2. • CONTENT.
1. Definition
2. Vital signs.
a) Temperature
b) Blood pressure
c) pulse
d) Respiratory rate (respirations)
e) Pulse oximetry (Oxygen saturation)
f) Urine output
g) Pain.
h) Electrocardiogram, ECG.
3. • Case scenario
Ms Joan F/51yo known ISS on ART, with Ca Cx. Received from theatre at 1845HRS
post TAH she was delirious (she kept saying, “doctor, theatre……repeatedly) at
arrival, initially BP – 100/58mmHg, P – 62b/m, sats – 91%RA, RBS – 9.3mmol/L.
But progressively in less than 10 minutes, she crushed, went silent and alarms
warning emergency with BP – 83/49mmHg, P – 55b/m, sats – 65%RA.
We supported on supplemental oxygen 4L/m, gave atropine 1mg bolus, increased
N/S flow that was already connected while left on monitor.
Vitals kept improving slowly and notably after 15mins, BP – 111/80mmHg, P –
87b/m, sats – 98% on 4L/m while she could communicate already. Then the oxygen
support was stepped down to 2L/m maintenance.
Patient handed over to the night team for care continuation with specific
recommendation to continue monitoring. Nothing unusual was reported in the
morning, meanwhile at 6am that morning BP – 95/57mmHg, P – 76b/m, O2 –
93%RA.
4. • Vital signs or parameters (commonly called ‘vitals’)are……
• When to take vitals.
a) On initial contact with client
b) During physical assessment of a client
c) Before and after an invasive procedure (or during some procedures) which
could be treatment or diagnostic like BT, paracentesis, thoracocentesis, biopsy
taking, tracheostomy care, surgeries, etc.
d) Before, during and after administration of certain drugs esp. those that affect
resp, cardiac functions or mental status including some chemotherapeutic
agents.
e) During acute changes of a clients condition.
f) During interdepartmental or interfacility patient transfers
g) Monitoring the progress or effect of an intervention a condition eg fever.
5. TEMPERATURE
Measured using the various types of thermometers.
Normal 36.4 – 37.5 degrees Celsius (C), or 97.5 – 99.5 degrees Fahrenheit (F); The
average in a healthy young adult is 37.0 degrees C or 98.6 degrees F.
Common measurement site include axilla, mouth, rectum (mostly in babies), ear.
And using various electronic devices (application of infrared).
NB: For any site chosen, please take precaution of the limitations or
contraindications and benefits, procedures and expectations. And that there are
also specific thermometers for some specific sites.
Rectal temperatures are usually 1 degree F or 0.5 degrees C higher and axillary
temperatures are about 1degree F or 0.5 degrees C lower than normal oral
temperatures.
6. • Nursing consideration.
• What is the relationship of the following variables to the temperature
measurement.
a) Time of the day
b) Environmental temperature
c) Age
d) Physical activity
e) Menstrual cycle
f) Pregnancy
g) Emotional stress
h) Illness
i) Nutritional status
The inability to obtain temperature should not be ignored, it could be severe
hypothermia of something life threatening.
7. BLOOD PRESSURE (BP)
Is the force on the walls of an artery exerted by the pulsating blood under pressure
for the heart. Written as systolic/diastolic BP. i.e. SBP/DBP.
When the heart contracts, the peak of maximum pressure during ejection is SBP
and blood remaining in arteries when ventricles relax is DBP, while the difference
between the two is pulse pressure.
BP=COxTPR and CO=SVxHR (BP- blood pressure, CO- cardiac output, TPR- total
peripheral resistance, SV- stroke volume and HR- heart rate).
Whether you record a high or low BP, we troubleshoot via the above parameters as
well as the regulation and BP variations in different situatons.
Normal is 120/80mmHg hence normotensive.
8. Hypertension is hugher than normal and classified as
Prehypertension, 120-139/80-89mmHg.
Stage 1 hypertension, 140-159/90-99mmHg
And stage 2 hypertension, 160 and above against 100 and above.
Postural or orthostatic hypotension – normotensive clients drops BP when changes
position to upright.
Orthostatic vital sign measurement involves checking BP and Pulse while patient is
supine, then sits and later stands leaving about three minutes in each case
between measurements.
9. Nursing considerations
1. Factors affecting BP
Age
Emotional status like Stress, excitement.
Medications like antihypertensives, opioid analgesics
Time of the day
Activity
Gender and physiological variations, like menopause, pregnancy.
Illness
10. 2. Guidelines
Site preference: avoid sites containing IV fluids, AV fistulas (whether pathological
created for treatment), breast or axillary surgery or traumatized extremity.
Leg may be used if brachial artery is inaccessible, with focus on the popliteal artery.
Allow client to rest for 15 – 30 mins after exercise or after smoking.
Ensure client is clam, quiet, preferably cuff at heart level.
Appropriate cuff size and wrap it evenly.
Ensure your digital BP machine is well calibrated to avoid false results.
When using steth, choose well fitting steth that doesn’t impair hearing.
11. PULSE.
Average pulse (P) or heart rate (HR) 60 – 100b/m. varying greatly with age.
Pulse is checked for presence, rate, rhythm and strength (force or amplitude or
fullness)
Pulse points.
Temporal artery
Carotid artery
Apical pulse
Brachial pulse
Radial pulse
Femoral pulse
Popliteal pulse
Etch.
12. • Nursing consideration
HR slows with age.
Exercise increases HR
Emotional extremes increase HR
Pain increases HR
Increase in body temperature increases HR
Stimulant and depressant medications
Low BP will usually increase HR and vise versa (Oncotic pressure).
Loss of blood or volume will usually increase HR
13. Pulse Deficit
Is when peripheral pulse rates are less than the ventricular (apical) pulse rate.
It could indicate compromised peripheral perfusion or cardiac dysrhythmias.
14. Respirations.
Normal rate for adult is between 12 – 20 b/m.
One respiration includes both inspiration and expiration.
Assess for rate (RR), depth, pattern, sounds associated and others like smell.
Nursing consideration
Many, if not all, factors affecting PR also affect RR.
Increased levels of CO2 or lower levels of O2 will increase RR
Head injury will likely decrease RR
Depressive medications will also decrease RR.
15. Pulse oximetry.
Is the noninvasive test that registers the oxygen saturation of a patients
haemoglobin
Normal should be above 95%, between 90% and 95% maybe allowable in some
clinical conditions or your clinical judgement and below 90% necessitates
notification or supportive intervention.
Low pulse oximeter readings will alert a provider before clinical symptoms or signs
ensure.
Uses the beer-lambart principle of absorbance, therefore make sure you don’t
select a site or extremity with an impediment to blood flow.
Common sites include fingers, toe (mostly in pediatrics), earlobe etc
Most accurate measurements by ABG analysis.
16. Nursing interventions
In some situations, a low pulse oximeter reading responds well to simple
interventions like deep breathing exercise. Chest physiotherapy.
Careful selection and inspection of the site to attach the sensor.
Check the machine
Support to sitting position incase cardiac patient
Don’t switch off alarms especially closely monitored patients.
View values in relation to clinical appreciation
Abruptly large fluctuations in reading should be crosschecked at the probe.
Act swift, calm and confidently depending on your clinical findings.
