Vital Signs: Five Components of Vital Signs



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CSI 101 Skills Lab # 3

Vital Signs Notes



Vital Signs:
Five Components of Vital Signs:

1. Temperature: Normal Ranges (36o– 38oC)

2. Pulse: 60-100/min

3. Respirations: 12-20/min

4. Blood Pressure: 120/80 mmHg

5. Pain Assessment: Numerical, Descriptive & Visual


Body Temperature:

Oral

37o C

Rectal

37.5oC

Axilla

36.5oC

Tympanic

37oC

Healthy individual body temperature deviates from 36-38o C. Cells, tissues and organs function best at these temperatures. Normal body temperature is 37o C. The bodies temperature is regulated by the anterior hypothalamus (protecting from hyperthermia) and posterior hypothalamus (protecting from hypothermia).


Factors Influencing Body Temperature:

Hypothermia: decrease metabolic rate, inadequate clothing, cold environment,

drug / alcohol consumption, inactivity, aging.

Hyperthermia: increase metabolic rate, inappropriate clothing, hot environment, inability

to perspire, medications, infectious process, exercise.
Increased body metabolism and metabolic activity accompany elevations in body temperature and may be as high as 10 –13 percent for each 1oC. Increased metabolic demand results in a increase in oxygen consumption.
Pulse and respirations: increase in pulse 10-15 beats/min. with each 1oC. Respiratory rate is increased due to the increase in oxygen demand.
Pulse:


Infant

120-160/min

Toddler

90-140/min

Adult

60-100/min



To calculate Maximum Heart Rate: 220 – age = _______ (Ex: 220 – 26 = 194)
Pulse sites: Temporal, Carotid, Brachial, Radial, femoral and Apical (for infants).

Pulse rate: count for 15 seconds and multiply by 4.
The quality of arterial pulsation indicates cardiac workload and cardiac efficiency. (Assessment of Peripheral Vascular Resistance)
Factors Influencing Pulse Rate:



Increase

Decrease


Exercise

short-term

trained athletes

Temperature

fever & heat

hypothermia

Emotions

pain, anxiety

severe pain

Drugs

+ chronotropic (epi)

- chronotropic (digitalis)

Hemorrhage

loss of blood




Quality of the pulse is assessed and may be noted on a point scale:

3+ - bounding – increase stroke volume

2+ - normal

1+ - weak thready – decrease stroke volume

O – absences


Respirations:

New Born

35-40/min

Child

20-30/min

Adult

12-20/min


Factors Influencing Respiratory Rate:




Increase

Decrease

Exercise

rate & depth




Acute pain

rate & depth




Anxiety

rate & depth




Smoking

rate




Narcotic




rate & depth

Tachypnea – increased respiratory rate. > 24/min.

Bradypnea - < 10/min. (depression of respiratory center – drugs, brain injury)

Apnea – total cessation of breathing

Dyspnea – difficult, labored, or painful breathing (air hungry), rapid, shallow breathing -pain, SOB, Hypoxemia
Blood Pressure:

Arterial blood pressure is an important parameter of the cardiovascular system and the status of fluid balance. Blood pressure has two components: systolic and diastolic.


Systolic pressure: the max pressure exerted on the arteries with the left ventricular systole.

Diastolic pressure: the elastic recoil pressure constantly present on the arterial walls.
Pulse pressure: the difference between the systolic and diastolic pressure.
Mean Blood Pressure = Diastolic + 1/3 (Pulse Pressure)

Blood pressure is a product of the cardiac output (Stroke Volume x Heart Rate) times the impedance to blood flow through the vessels, or peripheral vascular resistance. Factors that increase either the cardiac output or the vascular resistance will increase pressure.


Normal BP:

Age


Blood Pressure (mmHg)

New Born

40 (mean)

1 year

95/65

6 year

105/65

14-17 yrs

120/75

Adult

120/80



Peds:

Minimum systolic blood pressure (SBP) = 70 mmHg + (2 x age in years)


Classification of BP:




Systolic (mmHg)

Diastolic (mmHg)

Normal

<120

<80

Prehypertension

120 -139

80 - 89

Hypertension, Stage 1

140 - 159

90 - 99

Hypertension, Stage 2

> 160

> 100

7th Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of high Blood Pressure. (May 2003)

Orthostatic Hypotension: fall in systolic BP 25 mmHg and 10 mmHg accompanied by sign and symptoms.


Factors Influencing Blood Pressure:




Increase

Decrease

Pain

X




Sepsis




X

Anxiety

X




Smoking

X




Narcotics




X

Blood Loss




X



Contraindications:

  1. If the arm has intravenous fluid infusing. c. Same side of radical mastectomy

  2. Arm injured or diseased d. Arm has a shunt / fistula for renal

dialysis

Errors in BP Measurements:

High Readings: Low Readings:

1 - Inappropriate cuff size. 1 - Arm above level of heart.

2 - Wrapping cuff too loosely 2 - Failure to notice an ausculatory gap.

3 - After meals, smoking, bladder distended. 3 – Inability to hear sounds.

4 - Deflating the cuff to slowly.
Pain Scale: 3 Types
Pain is subject to an individual’s interpretation. Pain scale assessment allows the medical team to comfort and meet the needs of the individual. The individual reads the scale and chooses a word to describe the intensity of their pain. After identifying the level of pain rating that is comfortable for the individual, the medical team will ensure the pain management is effective. Two ways to manage pain: Drug therapy and Non-drug techniques (Slow Rhythmic Breathing).

1. Numerical ____________________________________________________________ 0 1 2 3 4 5 6 7 8 9 10 No Pain Severe

Pain
2. Descriptive ___________________________________________________________

No Pain Mild Moderate Severe Unbearable

Pain Pain Pain Pain



3. Visual (Nonverbal and Children)


Reference:



Potter Perry: Fundamentals of Nursing, Chapter 32: Vital Signs; Fourth edition, Mosby 1997.




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