1 Vital Signs Dr. Abdul-Monim Batiha Assistant Professor Critical Care Nursing Philadelphia University

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Vital SignsVital Signs

Dr. Abdul-Monim BatihaDr. Abdul-Monim BatihaAssistant ProfessorAssistant ProfessorCritical Care NursingCritical Care Nursing

Philadelphia University Philadelphia University

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Learning ObjectivesLearning Objectives

Describe factors that affect the Describe factors that affect the vital signs and accurate vital signs and accurate measurement of them.measurement of them.

Identify the normal range for each Identify the normal range for each vital sign.vital sign.

Identify the variations in normal Identify the variations in normal body temperature, pulsebody temperature, pulse,,

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Describe factors influencing Describe factors influencing the body heat production and the body heat production and loss.loss.

Describe appropriate Describe appropriate nursing care for alterations nursing care for alterations in body temperaturein body temperature..

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Identify nine sites used to Identify nine sites used to assess the pulse.assess the pulse.

List the characteristics List the characteristics that should be include that should be include when assessing pulses.when assessing pulses.

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Describe the mechanics of Describe the mechanics of breathing and the breathing and the mechanisms that control mechanisms that control respirations.respirations.

Identify the components of Identify the components of respiratory assessment.respiratory assessment.

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Differentiate systolic from Differentiate systolic from diastolic blood pressure.diastolic blood pressure.

Describe various methods Describe various methods and sites used to measure and sites used to measure blood pressure.blood pressure.

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IntroductionIntroduction The The vital or cardinal signsvital or cardinal signs are are

body temperature, pulse, respirations, body temperature, pulse, respirations, and blood pressure. and blood pressure. RecentlyRecently, many , many agencies agencies such as the such as the Veterans Veterans AdministrationAdministration have designated have designated painpain as a as a fifth vital signfifth vital sign, to be , to be assessed at the same time as each of assessed at the same time as each of the other four.the other four.

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Body TemperatureBody Temperature

Body temperature Body temperature reflects the reflects the balance between the heat produced balance between the heat produced and the heat lost from the body, and the heat lost from the body, measured in heat units called measured in heat units called degrees.degrees. There are two kinds of There are two kinds of body temperature: core temperature body temperature: core temperature and surface temperature. and surface temperature.

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Core temperatureCore temperatureIs the temperature of the deep Is the temperature of the deep

tissues of the body, such as the tissues of the body, such as the abdominal cavity and pelvic abdominal cavity and pelvic cavity. It remains relatively cavity. It remains relatively constant. The normal core body constant. The normal core body temperature is a range of temperature is a range of temperature 37C.temperature 37C.

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Surface temperatureSurface temperatureIs the temperature of the Is the temperature of the

skin, the subcutaneous skin, the subcutaneous tissue, and fat. It, by tissue, and fat. It, by constant, rises and falls in constant, rises and falls in response to the response to the environment.environment.

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The body continually The body continually produces heat as a by-produces heat as a by-product of product of metabolismmetabolism. . When the amount of heat When the amount of heat produced by the body equal produced by the body equal the amount of heat lost, the the amount of heat lost, the person is in person is in heat balance. heat balance.

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Factors affect the body's heat Factors affect the body's heat production. The most important are production. The most important are

these five: these five:

1.1. Basal metabolic rate (BMR).Basal metabolic rate (BMR). Is Is the rate of energy utilization in the the rate of energy utilization in the body required to maintain essential body required to maintain essential activities activities such as breathing, BMR such as breathing, BMR decrease with age. In general, the decrease with age. In general, the younger the person, the higher the younger the person, the higher the BMR. BMR.

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2. Muscle activity. 2. Muscle activity. Including shivering Including shivering increases the MR.increases the MR.

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3. Thyroxine output. Increased 3. Thyroxine output. Increased thyroxine output increases the thyroxine output increases the rate of cellular metabolism rate of cellular metabolism throughout the body. This effect throughout the body. This effect is called chemical is called chemical thermogenesis, the stimulation thermogenesis, the stimulation of heat production in the body of heat production in the body through increased cellular through increased cellular metabolism.metabolism.

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4.Epinephrine, norepinephrine, 4.Epinephrine, norepinephrine, and sympathetic stimulation. and sympathetic stimulation. These hormones immediately These hormones immediately increase the rate of cellular increase the rate of cellular metabolism in many body tissuesmetabolism in many body tissues. .

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Fever. Fever.

Fever increases the Fever increases the cellular metabolic rate cellular metabolic rate and thus increases the and thus increases the body's temperature body's temperature further. further.

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Factors affect the body's heat Factors affect the body's heat loss. The most important are:loss. The most important are:

1. Radiation is 1. Radiation is the transfer of the transfer of heat from the surface of one heat from the surface of one object to the surface of another object to the surface of another without contact between the without contact between the two objects.two objects.

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2. Conduction 2. Conduction is the transfer of is the transfer of heat from one molecule to a heat from one molecule to a molecule of lower temperature. For molecule of lower temperature. For example, when a body is immersed example, when a body is immersed in cold water the amount of heat in cold water the amount of heat transferred depends on the transferred depends on the temperature difference and the temperature difference and the amount and duration of the contact.amount and duration of the contact.

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3. Convection3. ConvectionIs the dispersion of heat by air Is the dispersion of heat by air

currents. The body usually has a currents. The body usually has a small amount of warm air adjacent small amount of warm air adjacent to it. This warm air rises and is to it. This warm air rises and is replaced by cooler air, and so people replaced by cooler air, and so people always lose a small amount of heat always lose a small amount of heat through convection.through convection.

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4. Vaporization4. Vaporization

Is continuous evaporation Is continuous evaporation of moisture from the of moisture from the respiratory tract and from respiratory tract and from the mucosa of the mouth the mucosa of the mouth and from the skin. and from the skin.

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Regulation of body Regulation of body temperaturetemperature

The system that The system that regulates body regulates body temperature has three temperature has three main parts:main parts:

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sensors in the shell and in sensors in the shell and in the core, an integrator in the core, an integrator in the hypothalamus, and an the hypothalamus, and an effectors system that effectors system that adjusts the production adjusts the production and loss of heat.and loss of heat.

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Most sensors or sensory receptors Most sensors or sensory receptors are in the skin. The skin has more are in the skin. The skin has more receptors for cold than warmth. receptors for cold than warmth. Therefore, skin sensors detect cold Therefore, skin sensors detect cold more efficiently than warmth.more efficiently than warmth.

When the skin becomesWhen the skin becomes chilledchilled over the entire body.over the entire body.

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Three physiologic processes to Three physiologic processes to increase the body temperature increase the body temperature

take placetake place

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Shivering increases heat Shivering increases heat production.production.

Sweating is inhibited to Sweating is inhibited to decrease heat loss.decrease heat loss.

Vasoconstriction Vasoconstriction decreases heat loss.decreases heat loss.

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The hypothalamic integrator, The hypothalamic integrator, the center the center that controls the core temperature, is that controls the core temperature, is located located in the in the preoptic areapreoptic area of the of the hypothalamus. When the sensors in the hypothalamus. When the sensors in the hypothalamus hypothalamus detect heatdetect heat, they , they send send out out signals intended signals intended to reduce the to reduce the temperaturetemperature that is to that is to decrease heat decrease heat productionproduction, and , and increase heat lossincrease heat loss. . When the When the cold sensorscold sensors are stimulated, are stimulated, signals are signals are sent out to increase heat sent out to increase heat production and decrease heat loss.production and decrease heat loss.

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Factors affecting Factors affecting body temperaturebody temperature

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1. 1. AgeAge

The infant is greatly influenced by the The infant is greatly influenced by the temperature of the environment and temperature of the environment and must be protected from extreme must be protected from extreme changes. Older people are also changes. Older people are also particularly sensitive to extremes in the particularly sensitive to extremes in the environmental temperature due to environmental temperature due to decreased thermoregulatory controls.decreased thermoregulatory controls.

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Diurnal variationsDiurnal variationsBody temperatures normally change Body temperatures normally change

throughout the day, varying as much throughout the day, varying as much as as 1.0C between the early morning 1.0C between the early morning and the late afternoon.and the late afternoon. The The point of point of highesthighest body temperature is usually body temperature is usually reached between reached between 8:00 PM and 8:00 PM and midnight, midnight, and the and the lowest pointlowest point is is reached during reached during sleepsleep between between 4:00 4:00 and 6:00 AM.and 6:00 AM.

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Exercise. Exercise. Hard work or Hard work or strenuous exercise can strenuous exercise can increase body temperature increase body temperature to as high 38.3 to 40C to as high 38.3 to 40C measured rectally.measured rectally.

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Stress.Stress. Stimulation of the Stimulation of the sympathetic nervous system sympathetic nervous system can increase the production of can increase the production of epinephrine and epinephrine and norepinephrine, thereby norepinephrine, thereby increasing metabolic activity increasing metabolic activity and heat production. and heat production.

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Hormones. Hormones. The women The women usually experience more usually experience more hormone fluctuations than hormone fluctuations than men. In women, progesterone men. In women, progesterone secretion at the time of secretion at the time of ovulation raises body ovulation raises body temperature by about 0.3 to temperature by about 0.3 to 0.6C above basal temperature.0.6C above basal temperature.

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Environment.Environment. Extremes Extremes in environmental in environmental temperatures can affect a temperatures can affect a person's temperature person's temperature regulatory systems.regulatory systems.

3535Copyright 2008 by Pearson Education, Inc.

Sites for Measuring Sites for Measuring Body Temperature Body Temperature

OralOralRectalRectalAxillaryAxillaryTympanic membrane Tympanic membrane Skin/Temporal artery Skin/Temporal artery


Types of Thermometers Types of Thermometers

ElectronicElectronic Chemical disposableChemical disposable Infrared (tympanic)Infrared (tympanic) Scanning infrared (temporal artery)Scanning infrared (temporal artery) Temperature-sensitive tapeTemperature-sensitive tape Glass mercuryGlass mercury

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Alterations in Alterations in body temperature body temperature

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PyrexiaPyrexiaA body temperature above the A body temperature above the

usual range is called usual range is called pyrexia pyrexia 38 to 40C, hyperthermia, or 38 to 40C, hyperthermia, or fever. fever. A very high fever, such A very high fever, such as 41Cas 41C is called hyperpyrexia. is called hyperpyrexia.

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Four common types of fevers Four common types of fevers areare

Intermittent fever, Intermittent fever, the the body temperature alternate body temperature alternate at regular intervals between at regular intervals between periods of fever and periods periods of fever and periods of normal or subnormal of normal or subnormal temperatures.temperatures.

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Relapsing fever, Relapsing fever, short short febrile periods of a few febrile periods of a few days are interspersed with days are interspersed with periods of 1 or 2 days of periods of 1 or 2 days of normal temperature.normal temperature.

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Constant fever, Constant fever, the body the body temperature fluctuates minimally temperature fluctuates minimally but always remains above normal.but always remains above normal.

A temperature A temperature that rises to fever that rises to fever level rapidly following a normal level rapidly following a normal temperature and then return to temperature and then return to normal within a few hours is normal within a few hours is called a called a fever spike.fever spike.

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Remittent fever, Remittent fever, a wide a wide range of temperature range of temperature fluctuations more than 2C fluctuations more than 2C occurs over the 24-hour occurs over the 24-hour period, all of which above period, all of which above normal.normal.

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Clinical Signs of FeverClinical Signs of FeverThe clinical signs of fever vary with The clinical signs of fever vary with the the onset, course, and abatement onset, course, and abatement stagesstages of the fever. These signs occur of the fever. These signs occur as a result of changes in the set point as a result of changes in the set point of the temperature control of the temperature control mechanism regulated by the mechanism regulated by the hypothalamus.hypothalamus.

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Onset (cold or Chill Stage)Onset (cold or Chill Stage)Increased heart rate.Increased heart rate.Increased respiratory rate and depth.Increased respiratory rate and depth.Pallid, cold skin and shivering. Pallid, cold skin and shivering.

Complaints of feeling cold.Complaints of feeling cold.Cyanotic nail beds.Cyanotic nail beds.Gooseflesh appearance of the skin.Gooseflesh appearance of the skin.Cessation of sweating.Cessation of sweating.

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Course StageCourse StageAbsence of chills.Absence of chills.Skin that feels warm.Skin that feels warm.Glassy eyed appearance.Glassy eyed appearance.Increased pulse and Increased pulse and

respiration rates.respiration rates.Increased thirst. Increased thirst.

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Mild to sever dehydrationMild to sever dehydrationDrowsiness, restlessness, delirium, Drowsiness, restlessness, delirium,

or convulsions.or convulsions.Herpetic lesions of the mouth.Herpetic lesions of the mouth.Loss of appetite.Loss of appetite.Malaise, weakness, and aching Malaise, weakness, and aching

muscles. muscles.

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Abatement stage of feverAbatement stage of fever

Skin that appears flushed aSkin that appears flushed and feels nd feels warm.warm.

Sweating.Sweating.Decreased shivering and possible Decreased shivering and possible

dehydration.dehydration.

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Nursing Interventions for clients Nursing Interventions for clients with Feverwith Fever

Monitor vital signs.Monitor vital signs.Assess skin color and Assess skin color and

temperature.temperature.Monitor white blood cell count, Monitor white blood cell count,

hematocrit value.hematocrit value.

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Remove excess blankets when Remove excess blankets when the client feels warm, but the client feels warm, but provide extra warmth when the provide extra warmth when the client feels chilled.client feels chilled.

Provide adequate nutrition and Provide adequate nutrition and fluids.fluids.

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Measure intake and output.Measure intake and output.Reduce physical activity to Reduce physical activity to

limit heat production, limit heat production, especially during the flush especially during the flush stage.stage.

Administer antipyretics as Administer antipyretics as ordered.ordered.

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Provide oral hygiene to keep the Provide oral hygiene to keep the mucous membranes moist.mucous membranes moist.

Provide a tepid sponge bath to Provide a tepid sponge bath to increase that loss through increase that loss through conduction.conduction.

Provide dry clothing and bed Provide dry clothing and bed linens.linens.

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Hypothermia:Hypothermia: is a core is a core body temperature below the body temperature below the lower limit of normal 35C. lower limit of normal 35C. The three physiologic The three physiologic mechanisms of mechanisms of hypothermia are:hypothermia are:

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Excessive heat loss.Excessive heat loss.Inadequate heat Inadequate heat

production to counteract production to counteract heat loss.heat loss.

Impaired hypothalamic Impaired hypothalamic thermoregulation.thermoregulation.

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The Clinical Signs of The Clinical Signs of HypothermiaHypothermia

Decreased body temperature, Decreased body temperature, pulse, and respirations.pulse, and respirations.

Severe shivering (initially)Severe shivering (initially)Feelings of cold and chills.Feelings of cold and chills.Pale, cool, waxy skin.Pale, cool, waxy skin.

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Hypotension and Hypotension and disorientation.disorientation.

Decreased urinary output.Decreased urinary output. Lack of muscle coordination.Lack of muscle coordination.Drowsiness progressing to Drowsiness progressing to

coma.coma.

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Nursing Interventions for Clients Nursing Interventions for Clients with hypothermiawith hypothermia

Provide a warm Provide a warm environment.environment.

Provide dry clothing.Provide dry clothing.Apply warm blanketsApply warm blankets..

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Keep limbs close to body.Keep limbs close to body.Cover the client's scalp with Cover the client's scalp with

a cap or turban.a cap or turban.Supply warm oral or Supply warm oral or

intravenous fluids.intravenous fluids.Apply warming pads.Apply warming pads.

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The The PulsePulse is a wave of blood is a wave of blood created by contraction of the created by contraction of the left ventricle of the heart. left ventricle of the heart. GenerallyGenerally the pulse wave the pulse wave represents the stroke volume represents the stroke volume outputoutput and the amount of blood and the amount of blood that that entersenters the arteries with the arteries with each ventricular contraction.each ventricular contraction.

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ComplianceCompliance of the arteries of the arteries is their ability to contract is their ability to contract and expand. When a and expand. When a person's arteries loss their person's arteries loss their distensibility as can happen distensibility as can happen in old age, in old age, greater pressure greater pressure is required to pump the is required to pump the blood into the arteries.blood into the arteries.

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Cardiac outputCardiac output is the volume of is the volume of blood pumped into the arteries by blood pumped into the arteries by the heart and the heart and equals equals the result of the the result of the stroke volume (SV) times the heart stroke volume (SV) times the heart rate (HR) per minute. rate (HR) per minute.

SV: The amount of blood ejected SV: The amount of blood ejected with each cardiac contractionwith each cardiac contraction

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For exampleFor example, 65mL x70 beats per , 65mL x70 beats per minute = 4.55 L per minute. When minute = 4.55 L per minute. When an adult is resting, the heart pumps an adult is resting, the heart pumps about about 55 liters liters of blood each minute.of blood each minute.

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In a healthy person,In a healthy person, the pulse the pulse reflects the heartbeat that is the reflects the heartbeat that is the pulse rate is the same as the pulse rate is the same as the rate of the ventricular rate of the ventricular contractions of the heart. contractions of the heart. HoweverHowever, in some types of , in some types of cardiovascular disease, the cardiovascular disease, the heartbeat and pulse rate heartbeat and pulse rate can can differ. differ.

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For exampleFor example, a client's heart , a client's heart may produce very weak or may produce very weak or small pulse waves that are not small pulse waves that are not detectable in a peripheral pulse detectable in a peripheral pulse far from the heart. In these far from the heart. In these instances, the nurse should instances, the nurse should assessassess the the heartbeat and the heartbeat and the peripheral pulse.peripheral pulse.

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A Peripheral pulseA Peripheral pulse is a pulse is a pulse located away from the heart, located away from the heart, for example, in the foot, wrist, for example, in the foot, wrist, or neck.or neck.

Apical pulse,Apical pulse, in contrast, is a in contrast, is a central pulse, that it is located central pulse, that it is located at the apex of the heart.at the apex of the heart.


Pulse SitesPulse Sites

RadialRadial Readily accessibleReadily accessible

TemporalTemporal When radial pulse is not accessibleWhen radial pulse is not accessible

CarotidCarotid During cardiac arrest/shock in adultsDuring cardiac arrest/shock in adults

Determine circulation to the brainDetermine circulation to the brain

ApicalApical Infants and children up to 3 years of ageInfants and children up to 3 years of age

Discrepancies with radial pulseDiscrepancies with radial pulse

Monitor some medicationsMonitor some medications

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Pulse SitesPulse Sites

BrachialBrachial Blood pressureBlood pressure

Cardiac arrest in infantsCardiac arrest in infants

FemoralFemoral Cardiac arrest/shockCardiac arrest/shock

Circulation to a leg;Circulation to a leg;

PoplitealPopliteal Circulation to lower legCirculation to lower leg

Posterior Posterior tibialtibial

Circulation to the footCirculation to the foot

Dorsalis Dorsalis pedispedis

Circulation to the footCirculation to the foot

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Factors Affecting Factors Affecting the Pulsethe Pulse

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Age.Age. Specific variations in Specific variations in pulse rates from birth to pulse rates from birth to adulthood.adulthood.

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Gender.Gender. After puberty, the After puberty, the average male's pulse rate is average male's pulse rate is slightly lower than the slightly lower than the female's.female's.

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Exercise.Exercise. The pulse The pulse rate normally increases rate normally increases with activity.with activity.

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FeverFeverThe pulse rate increases:The pulse rate increases:

a.a. in response to the lowered blood in response to the lowered blood pressure that results from pressure that results from peripheral vasodilatation associated peripheral vasodilatation associated with elevated body temperature.with elevated body temperature.

b. b. because of the increased metabolic because of the increased metabolic rate. rate.

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MedicationsMedicationsSome medications decrease the Some medications decrease the

pulse rate, and others increase it. pulse rate, and others increase it. For example, For example, cardiotonicscardiotonics (digitalis)(digitalis) decrease the heart decrease the heart rate, whereas epinephrine rate, whereas epinephrine increase it.increase it.

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Hypovolemia.Hypovolemia. Loss of blood from Loss of blood from the vascular system normally the vascular system normally increases pulse rate. increases pulse rate.

Stress.Stress. In response to stress, In response to stress, sympathetic nervous stimulation sympathetic nervous stimulation increases the overall activity of the increases the overall activity of the heart. Stress increases the rate as heart. Stress increases the rate as well as the force of the heartbeat.well as the force of the heartbeat.

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Position changes.Position changes. When a person When a person is sitting or standing, blood is sitting or standing, blood usually pools in dependent vessels usually pools in dependent vessels of the venous system. Pooling of the venous system. Pooling results in a transient decrease in results in a transient decrease in the venous blood return to the the venous blood return to the heart and subsequent reduction in heart and subsequent reduction in blood pressure and increase in blood pressure and increase in heart rate. heart rate.

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Pathology.Pathology. Certain Certain diseases such as some diseases such as some heart conditions or those heart conditions or those that impair oxygenation that impair oxygenation can alter the resting pulse can alter the resting pulse rate.rate.

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When assessing the pulse, When assessing the pulse, the nurse collects the the nurse collects the

following data:following data:

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Tachycardia.Tachycardia. An excessively fast An excessively fast heart rate over 100 BPM in adult heart rate over 100 BPM in adult is referred to as tachycardia.is referred to as tachycardia.

Bradycardia. ABradycardia. A heart rate in an heart rate in an adult of 60 BPM or less is called.adult of 60 BPM or less is called.

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The pulse rhythm.The pulse rhythm.

Is the pattern of the beats and Is the pattern of the beats and the intervals between the beats. the intervals between the beats. Equal timeEqual time elapses between elapses between beats of a normal pulse. A pulse beats of a normal pulse. A pulse with an with an irregularirregular rhythm is rhythm is referred to as a referred to as a dysrhythmia or dysrhythmia or arrhythmia.arrhythmia.

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Pulse volumePulse volumeAlso called the pulse strength or Also called the pulse strength or

amplitude, refers to the force of amplitude, refers to the force of blood with each beat. blood with each beat.

The elasticity of the arterial wallThe elasticity of the arterial wall reflects its expansibility or its reflects its expansibility or its deformities. deformities. A healthy, normal A healthy, normal artery feels straight, smooth, soft, artery feels straight, smooth, soft, pliable. pliable.

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Pulse deficitPulse deficit

The difference between the apical and The difference between the apical and radial pulse radial pulse

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Pulse pressurePulse pressure

The difference between systolic and The difference between systolic and diastolic blood pressure.diastolic blood pressure.

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Respiration Respiration is the act of breathing. is the act of breathing. External respirationExternal respiration refers to the refers to the interchange of oxygen and carbon interchange of oxygen and carbon dioxide between the alveoli of the lungs dioxide between the alveoli of the lungs and pulmonary blood. and pulmonary blood.

Internal respiration,Internal respiration, by contrast, takes by contrast, takes place throughout the body; it is the place throughout the body; it is the interchange of these same gases between interchange of these same gases between the circulating blood and the cells of the the circulating blood and the cells of the body tissues.body tissues.

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Inhalation Inhalation or or inspirationinspiration refers refers to the intake of air into the lungs. to the intake of air into the lungs. Exhalation Exhalation or or expiration expiration refers refers to breathing out or the movement to breathing out or the movement of gases from the lungs to the of gases from the lungs to the atmosphere. atmosphere. Ventilation Ventilation is also is also used to refer to the movement of used to refer to the movement of air in and out of the lungs.air in and out of the lungs.

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There are basically two types of There are basically two types of breathing:breathing:

Costal (thoracic) breathingCostal (thoracic) breathing involves the external intercostals involves the external intercostals muscles and other accessory muscles and other accessory muscles, muscles, such assuch as sternocleidomastoidsternocleidomastoid muscles. It muscles. It can be observed by the movement can be observed by the movement of the chest upward and outward.of the chest upward and outward.

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Diaphragmatic (abdominal) Diaphragmatic (abdominal) breathingbreathing involves the involves the contraction and relaxation of contraction and relaxation of the diaphragm, and it is the diaphragm, and it is observed by the movement of observed by the movement of the the abdomenabdomen, which occurs as , which occurs as a result of the a result of the diaphragm's diaphragm's contractioncontraction and downward and downward movement.movement.

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Mechanics and Regulation of Mechanics and Regulation of breathingbreathing

During inhalation,During inhalation, the diaphragm the diaphragm contracts (flattens), the ribs move contracts (flattens), the ribs move upward and outward, and the upward and outward, and the sternum moves outward, thus sternum moves outward, thus enlarging the thorax and enlarging the thorax and permitting the lungs to expand. permitting the lungs to expand.

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During exhalation,During exhalation, the diaphragm the diaphragm relaxes, the ribs move downward relaxes, the ribs move downward and inward, and the sternum and inward, and the sternum moves inward, thus decreasing the moves inward, thus decreasing the size of the thorax as the lungs are size of the thorax as the lungs are compressed. compressed.

Normally breathingNormally breathing is carried out is carried out automatically and effortlessly. automatically and effortlessly.

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Respiration is controlledRespiration is controlled Respiratory centers in medulla Respiratory centers in medulla

oblongata and the pons of the oblongata and the pons of the brain.brain.

by chemoreceptors located by chemoreceptors located centrally in the medulla and centrally in the medulla and peripherally in the carotid and peripherally in the carotid and aortic bodies. aortic bodies.

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These centers and receptors These centers and receptors respond to changes in the respond to changes in the concentrations of oxygen concentrations of oxygen (O2), carbon dioxide (CO2) (O2), carbon dioxide (CO2) and hydrogen (H) in the and hydrogen (H) in the arterial blood.arterial blood.

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Factors Affecting Factors Affecting RespirationRespiration

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SeveralSeveral factors influence factors influence respiratory rate. Those that respiratory rate. Those that increase the rate include exercise increase the rate include exercise (increase metabolism), stress (increase metabolism), stress (readies the body for fight or (readies the body for fight or flight), increased environmental flight), increased environmental temperature, and lowered oxygen temperature, and lowered oxygen concentration at increased concentration at increased altitudes.altitudes.

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Factors that may decrease the Factors that may decrease the respiratoryrespiratory rate include rate include decreased environmental decreased environmental temperature, certain medications temperature, certain medications e.g. narcotics and increased e.g. narcotics and increased intracranial pressure.intracranial pressure.

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Altered Breathing Patterns Altered Breathing Patterns and Soundsand Sounds

1. 1. Breathing Patterns RateBreathing Patterns RateTachypnea -----Tachypnea -----quick, shallow quick, shallow

breathsbreaths. Usually more than 24R/M. Usually more than 24R/MBradypnea------Bradypnea------abnormally slow abnormally slow

breathing. breathing. Usually less than 10R/MUsually less than 10R/MApnea---------Apnea---------cessation of breathing. cessation of breathing.

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VolumeVolumeHyperventilation------Hyperventilation------overexpansion overexpansion

of the lungs characterized by rapid and of the lungs characterized by rapid and deep breath. deep breath.

Hypoventilation-------Hypoventilation-------under-expansion under-expansion of the lungs, characterized by shallow of the lungs, characterized by shallow respirations.respirations.

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RhythmRhythmCheyne-stokes Cheyne-stokes

breathing------breathing------Rhythmic Rhythmic waxing and waning of waxing and waning of respiration, from very deep to respiration, from very deep to very shallow breathing and very shallow breathing and temporary apnea.temporary apnea.

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Ease or EffortEase or Effort

DyspneaDyspnea ----- -----difficult and labored difficult and labored breathing during which the individual breathing during which the individual has a persistent, unsatisfied need for air has a persistent, unsatisfied need for air and feels distressed.and feels distressed.

Orthopnea-Orthopnea-------------ability to breathe only ability to breathe only in upright sitting or standing positionsin upright sitting or standing positions

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Breath soundsBreath soundsAudible without amplificationAudible without amplificationStridor ------Stridor ------a shrill (high-pitch), a shrill (high-pitch),

harsh sound heard during inspiration harsh sound heard during inspiration with laryngeal obstruction.with laryngeal obstruction.

Stertor-------Stertor-------snoring or sonorous snoring or sonorous (loud) respiration, usually due to a (loud) respiration, usually due to a partial obstruction of the upper partial obstruction of the upper airway.airway.

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Wheeze------Wheeze------continuous, high-continuous, high-pitched musical squeak or whistling pitched musical squeak or whistling sound occurring on expiration and sound occurring on expiration and sometimes on inspiration when air sometimes on inspiration when air moves through a narrowed or moves through a narrowed or partially obstructed airway.partially obstructed airway.

Bubbling-------Bubbling-------gurgling sounds gurgling sounds heard as air passes through moist heard as air passes through moist secretions in the respiratory tract.secretions in the respiratory tract.

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Chest movementsChest movementsIntercostal retraction---iIntercostal retraction---indrawing ndrawing

between the ribsbetween the ribsSubsternal retraction---iSubsternal retraction---indrawing ndrawing

beneath(under) the breastbonebeneath(under) the breastboneSuprasternal retraction-----Suprasternal retraction-----

iindrawing above the clavicles ndrawing above the clavicles

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Secretions and coughingSecretions and coughingHemoptysis -------Hemoptysis -------the presence the presence

of blood in the sputum.of blood in the sputum.Productive cough-------Productive cough-------a cough a cough

accompanied by expectorated accompanied by expectorated secretions.secretions.

Nonproductive cough------Nonproductive cough------a dry, a dry, harsh cough without secretions.harsh cough without secretions.

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Blood pressureBlood pressure

Arterial blood pressure Arterial blood pressure is a measure of is a measure of the pressure exerted by the blood as it the pressure exerted by the blood as it flows through the arteries. Because the flows through the arteries. Because the blood move in waves.blood move in waves.

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There are two blood pressure:There are two blood pressure:

Systolic pressure,Systolic pressure, which is the pressure of the which is the pressure of the blood as a result of contraction of the ventricles, blood as a result of contraction of the ventricles, that is, the pressure of the height of the blood that is, the pressure of the height of the blood wave.wave.

Diastolic pressure,Diastolic pressure, which is the pressure when which is the pressure when the ventricles are at rest. Diastolic pressure is the ventricles are at rest. Diastolic pressure is the lower pressure, present at all times within the lower pressure, present at all times within the arteries.the arteries.

Pulse pressure, Pulse pressure, the difference between the the difference between the diastolic and the systolic pressures.diastolic and the systolic pressures.

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Blood pressure Blood pressure is measured in is measured in millimeters of mercury (mmHg) and millimeters of mercury (mmHg) and recorded as a fraction. recorded as a fraction. The systolic The systolic pressure pressure is written over the is written over the diastolic diastolic pressure. pressure. The average blood pressure of The average blood pressure of a healthy adult is 120/80 mm Hg.a healthy adult is 120/80 mm Hg.


Korotkoff’s Sounds Korotkoff’s Sounds

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First the nurse pumps the cuff 30 mm Hg First the nurse pumps the cuff 30 mm Hg above the point where the pulse is no above the point where the pulse is no longer felt , that is the point when the longer felt , that is the point when the blood flow in the artery is stopped.blood flow in the artery is stopped.

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Phase 1Phase 1First faint, clear tapping or thumping soundsFirst faint, clear tapping or thumping soundsSystolic pressureSystolic pressure

Phase 2Phase 2Muffled (muted), whooshing, or swishing Muffled (muted), whooshing, or swishing

soundsound



Phase 3Phase 3 Blood flows freely Blood flows freely Crisper and more intense soundCrisper and more intense sound Thumping quality but softer than in phase 1Thumping quality but softer than in phase 1

Phase 4Phase 4 Muffled and have a soft, blowing soundMuffled and have a soft, blowing sound

Phase 5Phase 5 Pressure level when the last sound is heardPressure level when the last sound is heard Period of silence Period of silence Diastolic pressureDiastolic pressure


Measuring Blood Pressure Measuring Blood Pressure

Direct (Invasive Monitoring) Direct (Invasive Monitoring) IndirectIndirect

Auscultatory Auscultatory Palpatory Palpatory

SitesSites Upper arm (brachial artery)Upper arm (brachial artery) Thigh (popliteal artery)Thigh (popliteal artery)

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Factors Affecting Blood PressureFactors Affecting Blood Pressure Age Age : Newborns have a mean systolic pressure : Newborns have a mean systolic pressure

of about 75 mm Hg. The pressure rises with age, of about 75 mm Hg. The pressure rises with age, reaching a peak at the onset of puberty, and reaching a peak at the onset of puberty, and then tends to decline somewhat.then tends to decline somewhat.

Exercise: Exercise: Physical activity increases the cardiac Physical activity increases the cardiac output and hence the blood pressure, thus 20 to output and hence the blood pressure, thus 20 to 30 minutes of rest following exercise is indicated 30 minutes of rest following exercise is indicated before the resting blood pressure can be reliably before the resting blood pressure can be reliably assessed.assessed.

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Stress:Stress: Stimulation of the sympathetic Stimulation of the sympathetic nervous system increases cardiac output nervous system increases cardiac output and vasoconstriction of the arterioles, thus and vasoconstriction of the arterioles, thus increasing the blood pressure reading. increasing the blood pressure reading. However, severe pain can decrease blood However, severe pain can decrease blood pressure greatly by inhibiting the pressure greatly by inhibiting the vasomotor center and producing vasomotor center and producing vasodilatation.vasodilatation.

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Race:Race: African American males over 35 African American males over 35 years have higher blood pressure than years have higher blood pressure than European American males of the same age.European American males of the same age.

Gender:Gender: After puberty, females usually After puberty, females usually have lower blood pressure than males of have lower blood pressure than males of the same age this difference is thought to the same age this difference is thought to be due to hormonal variations. After be due to hormonal variations. After menopause women generally have higher menopause women generally have higher blood pressure than before.blood pressure than before.

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Medication:Medication: Many medications may increase or Many medications may increase or decrease the blood pressure.decrease the blood pressure.

Obesity:Obesity: Both childhood and adult obesity Both childhood and adult obesity predispose to hypertension.predispose to hypertension.

Diurnal variations:Diurnal variations: Pressure is usually lowest Pressure is usually lowest early in the morning, when the metabolic rate is early in the morning, when the metabolic rate is lowest, then rises throughout the day and peaks lowest, then rises throughout the day and peaks in the late afternoon or early evening.in the late afternoon or early evening.

Disease process:Disease process: Any condition affecting the Any condition affecting the cardiac output blood volume, blood viscosity cardiac output blood volume, blood viscosity and/or compliance of the arteries has a direct and/or compliance of the arteries has a direct effect on the blood pressure. effect on the blood pressure.

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Hypertension: Hypertension: A blood pressure that is A blood pressure that is persistently above normal.persistently above normal.

Primary hypertensionPrimary hypertension an elevated blood an elevated blood pressure of unknown cause pressure of unknown cause

Secondary hypertensionSecondary hypertension an elevated blood an elevated blood pressure of known cause.pressure of known cause.

HypotensionHypotension is a blood pressure that is below is a blood pressure that is below normal.normal.

Orthostatic hypotensionOrthostatic hypotension is a blood pressure is a blood pressure that falls when the client sits or stands.that falls when the client sits or stands.

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Common Errors in Assessing Blood PressureCommon Errors in Assessing Blood Pressure Bladder cuff too narrowBladder cuff too narrow Bladder cuff too wideBladder cuff too wide Arm unsupported Arm unsupported Insufficient rest before the assessment.Insufficient rest before the assessment. Repeating assessment too quickly.Repeating assessment too quickly. Deflating cuff too quickly.Deflating cuff too quickly. Deflating cuff too slowly.Deflating cuff too slowly. Failure to use the same arm consistently.Failure to use the same arm consistently. Arm above level of the heart.Arm above level of the heart. Assessing immediately after a meal or smoker or has pain.Assessing immediately after a meal or smoker or has pain.

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Variations in Normal Vital Signs by Variations in Normal Vital Signs by AgeAgeOral temperature in degree Pulse AgeAgeOral temperature in degree Pulse Average and RangesRespirationsAverage and Average and RangesRespirationsAverage and RangesBlood pressure (mm RangesBlood pressure (mm HgHg))Newborns36.8130 (80-180)35(30-80)73/551 Newborns36.8130 (80-180)35(30-80)73/551 year36.8120 (80-140)30 (20-40)90/555-8 year36.8120 (80-140)30 (20-40)90/555-8 years37100 (75-120)20 (15-25)95/5710 years37100 (75-120)20 (15-25)95/5710 years3770 (50-90)19 (15-25)102/62Teen3775 years3770 (50-90)19 (15-25)102/62Teen3775 (50-90)18 15-20)120/80Adult3780 (60-100)16 (12-(50-90)18 15-20)120/80Adult3780 (60-100)16 (12-20)120/80Older adult (>70 years)3770 (60-100)16 20)120/80Older adult (>70 years)3770 (60-100)16 (15-20)Possible increased diastolic(15-20)Possible increased diastolic


Pulse Oximetry Pulse Oximetry

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NoninvasiveNoninvasiveEstimates arterial blood oxygen saturation Estimates arterial blood oxygen saturation

(SpO(SpO22))

Normal SpONormal SpO22 85-100%; < 70% life 85-100%; < 70% life

threatening threatening Detects hypoxemia before clinical signs Detects hypoxemia before clinical signs

and symptomsand symptomsSensor, photodetector, pulse oximeter unit Sensor, photodetector, pulse oximeter unit

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Pulse OximetryPulse Oximetry

Factors that affect accuracy include:Factors that affect accuracy include:Hemoglobin levelHemoglobin levelCirculationCirculationActivityActivityCarbon monoxide poisoningCarbon monoxide poisoning

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Prepare sitePrepare siteAlign LED and photodetectorAlign LED and photodetectorConnect and set alarmsConnect and set alarmsEnsure client safetyEnsure client safetyEnsure accuracyEnsure accuracy

Documents

1 Vital Signs Dr. Abdul-Monim Batiha Assistant Professor Critical Care Nursing Philadelphia University