Week 3 - Class 1 (Vital Signs)

Question 1

When should I assess vital signs?

Answer 1

Short Answer:
- Constantly

Long Answer:

• Newly admitted for baseline
• As per MD order or facility’s routine
• Pre and post surgery
• Pre and post certain procedures
• Before, during, & after administration of specific drugs
• As indicated by client condition/response: “I feel dizzy, weird, funny, different”
• It’s always the best place to start with any assessment – things can go south in the blink of an eye
• Generally, unless there is something that takes precedence, start with vital signs

Question 2

What plays a major role in collecting vital signs?

Answer 2

Your judgement

- When in doubt, do it

Question 3

Vital Signs:
Temperature
- Definition
- Normal Body Temp.
- Assessed to?

Answer 3

Represents the difference between heat produced by body metabolism and heat lost through the skin

Normal body temperature is 37 ºC (or 98.6° F)

Assessed to:
- To establish baseline, for comparison across time
- To monitor hyper/hypothermic states
- To assess for infection
- To monitor effectiveness of treatment for infection
monitor reaction in blood transfusion

Question 4

At what temperature are cells irreparably damaged & enzymes denatured, rendering death a certainty?

Answer 4

43C

Question 5

Where is the thermoregulatory centre located?

- What 3 things does it consists of and what to they do as a whole?

Answer 5

Hypothalamus
- It consists of the heat-loss centre, the heat-promoting centre, and the pre-optic region which all analyze and coordinate responses to maintain body temperature within the homeostatic range

Question 6

What are expected normal ranges of temperature?

• Oral
• Axilla
• Tympanic
• Temporal
• Rectal

Answer 6

1) Oral: 36.5 to 37.5C
2) Axilla: 35.9-37.2C
3) Tympanic: 36-37.5C
4) Temporal: 36.5-37.5C
5) Rectal: 37-37.5C

Question 7

Some considerations when taking temperature:

Answer 7

1) When using different methods to take temperatures, consider the temperature may be higher/lower than what appears
2) Does the order of vital signs matter?

Question 8

What does febrile and afebrile stand for?

Answer 8

Febrile: Has a fever

Afebrile: Does not have a fever

Question 9

What is the conversion between F and C

Answer 9

F to C:
(F - 32) / 1.3

C to F:
(C x 1.8) + 32

Question 10

What is the most common route when taking temperature?

Answer 10

Oral

Question 11

How do you know what route to take when measuring temperature?

Answer 11

1) Level of consciousness
- I’m not sticking an oral thermometer-probe into the mouth of my unconscious patient

2) Is there sufficient blood flow to the area?
- That’s how thermometers work – they sit next to a large blood vessel or close to the body’s core to sense body temperature
- If I have a client with impaired blood flow to, say, the mouth perhaps due to surgery or disease process, then I need to choose a different route

3) Is it safe?
- If I have a confused elderly person who does not understand my explanation or could possible bite down on the meal probe, I shouldn’t use the oral route
- This is an example of a time when using the axillary route would be ideal
- Non invasive, sometimes not even noticeable, but it’s a peripheral surface temperatures so lower than the others.
- Nurses factor this knowledge in when they are interpreting the results of the vital signs they’ve assessed.

4) Similarly, inserting a rectal thermometer into a baby’s rectum has the potential to perforate that tiny fragile little bowel
- Not safe, choose something else.

5) Consistency is important when tracking a patient’s temperature over time
- Assessing the temperature every 4 hours with a different route each time is potentially inaccurate and definitely inconsistent in terms of the trend for that patient
- Pick one and stick with it, unless contraindicated

Question 12

What are core temperature vs. surface temperature routes?

Answer 12

Core:

• Rectal
• Tympanic

Surface:

• Skin
• Oral
• Axilla

Question 13

What are less commonly used routes of temperature? Where are they used?

Answer 13

1) Esophageal
2) Pulmonary artery
3) Urinary bladder

Intensive care unit (ICU)

• It’s great because it is a true core temperature measurement, and this is important when patients are so ill, but it’s also invasive
• The ICU is set up with different equipment and lines to do this

Question 14

Which route of temperature is unreliable?

Answer 14

Tympanic

• Earwax
• Inconsistent technique
• Shape of ear canal

Rectal

• Impractical
• Invasive
• Time consuming
• A lot of blood flow and vessels located in that area

Question 15

How do you enhance accuracy of taking temperature?

Answer 15

1) Ask PT if they had anything hot, cold, gum, and/or smoked
- This affects blood flow

2) Placing the thermometer next to the sublingual artery
3) Position the ear straight so the infrared sensor on the thermometer can reach the tympanic membrane

Question 16

Vital Signs:

Respirations

Answer 16

1) Rate: # of inspirations / expirations per 30 seconds
- Count for a full 60 when irregular

2) Rhythm: regularity of inspiration/expiration. Observe muscle group use.
- Normal expiration is about twice as long as inspiration

3) Depth/effort: degree of movement in chest wall, use of accessory muscles, laboured
- Ex. Shallow

Question 17

Do you document on the rate, rhythm and depth/effort?

Answer 17

No, just the rate

Question 18

What are 3 abnormal respirations and breathing?

Answer 18

1. Croup cough & retractions
   - Here you’ll hear a distinctive sound indicative of croup
   - It’s sometimes described as sounding like a ‘barking seal which is kind of accurate
   - Look closely as well for retractions - These are movements of the chest wall that are sort of opposite to what you’d be expecting to happen
   - In this video, instead of chest wall ‘excursion’ (movement outward) with breathing, you see a sucking-in movement
   - You would document a finding like that as retractions, and it’s an abnormal characteristic of breathing that you would notice, perhaps while doing your vital signs
2. The next clip will show you an example of grunting
   - This is something that might not ring any respiratory bells until you learn that grunting is a sign of respiratory dysfunction/distress in very young children
3. Sleep apnea is something you may be familiar with already.
   - Apneic episodes stretches of time, that vary in length, during which the patient does not breathe
   Some people have severe apnea, others not so severe
   - There are interventions to assist with managing it and the health consequences of it, but assessment of this aspect of vital signs simply calls for you to be able to recognize and name it

Question 19

Increase or decrease of respiratory rates in the following circumstances?

• Young age
• Exercise
• Hypothermic
• Anxiety
• Smoking
• Upright body position
• Opioid/narcotic medications
• Medical condition (i.e. anemia)

Answer 19

1) Young age - increase
2) Exercise - increase
3) Hypothermic - decrease
4) Anxiety - increase
5) Smoking - increase
6) Upright body position - decrease
7) Opioid/narcotic medications - decrease
8) Medical conditions (i.e. anemia) - increase

Question 20

Vital Signs:

Pulse

Answer 20

The radial (i.e. princeps pollicis) pulse is the go-to site of assessment

• It is used for adults, and children 3 years and older
• Easily accessible site
• The radial artery is quite superficial so it doesn’t take much

Question 21

You never us your thumb to find/count the pulse…why not?

Answer 21

Your thumb has an artery running through it, so it has a pulse of its own!
- You don’t want your own pulse to interfere with your ability to accurately assess your patient’s pulse.

Question 22

What is a pulse?

Answer 22

With each ventricular contraction of the heart, a pulse wave travels from the aorta through to the distal ends of the arteries
- That’s what a pulse is, and that’s what you are counting.

Question 23

What is the pulse you actually feel?

Answer 23

Some people think that the pulse you feel under your fingers is the actual blood surging through the vessel, pulsing as it goes.
- That’s not it - It’s the reverberation from the impulse that you feel.

Question 24

How do you find the radial?

Answer 24

Located inside of wrist, close to hand, on thumb side:

• Use the pads of two fingers and gentle press
• Too much pressure and you will obliterate the pulse!
• If you cannot feel anything, try easing up on the pressure and repositioning your fingers

Question 25

How do you count the pulse?

Answer 25

Count for 30 seconds then multiply by 2 to get beats per minute

Question 26

What are three characteristics of the pulse?

Answer 26

1) Rate
2) Rhythm
3) Strength

Question 27

What do you do when the pulse is irregular?

Answer 27

Verify the apical pulse

When the radial pulse is found to be irregular, 2 steps need to be taken:

1) Count the radial for a full 60 seconds (not 30 seconds x 2)
2) Get your stethoscope and listen (auscultate) the heart rate at the point of maximal impulse (PMI) as shown in the diagram

• When you place your stethoscope at this location on the patient’s chest, you are listening to the apex of the heart (hence the ‘apical’ pulse).
• The apex is the bottom of the heart (and the base is the top, figure that out)
• Listen here, also for a full 60 seconds, and record your findings from both the radial and the apical sites
• The vital signs record you will use for documentation will have a place for you to record both, indicating to others that both were assessed and that there was likely a reason that was done - It’s not a routine thing to do

Question 28

Do we check the apical heart rates of babies?

Answer 28

Babies always have their apical heart rates checked, as we don’t palpate for pulses until kids are a little older

Question 29

Vital Signs:
Oxygen Saturation (SPO2)

Answer 29

Indirect measurement of the oxygen in the patient’s blood -Simply put!

• Infrared light source “reads” the patient’s red blood cells and determines the percent of those blood cells that are full stocked with oxygen
• This measurement, coupled with observation/physical assessment can reveal issues around oxygenation, such as whether the client is getting enough or has enough to supply his brain and other tissues
• The important distinction to remember here is that a patient CAN be profoundly deprived of oxygen and still have an oxygen saturation of 100% - Nurses must understand what this test is actually measuring

Question 30

What must nurses consider in addition to SPO2?

Answer 30

Monitoring a patient’s oxygenation status is built into every vital signs assessment:
- Nurses are looking at the patient’s overall appearance and behaviour, respiration changes, skin colour, cognitive status, every time vital signs are assessed

Question 31

What does the value of SPO2 really mean?

Answer 31

The monitor assesses, at that moment in time, what percentage of the patient’s red blood cells are fully loaded (or ‘saturated’) with oxygen

• Ideally, the patient has somewhere between 95-100% of his red blood cells full saturated by oxygen
• That means that there are 4 oxygen molecules stuck to the hemoglobin which is the part of the red blood cells that binds oxygen.
• The lower the saturation reading on the monitor, the more poorly oxygenated the patient is
• It’s measuring the percentage of red blood cells with all 4 of its seats occupied by an oxygen… it’s not measuring the percentage of red blood cells circulating in the patient’s body.

Even if the patient has 1 sad lonely red blood cell rattling around his body, as long as that cell has all 4 seats occupied by an oxygen, the monitor will read 100%
- Does this client need more oxygen? YES! Should I provide him with some supplemental oxygen? NO! It won’t do anything. He has nothing to bind it. This patient needs a blood transfusion. Then we can talk about oxygen.

Question 32

What are some factors to measuring SPO2?

Answer 32

1) Ensure finger is all the way in the probe
2) Ensure the light is against the nail bed
3) Hold PT’s hand if there are tremors
4) Contextual factors like carbon monoxide poisoning, smoke inhalation artificially elevates results
5) Is the PT restless/agitated//moving around alot?
6) Nail polish or artificial nails
7) Other light sources
8) Intravascular dyes
9) Jaundice
10) Peripheral edema - swollen hands/fingers

Question 33

Vital Signs:

Blood Pressure

Answer 33

Simply, blood pressure is a measure of the force of blood on the walls of the patient’s vessels at its max, when the heart contracts and ejects blood, and then at its min when the heart is filling up again
- We express these as systolic pressure (contraction) and diastolic pressure (relaxation) or SBP and DBP

Question 34

What is used to measure BP?

Answer 34

Blood pressure cuff and stethoscope

• Use the right cuff – there are different sizes, you will be fine with an adult sized cuff
• There are measurements on the cuff itself that you can use to determine if a particular person needs you to use a different size
• Electronic measurement more common in acute care settings, but require no actual skill -You’ll work with those later.
• For now, you have a manual cuff or ‘analogue’ cuff that looks like the one pictured above

Question 35

How do you make an assessment with a manual cuff?

Answer 35

Patient:

• Be calmly seated for at least 5 minutes
• Have their back supported (chair, bed)
• Have their arm bare
• Have their arm supported at the level of the heart
• Have their feet on the floor/in bed with their legs UNCROSSED
• Remain as quiet as they can right before and during the procedure

The manometer should be easily visible at the observer’s eye level
- You can clip it on the cuff if there’s a loop, but it’s usually easiest to place it flat on the bed where you can easily see it, or you can ask the patient to hold it for you, if appropriate

Question 36

How do you take blood pressure?

Answer 36

1) Palpate the brachial artery & place the cuff ~ 1 inch (2.5 cm) above the crease in the arm
2) Place the stethoscope in your ears & the diaphragm over the brachial artery, firm contact

3) Inflate the cuff, using documentation/judgment to determine how high
deflate at a rate of 4 mmHg/beat (or so, you’re not counting this)

4) As soon as you hear the first RHYTHMIC tapping sound make a mental note. It’s the SBP.
5) Continue deflating at the same steady rate, the last rhythmic sound, mental note. It’s the DBP.
6) Keep listening for another 10 mmHg before deflating all the way
7) Document your findings & communicate them to the patient.

Question 37

What are some tips when taking BP?

Answer 37

1) You want that cuff on snugly… You don’t need to ask the patient if it feels alright, that’s not his thing to know.
- It’s super hard to put it on too tight (chances are you’ll find it’s too loose) and even if he does think it’s tight, it’s about to get tighter = That’s blood pressure

2) You want that firm contact with your stethoscope over the artery
- If you just rest it there, you won’t hear anything
- Firm contact also helps you to keep your hand still
- You can hear every tiny movement of your hands in your ears

3) The part about looking at documentation or using judgment to know how high to inflate is pointing to a couple of things
- Usually, you have access to the patient’s vital signs
- In the hospital you will, and any sort of record will tell you what their blood pressure usually is, give or take
- It’s kind of rare that you have absolutely no info to work with
- Ask the patient if they know what their usual BP is, lots of them can tell you
- Either way, the point of knowing this is that you will inflate 30 mmHg or so higher than the their SBP tends to be
- This isn’t exact, and that’s ok… We’ll talk more about this ini lab.

4) You’re not counting 4 mmHg as you deflate, it’s a ballpark
- Once you buy your cuffs, roll up a towel and put the cuff on it. Inflate the cuff and practice steadily releasing the air and get to know what about 4 ish mmHg looks like

5) This is the hardest part, truly. You’ll hear a lot of noises that aren’t what you’re trying to hear. - You’re trying to hear the patient’s pulse, just like you can when you do an apical pulse
- It’s rhythmic, and steady, and sort of a taping or squishing or wooshing sound in some people
- The point is, it’s hard to tell the difference between the first sound, and the creaking of your own knuckles - The creaking of your knuckles is not rhythmic. - Once you hear a rhythm, you’ll know that’s the noise you want to follow all the way down

6) You’re not listening for the loudest sound, you’re listening for the first sound
- The first sound is sometimes abrupt and easy to identify, but more often than not, it’s a fade in that starts very quietly. So listen up.

7) Keep that steady release of the air, you’ll be hearing the patient’s pulse the entire time, you just don’t need to record any of those numbers
- You’re listen for the very last sound now. Also very quiet. If you can still hear the pulse, you’re not there yet. Very last sound. Followed by silence. Just do your best.

8) Listening for an additional 10 mmHg is just to capture something called an ‘auscultatory gap’ which some people have.
- All you need to do if you hear something during that 10 mmHg is trade that sound for what you thought the diastolic was… Some people have a gap.