02-05-2025 FUNDA Vital Signs

As discussed by Nurse Karl Wong.

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Signs are objective pieces of information observable and measurable by the healthcare practitioners. Contrastingly, symptoms are any piece of information reported by the client/patient regardless of whether it was measurable. Signs that fall under the categorization of “vital” are those that directly reflect the requisites for health of the patient. Contemporarily, there are five such vital signs:

Vital Sign	Reference Value
Blood Pressure	<120/<80 mm Hg
Temperature	Core: 36.5 - 37.5°C Surface: 35.5 - 36.5°C
Pulse Rate	60 - 100 BPM
Respiratory Rate	12 - 20 CPM

Moments of Vital Signs Taking

1. Admission: establishing baseline data is required upon admission. This is the first moment of vital signs taking.
2. Intervention: vital signs are taken before, during, and after any intervention.
3. Medication: vital signs are taken before, during, and after any medication administration.
4. Invasive Procedure: vital signs are taken before, during, and after any invasive procedures.
5. Changes in Status: a change in status determined by the nurse will require re-assessment.

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Temperature

Body temperature is the balance between heat generation and heat loss. In general, there are two types of body heat: core temperature, measured through contact with mucous membranes or directly from organs or muscles, and surface temperature, measured through the skin.

Methods of Heat Transfer (Loss)

1. Radiation: the transfer of heat without direct contact, such as the warmth felt from a campfire without directly touching the fire.
2. Conduction: the transfer of heat through contact with solids.
3. Convection: the transfer of heat through contact with gases i.e. drafts and wind.
4. Evaporation: the loss of heat as moisture evaporates from the surface of the body, which carries heat away from the body.

Taking Body Temperature

Site of Measurement	Heat Type	Reference Range	Considerations
Oral Temperature	Core	36.5 - 37.5°C	- Patient must be awake and oriented. - This is only used for patients 3 years old and above. - The bulb of the thermometer is placed sublingually, in contact with the side of the frenulum.
Rectal Temperature	Core	+1°C of oral; most accurate reading	- Uncomfortable; used for newborns and unconscious patients. - Clean gloves are used. - Insertion is done during inhalation when the sphincter relaxes. Insertion is 1.5” to 2” for adults and 0.5” to 1” for children.
Axillary Temperature	Surface	-1°C of oral; least accurate reading	- Safest and most comfortable method, but requires a longer time to take a reading. - The axilla must be dry. Hair may also be a problem.
Tympanic Temperature	Core	+0.3°C	- A fast and accurate method of taking temperature, often used in children. However, it may be uncomfortable, injurious, and affected by cerumen. - Straightening of the ear canal is required for a reading. For children up to three years of age, pull the ear back and down. If older, pull the ear back and up
Temporal Temperature	Surface	Same as core temperature.	- Patch-based; fast, used for children. It encounters the same problems of moisture and hair that produce inaccuracies in readings.

Mercury Thermometer Breakage

In the event of the breakage of a mercury thermometer, the nurse requires proper disposal protocol to avoid mercury poisoning. The nurse requires (a) any rubber gloves, (b) paper towels to soak up the mercury, (c) plastic bags for disposal sealed with tape, and (d) a flashlight to scan for beads of mercury. All contaminated materials must be disposed. Disposal via drain and vacuuming and sweeping are dangerous.

Body Temperature Abnormalities

1. Intermittent Fever: an intermittent fever is one whose temperature alternates between normal temperature and hyperthermia within one day. Common examples of this includes malaria and pulmonary tuberculosis.
2. Remittent Fever: a fever that maintains a high temperature with wide fluctuations (>2°C) over 24 hours.
3. Relapsing Fever: a fever with short periods (one to two days) of normal body temperature.
4. Constant Fever: a fever that maintains a high temperature with small fluctuations in temperature (<2°C) over 24 hours.

Frostbite

1. First Degree Frostbite: the skin is intact; it is often only reddened— circulation is intact.
2. Second Degree Frostbite: frost has penetrated into the epidermis.
3. Third Degree Frostbite: frost has penetrated into the subcutaneous tissue.
4. Fourth Degree Frostbite: tissue has become necrotic and blackened.

The Thermoregulatory Center of the Brain

The Hypothalamus is responsible for the regulation of the body. Damage to this region can cause thermal dysregulation.

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Pulse Rate

A pulse is produced by the sudden gushing of blood from contraction of the heart. Each pulse is equivalent to one stroke of the heart.

Parameters of a Heart Beat

1. Stroke Volume: the amount of blood sent through the body with each contraction of the heart.
2. Cardiac Output: the amount of blood sent through the body in one minute. This is equal to the stroke volume multiplied by the heart rate.
3. Heart Rate: the amount of contractions performed by the heart in one minute.
4. Compliance: the ability of vasculature to undergo distention when pressure is applied by a heart beat.

Age Group	Reference Range	Average
Newborns	120 - 160 BPM	130 BPM
Children	75 - 120 BPM	100 BPM
Adults	60 - 100 BPM	80 BPM
Older Adults	60 - 100 BPM	70 BPM

Taking Pulse Rate

A pulse can be classified as central or peripheral. This is based on its location. Only one area is commonly used as the central pulse, the apical pulse located on the left mid-clavicular line at the 4th to 5th intercostal space (or right under the nipple), also known as the point of maximal impulse. This is the true pulse that reflects all contractions. All other pulses that are not apical are considered peripheral and may reflect inaccurate findings depending on the individual e.g. peripheral vascular diseases.

Auscultation

Auscultation for apical pulse utilizes the diaphragm, and the bell for all peripheral pulses. Alternatively, a doppler may also be used.

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Respiratory Rate

Respiration is required in order to allow oxygen to enter the body and for carbon dioxide to exit the body. There are two processes involved— ventilation, the physical movement of air in and out of the lungs, and respiration, the actual gas exchange that occurs through diffusion. Respiration can be further divided between external respiration, gas exchange between the alveoli and blood, and internal respiration, gas exchange between the blood and body tissues.

Center for Respiration

The body determines the need for breathing based on chemoreceptors found in the carotid and aortic bodies. These detect the level of carbon dioxide in the blood and signals the person to breathe.

Breathing Pattern	Description
Costal/Thoracic Breathing	Breathing facilitated by the thoracic muscles/costals. Breathing in this way expands the thorax.
Diaphragmatic/Abdominal Breathing	Breathing facilitated by the diaphragm, the major respiratory muscle of the body. Breathing in this way expands the abdomen. - This is only normal in newborns.
Eupnea	Normal breathing pattern
Tachypnea	Increased rate of breathing
Bradypnea	Decreased rate of breathing
Apnea	The cessation of breathing
Cheyne-Stokes Respirations	Rapid, shallow breathing interrupted by periods of apnea.
Kussmaul Respirations/Hyperventilation	Rapid, deep breathing often found in acidosis.
Biot Respirations	Irregular; non-rhythmic breathing patterns. This may be observed when the medulla oblongata has been damaged.
Apneustic	Prolonged inhalation and shortened exhalation breathing.
Agonal Breathing	Failure to breath due to brainstem injury

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Blood Pressure

Blood pressure is the pressure placed on the blood vessels by the heart during its systolic and diastolic phases.

1. Systolic Pressure: the blood pressure at the moment of ejection/during contraction of the heart.
2. Diastolic Pressure: the blood pressure at the moment of filling/relaxation of the heart.
3. Pulse Pressure: the pressure difference between systolic and diastolic ($PP=SP-DP$) that indicates the amount of pressure produced by a contraction of the heart, which is often used to reflect fluid status of an individual. It normally sits around 40 mm Hg and ranges from 30 to 50 mm Hg.

Normal Blood Pressure Range

Hypertension categories according to the American Heart Association (AHA) may be classified according to the following. Only one criteria between systolic and diastolic pressure is required to classify an individual as pre-hypertensive or above; both criteria for normal blood pressure is required to classify an individual as normal.

Category	Systolic Blood Pressure	Diastolic Blood Pressure
Normal Blood Pressure	<120 mm Hg	<80 mm Hg
Prehypertension	120-139 mm Hg	80-89 mm Hg
Hypertension I	140-159 mm Hg	90-99 mm Hg
Hypertension II (Hypertensive crisis)	160+ mm Hg	100+ mm Hg

Taking Blood Pressure (Brachial)

Preparation

Patients must rest approximately 15 minutes after activity for an accurate blood pressure reading. For those who are caffeinated or have smoked, a 30 minute rest period is given in order to obtain an accurate reading. When reading, the patient is seated if possible.

The nurse inflates the cuff one to two inches above the brachial artery (if being taken at the popliteal fossa) up to 30 to 50 mm Hg above the pressure where the pulse becomes obliterated. Once deflated slowly (2 to 3 mm Hg/s), there are five Korotkoff sounds that the nurse hears:

1. Korotkoff 1: the first tap or thud indicating the return of blood flow, representing the systolic pressure.
2. Korotkoff 2: a swishing or whooshing
3. Korotkoff 3: a thumping sound
4. Korotkoff 4: a blowing sound
5. Korotkoff 5: The following silence. The point at which the diastolic has returned, and is recorded as the diastolic pressure.

Mistakes in Blood Pressure Taking

1. If the patient is sitting, the feet must not dangle; this will increase blood pressure.
2. Whether laying down or seated, the arm must be approximately at the level of the heart. If it is positioned higher, a low reading will appear, and if it positioned lower, a higher reading will appear.

Taking Blood Pressure (Thigh)

The thigh may also be used in order to obtain a blood pressure reading. The patient must be positioned supine with the knees slightly bent, and the same procedure is done. The findings, however, is around 30 mm Hg above the same finding done at the upper extremities.

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Pain

Pain is the unpleasant subjective experience that is a recent addition to the vital signs by the JCI. Pain is induced by the stimulation of ** nociceptors** that experience nociception. Pain levels are unique to the individual, and is a priority problem even by itself. It is related to:

1. Actual or potential tissue damage.
2. Loss or decrease in function.
3. Decrease in quality of life.

The Brain Center and the Phases of Nociception

The dorsal posterior insula is the center of nociception and detects pain. In reacting to pain, there are four phases of nociception:

1. Transduction: the exposure to noxious physical (mechanical and thermal) or chemical stimuli.
2. Transmission: the movement of nerve impulses through the neural networks of the body.
3. Modulation: the initial response of the body to noxious stimuli in the form of stimulatory or inhibitory in reference to the noxious stimuli— it may increase or decrease the sensation of pain. Put into practice, Cox inhibitors apply their analgesic effect by inhibiting the stimulatory effect of Cox on pain impulses. Similarly, endorphins are endogenous opioids that exert an inhibitory effect on noxious stimuli.
4. Perception: awareness of the pain sensation.

Gate Control Theory

The most accepted biological theory on the process of nociception. It proposes that there exists a “gate” in the nervous system that either opens or closes to modulate noxious stimuli. Specifically, this gating process occurs in the dorsal cord (substantia gelatinosa) of the spinal cord. Descending pathways sends modulators in the form of endorphins that modulate incoming dull, burning chronic pain.

1. Nociceptors (A-delta, and C-fibers) detect noxious stimuli.
2. A-delta fibers sent quick, sharp, localized pain through the ascending pathways to the brain via saltatory conduction. These are myelinated nerve cells that allow for faster conduction as impulses jump across the nodes of ranvier.
   • Endorphin, enkephalin, bradykinin, substance P, and histamine are substances that assist in nerve impulse through the ascending pathways.
3. The brain detects the pain, and sends appropriate modulators through the descending pathways to the dorsal cord (substantia gelatinosa) to control the dull, burning, chronic pain being sent by the C-fibers.

Concepts of Pain

1. Pain Threshold: the minimum amount of stimuli required to produce a response considered as pain.
2. Pain Tolerance: the maximum amount of stimuli an individual is able to manage.
3. Hyperalgesia: a hypersensitivity to noxious stimuli; an exaggerated response.
4. Allodynia: a normally non-painful stimuli becomes perceived as noxious.
5. Dysesthesia: an abnormal sensation, often presenting as pain. It is the misinterpretation of stimuli as other forms of stimuli, such as perceiving the sensation of feathers to that of warm or prickly feelings.
6. Desensitization: an increase in pain threshold from repeated or gradual exposure to stimuli.

Taking Pain Levels

The assessment of pain often uses the mnemonic “PQRST and U” of pain.

• Precipitating/Provoking and Palliative Factors: What causes the pain? What relieves the pain?
• Quality or Quantity: How severe are the symptoms? How does it look, feel, or sound? Quantify the level of pain using the pain scale.
• Region or Radiation: where is pain found? Does the pain spread or radiate anywhere?
• Severity Scale: how bad is the pain on a scale from 1 to 10?
• Timing and Treatment: when was the onset, what is the duration, and how often does pain occur? What has the patient done to attempt to relieve the pain?
• Understanding: assess the patient’s understanding of their pain— their health beliefs and thus their compliance.

Pain Scales

1. Numerical Rating Scale: a pain rating scale that bases pain from 1 to 10 with a chart of pre-defined levels of pain along the spectrum. Often, the nurse only presents 1 as no pain and 10 as the worst pain they have experienced .
2. Wong Baker Faces: a series of simplistic faces representing different levels of grimacing. This is used for pediatric clients who are unable to put their pain levels into words or numbers.
3. Visual Analog
4. FLACC Scale: a pediatric pain scale used for patients who are unable to express their pain. The nurse performs the assessment by checking their face, legs, arms, cry, and consoleability.

Pain Treatment Issues

A major problem with pain treatment, especially in chronic settings, is the use of medications. Opioids are often used, and are controlled substances because they are highly addictive and prone to dependence and abuse.

1. Tolerance: the development of ineffectiveness of pharmacologic intervention used for pain as the body adapts to the medications used for prolonged periods of time.
2. Dependence: the emergence of physiological and psychological withdrawal symptoms upon withdrawal of the medication. Physical dependence is the presence of physiological signs alone, while the involvement of psychological dependence can be classified as an addiction.