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Course: Fundamentals of Nursing�Topic: Measuring Vital signs

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Module Goals

Learners will be able to:

Discuss the various vital signs, including normal ranges..
Identify when to assess vital signs, including pain assessment.
Describe cultural and ethnic variations in vital signs, including pain assessment.
Demonstrate proper technique for for assessment of vital signs, including pain assessment.

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Vital Signs

Obtained before any physical assessment.
Measurement of body’s basic function.
Are measured by healthcare providers routinely when seeing clients.
Vital signs include:

Body Temperature
Pulse
Respiratory rate
Blood pressure
Oxygen Saturation
Pain

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Temperature

Typically measured in degree celsius (ºC).
Normal ranges vary in with different locations of the body.
Documentation varies with health care agencies in degrees Celsius.
Methods of measuring vary as per age, cognitive functioning, level of consciousness, health status, and agency policy.

Common methods include:

Oral
Tympanic
Axillary
Rectal
Temporal

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Table 1.3 Normal Temperature Ranges

Method	Normal Range
Oral	35.8 – 37.3ºC
Axillary	34.8 – 36.3ºC
Tympanic	36.1 – 37.9ºC
Rectal	36.8 – 38.2ºC

Hypothermia: Temperature below the lower limit i.e. below 95 F (35 C)
Hyperthermia: Abnormally high body temperature i.e. above 104 F( 40 C)
Pyrexia: Temperature exceeding upper limit i.e. Fever

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Oral Temperature

Ranges:

35.8 – 37.3ºC

(96.4 – 99.1ºF)

Oral thermometer has blue coloring, indicating it is an oral or axillary thermometer
Reading reliable when obtained close to the sublingual artery

Factors to be considered while choosing oral route

Recommendation: Wait 15 to 25 minutes following the consumption of a hot/cold beverage/food or 5 minutes after chewing gum or smoking

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Taking Oral Temperature

Remove cap using non touch technique.
Place the thermometer in the posterior sublingual pocket under the tongue, slightly off-center.
Instruct the client to keep their mouth closed but not bite on the thermometer.
Leave the thermometer in place for as long as is indicated by the device manufacturer (typically beeps within a few seconds).
Read the digital display of the results.
Wipe the thermometer and place it as per policy.

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Critical Thinking Question

You are about to take oral temperature on an adult conscious client. On taking consent, which statement given by the client indicates client has not understand the instructions correctly?

“I should not bite on the thermometer probe.”
“The thermometer will be placed under my tongue.”
“The thermometer will beep once it finishes taking the temperature.”
“I should keep my mouth slightly open while the thermometer is in place.”

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Axillary Temperature

Minimally invasive way to measure temperature.
It uses the same electronic device as an oral thermometer (with blue coloring).
Can be as much as 1ºC lower than the oral temperature.

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Taking Axillary Temperature

Open the thermometer.
Ask the client to raise their arm and place the thermometer probe in their armpit on bare skin as high up into the axilla as possible.
The probe should be facing behind the client.
Ask the client to lower their arm and leave the device in place until it beeps (usually about 10–20 seconds).
Read the displayed results and document as per policy.

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Tympanic Temperature

Typically 0.3 – 0.6°C higher than an oral temperature.
An accurate measurement.
Not suitable for the client who has a suspected ear infection.

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Taking Tympanic Temperature

Use non-touch techniques to place a probe by removing the tympanic thermometer from its holder.
Turn the device on.
Ask the client to keep their head still.
For the adult, gently pull the outer ear up and back to visualize the ear canal.
For an infant or child under age 3, gently pull the helix down
Insert the probe just inside the ear canal (do not force the thermometer into the ear).
Wait for the device to beep.
Read the results displayed, wipe the thermometer and then place the device back into the holder.

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Temporal Temperature

Can quickly measure the temperature of the skin on the forehead.
Usually 0.5°F (0.3°C) to 1°F (0.6°C) lower than an oral temperature.
Uses infrared technology to measure the temperature.
Less accurate: Direct sunlight, cold temperatures or a sweaty forehead can affect the readings.

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Taking Temporal Temperature

Activate the device with the power button.
Position it no more than 2 inches from the center of the forehead

(Some models need to be placed on the temporal region on forehead Either way, you’ll get the most accurate reading possible if the forehead is clean and clear of hair).

Make sure to hold the thermometer steady.
Press the temperature button.
The device will beep or flash when the temperature is ready to be read.

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Rectal Temperature

An invasive method.
Used only when other methods are not appropriate.
Measuring infant’s temperature, because of its accuracy.
Usually 1ºC higher than oral temperature.
Has red coloring to distinguish it from an oral/axillary thermometer.

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Taking Rectal Temperature

Ensure the client’s privacy.
Wash your hands and put on gloves.
Position the client on their side.
Remove the probe from the device and place a probe cover on the thermometer.
Lubricate the cover with a water-based lubricant, and then gently insert the probe 2–3 cm inside the anus.
Remove the probe when the device beeps (if digital) if its manual, need to wait for 1-2 minutes.
Read the result and then discard the probe cover in the trash can without touching it.
Cleanse the device as indicated by agency policy, remove gloves, perform hand hygiene.

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Critical Thinking Question

During nursing handover, nurse A says the client you are taking care of is hypertensive but afebrile. On saying so, you understand that client has which of the following vital signs?

Blood pressure reading of 120/80 mm of Hg and temperature of 101.2 degree fahrenheit
Blood pressure reading of 142/96 mm of Hg and temperature of 96.4 degree fahrenheit
Blood pressure reading of 142/96 mm of Hg and Spo2 of 98%
Blood pressure reading of 144/98 and Pain scale of 4 out of 10.

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Pulse

Pulse refers to number of times the heart beats per minute.
Palpated at many arterial points.
The most common locations include radial, brachial, carotid, and apical areas.
Measured in beats per minute.
Pulse rate differs with age.
Affected by: anxiety, blood pressure, pain, rest, crying, emotional states, fever, etc.
Best to assess when a client is resting and comfortable.

Note: Pulse should be counted for a full 60 seconds unless told otherwise by the healthcare provider

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Pulse Rate/Heart Rate

Age Group	Heart Rate
Preterm	120 – 180
Newborn (0 to 1 month)	100 – 160
Infant (1 to 12 months)	80 – 140
Toddler (1 to 3 years)	80 – 130
Preschool (3 to 5 years)	80 – 110
School Age (6 to 12 years)	70 – 100
Adolescents (13 to 18 years) and Adults	60 – 100

Tachycardia: Heart rate exceeding upper limit
Bradycardia: Heart rate below lower limit

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Character of Pulse

When assessing pulses, documentation include rhythm, rate, force, and equality.

Pulse rhythm:
Pulse Rate:
Force:
Equality:

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Character of Pulse

1. Pulse rhythm: Means it has constant beats/tempo with equal interval when felt by fingers

2. Pulse Rate: Number of beats, counted with the first beat felt by the finger, counted for full one minute

3. Pulse Force: Is the strength of pulse.Uses a four point scale:

3+: Full, bounding
2+ : Normal/strong
+1: Weak, diminished, thready
0: Absent/nonpalpable

4. Equality: Refers to a comparison of the pulse forces on both sides of the body

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Note:

Some cardiovascular conditions, such as atrial fibrillation, cause an irregular heart rhythm. If a pulse has an irregular rhythm, document if it is “regularly irregular” (e.g., three regular beats are followed by one missed and this pattern is repeated) or if it is “irregularly irregular” (e.g., there is no rhythm to the irregularity)
If a pulse is absent, a Doppler ultrasound device is typically used to verify perfusion of the limbs.
A nurse often palpates the radial pulse on a client’s right and left wrists at the same time and compares if the pulse forces are equal. However, the carotid pulses should never be palpated at the same time because this can decrease blood flow to the brain. Pulse equality provides data about medical conditions such as peripheral vascular disease and arterial obstruction.

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Radial Pulse

Use the pads of your first three fingers to gently palpate the radial pulse.

Placement: Fingertips are placed close to the flexor aspect of the wrist along the radius bone on the lateral side of the wrist (thumb side).

Press down with the fingertips until pulse is felt without disrupting the wave of the force.

Note: Radial pulse is difficult to find on newborns /under 5 age therefore, brachial or apical pulses are obtained.

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Carotid Pulse

Typically palpated during medical emergencies because it is the last pulse to disappear.

Technique:

Locate carotid artery in the sternomastoid muscle (between the muscle and the trachea, in the middle third of the neck).
Use pads of three fingers to palpate.
Both carotid arteries should not be palpated together as it obstructs blood supply to the brain.

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Brachial Pulse

Located on bicep tendon in the area of the antecubital fossa.
Palpated best when arm is hyperextended.
Palpated with pads of the three fingers medially from the tendon about 1 inch just above the antecubital fossa.
Need to move fingers around slightly to locate the best place.
Typically need to press fairly firm to palpate the brachial pulse.

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Apical Pulse

The most accurate method of obtaining a pulse.
Obtained by listening to the client’s chest wall with a stethoscope.
Found on left-center of one's chest just below the fifth intercostal space at the left midclavicular line.
Usually taken while the client is lying or sitting down.

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Critical Thinking Question

While taking vitals signs of an 28 years old client, a nurse finds the pulse rate to be 138 beats/min. What should the nurse do next?

Check the pulse again in 2 hours.
Check the blood pressure.
Record the information.
Report the rate to the primary care provider.

**What term would you use for this high pulse rate?

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Respiratory Rate

Refers to a person’s breathing and the movement of air into and out of the lungs.
A respiratory cycle (i.e., one breath while measuring respiratory rate) is one sequence of inspiration and expiration
Recorded as bpm (breaths per minutes)
Assessed for quality, rhythm, and rate.
The quality of a person’s breathing is normally relaxed and silent (Upnea)

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Respiratory Rate

Normal respirations have a regular rhythm in awake children and adults.
Newborns and infants commonly exhibit an irregular respiratory rhythm.
Normal respiratory rates vary based on age.
Factors influencing respiration are sleep cycle, emotional status, presence of pain, and crying when assessing a client’s respiratory rate.

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Respiratory Rate as Per Age

Age	Normal Range
Newborn to one month	30 – 60
One month to one year	26 – 60
1-10 years of age	14 – 50
11-18 years of age	12 – 22
Adult (ages 18 and older)	10 – 20

Apnea: Absence of breathing
Eupnea: Normal breathing
Orthopnea: unable to breath laying down
Dyspnea: breathing difficulty
Tachypnea: Respiratory rate exceeding upper limit
Bradypnea: Respiratory rate below lower limit

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Blood Pressure

The force of the blood pushing against the arterial walls during contraction and relaxation of the heart.
Two numbers are recorded when measuring blood pressure: Systolic and Diastolic.
Recorded as "mm of Hg" (millimeters of mercury).
The higher number (or systolic pressure) refers to the pressure inside the artery when the heart contracts (pumps blood).
The lower number (diastolic pressure) refers to the pressure inside the artery when the heart is at rest and is filling with blood.

b. Ernstmeyer & Christman, 2021

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Blood Pressure Category: Based on reading

Normal blood pressure: Systolic less than 120 and diastolic less than 80 (120/80).
Elevated blood pressure: Systolic 120 to 129 and diastolic less than 80.
Stage 1 high blood pressure: Systolic ranges between 130 to 139 or diastolic between 80 to 89.
Stage 2 high blood pressure: Systolic is 140 or higher or the diastolic is 90 or higher.

Hypertension: Blood pressure exceeding upper normal limit.
Hypotension: Blood pressure below the lower normal limit
Orthostatic hypotension: A sudden drop in blood pressure because of positional changes

(Ernstmeyer & Christman, 2021)^b

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Taking Blood Pressure

Client should not smoke or drink coffee for 30 minutes before taking blood pressure.
Have the client use the bathroom before the test.
Wait for 5 minutes before taking the measurement.
Client should sit with back supported .
Client should keep their feet on the floor uncrossed.
Place client’s arm on a solid flat surface (like a table) with the upper part of the arm at heart level.
Place the middle of the cuff directly above the bend of the elbow.
Inflate the cuff until the no radial pulse can be fels on the same arm.

Ernstmeyer & Christman, 2021

Sapra et al, 2021

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Taking Blood Pressure

Place the stethoscope diaphragm over the brachial artery and slowly deflate the cuff.
The first pulse sound (1st korotkoff sound) is systolic and last sound (2nd korotkoff sound) is diastolic blood pressure.
Take multiple readings. When you measure, take 2 to 3 readings one minute apart and record all the results.
Take your blood pressure at the same time every day, or as your healthcare provider recommends.
Report the health care provider in case of consistent abnormal recordings.

Ernstmeyer & Christman, 2021

Sapra et al, 2021

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Taking Blood Pressure with automatic machine

Position the client and place the correct sized blood pressure cuff on the bare arm.
Press the start button on the monitor.
The cuff will automatically inflate and then deflate.
The monitor digitally displays the blood pressure reading when done.
Not suitable for the client with a rapid or irregular heart rhythm, such as atrial fibrillation, or has tremors.

Ernstmeyer & Christman, 2021

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Nursing Consideration while taking Blood Pressure

No caffeinated drinks should be consumed for at least an hour and no smoking or no nicotine products for at least 15 minutes before prior to taking blood pressure.
Have clients empty the bladder: A full bladder adds 10 mm of hg allow client to sit for 5 mins before checking blood pressure.
No conversation while taking blood pressure: Talking and listening might add 10 mm of Hg.
Client’s arm needs to be supported, uncrossed legs: unsupported and crossed leg adds 6 mm of Hg.
Unsupported arm may add 10 mm of Hg.
Wrong size cuff gives false reading: smaller cuff gives false high and larger cuff gives false low blood pressure reading.

Sapra et al, 2021

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Case Study

A client walks into your clinic and you record his blood pressure at 150/98 mm of Hg. While asking about his previous blood pressure readings. Is this considered hypertension?

Why?
If the client has 3 separate recordings that are around the previous reading, what stage of hypertension would the client be in?

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Pain

Ernstmeyer & Christman, 2021

Pain is considered as the fifth vital sign
Pain assessment: Mnemonics:
“PQRSTU,” “OLDCARTES,” or “COLDSPA”.
Open-ended questions are asked to allow the client to elaborate on information.
If their answers do not seem to align, continue to ask focused questions to clarify information.

Note: The thorough version of pain, scales, assessment tools will be discussed in the chapter Pain.

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Pain Assessment: Mnemonic “OLDCARTES”

Onset: When did the pain start? How long does it last?
Location: Where is the pain?
Duration: How long has the pain been going on? How long does an episode last?
Characteristics: What does the pain feel like? Can the pain be described in terms such as stabbing, gnawing, sharp, dull, aching, piercing, or crushing?
Aggravating factors: What brings on the pain? What makes the pain worse? Are there triggers such as movement, body position, activity, eating, or the environment?

Ernstmeyer & Christman, 2021

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Pain Assessment: Mnemonic “OLDCARTES”

Radiating: Does the pain travel to another area or the body, or does it stay in one place?
Treatment: What has been done to make the pain better and has it been helpful? Examples include medication, position change, rest, and application of hot or cold
Effect: What is the effect of the pain on participating in your daily life activities?
Severity: Rate your pain from 0 to 10 being 0 no pain to 10 extreme pain

Ernstmeyer & Christman, 2021

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Pain Assessment Tools

Pain Scales

In addition to using the PQRSTU or OLDCARTES methods of investigating a client’s chief complaint, there are several standardized pain rating scales used in nursing practice

FACES SCALE
FLACC SCALE
COMFORT BEHAVIORAL SCALE
PAIN ASSESSMENT IN ADVANCED DEMENTIA (PAINAD) SCALE

Ernstmeyer & Christman, 2021

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Pain Assessment Tools

1. NUMERIC RATING SCALE: Represents scale from 0-10: 0 being no pain and 10 being extreme pain.

2. FACES SCALE: The FACES scale is a visual tool for assessing pain with children and others who cannot quantify pain on a scale of 0 to 10. pain is represented in faces E.g Wong Baker’s Face pain rating scale.

3. FLACC SCALE: The scale has five criteria, ( i.e., the Face, Legs, Activity, Cry, Consolability scale)which are each assigned a score of 0, 1, or 2. used in children between the ages of 2 months and 7 years or individuals.

Ernstmeyer & Christman, 2021

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Pain Assessment Tools

4. COMFORT BEHAVIORAL SCALE: Used in children of all ages who are receiving mechanical ventilation. Eight physiological and behavioral indicators are scored on a scale of 1 to 5 to assess pain and sedation.

5. PAIN ASSESSMENT IN ADVANCED DEMENTIA (PAINAD) SCALE: The Pain Assessment in Advanced Dementia (PAINAD) Scale is a simple, valid, and reliable instrument for assessing pain in noncommunicative clients with advanced dementia.

Ernstmeyer & Christman, 2021

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What would the nurse do?

A nurse is caring for an unconscious client who recently had head trauma due to road traffic accident. The client is on a respirator. Which of the following assessment methods is appropriate in this case?

FLACCE
Numerical pain scale
Behavioral Pain Scale
Wong-Baker FACES Pain Rating Scale

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Oxygen Saturation (SpO2)

An efficient, noninvasive method to assess a client’s oxygenation status.
Routinely assessed using pulse oximetry.
A pulse oximeter includes a sensor that measures light absorption of hemoglobin.
Is an estimated oxygenation level based on the saturation of hemoglobin.
Normal range: 94-100%.
Chronic respiratory conditions, such as COPD, the target range is often lower at 88% to 92%.

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Oxygen Saturation (SpO2)

For intermittent measurement of oxygen saturation, a spring-loaded clip is attached to a client’s finger or toe.
Sensor may be taped to a finger or toe in case of newborn and children.

Factors affecting SpO2: Nail polish, pigmentation of skin, excessive client movement/motion artifacts, decreased perfusion, anemia.

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Red Flags

Any abnormal reading i.e. below or exceeding normal range of pulse, respiratory rate, blood pressure, oxygen saturation, spo2 level is considered a red flag.

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Cultural Considerations

Muslim women and even men are not comfortable with the nurse of opposite sex.
Pain is perceived differently in different gender: Males do not easily verbalize the pain.
In a study it was found that South Asian males had significantly lower thermal pain thresholds and experienced higher pain intensity than British White males (Peacock & Patel, 2008).
African-American clients reported greater pain intensity than Caucasians (Peacock & Patel, 2008).

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Cultural Considerations

African Americans ages 35-64 years are 50% more likely to have high blood pressure than whites (CDC, 2017)
According to Vigil et al (2016),

African-American, Hispanic, and mixed-ethnicity clients reported higher levels of pain and had slower heart rate and respiratory rate than non-Hispanic White (NHWs).
Asian-American clients also had slower respiratory rate than NHW clients, on average.
Female clients and Clients with a greater number of documented behavioral problems had higher pain scores, slower heart rates, and faster respiratory rate.

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References:

Centre for Disease Control and Prevention (2017). Vital Signs: African American Health. Retrieved on 25th of July 2021 from https://www.cdc.gov/vitalsigns/aahealth/index.html

Ernstmeyer, K., & Christman, E. (Eds.). (2021). Open RN Nursing Fundamentals. By Chippewa Valley Technical College, licensed under CC BY 4.0. https://wtcs.pressbooks.pub/nursingskills/chapter/1-3-vital-signs/^a

Ernstmeyer, K., & Christman, E. (Eds.). (2021). Open RN Nursing Fundamentals. By Chippewa Valley Technical College, licensed under CC BY 4.0. https://wtcs.pressbooks.pub/nursingskills/chapter/3-3-blood-pressure-assessment/ ^b

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References:

Ernstmeyer, K., & Christman, E. (Eds.). (2021). Open RN Nursing Fundamentals. By Chippewa Valley Technical College, licensed under CC BY 4.0. https://wtcs.pressbooks.pub/nursingfundamentals/chapter/11-3-pain-assessment-methods/ ^c

Peacock, S., & Patel, S. (2008). Cultural Influences on Pain. Reviews in pain, 1(2), 6–9. https://doi.org/10.1177/204946370800100203

Sapra A, Malik A, Bhandari P. Vital Sign Assessment. [Updated 2021 May 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK553213/

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References:

Vigil, J. M., Coulombe, P., Alcock, J., Kruger, E., Stith, S. S., Strength, C., Parshall, M., & Cichowski, S. B. (2016). Patient Ethnicity Affects Triage Assessments and Patient Prioritization in U.S. Department of Veterans Affairs Emergency Departments. Medicine, 95(14), e3191. https://doi.org/10.1097/MD.0000000000003191

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