Vital Signs

Hospitalization:
For Patients: For Families:
 Concern about primary diagnosis  Concern
 Pain/Discomfort  Stress
 Stress / Costs  Costs
How you assess your Patient:
 Look, Listen, & Feel
o For the primary diagnosis but also to prevent any secondary injury or complication while the
patient stays under our care
 Assess, Diagnose, Provide interventions, Monitor, Evaluate, Maintain, Provide comfort
How often should we assess our Patients?
 The frequency of measuring vital signs and  The individual characteristics of the patient as
performing physical assessments should be articulated in the American Association of
based on each patient’s needs rather than Critical- Care Nurses Synergy Model— stability,
specific time intervals complexity, predictability, vulnerability, and
 • Vital signs are noted every 1 hour, and resiliency
sometimes as often as every 5 to 15 minutes,  Patients who are at greatest risk for an adverse
depending on the patient’s condition. outcome (eg, patients with frequently changing
physiological status, whose response to specific
therapy requires close monitoring) should
receive more frequent assessments.
Are there any National Standards?
• Reality is that no national standard can be set  Practice and policies should allow nurses to use
because of the variability of patients, nurses, their judgment to prioritize and adapt the
institutions, and available resources. patient’s care to address the patient’s unique
 Assessment and subsequent documentation situation.
should be determined for each population of
patients on the basis of their individual needs in
each individual setting.
Vital Signs: Some Routines Vital Signs:
When to take and document • General appearance
• At Admission • Respiratory rate (02 Saturation, ETCO2) •- Heart
• Before a procedure rate
• Before leaving the unit • Blood pressure
• Before transfer • Temperature
• Neuro Assessment
Did you say “MEWS”? (no longer going to be used / transitioning out of)
Has the Patient Changed?
• While taking vital signs and Neuro Exam • Has it happened before?
• Have you read the progress notes?
• New injuries • Orders?
• Facial expressions or reactions • Nurses notes?
• Change in color, appearance, odor

• How does the patient look?

Changed or Deteriorated?
 Change in patient’s behavior or affect?
- When did it start?
- What precipitated it?
- What have you done about it?
- Could it be related to medication’s the patient is taking?
 Do the vital signs fit the picture?
Get an AMPLE History:
• A...Does the patient have any allergies  L...Last meal
 M...Is the patient taking any medications  E...What are the events of the injury
 Problems....
• Medical problems
• Surgical procedures
• Previous hospitalization
Minor, Major, Life Threatening:
• Minor or major but • Is the patient critical?
• A simple call to MD will do? • Do I need to call a code?
• Determine if someone needs to stay with • Does the patient need to be intubated?
the patient
What 3 Major Organs can cause Respiratory Problems?
1) Heart 2) Brain 3) Lungs
Physical Assessment:
 Use your eyes, ears and hands
 When assessing a patient
 Start by looking
 Then listening
 Then touching
 Assessment is an active process
Respirations:
• Frequency depends on stability of patient • Airway and breathing is first consideration
• Maintain a patent airway at all times • Hypoxia must be prevented or corrected promptly
if it occurs
Always Ask:
Does the patient have a patent airway? Are the respirations effective?
• Open mouth and observe for • Spontaneous
• Blood, vomitus, loose teeth • Rate
• Cyanosis • Depth
• Swelling • Symmetry
Respiratory Patterns: Location (look these up if you need to)
 Cheyne-Stokes  Neurogenic Hyperventilation
 Cluster  Ataxic or Agonal
 Apheustic
Watch for Respiratory Problems:
• >>>PaC02, <<<pH, <<<<HC03 • Progressive • Working to breath
hypoxemia • Sitting up, will not lie down flat
• Changes in LOC • Exhaustion: RR >40, HR >>110, diaphoresis,
• Changes in color cyanosis
Assess For:
• Use of accessory muscles Dyspnea, tachypnea and cyanosis
• Distended neck veins • If it looks like an emergency
• Paradoxical chest movement • Then treat it as if it is an emergency
A clear and patent airway must be maintained at all times
• Hypoventilation
• Respiratory acidosis
• Hypoxia/hypercapnia • Cerebral edema

• Fix any noted abnormalities

• Determine need for equipment and delivery of oxygen
O2 Saturation and EtCO2
 Proportion of hemoglobin that is saturated with oxygen
 CO2 that is eliminated at the end of the exhalation
Heart Rate:
• Classic neuro sign is bradycardia • Pulse site and blood pressure
Tachycardia: • Perfusion?
• Rate above 100 • Effective?
• Always abnormal in the adult
Cardiac Function:
 New cardiac abnormality?  Atrial fib
 PVC’s?
• First consideration?  Rate?
• Decreases CO which decreases CBF
 Neuro peaked T waves

 Raised intracranial pressure can produce

widespread deep T-wave inversions with a
bizarre morphology

BP Readings:
From monitor: • Cuff
• Readings • Differences
• Wave (Art Line) • Loss of wave
• Changes
Blood Pressure and Heart Rate:
 What is the patient’s baseline?  Cushing Reflex:
 Medications?
• Are they compliant?  increased blood pressure
 History of essential hypertension?
  irregular breathing

 reduction of the heart rate

 Signs of increased intracranial

pressure...Neuro signs

• Increased systolic blood pressure

• Widening pulse pressure
• Decreased heart rate
Severe Hypertension:
• Can be catastrophic Non-neuro causes:
• Neuro causes: • Fluid overload
• IICP • Hypothermia, vasoconstriction
• ICH • Hypoventilation & hypercapnia
• Pain
• Metabolic disorders
Hypotension:
• Not a neuro thing usually Hypotension Due to HI
• Reduces brain perfusion
• Extremely dangerous  Rarely due to neuro
Think:
• Dehydration  Brain stem infarction
• Hypovolemia
• Hypoxia  Involvement of autonomic nervous system
• Sepsis
• Neuro causes?  Herniation

 High spinal cord injury

 Brain death

Temperature:
• Extreme variation may indicate hypothalamic • Fever
injury • Infection • Central
• Fever increases metabolic demands and oxygen • Hypothermia
requirements
Skin Signs:
 Very valuable  Knee caps
 Most reliable signs of shock  Temperature
 Color • Put your hands on them
 Pink or pale • Run your hand down their extremities
 Moisture
Glasgow Coma Scale
• Simple effect standardized test  Eye Open
Used to: Spontaneous (eyes open) 4
• Assess severity
• Compare treatments
• Guide to recovery
 Arouse patient maximally by voice, shaking or  To speech (any speech) 3
applying pain
 Test all 4 extremities  To pain 2
 Intubated or trached write ET/T/U
 Score of 7/8 intubate  Never 1

• Alone not sufficient  Best Verbal Response

• No information on:
• Pupil reactivity or symmetry • Extremity  Oriented (time, person, place) 5
movement
• C4 Quad has a score of 15  Confused, disoriented 4
• Maximally arouse patient
• ET (intubated) or untestable  Inappropriate (swearing, yelling) 3
• Score of 7 or 8 intubate
 Incomprehensible (moaning, groaning) 2
• A drop of 3 or more may indicate IICP
 None 1

 Best Motor Response

 Obeys 6

 Localizes (deliberate/purposeful) 5

 Withdrawal (moves away from stimulus) 4

 Abnormal flexion (decortication) 3

 Abnormal extension (decerebration) 2

 None (flaccidity) 1

Before Putting a Patient with Decreased LOC on His/Her Back…Check

• Speaking intact? Note:
• Gag response? • Hoarseness
• Swallow • Dysarthria
• Uvula midline Open mouth:
• Atrophy or spasticity of tongue
• Midline

Cardiac Anatomy & Physiology

Atria:
 right - accepts deoxygenated blood from superior  left - accepts oxygenated blood from pulmonary
vena cava (SVC) / veins and pumps blood into left ventricle
inferior vena cava (IVC) and pumps blood into right  smaller than right atrium - only accepts blood
ventricle  larger than left atrium from the lungs /
 accepts blood from the whole body pulmonic veins
 except the lungs
Ventricles:
ventricles left - accepts oxygenated blood from left atrium
chambers at the bottom and pumps blood to the body through the aorta
right - accepts deoxygenated blood from right  larger than right ventricle - has larger muscle
atrium and mass to compensate for SVR
pumps blood to the lungs through the pulmonic
arteries
smaller than left ventricle - pulmonary
vascular resistance (PVR) < systemic vascular
resistance (SVR)
Valves:
Atrioventricular: closure of tricuspid and mitral Semilunar: closure of pulmonic and
valves is S sound (lub) aortic valves is S2 sound (dub)
1
Coronary Arteries:
3 main branches
Right coronary artery
(RCA)
Left anterior descending (LAD)
Left circumflex (Cx)
Oxygenates all layers of the heart
Electrical Conduction:
 Sinoatrial (SA) node  Bundle of His
 initiates atrial depolarization – normally,  Conducts from AV node to bundle
noted as P waves branches
 conduction rate of 60 -100 bpm  Takes over if SA and AV node fails
 Atrial pathways  Paces at 25 to 40 beats per minute
 Conducts sinus impulse throughout right  Bundle branches and Purkinje fibers
atrium  Conducts from bundle of His to the
 Conducts sinus impulse to left atrium myocardium
through Bachman’s bundle  Takes over if all other pacing nodes fail
 Atrioventricular (AV) node  Paces at 25 to 40 beats per minute
 Regulates timing between atria and
ventricles
 Takes over if SA node fails
 Paces at 40 to 55 beats per minute
Vital Signs / Physical Assessment:
Heart rate (HR) Blood pressure (BP)
 Auscultate HR at point of maximum impulse   BP cuff size
(PMI) - 5th intercostal space (ICS) left mid   length of cuff bladder will wrap around ~ 80%
clavicular line (MCL) - for 60 seconds arm circumference  width of cuff bladder will
be ~ 1/3 upper arm
BP cuff placement - place cuff level with
phlebostatic axis
 4th ICS and half the anteroposterior diameter of
the chest
Chest Pain
 Pain - chest and/or cardiac in nature  Has the chest pain been ongoing (chronic pain)?
 Does the pain radiate or move to another Or did it just suddenly start (acute pain)?
 location?  Acute onset consider:
 heart attack pain may radiate to neck, jaw and  heart attack
down left side of arm  pulmonary embolism
 esophageal pain may radiate to throat or back  pneumothorax
dissecting aneurysm may radiate to between the  pericarditis
shoulder blades, abdomen or legs.  Chronic onset consider:
 angina
 esophagitis
 hiatal hernia
Inspection:
Visually examine patient’s skin, neck, chest, and arterial stasis ulcer vs
abdomen:  excruciating pain
 Skin: color Turgor Temperature Presence  chronic intermittent
of lesions  diminished or absent pulses
 Nail bed abnormalities/changes  pale skin
 pale nail bed can mean any number of things  cool/cold skin
(e.g. diabetes, malnutrition, severe anemia, venous stasis ulcer
cirrhosis, or kidney disease, etc) • cramping type pain • claudication
 Clubbing of fingers and nails • normal pulses
• ruddy colored skin • warm skin
Palpation: Auscultation
pulse characteristics The first heart sound - S1:
presence and symmetry closure of the atrioventricular valves (mitral valve
rate and rhythm and tricuspid valve)
• 0 -absent heard at the start of systole
• 1 -palpable but thready, easily obliterated with The second heart sound - S2:
light closure of the semilunar valves (aortic valve and
pressure pulmonic valve)
• 2 -normal, cannot obliterated with lightpressure heard at the end of systole
• 3 -full, cannot obliterate with pressure
• 4 -bounding The third heart sound - S3:
also called a ventricular gallop
associated with heart failure, especially left
ventricular overload can be “normal” in
adolescents and young adults
after the age of 40 is considered abnormal finding
Causes:
mitral regurgitation - left atrial overfilling occurs
and leads to rapid left ventricular filling when the
mitral valve opens
ventricular septal defect (VSD) - allows rapid filling
of left ventricle from the defect connecting to right
ventricle
Causes of S3:
 post-MI - may cause hypo-kinesis and/or a-kinesis causing a relative overload in the ventricles
 Dilated cardiomyopathy - the ventricular walls become thin and stiff so do not relax well to filling the
compromised ventricle rapidly
 aortic regurgitation
  left ventricular dysfunction
S4 Heart Sound:
 The fourth heart sound - S4 - also called a atrial gallop
 Causes
 LV hypertrophy
 Caused by systemic hypertension, hypertrophic
 Cardiomyopathy, or aortic stenosis
 RV hypertrophy
 Caused by pulmonary hypertension or pulmonic stenosis
Murmurs:
caused by turbulent blood flow through valves Sound characteristic:
high flow rate is the murmur harsh? blowing? rumbling?
flow through constricted valve / opening whistling?
backward / regurgitant blood flow through pitch of the murmur pitch high
incompetent (stenosis or insufficient closing) valves use diaphragm of stethoscope pitch low
use bell of stethoscope
important characteristics:
 radiation Other cardiac sounds to note:
where the murmur projects to pericardial friction rub
configuration or shape of the sound wave quadruple gallop
crescendo - gets louder mechanical valve
decrescendo - gets softer
crescendo-decrescendo - gets louder then gets
softer
plateau - volume is constant throughout the
murmur
Troponin Tests (Highest Known Sensitivity)
Troponin T: myocardium protein specific  Often ordered serial to monitor extent /
 normal: < 0.01 ng/ml duration of MI
 abnormal: > 0.01 ng/ml  Can be positive in other clinical situations
 indicates cardiac stress  Cardiac:
can only verify MI concurrently with other  Myocarditis (heart inflammation)
diagnostic exams  Cardiomyopathy (weakening of the heart)
 12 lead EKG  Heart failure
symptomatic history and physical (H&P)  Non-cardiac:
severe infections (sepsis)
 kidney disease
CK tests: CK Tests:
 No longer the gold standard to detect myocardial  CK-MB
infarction (MI)  Myocardium protein specific
 Also used to check for rhabdomyolysis  Normal: 0 - 4 ng/ml
 Can be used to verify troponin tests  Abnormal: > 4 ng/ml
Total CK  Indicates occurrence of MI
 normal: 24 - 195 g/L  CK-MB relative index
 abnormal: > 195 g/L  derived from formula
 indicates muscle damage • CK-MB / total CK x 100
 normal: < 3%
 abnormal: > 3%
  indicates occurrence of MI
B-type Natriuretic Peptide (BNP)
 Produced in the heart and released when the heart is stretched and working hard to pump blood
 Measure their levels in the blood in order to detect and evaluate heart failure
 Produced primarily by the left ventricle of the heart
 Associated with blood volume, blood pressure, and with the work that the heart must do in pumping
blood throughout the body
 When left ventricle is stretched, concentrations of BNP produced can increase markedly
 Indication that heart is working harder and having more trouble meeting the body's demands
 Increase in circulating BNP reflects diminished cardiac capacity
Levels often decrease with drug therapies for heart failure
 angiotensin-converting enzyme (ACE) inhibitors, beta blockers, and diuretics
 levels generally increase with age
 levels may be increased with kidney disease due to reduced clearance

normal values: no officially recognized values

0.5 - 30 pg/mL is generally considered acceptable/within normal limits
< 100 pg/mL essentially rules out heart failure
> 400 pg/mL indicate 95% likelihood of heart failure between 100 - 400 pg/mL warrant further
investigation
Lipid Panel
lipid panel (LDL)
 consists of 4 tests  total cholesterol
 normal: 160 - 199 mg/dL  borderline abnormal: 200 - 239 mg/dL  abnormal: > 240 mg/dL
 cholesterol, LDL cholesterol specifically, significantly contributes to atherosclerosis, the formation of
plaques in blood vessels
 increased risk for coronary artery disease (CAD)

 High density lipoprotein (HDL) cholesterol

 HDL cholesterol helps remove low-density liporotein (LDL) cholesterol
   optimal: > 60 mg/dL for men & women
   normal: 40 - 50 mg/dL for men / 50 - 60 mg/dL for women
   abnormal: < 40 mg/dL for men / < 50 mg/dL for women

low density lipoprotein (LDL)

normal: 60- 99 mg/dL
 borderline abnormal: 100 - 129 mg/dL
 abnormal: 130 - 159 mg/dL
 high abnormal: 160 - 189 mg/dL
 extreme abnormal: > 190 mg/dL
 elevated levels of LDL significantly contribute to atherosclerosis
 increased risk for coronary artery disease (CAD)

triglycerides
 normal: 40 - 149 mg/dL  borderline abnormal: 150 - 199 mg/dL  abnormal: 200 - 499 mg/dL
 extreme abnormal: > 500 mg/dL
 elevated triglycerides can significantly contribute to atherosclerosis
 increased risk for coronary artery disease (CAD)
Complete blood count (CBC)  anemia
 low hemoglobin (Hgb): < 7 g/dL
 low hematocrit (Hct): < 25 %
Chest Roentgenograph (X-Ray):
 Used to rule out or rule in presence of other  Pneumonia
diagnoses that cause significant chest pain that  Pleural effusion
may mask cardiac type pain  Pulmonary edema
 Pulmonary embolus  Pneumothorax
Computed Tomography (CT) Angiogram: Echocardiogram
 evaluate the blood vessels in the chest Sonogram of the heart
 rapid injection of an iodine-based intravenous (IV)  trans-thoracic echocardiogram (TTE)
contrast into a vein while obtaining CT images  more commonly used
 mostly used to rule out dissecting aortic  quicker to obtain
aneurysm  less invasive
Electrocardiogram: (ECG or EKG) Stress Electrocardiography:
 monitors for arrhythmias/dysrhythmias,  continuous telemetry
ischemia/infarction, and coronary artery disease  monitors heart during induction of physical or
(CAD) pharmacological stress
12 lead EKG:
 allows for 12 individual views of electrical activity Holter monitor
of the heart (1 lead gives 1 view)  continuous telemetry
 views only one moment in time  limited to 3-5 leads
Continuous telemetry:  can pull up periods of time each lead
 limited to 3-5 leads  portable
 can pull up periods of time each lead  patient wears holter which is connected to leads
 records telemetry for specific amount of time
Invasive Testing:
interventional radiological procedure Left heart catheterization: catheter insertion is
 Cardiac catheterization: use of long catheter retrograde through femoral / brachial artery through
with a guide wire and radiographically opaque the aorta
dye to assess blood flow and functionality  through the coronary arteries
o  presence of lesions  atrial  Stents are only placed if vessel occlusions are
function > 75% or patient is symptomatic
 ventricular function  valvular  through aortic valve
function  pressure / flow  cardiac  Assessing blood flow / pressures
output  Through left ventricle
  Radiographically opaque dye is iodine  Assessing wall integrity and motion
based cardiac catheterization
  Check for iodine allergies
Right heart catheterization
   catheter insertion is through femoral /
brachial vein through the vena cava vessels
   through right atria
   through tricuspid valve
   through right ventricle
   through pulmonic valve
   Into pulmonic arteries
Cardiac Sound Regions Abbreviations:
 M1 – mitral component of S1  AS – aortic stenosis
 T1 – tricuspid component of S1
 A2 – aortic component of S2  PS – pulmonic stenosis
 P2 – pulmonic component of S2
 TR –tricuspid regurgitation
 S3 – follows S2 heart sound, may indicate systolic
 MR – mitral regurgitation
heart failure occurs during passive left
ventricular (LV) filling
 AR – aortic regurgitation
 S4 – precedes S1 heart sound, may indicate
 PR – pulmonic regurgitation
diastolic heart failure occurs during active LV
filling  TS –tricuspid stenosis

 MS – mitral stenosis

 HCM–hypertrophic cardiomyopathy

Cardiac Dysrythmias:
Electrical Conduction Rates:
• SA node 60-100 • AV node 40-60
• Intra-Atrial ~ 60 • Ventricle 20-40
Waves / Intervals:

 P-wave: (atrial depolarization by SA Node) both  QT interval: beginning of ventricular

left and right depolarization to the end of ventricular
 P-R interval: the time it takes until the ventricles repolarization
depolarize (0.12-0.20 sec) o Longer QTs can be highly problematic
 QRS Interval: intraventricular septal  U-wave: (usually won’t see it on EKG) can be
depolarization (of ventricles) (0.06-0.10 sec) seen during events of bradycardia or
o Pathological = >0.12 sec hypokalemia. It is the Purkinje repolarization
o Note: Atrial repolarization is actually in  Isoelectric line – is a line where no electrical
 the QRS complex (you cannot see it) activity is seen. The baseline is flat
 T-wave: ventricular repolarization (0.30-0.40 sec)

1 minute = 5x5x60 sec = 1500 small boxes

1 minute = 5x60 sec = 300 large boxes
Five Lead System:
 Place an electrode pad with the white monitor
lead wire attached in the second ICS right mid
clavicular line
 Place an electrode pad with the black monitor
lead wire attached in the second ICS left mid
clavicular line
 Place an electrode pad with the green monitor
lead wire attached in the fifth ICS right anterior
axillary line
 Place an electrode pad with the red monitor lead
wire attached in the fifth ICS left anterior axillary
line
 Place an electrode pad with the brown monitor
lead wire attached in the fourth ICS at the right
sternal border to obtain MCl1. This lead
placement may be changed to any of the V
positions to obtain other MCl readings. Choose
the lead you wish to be displayed
Three Lead System:
• Place an electrode pad with the white monitor
lead wire attached in the second ICS right mid
clavicular line
• Place an electrode pad with the black monitor lead
wire attached in the second ICS left mid clavicular
line.
• Place an electrode pad with the red monitor lead
wire attached in the fifth ICS left anterior axillary
line. Choose the lead you wish to be displayed.

12-Lead ECG (10 Electrodes)

 R-R = Q”R”S – Q”R”S
Summary of use for each Leads
◆Lead V1 to distinguish Ventricular Tachycardia (VT) from Supraventricular Tachycardia (SVT) with aberrant
conduction
◆V1 lead of choice for dysrhythmia monitoring
❖Lead II or III if patient condition indicates need to monitor for atrial dysrhythmias
Major Sites of Dysrhythmias:
1) SA node (sinus rhythms) 3) AV node (junctional rhythms)
2) Atria (atrial rhythms) 4) Ventricles (ventricular rhythms)
NSR Sinus Tachycardia

Sinus Bradycardia
Sinus Arrhythmia: Sinoatrial (SA) Arrest or Block:

Atrial Dysrhythmias:
Premature Atrial Contraction (PAC)

Wandering Atrial Pacemaker:

Atrial Tachycardia:

Neuro Anatomy and Neurophysiology:

 Sensory neuron- detects impulses; receives data  Interneurons- sends information to another
from the surroundings neuron, links neurons, (thinks, interprets, perceives
 Motor neuron- sends out impulses to the muscles the environment)
to cause it to move  Trillions of neurons in the brain
Somatic Nervous System:
 Controls the voluntary muscle movements
Afferent nerves- relays sensation messages from the body to the CNS- receives
Efferent Nerves- relay messages from the brain to the muscles causing muscle contraction/movement -
acts
Autonomic Nervous System:
- Sympathetic Nervous System (SNS) – Flight or Fight
- Parasympathetic Nervous System (PNS) – Feed and breed or rest-and-digest
Cerebrum: Spinal Cord
- Highest level of nervous system Lowest functional level
- Cognition: memory, reasoning and decision Automatic motor responses i.e reflexes
making, thinking, intellect, stores information, Transmission of motor information: from brain to
awareness, perception the cord to the rest of the body
- Personality Transmission of sensory information: from the
- Speech body to the cord to the brain.
Skull: Cranial Vault:
 Sagittal suture- midline, joins the two parietal Brain- 80%
bones  Blood- 10%
 Coronal suture- joins the frontal and parietal  CSF- 10%
bones  Monro-Kellie Doctrine : The brain is enclosed in a
 Lambdoidal suture- joins the occipital and parietal rigid box.
bones  Total volume remains constant
 Basilar suture- joins the basilar surface of the  An increase in one of the elements (brain, blood,
occipital bone with the sphenoid bone. CSF) would result in the replacement and
displacement of the other one or two elements.