What are four Vital Sign and normal Range, what are management of an abnormal vital sign.

vital sign is the parameter of the health , it indicate how you body is functioning. or Indicators that permit to observe all changes in body or Indicators that permit to detect and monitor physiological changes and medical problems.

vital signs reflect changes that happen in our organism that otherwise might not be observed. vital signs are indicators of body functions . They are checked to monitor the functions of the body. All vital signs are objective data assessment that indicate how well or poorly the body is functioning.How many vital sign do we have?

we have 4Vital signs only :

1. Temperature (T)
2.  Pulse (P)
3. Respiration (R)
4. Blood pressure (BP).

TPR-BP

Taking vital signs is to measure Temperature, Pulse, Respiration and Blood Pressure, oxygen saturation and pain assessment.

All vital signs are parameters but all parameters are not vital signs.

When to assess client’s vital signs?

1. On patient admission to obtain baseline data 
2. On patient admission in hospitalization
3. In case there is changes in the patient’s health status
4. During physical examination 
5. Before and after administrating medications that could affect respiratory system, cardiovascular system and other systems 
6. Before and after surgery or invasive procedure
7. Before and after nursing interventions that can affect vital signs 

How often to assess client’s vital signs?

 Chiefly, the frequency depends

1. On the client’s health status

2. Nursing judgement

3. Agency policy, hospital protocol

4. Physician orders 

A. Temperature (T)

The body maintains a temperature range of between 35.8°C to 37.4 °C or from 96.6 °F to 99.3 °F, this being the optimum temperature range for the physiological functions of the body. This normal temperature range is maintained by keeping a balance between heat production and heat loss.

This continuous and unnoticed water is called insensible water loss and the accompanying heat loss is called insensible heat loss. The center for regulation of temperature is  is located in the hypothalamus.  The anterior hypothalamus promote heat loss and The posterior hypothalamus promote heat production and heat conservation. 

Purposes of taking or measuring body temperature.

1. To establish baseline data for subsequent evaluation
2. To identify whether the core temperature is within normal range
3. To determine changes in the core temperature in response to therapies i.e. treatments
4. To monitor clients at risk for imbalanced body temperature 

Types of thermometer

1. Mercury-in-glass thermometers
2. Electronic thermometers (Digital)
3. Infrared thermometer
4. Temporal artery thermometer
5. Temperature-sensitive tape
6. Chemical disposable thermometers. 

Sites for body temperature measurement

Temperature is commonly measured in 3 sites

1. Oral
2. Axillary
3. Rectal

Other sites are

1. Tympanic membrane 
2. Skin
3. Temporal artery

1. Oral Temperature

Indications: conscious adult , Wasted patient (cachectic)

Contraindications: 

1. hot and cold drinks intake or after smoking
2. Unable to close the mouth
3. Obstacle: infection or intervention of the mouth 
4. Infants and children under six 
5. Confused or comatose patients
6. Convulsions
7. Patients suffering from nausea or vomiting 
8. Patients under oxygen by a mask

2. Axillary temperature 

Taking the temperature by axilla measures the surface temperature of the body, and this method is not accurate if not correctly carried out.

Indications: Conscious adult, Functional arm, newborns

Contraindications: small children, Unconscious patient, Agitated patient

Advantages: Safest and least invasive method, Less potential for spreading microorganisms with than the oral and rectal  

Disadvantage: Breaking of material (thermometer), requires the longest time for assessment of 5 minutes or longer

3. Rectal temperature

The rectal temperature is considered to be the most accurate method of taking the temperature, and it is a true reflection of the core temperature of the body.

Indications :Infants, Unconscious patient, Every time that some doubts exist on a febrile state

Contra-indications : Diarrhea, Affection or anal injury, Rectal surgery 

Advantages : More reliable measurement

Disadvantages : Injury to the rectum is possible, More unpleasant for clients, difficult for clients who cannot turn to the side, presence of stool may interfere thermometer placement.

Surface temperature generally ranges from 35.8°C to 37.4 °C or from 96.6 °F to 99.3 °F

Normal Range  for Adult:

Orally 36,7oC to 37,2o C

Axillary 35,6oC to 36,7o C 

Rectally 36,7oC to 37,8o C 

New born 36.1- 37.7 (axillary) 

Alterations in body temperature 

2 primary alterations:

Pyrexia and Hypothermia 

Pyrexia also called Hyperthermia : body temperature above the normal range (High temperature).

Hypothermia: body temperature below the lower limit of normal (Low temperature).

Pyrexia or Hyperthermia or Fever(general term) : a body temperature above the usual normal range (generally T > 38 °C, 100.4 °F)

• A client with fever is referred to as febrile
• A client who does not have fever is afebrile
• A very high level of fever is called Hyperpyrexia

Hyperpyrexia : this is a state of hyperthermia characterized by an intense febrile state. Elevation of the temperature to 41 °C

( 105.8 °F)and beyond.

Heat exhaustion 

An increase in body temperature (38°- 40°C; 100.4°- 104.0°F) in response to environmental conditions that, in turn, causes diaphoresis (profuse perspiration).

It is characterized by Loss of excessive amounts of water and sodium from perspiring leads to thirst, nausea, vomiting, weakness, fainting and disorientation. 

A critical increase in body temperature (41°–44°C) resulting from exposure to high environmental temperatures

Dry, hot skin is the most important sign. 

The person becomes confused, or delirious, and experiences thirst, abdominal distress, muscle cramps, and visual disturbances. Loss of consciousness occurs if untreated. 

There is 4 common types:

1. Intermittent fever
2. Remittent
3. Relapsing
4. Constant

Remittent fever A wide range of temperature fluctuations (more than 2 °C) occurs over 24-hour period, all of which are normal. for example fever due to influenza.

Relapsing fever Short febrile periods of few days are interspersed with period of 1 to 2 days of normal temperature for example  Tuberculosis fever.

Constant fever Body temperature fluctuates minimally but always remains above normal.  for example Typhoid fever.

The clinical signs of fever vary with the onset, course and abatement stages of the fever.

Clinical manifestations of fever

Onset (cold or chill stage)

1. Increased heart rate, Increased respiratory rate 
2. Shivering due to increased skeletal muscle tension and contractions 
3. Pallid, cold skin due to vasoconstriction 
4. Cyanotic nail beds due to vasoconstriction 
5. Complaints of feeling cold 
6. “Gooseflesh” appearance of the skin due to contraction of the arrectores pilorum muscles 
7. Cessation of sweating
8. Rise in body temperature

Nursing intervention related to the fever 

 Respiration is controlled by:

a) Respiratory centers in the medulla oblongata and the Pons of brain

b) Chemoreceptors located centrally in medulla and peripherally in carotid and aortic bodies

 These centers and receptors respond to changes in the concentrations of oxygen, carbon dioxide, and Hydrogen in the arterial blood

Factors affecting Respirations

 Factors that increase the rate

1. Exercise

2. Stress (emotion)

3. Increased environmental temperature

4. Lowered oxygen concentration at increased altitudes

5. Position

Factors that decrease the rate

1.  Decreased environmental temperature

2.  Certain medications, example: narcotics

3.  Increased intracranial pressure

4.  Position

Breathing patterns and abnormal characteristics

 Breathing patterns

  Rate:

1.  Eupnea: Normal respiration that is quiet, rhythmic and effortless, normal in rate

2.  Tachypnea or polypnea: rapid respiration marked by quick, shallow breaths (abnormal fast breathing)

3.  Bradypnea: abnormally slow breathing

4.  Apnea: absence (cessation) of breathing

 Volume:

1. Hyperventilation (hyperpnea): an increase in the amount of air in the lungs, characterized by prolonged and deep breaths, may be associated with anxiety

2. Hypoventilation (hypopnea): a reduction in the amount of air in the lungs, characterized by shallow respirations

Rhythm:

a) Cheyne-Stokes breathing: Marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea.

Trouble of the frequency and the amplitude: Episodes of apnea alternating with hyperpnea

It is often associated with cardiac failure, increased intracranial pressure, or brain injury.

b) Kussmaül respiration:  Marked by times of pauses between every respiratory time: Inspiration - a short pause Expiration - a short pause, and so on

This rhythm evokes a state of acidosis, in particular of diabetic acidosis.

c) Biot’s breathing: Shallow breaths interrupted by apnea; may be seen in healthy people and in clients with central nervous system disorders.

Ease or effort:

 Dyspnea: difficult and labored breathing during which the individual has a persistent, unsatisfied need for air and feels distressed.

 Orthopnea: ability to breath only in upright sitting or standing positions

 Apnea is absence of breathing.

Breath Sounds

 Stridor is a shrill, harsh sound heard during inspiration with laryngeal obstruction

 Stertor is  snoring or sonorous respiration, usually due to a partial obstruction of the upper airway

 Stertorous breathing: noisy ventilation

 Wheeze: Continuous, high-pitched musical squeak or whistling sound occurring on expiration and sometimes on inspiration when air moves through a narrowed or partially obstructed airway

 Bubbling: gurgling sounds heard as air passes through moist secretions in the respiratory tract.

 Secretions and coughing:

 Productive cough is a cough accompanied by expectorated secretions

 Non-productive cough is a dry, harsh cough without secretions or dry cough

 Haemoptysis is  the presence of blood in the sputum

Respiratory rhythm : The regularity of the expirations and inspirations, Normally, respirations are evenly spaced .The rhythm of respiration is described as regular or Irregular.

The effectiveness of respiration.

This is measured in part by the uptake the oxygen from the air into the blood and release of carbon dioxide. The amount of oxygen saturated in arterial blood can be measured indirectly by pulse oximetry. 

 Respiration Rate per minute According to Age

Pulse and Blood Pressure

The Pulse and Blood pressure are physiological manifestations of circulatory system, constituted by the heart, vessels, (arteries, veins and capillaries) and blood.

Pulse

The pulse is the bounding of blood flow in an artery that is palpable at various points on the body The pulse is caused by the stroke volume ejection and distension of the walls of the aorta, which creates a pulse wave as it travels rapidly toward the distal ends of the arteries. As the pulse wave reaches a superficial peripheral artery and travels over an underlying bone or muscle, the pulse can be palpated by applying gentle pressure over a pulse point. Pulse is the rhythmic beating of the arteries due to the passage of blood propelled by every cardiac contraction. It is a wave of blood created by contraction of the left ventricle of the heart.  It informs us on heart activities and on its rhythm. 

Cardiac rhythm: Succession of contractions and relaxations that allows the heart to accomplish its function of pumping at a regular rhythm. 

A peripheral pulse: is a pulse located in the periphery of the body, for example , in the foot, hand, or neck 

Apical pulse, in contrast, is a central pulse; that is located at the apex of the heart

Features of pulse

A. Frequency. 

Pulse is expressed in heart beatings per minute.  It is the number of beatings of an artery discerned by the finger in determined time (usually during one minute). 

Normal values of pulse per age:

Age Normal heart rate (beats per minute)

Foetus 120-160

Newborn 100-170

1 year 100-120

2-5 years 80-100

6–10 years 70-110

Adult 60-100

Old people 60-70

B. Rhythm:

 Succession to equal interval of equal amplitude beatings.

A normal pulse is characterized by the regularity of beatings. Normally, the cardiac rhythm is regular, even in physiological factors.

An irregular pulse is a pulse that presents an irregular rhythm.

Volume and amplitude: Indicate the power of the beatings.

C. Volume:

Volume is the importance of the blood flux that not only depends on the strength of the cardiac systole, but also of the elasticity of the arteries.

D. Amplitude:

Amplitude is the intensity of pulsation, that is depended on resistance strength and blood pressure, it is normally the same at every beating.

Tension or resistance: This is the strength that the pulse resists the compression of the finger on the artery when taking the pulse.

Factors that influence the cardiac rhythm (pulse rate) include:
1.  Age
 2. Sex

3. Activity – exercise

4. Emotion
5. Fever
6. Digestion
7. Medications
8.  Bleeding (Hemorrhage)

Pulse abnormalities

 Frequency: Tachycardia and Bradycardia
a) Tachycardia or accelerated pulse
1. Excessive cardiac frequency, high to the normal, (more than 100 beats per minute) for adult. It can reach 120 to 160 beatings per minutes and even more.
2. We say tachycardia when the rhythm remained regular
3. We say tachyarrhythmia when it is fast and irregular.

b) Bradycardia (low pulse rate)
1. Low heartbeat rate (less than 60 beatings per minute for an adult person).
2. We say bradycardia when the rhythm remains regular and of bradyarrhythmia when it is slow and irregular. 

Rhythm
1.  Dysrhythmia or arrhythmia: a pulse with an irregular rhythm.  Tension or resistance disorders

In case of high blood pressure, the pulse gives the impression of a hard, rigid thread that rolls under the finger

2 TYPES OF PULSE

 Dicrotic pulse: Perception of two heartbeats for one diastole: the finger discerns a very strong beating and a weak beating, only count the strong beatings

 Bisferiens pulse: Perception of two heartbeats for one systole: the finger discerns a very strong beating and a weak beating, only count the strong beatings.

Pulse is assessed in different sites, the common sites are:
1.  Radial artery; This is the most commonly used. It is easily found in most people. Radial artery passes along the radial bone, on the thumb side of the inner aspect of the wrist.
 2. Brachial artery : pass in antecubital fossa
 3. Temporal artery (over the temporal bone of the head)
 4. Carotid artery (at the side of the neck below the lobe of the ear).

5. Femoral artery: where the femoral artery passes alongside the inguinal ligament
6. Popliteal artery: where the popliteal artery passes behind the knee
7. Posterior tibial artery: on the medial surface of the ankle where the posterior tibial artery passes behind the medial malleolus

8.  Pedal (dorsalis pedis): where the dorsalis pedis artery passes over the bones of the foot

Precaution 

 1. The pulse is taken on a patient at rest, sitting or lying down.
2.  Do not use thumb or just one or two fingers but always 3 fingers to feel the pulse.
3.  Do not press the artery with more force.
 Materials are Watch with second hand, Red pen and graphic chart, Stethoscope if apical pulse is to be taken

BLOOD PRESSURE

Blood pressure is the measurement of pressure pulsations exerted against the blood vessel walls during systole and diastole.

The cardiovascular system is a closed system and the measure of blood pressure determines the pressure of blood inside this system.

 It is measured in terms of millimeters of mercury (mm Hg)  as  standard But this can be converted to centimeters (cmHg)

The blood pressure gives two measures respondent to the cardiac contraction:
 The maximum (Maxima) indicates the measure of the systolic pressure, and the minimum (Minima) indicates the measure of diastolic pressure.
The variation of those two measures is the indication of assessment of cardiac activities and resistance offered by peripheral vessels.

The systolic blood pressure

Systolic pressure is the pressure exercised by the blood flow on the arterial wall at the time of the systole.

The diastolic blood pressure

 It is the pressure exercised by blood on the arteries during the diastole. This minimum pressure is constant on the level of the arteries.

Pulse pressure:

1.  This is the numeric difference between the systolic and diastolic pressure.

2.  Pulse pressure has an importance in health assessment to the diagnosis and to the prognosis.

3. This pressure represents the volume of blood thrown in the circulation during the systole

Five factors exist to maintain the normal BP

1. The pumping action of the heart (cardiac output)

2.  The peripheral resistance

3. The quantity of blood

4. The viscosity or consistence of the blood

5.  The elasticity of vessels

Physiological factors that influence the blood pressure, The common factors are:

1.  Exercise

2.  Stress

3.  Sex

4. Disease process

5. Position

6. Medications

7. Position

8. Obesity, age

Sites where to take blood pressure

 The blood pressure is usually taken on the arm using the brachial artery unless there is some damage to the arm.

If it is impossible to take BP on arms, for example because of cast, burn, lesions or various traumatism, the BP will be taken on thigh, but it is necessary to have a long sphygmomanometer to suit the thigh. Wrap the blood pressure cuff on the arm 1 inch above client’s brachial pulsation, with bladder centered over brachial artery.

Mean Arterial Pressure (MAP)

MAP represents the average pressure during the cardiac cycle.

It is calculated by:

 MAP= Systolic pressure + (2x Diastolic pressure)/3

MAP=S +(2x D)/3

 E.G. BP = 70/34 mmhg, MAP=46

Or MAP = diastolic pressure + 1/3 pulse pressure

Mean arterial pressure (MAP) represents average arterial pressure during cardiac cycle.

Has to be approximated because period of diastole is longer than period of systole.

Normal range of BP

 The systolic pressure varies between 90 and 140 mmHg, for an Adult

 For the diastolic pressure, it is between 60 and 90 mmHg, for an adult

The pulse pressure can vary from 30 to 50 mm Hg

In a healthy young adult, the pressure at the height of each pulse (the systolic pressure) is approximately 120 mm Hg, and the pressure at the lowest point of each pulse (diastolic pressure) is approximately 80 mm Hg.

Average of Normal values of BP are:

1.  New born: 70/40mmHg

2.  Infants: 90/50mmHg

3.  Adult: 120/ 60mmHg

Pathological variations of blood pressure.

It is necessary to distinguish the following pathological variations:

1. Hypotension,

2.  Hypertension.

The variations of the differential tension

Hypotension (Low Blood Pressure) When the maxima or systolic blood pressure is below 90 mm Hg.

 Hypertension (High Blood Pressure) when the systolic blood pressure or maxima is more than 140 mm Hg and that the diastolic pressure or minima is more than 90 mm Hg.

Management Hypotension

Management of hypertension include different step which are:

1. Put the patient in Trendelenburg

2. Alert the physician when you are at the hospital

3. Give physiological solution drip of preference or Ringer Lactate

4. Continue observation

5. Treat cause

6. Refer to the hospital

Management Hypertension

1.  Put the patient in supine position

2.  Assure calmness around him and to reassure maximum relaxation.

3. Refer to the hospital center if you are in health center or seek for medical advice

4. Give diuretic if the high blood pressure is very important

5.  Continue observation

6. Treat cause

7. Give glucose solution drip

Oxygen saturation (Sa02)

To measure the saturation of oxygen in blood

Measured by Pulse Oximeter

1.  Sao₂

2.  SPo₂

A pulse oximeter is a noninvasive device that estimates a client's arterial blood oxygen saturation (SaO2) by means of a sensor attached to the client's finger, toe, nose, earlobe, or forehead (or around the hand or foot of a neonate) the oxygen saturation measurement is expressed as a percentage SaO2 measure the amount of oxygen bound to hemoglobin

1. SaO₂ is expressed as the percentage of hemoglobin that is saturated with oxygen (SaO2), with 100% being fully saturated.

The pulse oximeter can detect hypoxemia before clinical signs and symptoms, such as dusky skin color and dusky nail-beds color develop.

Normal SaO2 is 95% to l00%,and an SaO2 below 70% is life threatening.  The values for SaO2 and SpO2 are the same

Factors Affecting Oxygen Saturation Readings

1. Hemoglobin

2.  Circulation

3.  Activity

4. Carbon Monoxide poisoning

Abnormalities

1.  Hypoxia and Hypoxemia :  Low level of oxygen in blood

2. Cyanosis 

1. HYPOXIA

 Early clinical manifestations of hypoxia include restlessness, apprehension, anxiety, dizziness, inability to concentrate, confusion, agitation, increased pulse rate, increased rate and depth of respiration, and elevated blood pressure (increase BP, unless the hypoxia is caused by shock).

If the hypoxia goes untreated, the respiratory rate may decline and changes in the level of consciousness progress to stupor, or coma indicating ischemia of neuronal cells resulting from oxygen deprivation.

2. CYANOSIS (bluish coloration of the skin) : this indicate Perfusion deficits resulting in poor circulation.

Clubbing of the fingers, which manifests as a flattened angle of the nailbed and a rounding of the fingertips, is a sign of chronic hypoxia.