Vital Signs

Measurements of
physiologic functioning,
specifically body
temperature, pulse,
respirations, and blood
pressure; may include pain
and pulse oximetry
 When to Assess Vital Signs
On admission
Change in client’s health status
Client reports symptoms such as chest
pain, feeling hot, or faint
Pre and post surgery/invasive
procedure
Pre and post medication administration
that could affect CV system
Pre and post nursing intervention that
could affect vital signs
Body Temperature
 Two kinds of body temperature
Core temperature – temperature on deep
tissue on the body, such as abdominal
cavity an pelvic cavity
 Surface temperature – temperature of the
skin, subcutaneous tissue and fat; rises and
falls in response to the environment
 Thermoregulation center
Hypothalamus
 Alterations in body temperature
Pyrexia, hyperthermia, Fever (in lay terms)
○ a body temperature above the usual range
○ A client who has fever is referred to as febrile,
the one who has not is afebrile.
Hyperpyrexia
○ A very high fever such as 41 oC (105.8 OF)
 Four Common types of fever
Intermittent – alternates at regular interval – periods
of fever and periods of normal (malaria)
Remittent – a wide range of temperature fluctuations
occurs over 24 hour period (colds, influenza)
Relapsing – short febrile episodes of few days,
interspersed – 1 to 2 days of normal temp.
Constant - fluctuates minimally; always remain in
above normal (typhoid fever)

○ Fever spike – temp. rises to fever rapidly following a

normal temp and then returns to normal within few
hours.
Temperature: Lifespan Considerations
Infants Unstable
Newborns must be kept warm to
prevent hypothermia
Children Tympanic or temporal artery sites
preferred

Elders Tends to be lower than that of

middle-aged adults

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Sites for Measuring
Body Temperature
 Oral
 Rectal
 Axillary
 Tympanic membrane
 Skin/Temporal artery

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Types of Thermometers

 Electronic
 Chemical disposable
 Infrared (tympanic)
 Scanning infrared (temporal artery)
 Temperature-sensitive tape
 Glass mercury

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Nursing Care for Fever
 Monitor vital signs
 Assess skin color
and temperature
 Monitor laboratory
results for signs of
dehydration or
infection
 Remove excess
blankets when the
client feels warm
 Provide adequate
nutrition and fluid
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 Measure intake and
output
 Reduce physical
activity
 Administer antipyretic
as ordered
 Provide oral hygiene
 Provide a tepid
sponge bath
 Provide dry clothing
and bed linens
Nursing Care for Hypothermia
 Provide warm environment
 Provide dry clothing
 Apply warm blankets
 Keep limbs close to body
 Cover the client’s scalp
 Supply warm oral or intravenous fluids
 Apply warming pads

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Pulse Sites
Radial Readily accessible

Temporal When radial pulse is not accessible

Carotid During cardiac arrest/shock in adults

Determine circulation to the brain
Apical Infants and children up to 3 years of age
Discrepancies with radial pulse
Monitor some medications

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Pulse Sites
Brachial Blood pressure
Cardiac arrest in infants

Femoral Cardiac arrest/shock

Circulation to a leg;
Popliteal Circulation to lower leg
Posterior tibial Circulation to the foot
Dorsalis pedis Circulation to the foot

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Factors Affecting
Pulse
 Age
 Gender
 Exercise
 Fever
 Medications
 Hypovolemia
 Stress
 Position changes
 Pathology

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Pulse: Lifespan
Considerations
Infants Newborns may have heart murmurs that
are not pathological

Children The apex of the heart is normally

located in the fourth intercostal space in
young children; fifth intercostal space
in children 7 years old and older

Elders Often have decreased peripheral

circulation

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Characteristics of the Pulse
 Rate
 Rhythm
 Volume
 Arterial wall elasticity
 Bilateral equality

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Pulse Rate and Rhythm
 Rate  Rhythm
 Beats per minute  Equality of beats and
 Tachycardia intervals between
 Bradycardia beats
 Dysrhythmias
 Arrhythmia

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Characteristics of the Pulse
 Volume
Strength or amplitude
Absent to bounding
 Arterial wall elasticity
Expansibility or deformity
 Presence or absence of bilateral
equality
Compare corresponding artery

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Measuring Apical Pulse

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Apical-Radial Pulse
 Locate apical and radial sites
 Two nurse method:
Decide on starting time
Nurse counting radial says “start”
Both count for 60 seconds
Nurse counting radial says “stop”
Radial can never be greater than apical

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Inhalation
 Diaphragm contracts
(flattens)
 Ribs move upward
and outward
 Sternum moves
outward
 Enlarging the size of
the thorax

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Exhalation
 Diaphragm relaxes
 Ribs move downward
and inward
 Sternum moves
inward
 Decreasing the size
of the thorax

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Respirations:
Lifespan Considerations
Infants Some newborns display “periodic
breathing”

Children Diaphragmatic breathers

Elders Anatomic and physiologic changes

cause respiratory system to be less
efficient

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 Respiratory Control Mechanisms
 Respiratory centers
Medulla oblongata
Pons
 Chemoreceptors
Medulla
Carotid and aortic bodies
 Both respond to O2, CO2, H+ in arterial
blood

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Components of Respiratory Assessment

 Rate
 Depth
 Rhythm
 Quality
 Effectiveness

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Respiratory Rate and Depth
 Rate  Depth
 Breaths per minute  Normal
 Eupnea  Deep
 Bradypnea  Shallow
 Tachypnea

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Components of Respiratory Assessment
 Rhythm  Effectiveness
 Regular  Uptake and transport of
 Irregular O2
 Transport and
 Quality
elimination of CO2
 Effort
 CO2 Major Chemical
 Sounds
Stimuli for respirations
 Hypoxemia or Hypoxia
 Hyperventilation
 Hypoventilation

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Systolic and Diastolic Blood Pressure
 Systolic  Measured in mm Hg
 Contraction of the  Recorded as a
ventricles fraction, e.g. 120/80
 Diastolic  Systolic = 120 and
 Ventricles are at rest
Diastolic = 80
 Lower pressure
present at all times
 Pulse Pressure =
difference between
systolic and diastolic
pressures

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Blood Pressure:
Lifespan Considerations
Infants Arm and thigh pressures are
equivalent under 1 year of age

Children Thigh pressure is 10 mm Hg higher

than arm

Elders Client’s medication may affect how

pressure is taken

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Korotkoff’s Sounds

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Korotkoff’s Sounds
 Phase 1
First faint, clear tapping or thumping sounds
Systolic pressure
 Phase 2
Muffled, whooshing, or swishing sound

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Korotkoff’s Sounds
 Phase 3
Blood flows freely
Crisper and more intense sound
Thumping quality but softer than in phase 1
 Phase 4
Muffled and have a soft, blowing sound
 Phase 5
Pressure level when the last sound is heard
Period of silence
Diastolic pressure

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Measuring Blood Pressure
 Direct (Invasive Monitoring)
 Indirect
Auscultatory
Palpatory
 Sites
Upper arm (brachial artery)
Thigh (popliteal artery)

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Pulse Oximetry

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

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Pulse Oximetry
 Factors that affect accuracy include:
Hemoglobin level
Circulation
Activity
Carbon monoxide poisoning

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Pulse Oximetry
 See Skill 29-7
 Prepare site
 Align LED and photodetector
 Connect and set alarms
 Ensure client safety
 Ensure accuracy

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Delegation of Measurement
of Vital Signs
 General considerations prior to
delegation
Nurse assesses to determine stability of
client
Measurement is considered to be routine
Interpretation rests with the nurse

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Documentation of Plan of
Care/Reporting
 Documenting
A process of making entry on a client
record; also know as recording, or charting.
Clinical record, also called a chart or client
record, is a formal, legal documents that
provides evidence of a client’s care.
Ethical and Legal Considerations
 The nurse has a duty to maintain
confidentiality of all patient information
(American N urses Association Code of
Ethics 2001)
 Clients record if protected legally as private
record of the clients care
 Access to the record is restricted to health
professionals involved in giving care to the
client.
 The institution, agency, or hospital is the
rightful owner of the clients record.
Purposes of client Records
 Purpose is for education and research
 Students and graduate health
professionals are allowed to access to
the clients record.
 The records are used in client
conferences, clinics, rounds, clients
studies, and written papers.
 Purposes :
Communication – serves as the vehicle
Planning Client Care – baseline and ongoing data to
evaluate the effectiveness of the NCP.
Auditing Health Agencies – review of client records for
quality assurance
Research – information contained in record can be a
valuable source of data for research.
Education – provide comprehensive view of the client,
illness, effective treatment strategies.
Reimbursement – to facilitates payment from the
federal government and other insurance companies.
Legal Documentation – admissible in court as evidence;
order from the court – “ Subpoena Ducestecum ”
Health Care Analysis – health care planners to identify
agencies needs.
Documentation System
 Source-Oriented Record – traditional
client record – different department or
persons makes notations in a separate
sections – narrative charting.
 Problem Oriented Medical Record
(POMR) – data arranged according to
problems
Four basic components – database,
problem list, plan of care, progress notes.
 Source-oriented Records
 Traditional client record
 Each discipline makes notations in a
separate section
 Information about a particular problem
distributed throughout the record
 Narrative charting used

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 Problem-oriented Medical Records
(POMR)
 Data arranged according to client problem
 Health team contributes to the problem list,
plan of care, and progress notes for each
problem
 Uses SOAP, SOAPIE, SOAPIER
documentation
 Encourages collaboration
 Easier to track status of problems
 Vigilance required to maintain problem list
 Less efficient documentation process

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PIE Documentation
 Groups information into three
categories: Problem, Interventions,
Evaluation
 Consists of client assessment, flow
sheet, and progress notes

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Focus Charting
 Focus on client concerns and strengths
 Progress notes organized into DAR
format
 Holistic perspective of client and client’s
needs
 Nursing process framework for the
progress notes

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Charting by Exception (CBE)
 Incorporates flow sheets, standards of
nursing care, bedside chart forms
 Agencies develop standards of nursing
practice
 Documentation according to standards
involves a check mark
 Exceptions to standards described in
narrative form on nurses’ notes

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Sample Vital Signs Graphic Record

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 Computerized Documentation
 Developed to manage volume of
information
 Use of computers to store the client’s
database, new data, create and revise
care plans and document client’s
progress
 Information easily retrieved
 Possible to transmit information from
one care setting to another

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Computerized Charting

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Legal and Ethical
Standards for Documentation
 Client’s record is a legal document
 May be used to provide evidence in
court

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Factors to Consider
 Timing  Accuracy
 Legibility  Sequence
 Permanence  Appropriateness
 Accepted  Completeness
terminology  Conciseness
 Correct spelling  Legal prudence
 Signature

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Guidelines for Reporting
Client Data
 Should be concise, including pertinent
information but no extraneous detail
 Types of reporting:
Change-of-shift report
Telephone reports
Care plan conference
Nursing rounds

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Guidelines for
Change-of-Shift Report
 Follow a particular order
 Provide basic identifying information
 For new clients provide the reason for
admission or medical diagnosis/es,
surgery, diagnostic tests and therapies
in the past 24 hours
 Significant changes in client’s condition

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Guidelines for
Change-of-Shift Report
 Provide exact information
 Report client’s need for emotional support
 Include current nurse and physical-prescribed
orders
 Provide a summary of newly admitted clients,
including diagnosis, age, general condition, plan of
therapy, and significant information about the
client’s support people
 Report on clients who have been transferred or
discharged
 Clearly state priorities of care and care due after
the shift begins
 Be concise

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Guidelines for Receiving a Telephone
Report
 Document date and time
 Record the name of person giving the
information
 Record the subject of the information
received
 Repeat information to ensure accuracy
 Sign the notation

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Guidelines for Giving a Telephone
Report
 Be concise and accurate
 State name and relationship to client
 State the client’s name, medical diagnosis,
changes in nursing assessment, vital signs
related to baseline, significant laboratory
data, related nursing interventions
 Have chart ready to give any further
information needed
 Document the date, time, and content of
the call

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Guideline for Receiving
Telephone and Verbal Orders
 Know the state nursing board’s position
on who can give and accept
 Know the agency policy
 Ask prescriber to speak slowly and
clearly
 Ask prescriber to spell out the
medication if unfamiliar
 Question the drug, dosage, or changes
if seem inappropriate

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Guideline for Receiving
Telephone and Verbal Orders
 Write the order down or enter into a
computer
 Read the order back to the prescriber
 Use words instead of abbreviations
 Write the order on the physician’s order
sheet, record date, time, indicate it was
a telephone order, and sign name with
credentials

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Guideline for Receiving
Telephone and Verbal Orders
 When writing a dosage always put a
number before a decimal, but never
after a decimal
 Write out units
 Transcribe the order
 Follow agency protocol about signing
the telephone order
 Never follow a voice-mail order

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Prohibited Abbreviations, Acronyms,
and Symbols
 JCAHO National Patient Safety Goals
(2004)
 “Do Not Use” list
 Many banned abbreviations refer to
medications
 Others derived from Latin

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Health and Illness
 Health – presence or absence of
diseases
“A state of complete physical, mental and
social well-being, and not merely the absent
of disease or infirmity. (WHO 1948)
 Wellness – a state of well-being. The
whole being of the individual
 Illness – highly personal state in which
persons holistic views of functioning is
thought to be diminished
 Dimensions of Wellness
 Variables influencing health status
Health status
Health beliefs
Health behaviors/practices
 Internal Variables – non-modifiable variables
Biologic dimension – genetic, gender, age
Psychological dimension (emotional) – mind-body
interactions and self concept
Cognitive dimensions – intellectual factors, lifestyle choices
and spiritual and religious belief.
 External Variables – modifiable, variables affecting
Environment, standards of living, family and cultural beliefs
and social support network.
Dimensions of Wellness

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Physical Dimension

 Ability to carry out daily tasks

 Achieve fitness
 Maintain nutrition
 Avoid abuses

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Social Dimension

 Interact successfully
 Develop and maintain intimacy
 Develop respect and tolerance for others

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Emotional Dimension

 Ability to manage stress

 Ability to express emotion

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Intellectual Dimension

 Ability to learn
 Ability to use information effectively

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Spiritual Dimension

 Belief in some force that serves to unite

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Occupational Dimension

 Ability to achieve balance between work and

leisure

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Environmental Dimension

 Ability to promote health measure that

improves
Standard of living
Quality of life

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Health – Illness Continua
 Grids or graduated scales – used to
measure persons perceived level of
wellness
Dunn’s High Level wellness (environmental
axis)

Travi’s Illness-Wellness Continuum

Health-Illness Continuum
 Measure person’s perceived level of wellness
 Health and illness/disease opposite ends of a health
continuum
 Move back and forth within this continuum day by day
 Wide ranges of health or illness

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Three levels of Prevention
 Prevention – avoiding the development of
diseases in the future.

 Primary Prevention
Health promotion
Protection against specific health problems
Purpose is to decrease the risk or exposure of
individual or community to disease.
○ Example of primary prevention
 Stop smoking, avoid prolong exposure to the sun
 Support antipollution legislation
 Practice safe sex, monogamy, or abstinence
Secondary preventions
 Early identifications of health problems
 Prompt intervention o alleviate health
problems
 Goal is to identify client in an early stage of
disease process and limiting future
disability
Examples:
○ Undergo screening for tuberculosis
○ Have yearly, papinicolaou smears and
mammograms per recommended guidelines .
○ Practice monthly SBE & STE
Tertiary level of prevention
 Focuses on restoration and rehabilitation
 Returning the individual to an optimal level
of functioning.
Examples:
○ Have a speech therapy after stroke
○ Have a complete blood count before
chemotherapy
○ Participate in stroke or coma rehabilitation
○ Substance abuse or drug addict rehabilitation
center.
Levels of Care
 Health Promotion
Behavior motivated by the desire to increase
well being and actualize human health
potential (Pender, Murdaugh, Parsons;
2006)
Not disease oriented
Seeks to expand positive potential for health
 Disease Prevention
Also known as Health protection
Illness of injury specific
Motivated by avoidance of illness
Seeks to thwart the occurrence of insults to health and
well being
 Health Maintenance
Maintaining the current healthy status
 Curative
cures diseases or condition
 Rehabilitative
Assisting clients to restore their health and recuperate
 Health Promotion Model (HPM)
Link to HPM Figure 16-4 pg. 279
 Competence or approach-oriented
model
 Motivational source for behavior
changes based on individual’s
subjective value of the change

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Variables of HPM
 Individual characteristics and experiences
Prior related behaviors
Personal factors
 Behavior-specific cognitions and affect
Perceived benefits of action
Perceived barriers to action
Perceived self-efficacy
Activity-related affect
Interpersonal factors
Situational influences

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 Variables of HPM
 Commitment to a plan of action
 Immediate competing demands and
preferences
 Behavioral outcome

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