Chapter

29

Vital Signs

Kozier & Erb's Fundamentals of Nursing, 8e Berman, Snyder, Kozier, Erb Copyright 2008 by Pearson Education, Inc.

Learning Outcomes
1. 2. Describe 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.
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3. 4. 5. 6. 7.

Learning Outcomes
8. 9. 10. 11. 12. 13. 14. Describe 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 Korotkoff¶s 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.
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Pretest
‡ Use your clickers to complete the following pretest.

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Question 1
The client¶s temperature at 8:00 AM using an oral electronic thermometer is 36.1°C (97.2°F). If the respiration, pulse, and blood pressure are within normal range, what would the nurse do next? 1. Wait 15 minutes and retake it. 2. Check what the client¶s temperature was the last time. 3. Retake it using a different thermometer. 4. Chart the temperature; it is normal.
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Rationales 1
1. 2. Depending 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 client¶s 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.

3.

4.

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Question 2
Which of the following clients meets the criteria for selection of the apical site for assessment of the pulse rather than a radial pulse? 1. 2. 3. 4. A client is in shock The pulse changes with body position changes A client with an arrhythmia It is less than 24 hours since a client's surgical operation
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Rationales 2
1. For clients in shock, use the carotid or femoral pulse. 2. The radial pulse is adequate for determining change in orthostatic heart rate. 3. 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. 4. The radial pulse is appropriate for routine postoperative vital sign checks for clients with regular pulses. Copyright 2008 by Pearson Education, Inc.

Question 3
It would be appropriate to delegate the taking of vital signs of which of the following clients to a UAP? 1. 2. 3. 4. 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.

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Rationales 3
1. Correct. 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.

2. 3.

4.

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Question 4
A nursing diagnosis of Ineffective Peripheral Tissue Perfusion would be validated by which one of the following: 1. Bounding radial pulse 2. Irregular apical pulse 3. Carotid pulse stronger on the left side than the right 4. Absent posterior tibial and pedal pulses
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Rationales 4
1. Abounding radial pulse is more indicative that perfusion exists. 2. Apical pulses are central and not peripheral. 3. Carotid pulses are central and not peripheral. 4. 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.

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Question 5
The nurse reports that the client has dyspnea when ambulating. The nurse is most likely to have assessed which of the following?
1. 2. 3. 4. Shallow respirations Wheezing Shortness of breath Coughing up blood
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Rationales 5
1. 2. 3. Shallow 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.
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4.

Vital Signs
‡ Monitor functions of the body ‡ Should be a thoughtful, scientific assessment

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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
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Factors Affecting Body Temperature
‡ Age ‡ Diurnal variations (circadian rhythms) ‡ Exercise ‡ Hormones ‡ Stress ‡ Environment
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Factors Affecting Pulse
‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Age Gender Exercise Fever Medications Hypovolemia Stress Position changes Pathology
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Factors Affecting Respirations
‡ ‡ ‡ ‡ Exercise Stress Environmental temperature Medications

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Factors Affecting Blood Pressure
‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Age Exercise Stress Race Gender Medications Obesity Diurnal variations Disease process
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Temperature: Lifespan Considerations
Infants Unstable Newborns must be kept warm to prevent hypothermia Tympanic or temporal artery sites preferred Tends to be lower than that of middle-aged adults

Children

Elders

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Pulse: Lifespan Considerations
Infants Children
Newborns may have heart murmurs that are not pathological 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 Often have decreased peripheral circulation

Elders

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Respirations: Lifespan Considerations
Infants Some newborns display ³periodic breathing´ Diaphragmatic breathers

Children

Elders

Anatomic and physiologic changes cause respiratory system to be less efficient
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Blood Pressure: Lifespan Considerations
Infants Arm and thigh pressures are equivalent under 1 year of age Thigh pressure is 10 mm Hg higher than arm Client¶s medication may affect how pressure is taken

Children

Elders

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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 ‡ 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

‡

‡

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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 Temporal Carotid Apical
Readily accessible When radial pulse is not accessible During cardiac arrest/shock in adults Determine circulation to the brain 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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Characteristics of the Pulse
‡ ‡ ‡ ‡ ‡ Rate Rhythm Volume Arterial wall elasticity Bilateral equality

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Pulse Rate and Rhythm
‡ Rate
± Beats per minute ± Tachycardia ± Bradycardia

‡ Rhythm
± Equality of beats and intervals between 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 ³start´ ± Both count for 60 seconds ± Nurse counting radial says ³stop´ ± 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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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
± ± ± ± Breaths per minute Eupnea Bradypnea Tachypnea

‡ Depth
± Normal ± Deep ± Shallow

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Components of Respiratory Assessment
‡ Rhythm
± Regular ± Irregular

‡ Effectiveness
± Uptake and transport of O2 ± Transport and elimination of CO2

‡ Quality
± Effort ± Sounds

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Systolic and Diastolic Blood Pressure
‡ Systolic
± Contraction of the ventricles

‡ Diastolic
± Ventricles are at rest ± Lower pressure present at all times

‡ Measured in mm Hg ‡ Recorded as a fraction, e.g. 120/80 ‡ Systolic = 120 and Diastolic = 80

‡ Pulse Pressure = difference between systolic and diastolic pressures
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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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Delegating to UAP
‡ Body temperature
± Routine measurement may be delegated to UAP ± UAP reports abnormal temperatures ± Nurse interprets abnormal temperature and determines response

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Delegation to UAP
‡ Pulse
± Radial or brachial pulse may be delegated to UAP ± Nurse interprets abnormal rates or rhythms and determines response ± UAP are generally not responsible for assessing apical or one person apical-radial pulses

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Delegating to UAP
‡ Respirations
± Counting and observing respirations may be delegated to UAP ± Nurse interprets abnormal respirations and determines response

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Delegation to UAP
‡ Blood pressure
± May be delegated to UAP ± Nurse interprets abnormal readings and determines response

‡ Oxygen saturation
± Application of the pulse oximeter sensor and recording the Sp02 may be delegated to UAP ± Nurse interprets oxygen saturation value and determines response
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Post Test
‡ Use your clickers to complete the following post test.

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Question 1
The client¶s temperature at 8:00 AM using an oral electronic thermometer is 36.1°C (97.2°F). If the respiration, pulse, and blood pressure are within normal range, what would the nurse do next? 1. Wait 15 minutes and retake it. 2. Check what the client¶s temperature was the last time. 3. Retake it using a different thermometer. 4. Chart the temperature; it is normal.
Copyright 2008 by Pearson Education, Inc.

Rationales 1
1. 2. Depending 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 client¶s 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.

3.

4.

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Question 2
Which of the following clients meets the criteria for selection of the apical site for assessment of the pulse rather than a radial pulse? 1. 2. 3. 4. A client is in shock The pulse changes with body position changes A client with an arrhythmia It is less than 24 hours since a client's surgical operation
Copyright 2008 by Pearson Education, Inc.

Rationales 2
1. For clients in shock, use the carotid or femoral pulse. 2. The radial pulse is adequate for determining change in orthostatic heart rate. 3. 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. 4. The radial pulse is appropriate for routine postoperative vital sign checks for clients with regular pulses. Copyright 2008 by Pearson Education, Inc.

Question 3
It would be appropriate to delegate the taking of vital signs of which of the following clients to a UAP? 1. 2. 3. 4. 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.

Copyright 2008 by Pearson Education, Inc.

Rationales 3
1. Correct. 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.

2. 3.

4.

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Question 4
A nursing diagnosis of Ineffective Peripheral Tissue Perfusion would be validated by which one of the following: 1. Bounding radial pulse 2. Irregular apical pulse 3. Carotid pulse stronger on the left side than the right 4. Absent posterior tibial and pedal pulses
Copyright 2008 by Pearson Education, Inc.

Rationales 4
1. Abounding radial pulse is more indicative that perfusion exists. 2. Apical pulses are central and not peripheral. 3. Carotid pulses are central and not peripheral. 4. 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.

Copyright 2008 by Pearson Education, Inc.

Question 5
The nurse reports that the client has dyspnea when ambulating. The nurse is most likely to have assessed which of the following?
1. 2. 3. 4. Shallow respirations Wheezing Shortness of breath Coughing up blood
Copyright 2008 by Pearson Education, Inc.

Rationales 5
1. 2. 3. Shallow 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.
Copyright 2008 by Pearson Education, Inc.

4.

Resources
‡ Audio Glossary ‡ HyperHEART 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.
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Resources
‡ The 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 detail MEDLINEplus--Pulse Describes pulse in detail MEDLINEplus--Temperature measurements Describes temperatures in detail A Practical Guide to Clinical Medicine--Vital Signs An in-depth look at vital signs. Has graphic pictures to explain vital signs.

‡ ‡ ‡ ‡

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