Lecture Notes: Measuring Vital Signs

Introduction

• Lecturer: Andrea Murdoch, DNPRN
• Topic: Measuring Vital Signs
• Covering: The who, what, why, when, and where of Vital Signs

What are Vital Signs?

• Definition: Assessment of vital physiological functions
• Main Vital Signs:
  • Temperature
  • Pulse
  • Respiration
  • Blood Pressure
• Importance: Frequent assessment by nurses, provides baseline data on patient's health
  • Normal vital signs do not guarantee physiological well-being
  • Evaluated in the context of overall assessment

Additional Vital Signs

• Pain
• Oxygen Saturation (Normal range: 95-100%)
• Smoking status
• Emotional distress

When to Measure Vital Signs

• On admission to hospital
• At the beginning of each shift
• Before certain medications
• With changes in patient's condition
• Routinely every four hours in hospitals
• Home health settings: Each visit
• Nursing homes: Weekly or monthly

Temperature

• Definition: Degree of heat maintained by the body
• Thermoregulation: Process of maintaining stable internal body temperature
• Core Temperature: Measured via rectal, typically higher than surface temperature
• Normal Temperature:
  • Oral: 98 - 98.6°F
  • Rectal: 99 - 99.6°F
• Variations: Age, gender, environment, and individual differences
• Response to Temperature Variations: Hypothalamus regulates via vasodilation and shivering

Factors Influencing Body Temperature

• Developmental level
• Environment
• Gender
• Exercise
• Emotions and stress
• Circadian rhythm

Fever

• Defined as oral temperature >100°F or rectal >101°F
• Phases of Fever:
  • Initial: Temperature rises
  • Course: Temperature maxes out
  • Defervescence: Temperature returns to normal
• Types of Fever:
  • Intermittent, Remitting, Constant, Relapsing

Example Problems

• Hyperthermia: Symptoms and interventions
• Hypothermia: Symptoms and interventions

Pulse

• Definition: Rhythmic expansion of an artery
• Normal Pulse Rate: 60-100 bpm
• Factors Influencing Pulse: Development, sex, exercise, stress, fever, disease, medications

Respirations

• Definition: Exchange of oxygen and carbon dioxide
• Normal Rate: 12-20 breaths/min
• Factors Influencing Respirations: Development, exercise, pain, stress, smoking, fever

Blood Pressure

• Definition: Pressure of blood against arterial walls
• Regulation: Cardiac function, peripheral resistance, blood volume
• Factors Influencing Blood Pressure: Age, sex, lifestyle, exercise, body position, stress

Equipment and Techniques

• Temperature: Thermometers (electronic, infrared, chemical)
• Pulse: Stethoscope, apical and radial pulse measurement
• Respirations: Watch with second hand, stethoscope
• Blood Pressure: Stethoscope, sphygmomanometer, electronic monitors

Conclusion

• Evaluation and Delegation of Vital Signs: Interpret trends, understand patient's baseline and context
• Questions and Feedback: Encouraged to discuss on the board, and complete evaluations