Vital SignsModule 1

(Cardinal Signs) abr. V.S.

Includes body temperature, pulse rate, respiratory rate, and blood pressure

• Checked to monitor the functions of the body

• Reflect changes in function that might not be observed.

Frequency may be determined by facility policy, medical or nursing order,

e.g. V.S. q4h (every 4 hours)

This should be considered the minimum however, and should be performed whenever the situation indicates it.

Vital Signs

Normal Values By Age

Age Temp Degrees Celsius

Pulse Average

And Ranges

Respirations

Averages and Ranges

Blood Pressure (mmHg)

Newborns 36.8 (axillary) 130 (80-180) 35 (30-80) 73/55

1-3 years 37.7 (rectal) 120 (80-140) 30 (20-40) 90/55

6-8 years 37 (oral) 100 (75-120) 20 (15-25) 95/57

10 years 37 (oral) 70 (50-90) 19 (15-25) 102/62

Teen years 37 (oral) 70 (50-90) 18 (15-20) 120/80

Adult 37 (oral) 80 (60-100) 16 (12-20) 120/80

Older Adult(>70 )

36 (oral) 80 (60-100) 16 (15-20) Possible incr. Diastolic

Body Temperature and Factors Affecting It

The hypothalamus constantly regulates body temperature to maintain heat balance, through action on effectors such as shivering, sweating, vasoconstriction, vasodilatation, and release of epinephrine

Factors effecting the body’s heat production:•Basal Metabolic Rate (BMR)

•Muscle Activity (increases BMR)

•Thyroxine output, increases cellular metabolism (chemical thermogenesis)

•Epinephrine, norepinephrine, and sympathetic stimulation

•Fever, increases cellular metabolic rate

Factors Affecting Body Temperature

1. Age – infants and >75 years have trouble regulating body temperature

2. Diurnal Variations (Circadian rhythms)3. Exercise or Hard Work (Can increase temp to

38.3 – 40 C)4. Hormones (e.g ovulation)5. Stress- sympathetic nervous system stimulation6. Environment – extremes in temperature7. Disease process

Age Temp Degrees Celsius

Newborns 36.8 (axillary)

1-3 years 37.7 (rectal)

6-8 years 37 (oral)

10 years 37 (oral)

Teen years 37 (oral)

Adult 37 (oral)

Older Adult(>70 )

36 (oral)

Normal Temperature Values

Alterations in Temperature

Pyrexia –Body Temperature above normal (also called hyperthermia or fever)

Hyperpyrexia – Very high fever such as 41C

Afebrile – Normal temperature

Hypothermia – Core body temperature below normal levels

Clinical Signs of FeverOnset (Cold or Chill Stage)

• Increased heart rate

•Increased respiratory rate

•Shivering

•Pallid,. cold skin

•Complaints of feeling cold

•Cyanotic Nail Beds

•Goosebumps

•Cessation of Sweating

Course

• Absence of chills

• Skin that feels warm

• Photosensitivity

• Glassy-eyed appearance

• Increase pulse and resp. rate

• Increased Thirst

• Mild to severe dehydration

• Drowsiness

• Malaise, weakness, and aching muscles

• Loss of appetite

Clinical Signs of Hypothermia

• Decreased body temperature, pulse, and respirations

• Severe shivering (initially)

• Feelings of cold and chills

• Pale, cool waxy skin

• Hypotension

• Decreased urinary output

• Lack of muscle coordination

• Disorientation

• Drowsiness progressing to coma

Ways of Measuring Body Temperature

• Oral Temperature – (36- 38C)• Rectal Temperature -

Approx. 0.5 C Higher• Axillary Temperature –

Approx. 0.5 C Lower• Tympanic Temperature –

Higher than oral• Body Surface Temperature –

Lower than oral

Types of Thermometer

• Mercury in Glass thermometer

• Electronic thermometer

• Tympanic (infrared) thermometer

• Chemical disposable thermometer

• Temperature sensitive tape

Pulse

Wave of blood created by contraction of the left ventricle, generally represents the heart rate in the normal healthy person

Peripheral Pulse – Pulse in the periphery of the body (i.e. arm, leg, foot.

Apical Pulse –Pulse at the apex of the heart

Factors Affecting Pulse Rate

• Age – generally decreases with age

• Sex – After puberty male’s pulse less than female’s

• Exercise – increases with exercise

• Fever – increases in response to peripheral vasodilatation

• Medications – may increase or decrease dependent on med.

• Hemorrhage – increases due to hypovolemia

• Stress – increases due to sympathetic nervous stimulation

• Position Changes – increases with change of body position when sitting or standing

Pulse Sites

Normal Pulse Rates

Age Pulse Average

And Ranges

Newborns 130 (80-180)

1-3 years 120 (80-140)

6-8 years 100 (75-120)

10 years 70 (50-90)

Teen years 70 (50-90)

Adult 80 (60-100)

Older Adult(>70 )

80 (60-100)

Assessment of the PulseRate

• Assess for 30 –60 seconds

• Tachycardia - > Normal (>100 in adult)

• Bradycardia - < Normal (< 60 in adult)

Pulse Rhythm

• Regular – equal time between beats

• Irregular rhythm may be referred to as dysrhythmia or arrhythmia

Assessment of Pulse cont…Pulse Volume

Scale Description of Pulse

0 Absent, not discernable

1 Thready or weak, difficult to feel

2 Normal, detected readily, obliterated by strong pressure

3 Bounding, difficult to obliterate

Elasticity or Arterial Wall

How does it feel, is it pliable. Is it smooth or rough and twisted (tortuous)

Pulse Deficit – Difference between apical and radial pulse

Respiration

Respiration is the act of breathing

Respiration

External Respiration – exchange of oxygen and carbon dioxide between the alveoli of the lungs and the pulmonary blood

Internal Respiration – Interchange of these gases between the blood and the body’s cells

Inhalation or Inspiration – Movement of air into the lungs

Exhalation or Expiration – Breathing the air out of your lungs

Hyperventilation – Rapid deep respirations

Hypoventilation – Shallow respirations

RespirationCostal (Thoracic) Breathing – involves the external inter-costal muscles and accessory muscles such as the sternocleidomastoid muscles, major & minor pectoralis

Diaphragmatic Breathing – involves the contraction and relaxation of the diaphragm

A client’s resting respirations should be assessed for 30 – 60 seconds. A nurse should be aware of:

• The clients normal breathing pattern

• The influence of the clients health problems on respirations

• Any medications or therapies that might affect respirations

• the relationship of client’s respirations to cardiovascular function

Respiration Normal ValuesAge Respirations

Averages and Ranges

Newborns 35 (30-80)

1-3 years 30 (20-40)

6-8 years 20 (15-25)

10 years 19 (15-25)

Teen years 18 (15-20)

Adult 16 (12-20)

Older Adult(>70 )

16 (15-20)

Assessing RespirationsRespiratory Rate

Eupnea – Normal rate and depth

Bradypnea – Abnormally slow

Tachypnea or Polypnea – Abnormally fast

Apnea – Absence of respirations

Depth

•Deep respirations

•Shallow respirations

Depth of respirations can be affected by body position

Assessing Respirations cont…

Respiratory Rhythm or Pattern

• Regular

• Irregular (infants may have less regular rhythm)

Respiratory Quality or Character

• Amount of respiratory effort (e.g. laboured) Dyspnea – difficulty breathing. Orthopnea – ability to breathe only in upright sitting or standing position

• Sound of Breathing (e.g. wheezes, bubbles, stridor, stertor)

• Effectiveness of breathing (O2, CO2 in blood) Can be measured with Pulse Oximeter

Breathing Rhythm and SoundsCheyne-Stokes breathing – rhythmic waxing and wandering of respirations, from very deep to very shallow breathing and temporary apnea; often associated with cadiac failure, increased intercranial pressure, or brain damage.

Stridor – a shrill, harsh sound heard during inspiration with laryngeal obstruction.

Stertor – sonorous respiration, usually due to 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 narrow or partially obstructed airway

Breathing Rhythm and Sounds

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

Kussmauls’s Respiration – Deep rapid breathing; dyspnea occurring in paroxysms often preceding diabetic coma; air hunger

Blood PressureArterial blood pressure is a measurement of the pressure exerted by the blood as it flows through the arteries.

• BP Measured in mmHg (millimeters of Mercury)

• Two blood pressure measures: Systolic and Diastolic expressed and a fraction Systolic/Diastolic (e.g. 120/80)

Systolic Pressure – Pressure resulting from the contraction of the ventricles of the heart (Systole) and is the top of the pressure wave.

Diastolic Pressure – Pressure when the ventricles are at rest (Diastole) and is the lowest pressure present at all times

Pulse Pressure – The difference between the systolic and diastolic pressures

Determinants of Blood Pressure

Several factors determining blood pressure:

• Pumping Action of the Heart (Cardiac Output)

• Peripheral Vascular Resistance

• Blood Volume

• Blood Viscosity

Factors Affecting Blood Pressure• Age : As children get older Blood Pressure increases until after

puberty. Older individuals often have higher Bp due to decreased elasticity of arteries

• Exercise: Generally increases due to increased C.O.• Stress: Increase due to sympathetic stimulation (increased C.O. and

peripheral vasoconstriction• Race: African American males tend to have higher BP• Obesity: Often higher with increasing weight• Sex: Females pre-menopause usually lower than men, but higher post-

menopause due to hormonal influences• Medications: Dependent on medication• Diurnal Variations: lowest BP in the early morning, peaks in late

afternoon or early evening• Disease Process: (e.g. Arteriosclerosis) • Body Position: Lower when lying down. Orthostatic Changes• Caffeine, Nicotine, Excessive Licorice

Normal BP Readings

Age Blood Pressure (mmHg)

Newborns 73/55

1-3 years 90/55

6-8 years 95/57

10 years 102/62

Teen years 120/80

Adult 120/80

Older Adult(>70 )

Possible incr. Diastolic

Abnormal BP Readings

Hypertension – Elevated Blood Pressure Reading (In adults generally > 140/90 Usually diagnosed by 3 elevated readings on separate occasions

Hypotension – Low Blood Pressure. Systolic BP consistently between 85 and 110 mmHg in an Adult

Orthostatic Hypotension – Blood pressure falls when the client sits or stands

Stethoscope, Cuff and Sphygmomanometer

Aneroid

Mercury

BP EquipmentOther BP measuring equipment include:

• Electronic Sphygmomanometers (e.g. Dinamap) Readings often higher

• Doppler Ultrasound Stethoscope

Blood Pressure can be assessed on upper arm, forearm, and thigh (readings on the thigh could be 10-40 mmHg higher than arm)

Various size BP cuffs are available and the appropriate size cuff must be used to take BP.

Cuff width should be 40% of limb circumference (This method should be used rather than age to pick cuff size)

Auscultatory MethodKorotkoff’s Sounds – Sounds heard when auscultating BP and consists of 5 Phases:

Phase 1 – A sharp tapping

Phase 2 – Swishing or whooshing sound

Phase 3 – A thump softer than the tapping is phase 1

Phase 4 – A softer blowing muffled sound that fades

Phase 5 – Silence

Auscultatory Gap – Occurs primarily in hypertensive clients. Temporary disappearance of sounds normally heard, when the cuff pressure is high, with reappearance at a lower level

Palpation Method

Measuring BP by palpating the artery. As pressure is released from the cuff, the first pulsation felt is the Systolic pressure. A single whip-like vibration is felt in addition to the pulsations as the diastolic pressure nears, and the point when the vibration is no longer felt is the diastolic pressure.

Factors Affecting Accuracy of BP• No secondary factors impacting BP for 30 minutes previously

• No Talking, ensure no clothing is rubbing against stethoscope

• Read Mercury sphygmomanometer at eye level (parallax)

• Ensure appropriate cuff size is used (40% of limb circumference)

• Place BP cuff 3 cm above elbow

• Using the bell of the stethoscope is recommended

• If BP repeated too soon inaccurate reading may occur

• If cuff too loose or uneven (false high)

• Failure to identify auscultatory gap