Kozier Ch 29 Vital Signs

Admission to your agency or your unit.

Any change in health status.

Before and after invasive procedures.

• Before particular medications i.e.
• respiratory and cardiac meds.

Before and after nursing interventions such as ambulating a pt.

• Refers to a balance between the heat produced
• by the body and that lost by the body.

• Heat balance-
• refers to amount of heat being produced by
• the organism and the amount heat being lost being equal

Core Temperature - deep tissue of body - abdominal and pervic cavity

Surface Temperaure - temp at skin, sub Q, and fat

1. Basal metabolic rate (BMR) - rate of energy use required to maintain essential activities (breathing)

2. Muscular activity example: shivering -increases BMR

• 3. Thyroxine output - increases rate of cellular metabolism
• Chemical Thermogenesis - heat production in body through increased cellular metabolism

4. EPI & NOR - increase rate of cellular metabolism - directly effect liver and muscle cells

5. Fever - increases cellualr metabolic rate

• Heat Loss:
• 1. Radiation - transfer of heat from one object to another without touching

2. Conduction-convection - heat transfer from one molecule to a molecule of lower temperature (convetion is heat transfer in air)

• 3. evaporation - loss of heat through moisture in respiratory tract and mucous membranes
• - insensible heat loss & insensible water loss

• 1. Age - infants - puberty very affected by temperature changes
• Older people >75 less sub Q fat and much more affected by the environment

2. Circadian rhythms - temp.can vary as much as one degree during the day with the highest being between 4-6pm. And lowest between 4-6 am.

3. Exercise

4. Hormones - progesterone on ovulation

5. Stress - release of EPI & NOR

6. Environment

Fever - body temp above usual range

very high fever (41^oC or 105.8^oF)

client who has a fever is referred to as febrile

client who does not have a fever

body temp alternated between periods of fever and periods of normal or subnormal temperatures

• temp rises to fever level rapidly and them returns to normal within a few hours
• - often caused by bacterial blood infections

lowe than 36.5^oC or 96^oF

• core temp is below lower limit of normal
• Caused by:
• 1. Excessive heat loss
• 2. Inadequate heat production to counteract heat loss
• 3. impaired hypothalamic thermoregulation

96.4-99.1 Fahrenheit average 98.6 F.

35.8-37.3 Celsius average 37 C.

Generally considered an axillary temp. is one degree lower and rectal temp. is one degree higher.

• 1. Oral - wait 10 mins after eating/ drinking
• Traditional style stays in for 5 minutes

• 2. Rectal
• -Pt. is placed in Sims position with leg flexed.
• -Sheath is placed over the thermometer, water soluble lubricant is used.
• -Inserted 1-1.5 inches into the rectum and held in place.

• 3. Tympanic membrane -
• Pull pinna upward and backward for an adult

• Pulse– represents the contraction of the left
• ventricle of the heart.

Peripheral pulse- a pulse located away from the heart.

Apical pulse-is a central pulse located at the apex of the heart. It is also called the point of maximal impulse (PMI).

• Temporal
• Carotid
• Apical
• Brachial
• Radial
• Femoral
• Popliteal
• Posterior/tibial
• Dorsalis/pedis

• Newborn 120-160
• Toddler 90-140
• School Age 75-100
• Adolescent 60-90
• Adult 60-100

• -heart rate over 100 in an adult.
• apical pulse should be assessed

• -heart rate less than 60 in an adult
• apical pulse should be assessed

• -pattern of beats and intervals between them
• normal = equal time between beats

• dysrhythmia or arrhythmia - pulse with irregular rhythem
• irregular = radon, irrugular beats
• regularly irregular - predictable pattern of irregular beats

-also called strength or amplitude

• normal - felt with moderate pressure and can be obilterated with greater pressure
• full or bounding - only obliterated with difficulty
• weak, feeble, thready - easily obliterated

• •Age-pulse decreases with age.
• •Gender-after puberty male pulses slightly less.
• •Exercise-normally increases with exercise however athlete’s tend to have a lower pulse due increased development of heart.
• •Fever-hrt. Rate will increase due to peripheral vasodilation which occurs with increased body temp. which lowers bld. Pressure.
• •Medications-some decrease, some increase.
• •Hypovolemia-loss of bld. Increases hrt. Rate in response to decreased bld. Volume.
• •Stress-increases rate and force of heartbeat.
• •Position changes-
• •Pathology-certain diseases particularly cardiac can increase or decrease hrt. Rate.

• - the act of breathing.
• Also called ventilation.

• Inhalation or inspiration is the movement
• into the lungs of air.

• Exhalation or expiration is the movement out
• of the lungs of air.

• Costal or thoracic breathing-using chest muscles.
• Women tend to be thoracic breathers.

• Diaphragmatic (abdominal) breathing- notice
• in the abdominal muscles due to the movement of the diaphragm. - men usually

• Newborn 30-60
• Toddler 24-40
• School-Age 18-30
• Adolescent 12-16
• Adult 12-20

• -abnormally slow respirations.
• <12 in an adult.

-abnormally fast respirations.

>20 in an adult.

-absence of breathing

-very deep, rapid respirations

-very shallow respirations

• Matter of counting the number of times per
• minute a client has a complete respiratory cycle.

Respiratory rhythm-refers to regularity of inspiration and expiration.

Respiratory quality-refers to depth and quality.

Arterial blood pressure is the measure of he pressure exerted by the blood as it is flowing through the arteries.

• Systolic pressure represents the pressure exerted on the arteries with the contraction of the ventricles. It is
• expressed as the top number in a blood pressure.

Diastolic pressure represents the pressure exerted when the ventricles are at rest. It is the bottom number.

• Blood pressure is measured in mmHg.
• Blood pressure is expressed as a fraction.

• difference between the systolic and diastolic pressures
• Normal pulse pressure
• is 40mmHg. May be as high as 100.

Consistently high pulse pressures occur in arteriosclerosis.

Low pulse pressure occurs in heart failure.

-blood pressure is always above normal

blood pressure that is constantly below normal

blood pressure that falls when the client sits or stands

a drop of 20 mmHg or more may indicate orthostatic hypotension

Symptoms: dizziness, lightheadedness, falling

• Newborn
• Systolic 60-90 diastolic 20-60
• Toddler 80-112 50-80
• School age 84-120 54-80
• Adolescent 94-140 62-88
• Adult 110-140 60-90

Systolic Diastolic

• Normal < 120 and < 80
• Prehypertension 120-139 80-89
• Stage One (hyper) 140-159 or 90-99
• Stage Two (hyper) > 160 or > 100

• •Age- pressure rises with age, peak is at onset of puberty then goes down some.
• •Exercise-increases c.o. so increases BP
• •Stress-due to stimulation of the sympathetic nervous system. (EPI & NOR)
• •Race-african american males tend to have higher pressures.
• •Gender-after puberty women are lower but then after menopause tend to be tend to be higher.
• •Medications
• Obesity
• •Diurnal variations-pressure tends to be lower in am - peaks in late afternoon or early evening
• Disease process-any disease which affects c.o. affects bp.

• Measured with a sphygmomanometer and a stethoscope.
• 1. Make sure cuff is proper size.
• 2. Take blood pressure without clothing on the limb to be used.
• 3. Have client sitting or supine with arm slightly flexed at the level of the heart.
• 4. Legs should not be crossed.
• 5. Palpate brachial pulse at the antecubital
• level.

• Burns or trauma.
• Injury or disease.
• Cast or bandage.
• Surgical removal of axilla
• IV infusing in the limb.
• Arteriovenous fistula for renal dialysis.

• 1. Place cuff 1 inch above the level of the brachial pulsation. Fit snuggly but not too tightly.
• 2. Sphygmomanometer should be eye level.
• 3. Inflate cuff while palpating the brachial pulse.
• 4.Release pressure all the way and wait 1-2 minutes.
• 5. Position stethoscope over the artery, pump up cuff to 30 mmHg over palpated number.
• 6. Release cuff 2-3 mmHg per sec. and note first sound and last sound.

Now considered to be the “fifth vital sign”.

• Generally measured on a numerical scale from
• 1-10.

Assessed prn and with vital signs

• Measured with pulse oximeter.
• Noninvasive method of measuring arterial blood oxygen saturation.
• Can detect hypoxemia before clinical signs are evident.
• Normal oxygen saturation (SaO2) is 95%-100%.
• SaO2 < 70% is life threatening

Hemoglobin-if hemoglobin is completely saturated reading will appear normal.

Circulation-if client has impaired circulation monitor will be unable to read.

Activity-such as shivering or movement.

Carbon monoxide poisoning-monitor is unable to tell the difference between carbon monoxide and oxygen saturation