Health Assessment

Chapter 10

Vital Signs

Include temperature, respiratory rate, pulse, and blood pressure

Data that is trended throughout patient experiences in multiple clinical practice settings

Follow stated facility guidelines for monitoring.

Use nursing judgment to warrant additional assessment.

Objective Data: Vital Signs

Vital Signs: Temperature (1 of 3)

Mechanism of regulation

Cellular metabolism requires a stable core, or “deep body,” temperature of a mean of 37.2° C (99° F).

Body maintains steady temperature through feedback mechanism regulated in hypothalamus of brain.

Balances heat production with heat loss

Various routes of temperature measurement reflect body’s core temperature.

Vital Signs: Temperature (2 of 3)

Normal temperature is influenced by the following:

Diurnal cycle of 1° F to 1.5° F, with trough occurring in early morning hours and peak occurring in late afternoon to early evening

Menstruation cycle in women: progesterone secretion, occurring with ovulation at midcycle, causes a 0.5° F to 1.0° F rise in temperature that continues until menses

Exercise: moderate to hard exercise increases body temperature

Age: wider normal variations occur in infant and young child due to less effective heat control mechanisms; in older adults, temperature usually lower than in other age groups, with a mean of 36.2° C (97.2° F)

Vital Signs: Temperature (3 of 3)

Normal temperature readings

Oral temperature accurate and convenient

Oral sublingual site has rich blood supply from carotid arteries that quickly responds to changes in inner core temperature.

Normal oral temperature in a resting person is
37° C (98.6° F), with a range of 35.8° C to 37.3° C (96.4° F to 99.1° F)

Rectal measures 0.4° C to 0.5° C (0.7° F to 1° F) higher

Shake

a mercury-free glass thermometer down to 35.5° C (96° F) and place it at base of tongue in either of posterior sublingual pockets; not in front of tongue.

Instruct

person to keep his or her lips closed.

Leave

in place 3 to 4 minutes if person is afebrile, and up to 8 minutes if febrile; take other vital signs during this time.

Wait

15 minutes if person has just taken hot or iced liquids and 2 minutes if he or she has just smoked.

The Procedure: Oral Temperature

Take

rectal temperature only when other routes are not practical due to clinical presentation.

Wear gloves and insert lubricated

rectal probe cover on an electronic thermometer only 2 to 3 cm (1 in) into adult rectum, directed toward umbilicus.

For a glass thermometer, leave in place for 2½ minutes.

Disadvantages to rectal route are patient discomfort and time-consuming and disruptive nature of activity.

The Procedure: Rectal Temperature

Tympanic membrane thermometer (TMT) senses infrared emissions of tympanic membrane (eardrum).

Tympanic membrane shares same vascular supply that perfuses hypothalamus (internal carotid artery).

Probe tip has shape of otoscope.

Gently place covered probe tip in person’s ear canal; temperature can be read in 2 to 3 seconds.

The Procedure: Temperature Tympanic Membrane (1 of 2)

The Procedure: Temperature Tympanic Membrane (2 of 2)

Tympanic membrane thermometer (TMT)

Minimal chance of cross-contamination with tympanic thermometer because ear canal is lined with skin and not mucous membrane

Used with unconscious patients or with those who are unable or unwilling to cooperate with traditional techniques

Advantages of speed, convenience, safety, reduced risk for injury and infection, and noninvasiveness

Temporal artery thermometer (TAT)

Uses infrared emissions from temporal artery

Sliding probe across forehead

Takes multiple readings and produces average result

Reading takes approximately 6 seconds.

The Procedure: Temporal Artery Thermometer

Temperature Scales

Report temperature in degrees Celsius unless your agency uses Fahrenheit scale.

Report temperature and route

Use this conversion

Degrees C = 5/9 (F − 32)

Degrees F = (9/5 × C) + 32

Familiarize yourself with both scales.

Note it is far easier to learn to think in centigrade scale than to take time for paper-and-pencil conversions.

Vital Signs: Pulse

Pulse: palpable flow felt in the periphery as a result of pressure wave generation from stroke volume

Provides indicator of rate and rhythm of heartbeat as well as local data on condition of artery

Palpation technique

Using pads of the first three fingers, palpate radial pulse at flexor aspect of wrist laterally along radius bone until strongest pulsation is felt.

If rhythm is regular, count number of beats in 30 seconds and multiply by 2.

The 30-second interval is most accurate and efficient when heart rates are normal or rapid and when rhythms are regular.

For irregular pulse, count for full minute.

Assess pulse for rate, rhythm, force, and elasticity.

Heart Rate

In resting adult, normal heart rate range is 60 to 100 beats per minute (bpm).

Rate normally varies with age.

More rapid in infancy and childhood and moderate during adult and older years

Rate also varies with gender; after puberty, females have slightly faster rate than males.

In adult, a heart rate less than 60 bpm is bradycardia.

This occurs normally in well-trained athletes whose heart muscle develops along with skeletal muscles.

Stronger, more efficient heart muscle pushes out a larger stroke volume with each beat, thus requiring fewer beats per minute to maintain a stable cardiac output.

A more rapid heart rate, over 100 bpm, is tachycardia.

Occurs normally with anxiety or with increased exercise to match body’s demand for increased metabolism

Heart Rhythm

Rhythm of pulse normally has a regular, even tempo.

Sinus dysrhythmia: one irregularity commonly found in children and young adults

Heart rate varies with respiratory cycle, speeding up at peak of inspiration and slowing to normal with expiration.

Inspiration momentarily causes a decreased stroke volume from left side of heart.

To compensate, heart rate increases.

If any other irregularities are felt, auscultate heart sounds for a more complete assessment.

Heart Force: Strength of Pulse

Force of pulse is strength of heart’s stroke volume.

Weak, thready pulse reflects a decreased stroke volume (e.g., as occurs with hemorrhagic shock).

Full, bounding pulse denotes increased stroke volume, as with anxiety, exercise, and some abnormal conditions.

Pulse force recorded using three-point scale

3+ Full, bounding

2+ Normal

1+ Weak, thready

0 Absent

Vital Signs: Respirations

Normally person’s breathing is relaxed, regular, automatic, and silent.

Because most people are unaware of their breathing, do not mention that you will be counting respirations, because sudden awareness may alter normal pattern.

Instead, maintain your position of counting radial pulse and unobtrusively count respirations.

Count for 30 seconds or a full minute if you suspect an abnormality.

Avoid 15-second interval; the result can vary by a factor of + or −4, which is significant with small number.

Also, a fairly constant ratio of pulse rate to respiratory rate exists, which is about 4:1.

Normally both pulse and respiratory rates rise as a response to exercise or anxiety.

Vital Signs: Blood Pressure

Blood pressure (BP) is force of blood pushing against side of its container, vessel wall.

Strength of push changes with event in cardiac cycle.

Systolic pressure: maximum pressure felt on artery during left ventricular contraction, or systole

Diastolic pressure: elastic recoil, or resting, pressure that blood exerts constantly between each contraction

Pulse pressure: difference between systolic and diastolic

Reflects stroke volume

Mean arterial pressure (MAP): pressure forcing blood into tissues, averaged over cardiac cycle

Vital Signs: Blood Pressure
Factors (1 of 2)

Average BP in young adult is 120/80 mm Hg; varies normally with many factors:

Age: gradual rise through childhood and into adult years

Gender: after puberty, females show a lower BP than males; after menopause, females higher than males

Race: Differences exist relative to combination of genetics and environment.

Diurnal rhythm: Daily peak and trough levels r/t timing cycles

Vital Signs: Blood Pressure
Factors (2 of 2)

Average BP in young adult is 120/80 mm Hg; varies normally with many factors:

Weight: Obesity increases blood pressure as compared to normal weight recorded measurements of same age.

Exercise: Will cause a transitory increase in blood pressure

Emotions: Will increase in response to sympathetic nervous system response

Stress: Will increase in response to increased stress and tension

Blood Pressure

Blood Pressure Factors

Level of BP determined by five factors

Cardiac output: increase in CO leads to increase in BP whereas decrease in CO leads to decrease in BP

Peripheral vascular resistance: increased resistance (vasoconstriction) leads to increase in BP whereas decrease in resistance(vasodilation) leads to decrease in BP

Volume of circulating blood: fluid retention leads to increased BP whereas hemorrhages leads to decreased BP

Viscosity: increase associated with increase in BP

Elasticity of vessel walls: increasing rigidity associated with increase in BP

Measuring Blood Pressure

Blood pressure measured with stethoscope and aneroid sphygmomanometer

Aneroid gauge subject to drift and must be recalibrated at least once each year and must rest at zero.

Cuff is inflatable bladder inside a cloth cover.

Width of rubber bladder should equal 40% of circumference of person’s arm; length of bladder should equal 80% of this circumference.

The Procedure: Arm Pressure (1 of 2)

Person may be sitting or lying, with bare arm supported at heart level.

Palpate brachial artery; with cuff deflated, center it about 2.5 cm (1 in) above brachial artery and wrap it evenly.

Now palpate brachial or radial artery.

Inflate cuff until artery pulsation obliterated and then 20 to 30 mm Hg beyond.

This will avoid missing an auscultatory gap, when Korotkoff sounds disappear during auscultation.

Deflate cuff quickly and completely; wait 15 to 30 seconds before reinflating so blood trapped in veins can dissipate.

The Procedure: Arm Pressure (2 of 2)

Place bell of stethoscope over site of brachial artery, making a light but airtight seal.

Diaphragm endpiece usually adequate, but bell designed to pick up low-pitched sounds of blood pressure reading

Rapidly inflate cuff to maximal inflation level you determined.

Then deflate the cuff slowly and evenly, about 2 mm Hg per heartbeat.

Note points at which you hear first appearance of sound, muffling of sound, and final disappearance of sound.

Phases of sound: I through V

Note first appearance of sound.

Hear muffling of sound.

Hear final disappearance of sounds.

For all age-groups, fifth Korotkoff phase is now used to define diastolic pressure.

However, when a variance greater than 10 to 12 mm Hg exists between phases IV and V, record both phases along with systolic reading.

Clear communication is important because results significantly affect diagnosis and planning of care.

Korotkoff Sounds

Leads to high readings

Taking when physiologically active, following activity, or emotionally labile

Narrow cuff size and/or applied too loose

Reinflating during procedure

Leads to low readings

Decreased inflation

Too large cuff size

Can lead to high or low readings—examiner/observer error

Position of arm or leg

Improper cuff size

Deflating cuff too quickly

Common Errors in BP Measurement

Orthostatic or (Postural) Vital Signs

Take serial measurements of pulse and blood pressure in the following situations:

You suspect volume depletion.

Person is known to have hypertension or taking antihypertensive medications.

Person reports fainting or syncope.

Position changed from supine to standing, normally slight decrease (less than 10 mm Hg) in systolic pressure may occur.

The Procedure: Orthostatic Vital Signs

Have person rest supine for 2 or 3 minutes, take baseline readings of pulse and BP, and then repeat with person sitting and then standing.

For person who is too weak or dizzy to stand, assess BP supine and then sitting with legs dangling.

Record BP by using even numbers.

Also record person’s position, arm used, and cuff size, if different from standard adult cuff.

Record pulse rate and rhythm, noting whether pulse is regular.

The Procedure: Thigh Pressure

When BP measured at arm is excessively high, compare it with thigh pressure to check for coarctation of aorta (congenital form of narrowing).

Particularly in adolescents and young adults

Normally thigh pressure higher than that in arm

If possible, turn person to prone position on abdomen.

Wrap large cuff around lower third of thigh, centered over popliteal artery on back of the knee.

Auscultate popliteal artery for reading.

Normally systolic value is 10 to 40 mm Hg higher in thigh than in arm, and diastolic pressure is same.

Infants and Children: Developmental Competence

Vital signs

BP is not normally checked in children less than 3 years of age.

Whenever possible, avoid rectal route and take a tympanic, inguinal, or axillary temperature.

Infant: reverse order of vital signs to respirations, pulse and temperature

Preschooler: consider normal fear of body mutilation may increase with any invasive procedure

School-age: Promote cooperation by explanation and participation in handling equipment

Adolescent: Same consideration as with adults

Infants and Children: Temperature: Tympanic and Temporal Artery

Tympanic measurement (TMT and TAT)

Useful with toddlers who squirm at restraint needed for rectal route, and useful with preschoolers not yet able to cooperate for oral temperature

Rapid that it is usually over before child realizes it

Infants and Children: Temperature: Axillary and Oral

Axillary route safer and more accessible than rectal route; however, its accuracy and reliability have been questioned

When axillary route used, place tip well into axilla, and hold child’s arm close to body.

Use oral route when child old enough to keep mouth closed; usually at age 5 or 6, although some 4-year-old children can cooperate.

When available, use an electronic thermometer because it is unbreakable and it registers quickly.

Infants and Children: Temperature: Rectal

Use rectal route with infants or with other age groups when other routes are not feasible, such as with the child who is unable to cooperate, agitated, unconscious, critically ill, or prone to seizures.

Infant may be supine or side lying, with examiner’s hand flexing knees up onto the abdomen.

Separate buttocks with one hand, and insert lubricated electronic rectal probe no farther than 2.5 cm (1 in); insertion any deeper risks rectal perforation.

Normally rectal temperatures measure higher in infants and young children than in adults, with an average of 37.8° C (100° F) at 18 months.

Also, temperature normally may be elevated in late afternoon, after vigorous playing or after eating.

Infants and Children: Pulse, Heart Rate, and Respirations

Pulse

Palpate or auscultate an apical rate with infants and toddlers.

In children older than 2, use radial site.

Count pulse for a full minute to take into account normal irregularities, such as sinus dysrhythmia.

Heart rate normally fluctuates more with infants and children than adults from exercise, emotion, and illness.

Respirations

Watch infant’s abdomen for movement, because infant’s respirations are normally more diaphragmatic than thoracic.

Sleeping respiratory rate is the most accurate in infants.

Count for a full minute due to pattern variation.

Infants and Children:
Blood Pressure (1 of 3)

In children aged 3 and older, and in younger children at risk, measure a routine BP at least annually.

For accurate measurement in children, make some adjustment in choice of equipment and technique.

Most common error is to use incorrect size cuff.

Cuff width must cover two thirds of upper arm, and cuff bladder must completely encircle it.

Use a pediatric-sized endpiece on stethoscope to locate sounds.

Infants and Children:
Blood Pressure (2 of 3)

If possible, allow crying infant to become quiet for 5 to 10 minutes before measuring the BP; crying may elevate the systolic pressure by 30 to 50 mm Hg.

Use disappearance of sound (phase V Korotkoff) for diastolic reading in children.

In children, height more strongly correlated with BP than age

New charts avoid misclassification as normotensive or hypertensive of children who are at extremes of normal growth.

Infants and Children:
Blood Pressure (3 of 3)

For children of same age, BP classified as 90th and 95th percentiles lower for very short children, whereas tall children given higher normal range

Children younger than 3 years have such small arm vessels that it is difficult to hear Korotkoff sounds with a stethoscope.

Instead, use an electronic BP device that uses oscillometry, such as Dinamap, and gives digital readout for systolic, diastolic, and MAP and pulse.

Or use a Doppler ultrasound device to amplify sounds

The Aging Adult: Vital Signs (1 of 2)

Temperature: changes in body’s temperature regulatory mechanism leave aging person less likely to have fever but at greater risk for hypothermia

Temperature is less reliable index of older person’s true health state; sweat gland activity is also diminished.

Pulse: normal range of heart rate is 60 to 100 bpm, but rhythm may be slightly irregular

Radial artery may feel stiff, rigid, and tortuous in older person, although does not necessarily imply vascular disease in heart or brain.

Increasingly rigid arterial wall needs faster upstroke of blood, so pulse is actually easier to palpate.

The Aging Adult: Vital Signs (2 of 2)

Respirations: aging causes decrease in vital capacity and decreased inspiratory reserve volume

You may note shallower inspiratory phase and an increased respiratory rate.

Blood pressure: aorta and major arteries tend to harden with age

As heart pumps against a stiffer aorta, systolic pressure increases, leading to widened pulse pressure.

In many older people, both systolic and diastolic pressures increase, making it difficult to distinguish normal aging values from abnormal hypertension.

Measurement of Oxygen
Saturation (1 of 2)

Pulse oximeter: a noninvasive method to assess SpO2

Sensor attached to person’s finger or ear lobe has diode that emits light and detector measures relative amount of light absorbed by HbO2 and unoxygenated (reduced) Hb.

Compares ratio of light emitted to light absorbed and converts this ratio to percentage of oxygen saturation

Measurement of Oxygen
Saturation (2 of 2)

Healthy person with no lung disease and no anemia normally has an SpO2 of 97% to 98%.

Select appropriate pulse oximeter probe.

Finger probe spring loaded and feels like clothespin attached to finger but does not hurt.

At lower oxygen saturations, ear lobe probe more accurate and less affected by peripheral vasoconstriction.

Doppler Techniques

In many situations, pulse and BP measurement is enhanced by using an electronic device, Doppler ultrasonic flow meter.

Technique works by a principle that sound varies in pitch in relation to distance between sound source and listener: pitch is higher when distance is small, and pitch lowers as distance increases.

In this case, sound source is blood pumping through artery in rhythmic manner.

Handheld transducer picks up changes in sound frequency as blood flows and ebbs, and it amplifies them.

The Procedure:
Doppler Techniques (1 of 2)

Listener hears whooshing pulsatile beat.

Doppler technique is used to locate peripheral pulse sites.

For BP measurement, Doppler technique augments Korotkoff sounds.

Through this technique, you can evaluate sounds that are hard to hear with a stethoscope, such as those in critically ill individuals with a low BP, in infants with small arms, and in obese persons in whom sounds are muffled by layers of fat.

Also, proper cuff placement is difficult on obese person’s cone-shaped upper arm.

In this situation, you can place cuff on more even forearm and hold Doppler probe over radial artery.

The Procedure:
Doppler Techniques (2 of 2)

For either location, use the following procedure:

Apply coupling gel to transducer probe.

Turn Doppler flow meter on.

Touch probe to skin, holding probe perpendicular to artery.

A pulsatile whooshing sound indicates location of artery.

May need to rotate probe, but maintain contact with skin.

Do not push probe too hard or you will wipe out pulse.

Inflate cuff until sounds disappear; then proceed another 20 to 30 mm Hg beyond that point.

Slowly deflate cuff, noting point at which first whooshing sounds appear; this is systolic pressure.

Hypotension

Seen in acute myocardial infarction (AMI), shock, hemorrhage, vasodilation, and/or Addison’s disease

Essential or primary HTN

BP Pressure Guidelines

ACC/AHA Task Force

JNC-8 Guidelines

Cardiovascular risk stratification

Major risk factors impacting target organs

Smoking, dyslipidemia, diabetes mellitus, above 60 years of age, gender (men and postmenopausal women), and family history of cardiac disease

Abnormal Findings Associated with Vital Signs

Prevention and management

Weight loss

Limit alcohol use

Increase aerobic exercise activity pattern

Reduce sodium intake

Maintain adequate sources of dietary potassium, calcium and magnesium

Smoking cessation

Reduce intake of saturated fats and cholesterol

Lifestyle Modifications for HTN

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