FUNDAMENTALS OF NURSING

VITAL SIGNS
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 VOCABULARY

KNOW VOCABULARY WORDS

GUIDELINES FOR VS MEASUREMENT

VITAL SIGNS INCLUDE:

TEMPERATURE (T)
PULSE (P)
RESPIRATIONS (RR)
BLOOD PRESSURE (BP)

1ST SIGN THAT SOMETHING IS WRONG WITH YOUR PATIENT

ARE INTERRELATED—A CHANGE IN ONE WILL AFFECT ANOTHER

NURSE MUST KNOW NORMAL RANGES OF VITAL SIGNS

 PROCEDURE FOR OBTAINING
TEMPERATURE

 VARIATIONS WNL 97-99.6 F

– AGE
– EXERCISE
– HORMONES
– LOW IN AM AND PEAKS BETWEEN 4-6PM
– STRESS
– ENVIRONMENT
– INGESTION
– SMOKING

 WHEN HEAT LOST = HEAT PRODUCED IT IS CALLED HOMEOSTASIS

 T or thermoregulation is controlled by the HYPOTHALAMUS in the brain

 **TEMPERATURE IS THE LEAST LIKELY AFFECTED BY PAIN

Figure 11-2

(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)

Disposable, single-use thermometer strip.

ORAL—BLUE OR CLEAR TIPPED
RECTAL—RED TIPPED

(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)

Electronic thermometer.
TYMPANIC—FAST AND ACCURATE

(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)

Tympanic thermometer with probe cover inserted into auditory canal.

 TEMPERATURE
 TEMPERATURE LOCATIONS /sites
– ORAL—
– Do not use if:
 HAD ORAL SURGERY, CANNOT HOLD THERMOMETER PROPERLY, AND IF CHILLING

– RECTAL—
 MOST RELIABLE, USUALLY MEASURES 1 DEGREE HIGHER
 USED ON NEWBORN TO ENSURE PATENT ANUS
 DO NOT USE:
– ON CARDIAC PATIENTS DUE TO VAGAL STIMULATION (DROPS PULSE)

– AXILLARY— (recorded AX)

 LEAST ACCURATE BUT NON-INVASIVE. USUALLY 1 DEGREE LOWER

– TYMPANIC—
 USE IF ORAL TEMP CONTRAINDICATED
 ACCURATE, SAFE, NON INVASIVE

 TEMPERATURE RANGES
– HUMAN LIFE CANNOT EXIST OUTSIDE OF 77-113 F NOT COMPATIBLE FOR CELLULAR ACTIVITY <93 OR >105.8

 HYPOTHERMIA—ABNORMALLY LOW BODY TEMPERATURE

 HYPERTHERMIA—TEMPERATURE ABOVE NORMAL

 AFEBRILE—NO TEMPERATURE

 HYPERPYREXIA—TEMP >105 F
 FEVER
 SIGNS OF FEVER
– USUALLY 1ST SIGN OF INFECTION
– THIRST
– ANOREXIA
– FLUSHED SKIN
– GLASSY EYES
– PERSPIRATION
– HEADACHE
– INCREASED PULSE AND RESPIRATION
– RESTLESS, SLEEPY, DISORIENTATION, CONVULSIONS

 CLASSIFICATIONS OF FEVER
– CONSTANT
– INTERMITTENT
– REMITTENT

 C = 9/5 + 32 F = -32 X 5/9

 TEMPERATURE

 FACTORS AFFECTING TEMPERATURE

– AGE
– EXERCISE
– HORMONAL INFLUENCE
– DIURNAL VARIATIONS
– STRESS
– ENVIRONMENT
– INGESTION OF HOT OR COLD LIQUIDS
– SMOKING
 FACTORS TO ASSESS IN DETERMINING
POTENTIAL ALTERATIONS IN PULSE

PULSE REPRESENTS THE WAVE OF

PRESSURE PRODUCED WHEN THE
HEART CONTRACTS

 NURSE NOTES THE

RATE, RHYTHM, AND
VOLUME WHEN TAKING
A PULSE.
 FACTORS TO ASSESS IN DETERMINING
POTENTIAL ALTERATIONS IN PULSE

 RATE
– NORMAL RATE IS 60-100 BPM
– TACHYCARDIA-->100 BPM
 Several causes…

– HYPOVOLEMIA—LOW BLOOD VOLUME

– BRADYCARDIA--<60 BPM
 Several causes…

– **ALWAYS ASSESS PULSE BEFORE GIVING CARDIOTONIC MEDS

 THEY USUALLY STRENGTHEN AND SLOW THE HEARTBEAT
 PULSE

 RHYTHM
– TIME BETWEEN BEATS
 SHOULD BE EQUAL AND REGULAR

– DYSRHYTHMIA = abnormality

– ARRHYTHMIA = Irregularity
 PULSE

 VOLUME = amount of blood with every

beat
– 0=ABSENT
– 1+=THREADY (difficult to palpate, disappears
easily with pressure)
– 2+=WEAK (difficult to palpate)
– 3+=NORMAL
– 4+=BOUNDING (felt easily with slight pressure)
 PULSE
 INFLUENCING FACTORS
– AGE
– EXERCISE
– FEVER, HEAT
– ACUTE PAIN, ANXIETY
– UNRELIEVED SEVERE PAIN, CHRONIC PAIN
– MEDICATIONS
– HEMORRHAGE
– POSTURAL CHANGES
– METABOLISM
– EMOTION
– SIZE
– HEART CONDITION
 SITES FOR PULSE MEASUREMENT

 TEMPORAL—TEMPORALIS ARTERY (not common)

 CAROTID—COMMON FOR MONITORING DURING

EXERCISE

 APICAL—DESIRED SITE IF PATIENT HAVING CHEST PAIN

– ALWAYS TAKE FOR 1 MINUTE

 BRACHIAL—INSIDE ELBOW (excellent site for newborns,

infants)

 RADIAL—THUMB SIDE OF WRIST

 SITES FOR PULSE MEASUREMENT

 FEMORAL—INNER LEG, BEND OF LEG BY GROIN

 POPLITEAL—BEHIND KNEE

 PEDAL—
– DORSALIS PEDIS (TOP OF FOOT)
– POSTERIOR TIBIAL (BEHIND MEDIAL MALLEOLUS)

 USE PADS OF INDEX FINGERS WITH LIGHT PRESSURE.

DO NOT OCCLUDE BLOOD FLOW
Figure 11-7

PULSE
SITES
Figure 11-9

(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St.
Louis: Mosby.)

A, Point of maximum impulse is at fifth intercostal space. B,

Assessing apical pulse.
 PROCEDURE FOR DETERMINING
RESPIRATORY STATUS

RESPIRATION IS TAKING IN OXYGEN AND

BREATHING OUT CARBON DIOXIDE
-THE PROCESS OF INHALING AND EXHALING
 PROCEDURE FOR DETERMINING
RESPIRATORY STATUS

 INTERNAL RESPIRATIONS—EXCHANGE OF GAS AT THE

ALVEOLAR LEVEL
– DIFFUSION—EXCHANGE OF O2 AND CO2 BETWEEN
ALVEOLI AND RBCs
– PERFUSION—DISTRIBUTION OF BLOOD THROUGH
PULMONARY CAPILLARIES
– VENTILATION—MECHANICAL MOVEMENT OF AIR
– ALVEOLAR—TINIEST AIR CELLS OF THE LUNGS
– OXIDATION—O2 CONTENT OF COMPOUND
INCREASED
 RESPIRATORY CONTINUED
 EXTERNAL RESPIRATIONS
– INSPIRATION—AIR IN
– EXPIRATION—AIR OUT
– EACH RISE AND FALL OF THE CHEST IS ONE RESPIRATION

 RATE—CONTROLLED BY MEDULLA OBLONGATA IN THE BRAIN

– EUPNEA—Normal Breathing
 NORMAL ADULT RATE IS 12-20 BPM
– TACHYPNEA—Rapid Breathing
 RAPID RESPIRATIONS >20 BPM
– BRADYPNEA—Slow Breathing
 SLOW RESPIRATIONS <12 BPM
 RESPIRATORY CONTINUED

 METABOLISM
– ACTIVITY
– DEPTH
– DIAPHRAM
– RHYTHM
– INTERCOSTAL MUSCLES
 RESPIRATORY CONTINUED

 RESPIRATORY TERMS
– EUPNEA—NORMAL BREATHING

– DYSPNEA—BREATHING WITH DIFFICULTY

 SHORTNESS OF BREATH (SOB)

– APNEA—LACK OF RESPIRATION
 RESPIRATORY CONTINUED

 RESPIRATORY TERMS
– CHEYNE STOKES—ALTERNATING APNEA AND
DEEP, RAPID BREATHING
 RESPIRATORY CONTINUED

 RESPIRATORY TERMS

– KUSSMAUL—DEEP AND RAPID

PATTERNS OF RESPIRATIONS
 RESPIRATORY CONTINUED

 RESPIRATORY TERMS
– ORTHOPNEA:
 DIFFICULTY
BREATHING
LYING DOWN
 MUST SIT UP OR
STAND TO
BREATHE
 RESPIRATORY CONTINUED

 RESPIRATORY TERMS
– HYPERVENTILATION—RATE EXCEEDS
METABOLIC NEEDS
– HYPOVENTILATION—RATE NOT
ENOUGH FOR METABOLIC NEEDS
 RESPIRATORY CONTINUED

 RESPIRATORY TERMS
– HYPOXIA—LOW CELLULAR OXYGEN
– ANOXIA—LACK OF OXYGEN AT CELL
LEVEL, NO SYSTEMIC O2
 RESPIRATIONS

 INFLUENCING FACTORS
– DISEASE OR ILLNESS
– STRESS
– FEVER (HYPERPYREXIA)
– AGE
– GENDER
– BODY POSITION
 RESPIRATIONS

 INFLUENCING FACTORS
– MEDICATIONS (NARCOTICS DECREASE RR)
– EXERCISE
– ACUTE PAIN
– SMOKING
– BRAIN STEM INJURY

 OCCASIONAL SIGHING IS NORMAL—AERATES

ALVEOLI
 FACTORS TO ASSESS IN DETERMINING
ALTERATIONS IN BLOOD PRESSURE

 BLOOD PRESSURE
– SYSTOLIC PRESSURE: HIGHEST NUMBER
AND PRESSURE (1ST SOUND HEARD)
– DIASTOLIC PRESSURE: LOWEST NUMBER
AND PRESSURE
 REPRESENTS PRESSURE BETWEEN
CONTRACTIONS
 FACTORS TO ASSESS IN DETERMINING
ALTERATIONS IN BLOOD PRESSURE

 BLOOD PRESSURE
– PULSE PRESSURE: DIFFERENCE BETWEEN
SYSTOLIC AND DIASTOLIC
– ESSENTIAL HYPERTENSION: ELEVATED
BLOOD PRESSURE WITH NO KNOWN CAUSE
 BLOOD PRESSURE REFLECTS CARDIAC
OUTPUT
– USUALLY 5 QTS OR 5 LITERS
 BLOOD PRESSURE

 HYPERTENSION: BP ABOVE NORMAL LIMITS—

USUALLY >140/90
– BP INCREASED BY:
– INCREASED ICP
– PAIN
– END STAGE RENAL DISEASE (ESRD)
– EXERCISE
– SMOKING
– VASOCONSTRICTION: NARROWING OF VESSELS
– VASODILATION: WIDENING OF VESSELS
 BLOOD PRESSURE

 FACTORS AFFECTING BP
– AGE
– ANXIETY, FEAR, PAIN, EMOTIONAL STRESS
– MEDICATIONS
– DIURNAL FACTORS
– RACE—BLACKS HAVE INCREASED RISK FOR
HTN
 BLOOD PRESSURE

 FACTORS AFFECTING BP
– HORMONES
– SEX: MEN HAVE INCREASED RISK FOR HTN
– OBESITY: DUE TO MORE VESSELS TO PUMP
THROUGH
– FAMILY HISTORY
– HIGH CHOLESTEROL LEVELS
 BLOOD PRESSURE

 DIAGNOSIS OF HTN
– NOT DIAGNOSED WITH ONE READING
– MOST CONCERNED WITH DIASTOLIC
– FALSE HIGH READINGS CAUSED BY PATIENT
TALKING OR ARM NOT BEING SUPPORTED
 HYPOTENSION <90/50 IS NOT HEALTHY
 BLOOD PRESSURE

 CAUSES OF HYPOTENSION
– SHOCK
– HEMORRHAGE (DECREASED VOLUME, DECREASED
PRESSURE)
– GENERAL ANESTEHESIA—DEPRESSES VASOMOTOR
CENTER IN BRAIN STEM
– ALCOHOL
– POSTURAL CHANGES
 ORTHOSTATIC HYPOTENSION: OCCURS WHEN
CHANGING POSITION TOO QUICKLY
 ACTIONS NEEDED TO TAKE AN
ACURATE BLOOD PRESSURE

 EQUIPMENT
 KOROTKOFF SOUNDS
 ENVIRONMENTAL CONSIDERATIONS
– QUIET
– CORRECT CUFF SIZE
– GUAGE AT EYE LEVEL
– POSITION OF PATIENT—
 LYING OR SITTING WITH FEET FLAT ON FLOOR
 LEGS NOT CROSSED
Figure 11-11

(From Sorrentino, S.A. [2004]. Mosby’s textbook for nursing assistants [6th ed.]. St. Louis: Mosby.)

Aneroid manometer and cuff.

Figure 11-17

Electronic sphygmomanometer.
Figure 11-12

(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)

Wall-mounted aneroid sphygmomanometer.

Figure 11-14

(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St.
Louis: Mosby.)

Doppler stethoscope over brachial artery to measure blood pressure.

 BLOOD PRESSSURE

 NURSING INTERVENTIONS
– AVOID TAKING BPs:
 IN ARM WITH IV’S, INJURY OR DISEASE, CAST OR
BANDAGED, OR PARALYZED FROM STROKE
– IF YOU HAVE DIFFICULTY TAKING A BP,
RELEASE CUFF, WAIT 1-2 MINUTES AND TRY
AGAIN
 BLOOD PRESSSURE

 PLACEMENT
– NEVER ON MASTECTOMY SIDE
– IN LEG, SYSTOLIC & DIASTOLIC 10-40MM HG
HIGHER
 HOME DEVICES—NOT ALWAYS ACCURATE
 PROCEDURE FOR OBTAINING
ACCURATE HEIGHT AND WEIGHT

 DEFINITIONS
– HEIGHT AND WEIGHT ARE A RATIO—YOU NEED
BOTH
 PURPOSE
– ASSESS GROWTH AND DEVELOPMENT
– CALCULATE DRUG DOSAGE
– ASSESS EFFECTIVENESS OF DRUG THERAPY
– S/S OF DISEASE
– DETERMINE NUTRITION OR FLUID BALANCE
 PROCEDURE FOR OBTAINING
ACCURATE HEIGHT AND WEIGHT

 TO GET ACCURATE WEIGHT:

– BALANCE SCALE FIRST.
– SAME TIME, SAME SCALE, SAME CLOTHES
– IDEAL TIME:
 AFTER VOIDING & BEFORE BREAKFAST

 HEIGHT OBTAINED BY MEASUREMENT

Figure 11-18

(From Sorrentino, S.A. [2004]. Mosby’s textbook for nursing assistants. [6th ed.]. St. Louis: Mosby.)

Types of scales. A, Standing scale. B, Chair scale. C, Lift scales.

 FACTORS TO ASSESS IN DETERMINING
POTENTIAL ALTERATIONS IN
OXYGEN SATURATION

 KEY TIMES TO ASSESS

 PULSE OXIMETRY
– NAILBED—CLOTHESPIN
– MEASURES ARTERIAL OXYGEN SATURATION
(SAO2)
– <70% IS LIFE THREATENING
 FREQUENCY OF VS MEASUREMENT

 ADMISSION
 FACILITY POLICY/PHYSICIAN ORDER
 INSTABILITY
 BEFORE/AFTER SURGERY/PROCEDURE
 BEFORE/AFTER MEDS
 ROUTINELY DURING PROCEDURES
 WHEN CLIENT REPORTS SX OF DISTRESS
NORMAL LIMITS FOR VARIOUS AGES

 DISCUSS PATIENT/FAMILY TEACHING IN

REGARDS TO VITAL SIGNS
 THE END!!!

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