘Accessible and convenient Thermometers can break if bitten Inaccurate if cient has just ingested hot or cold food or fd or smoked. ‘Could injure the mouth folowing oral surgery Rectal Reliable measurerant lnconveniant and more unpleasant for cfents; ciicul for cent who cannot tun to the sid. ‘Couid inure the rectum. Presence o stol may interfere with thermometer placement. Aviary Sole end noninvasive ‘The thermometer may need tobe let in place along te to obtain an accurate ‘measurement. TTmparic membrane Readily accessibe; elects the Can be uncomfortable and involves risk of injuring the membrane ifthe ‘core temperature; very fast probe is inserted too far. Repeated measurements may var. Right and left measurements can dif. Presence of cerumen can affect the reading ‘Temporal artery Sale and noninvasive; vey fast [Requires electronic equipment that may be expensive or unavaiiable. Variation in technique needed if the cfent has perspiration on the forehead. 510 Unit7 © Assessing Heath DO eMC LoL PURPOSES ‘To establish baseline data for subsequent evaluation ‘+ Toidentity whether the core temperature is within normal range ‘To determine changes in the core temperature in response 10 pectic therapies (e.g, antipyretic medication, immunosuppres- Sve therapy, invasive procedure) + To monitor cents at rsk for imbalanced body temperature (2... clents at risk for infection or diagnosis of infection; those \who have been exposed fo temperature extremes) ASSESSMENT Assess * Ginical signs of fever ‘+ Ginical signs of hypothermia PLANNING DELEGATION Routine measurement of the client's temperature can be delegated to unlicensed assistive personnel (UAP), oF be performed by family ‘members/caragwvers in nonhaspital settings. The nurse must explain the appropriate type of thermometer and site to be used and ensure that the person knows when to report an abnormal temperature land how to record the finding, The interpretation of an abnormal ‘temperature and determination of appropriate responses are done by the nurse. Equipment ‘Thermometer Tharmometer sheath or cover ‘Water-soluble lubricant fora rectal temperature IMPLEMENTATION Preparation Check that al equioment i functioning normaly Performance 1. Prior to perorring the procedure, intoduce so and vey the cients identity using agency protocol, Explain tothe cient ‘what you are going to do, wits necessary, end how he or she can participate Discuss how the results willbe used in planning further care or treatments. 2. Perform hand hygiene and observe appropriate infection prevention procedures. Apply gloves if performing a rectal Tomparatur. 3. Provide for cent privacy. 4. Poston the cient appropriately (eg, lateral or Sims’ postion {or inserting a rectal thermometer. 5. Place the thermometer (Box 29-4) ‘Apply a protective sheath or probe cover if appropriate. * Lubricate a rectal thermometer. Wait the appropriate amount of tm Electronic and tympanic ‘thermometers wil indicate that the reading is complete through alight or one. Check package insizuctons for length of time to ‘walt prior to reading chemical dot or tape thermemters. EVALUATION Compare the temperature measurement to baseline data, nor- mal range for age of client, and client's previous temperatures. ‘Analyze considering time of day and eny additional influencing factors and other vital signs. + Conduct appropriate folow-up such as notifying the primary care provider if temperature is outside of a specific range lr is not responding fo interventions, giving a medication, or + Site and method most appropriate for measurement ‘Factors that may alter core body temperature INTERPROFESSIONAL PRACTICE Measuring the temperature may be within the scope of practice for many health care providers. Although these other providers may verbally communicate ther findings and plan to the health care team members, the nurse must also know where to locate their docurien- tation in the client's medical record. * Clean gloves fora rectal temperature “Towal for axilary temperature + Tissues/wipes: CLINICAL ALERT! BBe sure to record the temperature from an electronic thermometer bbetore replacing the probe into the charging unt. With many modal, replacing the probe erases the temperature from the display. 77, Remove the thermometer and discard the cover or wipe with a tissue if necessary. If gloves were applied, remove and discard them. + Perform hand hygiene, 8, Read the temperature and record it on your worksheet. the ‘temperature is obviously too high, too low, or inconsistent with tha cliant’s condition, recheck it with a thermometer known to 'be functioning property. ‘9. Wash the thermometer if necessary and retum it to the storage location. 410. Document the temperature in the client record. @A rectal ‘temperature may be recorded with an “R’ next to the value ‘or with the mark on a graphic sheet circled. An axilary ‘temperature may be recorded with “AX" or marked on a ‘graphic sheet with an X. tring the cnt’ environment. This includes teaching the olient how to lower an elevated temperature through actions such as increasing fd intake, coughing and dese breathing, 9001 compresses, oF removing heavy coverings. Interventions for hypothermia include intake of warm fluids and use of warm cor dsctrc blanks ‘+ Any baseline data about the normal heart rate forthe client. For example, a physically ft athlete may have a resting heat rate be- low 60 beats'min. ‘+ Whether the dent should assume a particular position (eg, sit ting). In some clients, the rate changes with the position because of changes in blood flow volume and antonomic nervous system activity ‘When assessing the pulse, the nurse collects the following data the rate, rhythm, volume, arterial wall elasticity, and presence or absence of bilateral equality. An excessively fast heart rate (eg, over 100 beats/min in an adult i relerred to as tachycardia, A heart rate in an adult of less than 60 beats/min i called bradycardia. Ifa

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