Vital Signs TPR
Vital Signs TPR
Vital Signs TPR
vital signs are body temperature, the pulse, respiration and blood
pressure
Body temperature – T
Pulse or heart rate – PR / HR
Respiratory rate – RR
Blood Pressure – BP
when a client has a change in health status (ex. Chest pain, skin warm to touch)
before and after administration of medication that could affect the respiratory or cardiovascular
system
before and after any nursing intervention that could affect vital signs
VS can be monitored q 15 mins, q 30 mins, 1hr, q 2 hrs, q 4 hrs or depending on the doctor’s
order
Temperature
- reflects the balance between the heat that is produced in your body and the heat that is lost from the
body
- heat is lost thru the skin, the lungs and the body’s waste products
2 kinds
1. Core temperature – the temp of the deep tissues of the body,
such as the abdominal cavity and pelvic cavity
- it remains relatively constant and is a range of temp
2. Surface temperature – the temp of the skin, the subcutaneous
tissue and fat
- it rises and falls in response to the environment
* The body continually produces heat as a by-product of
metabolism
* When the amount of heat produced by the body is equals the
amount of heat lost, the person is in heat balance
* As long as heat production and heat loss are properly balanced,
body temp remains constant
Factors that affect the body’s heat production:
1. Basal metabolic rate (BMR)
- the rate of energy utilization in the body required to maintain activities such
as breathing
- metabolic rate decreases with age, the younger the person the higher the
BMR
2. Muscle Activity
- muscle activity, including shivering, increase metabolic rate
3. Thyroxine output
- Increased thyroxine output increases the rath of cellular metabolism
throughout the body
Thyroxine - it is the one that controls how much energy your body uses on
like your metabolic rate. it also is involved in digestion how your heart and
muscles work, how your brain develops.
4. Epinephrine, norepinephrine and sympathetic stimulation/stress response
- these hormones immediately increase the rate of cellular metabolism in
many body tissues
5. Fever
- increases the cellular metabolic rate and thus increases body temp
ANTIPYRETICS
Tylenol (acetaminophen) – also an analgesic
Dose: 325 – 650 P.O. q 4 hrs
Can be taken every 4-6 hrs
Aspirin (ASA) – Lowers temp. Is classified as analgesic, anti-inflammatory and anti-
platelet
Dose: 325 – 650 P.O. q 4 hrs
Ibuprofen (Advil, Motrin) is an analgesic, antipyretic
Dose: 200 – 600 mg q 6 hrs, not q 4 hrs
* over the counter antipyretic medications like Biogesic, Bioflu etc.
thermometer placement
oral - place the tip on either side of the frenulum
you place the tip of the thermometer or the probe of the thermometer
Axillary – Pat axilla dry if very moist
Tympanic – pull the pinna slightly upward and backward for an adult
- pull the pinna straight back and upward for children over 3 years old
- pull the pinna slightly downward and backward for children below 3 years of age
- with the probe flush on the center of the forehead depress the red button keep depressed
- slowly slide the probe midline across the forehead to the hairline, not down the side of the face
- lift the probe from the forehead and touch on the neck just behind the earlobe. Release the
button.
Advantages Disadvantages
ORAL - accessible - thermometers can break if
- convenient bitten
- inaccurate if client has just
ingested hot or cold food or
fluid or smoked
- could injure the mouth
following oral surgery
AXILLARY - safe and non-invasive - the thermometer may need
to be left in place a long time
to obtain an accurate
measurement
RECTAL - reliable measurement - inconvenient and more
unpleasant for clients
specially those who cannot
turn to sides
- could injure the rectum
- presence of stool may
interfere with thermometer
placement
TYMPANIC MEMBRANE - readily available - can be uncomfortable and
- reflects the core involves risk of injuring the
temperature membrane if the probe is
- very fast inserted too far
- repeated measurements
may vary. Right and left
measurements can differ
- presence of cerumen can
affect the reading
TEMPORAL ARTERY - safe and non-invasive - requires electronic
- very fast equipment that may be
expensive or unavailable
- variation in technique
needed if client has
perspiration on the forehead
RESPIRATORY ASSESSMENT
Respiration – is the act of breathing
Ventilation – is also used to refer to the movement of air in and out of the lungs.
Inhalation or Inspiration – refers to the intake of air into the lungs. Diaphragm contracts (moves
down).
Exhalation or Expiration – refers to breathing out or the movement of gases from the lungs to
the atmosphere. Diaphragm relaxes (moves up).
ASSESSING RESPIRATIONS
- resting respirations should be assessed when the client is relaxed because exercise
affects respirations, increasing their rate and depth
- respiration is also assessed after exercise to identify the client’s tolerance to activity
- anxiety is likely to affect respiratory rate and depth as well
The normal respiratory rate changes with age. The normal rates are as given below for specific
ages:
Newborns: 30-40 breaths per minute
Less than 1 yr: 30-40 breaths per minute
1-3 years: 23-35 breaths per minute
3-6 years: 20-30 breaths per minute
6-12 years: 18-26 breaths per minute
12-17 years: 12-20 breaths per minute
Adults over 18: 12-20 breaths per minute.
Rates:
Tachypnea – quick, shallow breaths
Bradypnea – abnormally slow breathing
Apnea – cessation of breathing
Volumes:
Hyperventilation – overexpansion of the lungs characterized by rapid and deep breaths
Hypoventilation – under expansion of the lungs, characterized by shallow respirations
Rhythm:
Cheyne-strokes breathing – rhythmic waxing and waning of respirations, from very deep to very
shallow breathing and temporary apnea.
Ease or Effort:
Dyspnea – difficult and labored breathing during which the individual has a persistent,
unsatisfied need of air and feels distressed.
Orthopnea – ability to breathe only in upright sitting or standing positions.
AUDIBLE WITHOUT AMPLIFICATION
Stridor – a shrill, harsh sound heard during inspiration with laryngeal obstruction
Stertor – snoring or sonorous respiration, usually due to a partial obstruction of the upper airway
Wheeze – continuous, high-pitched musical squeak or whistling sound occurring on expiration
and sometimes on inspiration when air moves through a narrowed or partially
obstructed airway.
Bubbling – gurgling sounds heard as air passes through moist secretions in the respiratory tract
CHEST MOVEMENTS
Intercostal retraction – indrawing between the ribs
Substernal Retraction – indrawing beneath the breastbone
Suprasternal retraction – indrawing above the clavicles
Infants / Children – crying needs to be quieted before assessing respirations for there could be
abnormal respiratory rate and rhythm
- they use their diaphragms for inhalation and exhalation, if necessary, place
your hand gently on infant’s abdomen to feel the rapid rise and fall during
respirations.
Older Adults – ask client to remain quiet, or count respirations after taking the pulse
- Any changes in rate or type of breathing should be reported immediately
PULSE ASSESSMENT
Pulse Rate and Heart Rate
* your pulse is your heart rate, or the number of times your heart beats in one minute.
* the pulse is a wave of blood created by contraction of the left ventricle of the heart
* the pulse wave represents the stroke volume output or the amount of blood that enters the
arteries with each ventricular contraction
* compliance of the arteries is their ability to contract and expand
* When a person’s arteries lose their distensibility as can happen with age, greater pressure is
required to pump blood into the arteries.
CARDIAC OUTPUT
* Is the volume of blood pumped into the arteries by the heart and equals the result of the stroke
volume times the heart rate per minute
* SV x HR/min = CO
* ex. 75 ml. x 60 beats/min = 4,500 ml/min or 4.5 L/min
*When an adult is resting the heart pumps about 5 liters of blood each minute
Peripheral Pulse – is a pulse located away from the heart, example in the foot or wrist
Apical Pulse – is a central pulse, located in the apex of the heart, also referred to as the
point of maximal impulse (PMI)
PULSE SITES:
Temporal – where the temporal artery passes over the temporal bone of the head
Carotid – at the side of the head where the carotid artery runs between the trachea and the
sternocleidomastoid muscle
Apical – at the apex of the heart
Adults – left side of the chest, about 3 inches to the left of the sternum at the 5th
intercostal space (area between the ribs)
Older Adult – the apex may be further left if conditions are present that have led to an
enlarged heart
Before 4 yrs of age – the apex is left to the midclavicular line
Between 4 and 6 yrs – it is at the midclavicular line
For 7 to 9 yrs – the apical pulse is located at the 4th or 5th intercostal space
Brachial – at the inner aspect of the biceps muscle of the arm or medially in the antecubital
space
Radial – where the radial artery runs along the radial bone, on the thumb side of the inner aspect
of the wrist
Femoral – where the femoral artery passes alongside the inguinal ligament
Popliteal – where the popliteal artery passes behind the knee
Posterior Tibial – on the medial surface of the ankle where the posterior tibial artery passes by
the medial malleolus
Dorsalis Pedis/Pedal – where the dorsalis pedis artery passes over the bones of the foot on an
imaginary line drawn from the middle of the ankle to the space between the bid and
second toes.
BLOOD PRESSURE
- is the measurement of force applied to artery walls
Arterial Blood Pressure – is a measure of the pressure exerted by the blood as it
flows through the arteries.
- Blood moves in waves
- measured in millimeters of mercury (mm Hg)
- recorded as a fraction Systolic pressure/Diastolic Pressure
- A typical blood pressure for a healthy adult is 120/80 mm Hg
2 BP Measurements
Systolic Pressure – Pressure of the blood as a result of contraction of the ventricles, the
pressure of the height of blood wave. Pumping.
Diastolic Pressure – Pressure when the ventricles are at rest, it is the lower pressure
present at all times in the arteries. Filling.
Mean Arterial Pressure – it is useful also to determine the mean arterial pressure (MAP)
because this represents the pressure actually delivered to the body’s organs
- MAP greater than 65 will keep all organs perfused
Formula: MAP = SBP + (2 x DBP)
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2 Types of Hypertension
Primary Hypertension – is an elevated blood pressure of unknown cause
Secondary Hypertension – is an elevated blood pressure of known cause
2 Types of Sphygmomanometer
*Aneroid
*Digital/Electronic – eliminates the need to listen for the clients systolic and diastolic BP
through a stethoscope
- should be calibrated periodically to check accuracy
2 Methods in Assessing BP
1. Direct (Invasive Monitoring)
- involves insertion of a catheter into the brachial, radial, femoral artery
- arterial pressure is represented by a wavelike form displayed on a monitor
- pressure reading is highly accurate
2. Indirect (Non-invasive Monitoring)
A. Auscultatory
- commonly used in hospitals, clinics and homes
- external pressure is applied on the artery, then pressure is read from the
sphygmomanometer, while listening for sounds with a stethoscope
Phase 5: Silence
- silence that occurs when the cuff pressure is released enough to allow
normal blood flow. This is known as the second diastolic reading.
B. Palpatory
- used when Korotkoff’s sounds cannot be heard
- or used when electronic devices to amplify the sounds are not available
- or during auscultatory gap – temporary disappearance of a sound and
reappearance of the sound at a lower level
- nurse uses light to moderate pressure to palpate the pulsations of the
artery as the pressure in the cuff is released
- first pulsations of the artery are felt, the systolic pressure as the pressure
in the cuff is released and pressure is read in the sphygmomanometer
- a single whiplike vibration is felt in addition, to the pulsations identifies
the point nearing the diastolic pressure
Pain Assessment
- 5th vital signs
- it is an unpleasant and highly personal experience that may be imperceptible to
others, while consuming all parts of an individual’s life
- according to Margo McCaffery, a nurse expert on pain, “pain is whatever the
person says it is and exists whenever he says it does”.
- an unpleasant sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such damage