Learning OutcomesDescribe factors that affect the vital signs and accurate measurement of them.Identify the variations in normal body temperature, pulse, respirations, and blood pressure that occur from infancy to old age.Compare methods of measuring body temperature.Describe appropriate nursing care for alterations in body temperature.Identify nine sites used to assess the pulse and state the reasons for their use.List the characteristics that should be included when assessing pulses.Explain how to measure the apical pulse and the apical-radial pulse.

Learning OutcomesDescribe the mechanics of breathing and the mechanisms that control respirations.Identify the components of a respiratory assessment.Differentiate systolic from diastolic blood pressure.Describe five phases of Korotkoffs sounds.Describe methods and sites used to measure blood pressure.Discuss measurement of blood oxygenation using pulse oximetry.Identify when it is appropriate to delegate measurement of vital signs to unlicensed assistive personnel.

PretestUse your clickers to complete the following pretest.

Question 1The clients temperature at 8:00 AM using an oral electronic thermometer is 36.1C (97.2F). If the respiration, pulse, and blood pressure are within normal range, what would the nurse do next?

Wait 15 minutes and retake it.Check what the clients temperature was the last time.Retake it using a different thermometer.Chart the temperature; it is normal.

Rationales 1Depending on that finding, you might want to retake it in a few minutes (no need to wait 15 minutes).Correct. Although the temperature is slightly lower than expected for the morning, it would be best to determine the clients previous temperature range next. This may be a normal range for this client.There is no need to take temperature again with another thermometer to see if the initial thermometer was functioning properly. Chart after determining that the temperature has been measured properly.

Question 2Which of the following clients meets the criteria for selection of the apical site for assessment of the pulse rather than a radial pulse?

A client is in shockThe pulse changes with body position changesA client with an arrhythmiaIt is less than 24 hours since a client's surgical operation

Rationales 2For clients in shock, use the carotid or femoral pulse.The radial pulse is adequate for determining change in orthostatic heart rate.Correct. The apical rate would confirm the rate and determine the actual cardiac rhythm for a client with an abnormal rhythm; a radial pulse would only reveal the heart rate and suggest an arrhythmia. The radial pulse is appropriate for routine postoperative vital sign checks for clients with regular pulses.

Question 3It would be appropriate to delegate the taking of vital signs of which of the following clients to a UAP?

A patient being prepared for elective facial surgery with a history of stable hypertension.A patient receiving a blood transfusion with a history of transfusion reactions.A client recently started on a new antiarrhythmic agent.A patient who is admitted frequently with asthma attacks.

Rationales 3Correct. Vital signs measurement may be delegated to UAP if the client is in stable condition, the findings are expected to be predictable, and the technique requires no modification. Only the preoperative client meets these requirements. This client is unstable and vital signs measurement cannot be delegated.In addition to the client being unstable, UAP are not delegated to take apical pulse measurements for the client with an irregular pulse as would be the case with the client newly started on antiarrhythmic medication.This client is unstable and vital signs measurement cannot be delegated.

Question 4A nursing diagnosis of Ineffective Peripheral Tissue Perfusion would be validated by which one of the following:

Bounding radial pulseIrregular apical pulseCarotid pulse stronger on the left side than the rightAbsent posterior tibial and pedal pulses

Rationales 4Abounding radial pulse is more indicative that perfusion exists.Apical pulses are central and not peripheral.Carotid pulses are central and not peripheral.Correct. The posterior tibial and pedal pulses in the foot are considered peripheral and at least one of them should be palpable in normal individuals.

Question 5The nurse reports that the client has dyspnea when ambulating. The nurse is most likely to have assessed which of the following?

Shallow respirationsWheezingShortness of breathCoughing up blood

Rationales 5Shallow respirations are seen in tachypnea (rapid breathing).Wheezing is a high-pitched breathing sound that may or may not occur with dyspnea.Correct. Dyspnea, difficult or labored breathing, is commonly related to inadequate oxygenation. Therefore, the client is likely to experience shortness of breath, that is, a sense that none of the breaths provide enough oxygen and an immediate second breath is needed. The medical term for coughing up blood is hemoptysis and is unrelated to dyspnea.

Vital SignsMonitor functions of the bodyShould be a thoughtful, scientific assessment

When to Assess Vital SignsOn admissionChange in clients health statusClient reports symptoms such as chest pain, feeling hot, or faintPre and post surgery/invasive procedurePre and post medication administration that could affect CV systemPre and post nursing intervention that could affect vital signs

Factors Affecting Body Temperature AgeDiurnal variations (circadian rhythms)ExerciseHormonesStressEnvironment

Factors Affecting Pulse AgeGenderExerciseFeverMedicationsHypovolemiaStressPosition changesPathology

Factors Affecting Respirations ExerciseStressEnvironmental temperatureMedications

Factors Affecting Blood Pressure AgeExerciseStressRaceGenderMedicationsObesityDiurnal variationsDisease process

Temperature: Lifespan Considerations

Pulse: LifespanConsiderations

Respirations:Lifespan Considerations

Blood Pressure:Lifespan Considerations

Sites for Measuring Body Temperature OralRectalAxillaryTympanic membrane Skin/Temporal artery

Types of Thermometers ElectronicChemical disposableInfrared (tympanic)Scanning infrared (temporal artery)Temperature-sensitive tapeGlass mercury

Nursing Care for Fever Monitor vital signsAssess skin color and temperatureMonitor laboratory results for signs of dehydration or infectionRemove excess blankets when the client feels warm Provide adequate nutrition and fluidMeasure intake and outputReduce physical activity Administer antipyretic as orderedProvide oral hygiene Provide a tepid sponge bath Provide dry clothing and bed linens

Nursing Care for Hypothermia Provide warm environmentProvide dry clothingApply warm blanketsKeep limbs close to bodyCover the clients scalp Supply warm oral or intravenous fluidsApply warming pads

Pulse Sites

Pulse Sites

Characteristics of the PulseRateRhythmVolumeArterial wall elasticityBilateral equality

Pulse Rate and RhythmRateBeats per minuteTachycardiaBradycardia

RhythmEquality of beats and intervals between beatsDysrhythmiasArrhythmia

Characteristics of the Pulse VolumeStrength or amplitudeAbsent to boundingArterial wall elasticityExpansibility or deformityPresence or absence of bilateral equality Compare corresponding artery

Measuring Apical Pulse

Apical-Radial PulseLocate apical and radial sitesTwo nurse method:Decide on starting timeNurse counting radial says startBoth count for 60 seconds Nurse counting radial says stopRadial can never be greater than apical

InhalationDiaphragm contracts (flattens)Ribs move upward and outwardSternum moves outwardEnlarging the size of the thorax

ExhalationDiaphragm relaxesRibs move downward and inwardSternum moves inwardDecreasing the size of the thorax

Respiratory Control MechanismsRespiratory centersMedulla oblongataPons ChemoreceptorsMedullaCarotid and aortic bodiesBoth respond to O2, CO2, H+ in arterial blood

Components of Respiratory AssessmentRateDepthRhythmQualityEffectiveness

Respiratory Rate and DepthRateBreaths per minuteEupneaBradypneaTachypnea

DepthNormalDeepShallow

Components of Respiratory AssessmentRhythmRegularIrregularQuality EffortSoundsEffectivenessUptake and transport of O2Transport and elimination of CO2

Systolic and Diastolic Blood PressureSystolic Contraction of the ventriclesDiastolic Ventricles are at restLower pressure present at all timesPulse Pressure = difference between systolic and diastolic pressuresMeasured in mm HgRecorded as a fraction, e.g. 120/80Systolic = 120 and Diastolic = 80

Korotkoffs Sounds

Korotkoffs Sounds Phase 1First faint, clear tapping or thumping soundsSystolic pressurePhase 2Muffled, whooshing, or swishing sound

Korotkoffs Sounds Phase 3Blood flows freely Crisper and more intense soundThumping quality but softer than in phase 1Phase 4Muffled and have a soft, blowing soundPhase 5Pressure level when the last sound is heardPeriod of silence Diastolic pressure

Measuring Blood Pressure Direct (Invasive Monitoring) IndirectAuscultatory Palpatory SitesUpper arm (brachial artery)Thigh (popliteal artery)

Pulse Oximetry

Pulse Oximetry NoninvasiveEstimates arterial blood oxygen saturation (SpO2)Normal SpO2 85-100%; < 70% life threatening Detects hypoxemia before clinical signs and symptomsSensor, photodetector, pulse oximeter unit

Pulse OximetryFactors that affect accuracy include:Hemoglobin levelCirculationActivityCarbon monoxide poisoning

Pulse Oximetry See Skill 29-7Prepare siteAlign LED and photodetectorConnect and set alarmsEnsure client safetyEnsure accuracy

Delegation of Measurement of Vital SignsGeneral considerations prior to delegationNurse assesses to determine stability of clientMeasurement is considered to be routineInterpretation rests with the nurse

Delegating to UAPBody temperatureRoutine measurement may be delegated to UAP UAP reports abnormal temperaturesNurse interprets abnormal temperature and determines response

Delegation to UAPPulseRadial or brachial pulse may be delegated to UAPNurse interprets abnormal rates or rhythms and determines responseUAP are generally not responsible for assessing apical or one person apical-radial pulses

Delegating to UAPRespirationsCounting and observing respirations may be delegated to UAPNurse interprets abnormal respirations and determines response

Delegation to UAPBlood pressureMay be delegated to UAPNurse interprets abnormal readings and determines responseOxygen saturationApplication of the pulse oximeter sensor and recording the Sp02 may be delegated to UAPNurse interprets oxygen saturation value and determines response

Post TestUse your clickers to complete the following post test.

Question 1The clients temperature at 8:00 AM using an oral electronic thermometer is 36.1C (97.2F). If the respiration, pulse, and blood pressure are within normal range, what would the nurse do next?

Wait 15 minutes and retake it.Check what the clients temperature was the last time.Retake it using a different thermometer.Chart the temperature; it is normal.

Rationales 1Depending on that finding, you might want to retake it in a few minutes (no need to wait 15 minutes).Correct. Although the temperature is slightly lower than expected for the morning, it would be best to determine the clients previous temperature range next. This may be a normal range for this client.There is no need to take temperature again with another thermometer to see if the initial thermometer was functioning properly. Chart after determining that the temperature has been measured properly.

Question 2Which of the following clients meets the criteria for selection of the apical site for assessment of the pulse rather than a radial pulse?

A client is in shockThe pulse changes with body position changesA client with an arrhythmiaIt is less than 24 hours since a client's surgical operation

Rationales 2For clients in shock, use the carotid or femoral pulse.The radial pulse is adequate for determining change in orthostatic heart rate.Correct. The apical rate would confirm the rate and determine the actual cardiac rhythm for a client with an abnormal rhythm; a radial pulse would only reveal the heart rate and suggest an arrhythmia. The radial pulse is appropriate for routine postoperative vital sign checks for clients with regular pulses.

Question 3It would be appropriate to delegate the taking of vital signs of which of the following clients to a UAP?

A patient being prepared for elective facial surgery with a history of stable hypertension.A patient receiving a blood transfusion with a history of transfusion reactions.A client recently started on a new antiarrhythmic agent.A patient who is admitted frequently with asthma attacks.

Rationales 3Correct. Vital signs measurement may be delegated to UAP if the client is in stable condition, the findings are expected to be predictable, and the technique requires no modification. Only the preoperative client meets these requirements. This client is unstable and vital signs measurement cannot be delegated.In addition to the client being unstable, UAP are not delegated to take apical pulse measurements for the client with an irregular pulse as would be the case with the client newly started on antiarrhythmic medication.This client is unstable and vital signs measurement cannot be delegated.

Question 4A nursing diagnosis of Ineffective Peripheral Tissue Perfusion would be validated by which one of the following:

Bounding radial pulseIrregular apical pulseCarotid pulse stronger on the left side than the rightAbsent posterior tibial and pedal pulses

Rationales 4Abounding radial pulse is more indicative that perfusion exists.Apical pulses are central and not peripheral.Carotid pulses are central and not peripheral.Correct. The posterior tibial and pedal pulses in the foot are considered peripheral and at least one of them should be palpable in normal individuals.

Question 5The nurse reports that the client has dyspnea when ambulating. The nurse is most likely to have assessed which of the following?

Shallow respirationsWheezingShortness of breathCoughing up blood

Rationales 5Shallow respirations are seen in tachypnea (rapid breathing).Wheezing is a high-pitched breathing sound that may or may not occur with dyspnea.Correct. Dyspnea, difficult or labored breathing, is commonly related to inadequate oxygenation. Therefore, the client is likely to experience shortness of breath, that is, a sense that none of the breaths provide enough oxygen and an immediate second breath is needed. The medical term for coughing up blood is hemoptysis and is unrelated to dyspnea.

ResourcesAudio GlossaryHyperHEART Shows the heart pumping and talks about diastolic and systolic cycles. Has tutorials for atrial systole and others. Very fun site.Best Practice--Vital Signs Reviews research studies related to vital signs. Covers all aspects of vital signs and even gives implications for practice and recommendations. The Medical Center--Vital Signs Provides an overview of vital signs. Nicely done.

ResourcesThe National Women's Health Information Center Good overview of blood pressure, especially high blood pressure, and its effects on women.MEDLINEplus--Blood Pressure Describes blood pressure in detailMEDLINEplus--Pulse Describes pulse in detailMEDLINEplus--Temperature measurements Describes temperatures in detailA Practical Guide to Clinical Medicine--Vital Signs An in-depth look at vital signs. Has graphic pictures to explain vital signs.

Figure 29-1 Estimated ranges of body temperatures in normal persons.Oral thermometer placement.Inserting a rectal thermometer.Placing the thermometer in the center of the axilla.Inserting the tympanic thermometer.Positioning a temporal artery thermometer.Second intercostal space. Third intercostal space. Fifth intercostal space, MCL.A stethoscope with both a bell-shaped and flat-disc amplifier. Close-up of a flat-disc amplifier (left) and a bell amplifier (right). Taking an apical pulse using the flat disc of the stethoscope. Note how the amplifier is held against the chest.Figure 29-15 Respiratory inhalation - anterior view.Figure 29-16 Respiratory exhalation - anterior view.Figure 29-22 Korotkoffs sounds can be differentiated into five phases. In the illustration the blood pressure is 138/90 or 138/102/90.Figure 29-21 Determining that the bladder of a blood pressure cuff is 40% of the arm circumference or 20% wider than the diameter of the midpoint of the limb.Figure 29-24 Fingertip oximeter sensor (adult).