Vital or Cardinal Signs

P  Prakash

Vital or Cardinal Signs1

Table 1.1 Description of vital signs with its normal value

S. no.	Vital signs	Description	Normal value
1.	Temperature	Difference between heat gain and heat loss	98.6°F (or) 37°C
2.	Pulse	Rhythmic expansion and contraction of arteries as a blood pumped to them by heart rate	72 beats per minute
3.	Blood pressure	Pressure exerted by blood against the walls of blood vessels especially arteries	120/80 mm Hg
4.	Respiration	Act of breathing (inhalation and exhalation of air)	16–20 breaths per minute
5.	SPO₂	SPO₂ denotes oxygen saturation in blood (i.e. percentage of hemoglobin binding sites in blood occupied by oxygen)	95–100
6.	Pain score	An unpleasant feeling conveyed to the brain by sensory neuron	0 or no pain
7.	Capillary blood glucose	A way of monitoring the level of glucose concentration in blood	80–120
8.	Glasgow Coma Scale (GCS)	Scale used to assess level of consciousness among patients	15–best response
9.	ET CO₂ (End tidal carbon dioxide)	A graphical measurement of carbon dioxide partial pressure during expiration	1–5 mm Hg
10.	Dyspnea	Difficulty in breathing or breathlessness or client become conscious aware in breathing	–
11.	Gait speed	A screening measure reflects both the physical and cognitive functioning. Considered as vital sign for elders.	0.94–1.26 meter per second (elders)

Flowchart 1.1: Core temperature vs surface temperature

Table 1.2 Basic concepts in thermoregulation

S. no.	Basic concepts	Description
1.	Vital center of brain	Preoptic area of anterior hypothalamus
2.	System helps in thermoregulation	Integumentary system (act as barrier to protect body from environment and thereby control temperature)
3.	Hormones increases body temperature	T3, T4 (thyroid hormones increases basal metabolic rate thereby raises temperature)

Table 1.3 Description about methods of heat loss

Methods of heat loss	Description
Conduction	By direct contact from a hot part to cold part
Convection	Transfer of heat by circulating air
Evaporation	Liquid state change to vapor
Radiation	Heat transfer from surface of one object to other which is not contact with each other

Flowchart 1.2: Stages during fever

Table 1.4 Description about types of fever

Types of fever	Description
Lysis	Fall of temperature in zigzag manner before reaching to normal
Constant fever (or) continuous fever	Temperature varies not more than 2°C between morning and evening. Temperature does not reach normal for period of days/weeks.
Remittent fever	Temperature varies more than 2°C between morning and evening. Temperature does not reach normal for period of days/weeks.
Intermittent fever (or) quotidian fever	Temperature reaches to high level and it returns to normal at regular intervals
Inverse fever	Temperature reaches to high in morning and it returns to normal in evening
Hectic (or) swinging fever	Difference between the highest degree of temperature and the lowest degree of temperature is very high
Relapsing fever	Brief febrile periods followed by one or two days of normal temperature
Rigor	Sudden shivering during fever
Hyperthermia (or) pyrexia	Temperature above 105°F
Hypothermia	Temperature below 95°F

Formula to convert fahrenheit into celsius: C = (F–32) × 5/9

Formula to convert celsius into fahrenheit: F = (C × 9/5) + 32

CLASSIFICATION OF BODY TEMPERATURE

Table 1.5 Normal temperature based on the measurement in different body parts

S. no.	Temperature assessment in different body parts	Normal value
1.	Oral	98.6°F
2.	Rectal	97.6°F
3.	Axilla	99.6°F

Table 1.6 Classification—temperature variations

S. no.	Categories	Value
1.	Hypothermia	<95°F
2.	Normal	97.7–99.5°F
3.	Hyperthermia	99.5–100.9°F
4.	Hyperpyrexia	104.0–106.7°F

Fig. 1.1: Types of thermometer

Flowchart 1.3: Concept of thermoregulation

PULSE VARIABLES

Rate: 60 to 90 beats per minute is normal
- Tachycardia (decreased pulse rate)
- Bradycardia (increased pulse rate)
Rhythm: Regular or irregular pulse (arrhythmia—irregular or abnormal rhythm)
Volume: Strength or intensity of pulse
- Described in terms: Strong, bounding, thready, weak and feeble.

SITES OF PULSE

Radial: Medial ventral wrist below the base of thumb
Apical: Left side of chest in fifth intercostal space and midclavicular line5

Fig. 1.2: Sites of taking pulse rate
Ulnar: Located on medial of the wrist
Temporal: Anterior to upper third of year
Carotid: Below angle of jaw on each sides of trachea
Femoral: In groin between pubis and hip bone
Dorsal pedalis: Medial dorsal of foot
Posterior tibial: Below posterior malleolus of foot
Popliteal: Popliteal fossa behind knee
Brachial: Medial antecubital fossa

PULSE STRENGTH

0 – Absent

1 – Weak

2 – Normal

3 – Full

4 – Bounding

MONITORING BLOOD PRESSURE

Instrument used—sphygmomanometer
If the patient done any strenuous activity (e.g. exercises) check BP after 15 minutes (remember strenuous activities will show BP raised)
Maintain proper interpersonal relation, i.e. talk to patient (remember white coat hypertension)—BP may be raised because of nurses who does not communicate with patient and check BP will make the client fearful which in-turn raise client BP6
BP apparatus has to be kept in patients chest level
Tie BP cuff in left hand (if not contraindicated) to get accurate BP since heart was present towards the left side
Cuff has to be tied 2 inches above the antecubital fossa and ensure that tubings are crossing over antecubital fossa
Palpate the radial pulse, inflate BP cuff and when you does not feel the radial pulse, then use stethoscope to hear Korotkoff's sounds
First sound where you started to hear is systolic BP and where the sound completely vanish is diastolic BP
Document it immediately.

Table 1.7 Classification of blood pressure

Description	Systolic BP	Diastolic BP
Normal/normotension	120	80
Prehypertension	>120–139	>80–89
Grade I hypertension	140–159	90–99
Grade II hypertension	>160	>100
Prehypotension	110–119	70–79
Grade I hypotension	100–109	60–69
Grade II hypotension	90–99	50–59

Fig. 1.3: Parts of BP apparatus

Fig. 1.4: Parts of stethoscope

O₂ SATURATION

Saturation of oxygen measured using pulse oximeter.

Fig. 1.5: Pulse oximeter

Table 1.8 Action plan based on SPO₂ level

SPO₂ level	Action plan
>95	Normal
91–95	Check probe placement is proper and monitor continuously
85–90	Assess airway Encourage coughing Fowler's position (raise head end of bed) Suction airway if necessary Oxygen administration Approach physician/pulmonologist 8
< 85	Assess airway Check out any medication may cause respiratory depression (e.g. saloxone, flumazenil, lorazepam) Fowler's position (raise head end of bed) Suction airway if necessary 100% of oxygen administration (consider the contraindication of O₂ administration such as COPD–loss of hypoxic drive to breathe, High fever–high-risk for seizure, pacemakers/epidural pain pump–malfunction of device under pressure, Eustachian tube dysfunction–barotrauma to tympanic membrane) Prepare for manual ventilation (set proper intubation tray) Approach physician/pulmonologist

Table 1.9 Chance of false SPO₂ reading

False high SPO₂ reading	False low SPO₂ reading	Not regular in pattern
Hypovolemic shock Severe anemia Carbon monoxide poisoning	Poor peripheral blood circulation Chill extremities Dark pigmentation of skin Raynaud's disease Nail polish On medications which cause peripheral vasoconstriction	Patient movements

PAIN SCORE

Numerical score ranges from 0 to 10.
Descriptive pain scale ratings are no pain, mild pain, moderate pain, severe pain, very severe pain.

TYPES OF PAIN

Acute pain
Chronic pain
Depends on where it felts: Somatic, visceral and neuropathic.
Phantom pain: Pain felt in part of body which has been lost (common in amputated clients).
Psychogenic pain (psychalgia or somatoform pain): Pain due to mental, emotional or behavioral factors.
Breakthrough pain: Severe pain able to ‘breakthrough’ medications (e.g. cancer pain).
Pain asymbolia: Congenital insensitivity to pain.9

Table 1.10 Assessment of pain

PQRST

COLDERRA

P – Provokes (What provoke pain – stress, injury, exertion, postprandial, etc.)

Q – Quality (Is it achy, deep pressing, sharp, dull)

R – Radiation/relief (Is it spreads to other parts of body? What makes pain to be relieved?)

S – Severity/signs and symptoms (Grade pain using pain scale, mention associated symptoms along with pain such as fever, nausea, vomiting, giddiness, shortness of breath, etc.)

T – Time of onset and duration (When it start? How long it last? Is it sudden or gradual onset? Whether is it constant/intermittent?)

C – Characteristics (Is it achy, deep pressing, sharp, dull)

O – Onset (When it start? Is it sudden or gradual onset?)

L – Location (Where the pain is)

D – Duration (How long pain persist? Whether is it constant/intermittent?)

E – Exacerbation (What make the pain worsens?)

R – Radiation (Whether pain spread to other parts of body?)

R – Relief (What makes pain to be relieved?)

A – Associated signs and symptoms (Mention associated symptoms along with pain such as fever, nausea, vomiting, giddiness, shortness of breath, etc.)

Table 1.11 Glasgow Coma Scale (GCS) to measure level of consciousness

S. no.	Behavior	Response	Score
1.	Eye opening	Spontaneous To speech To pain No response	4 3 2 1
2.	Verbal response	Oriented to time, place and person Confused Inappropriate sounds Incomprehensive words No response	5 4 3 2 1
3.	Motor response	Obeys commands Moves to localize pain Flexion withdrawal from pain Abnormal flexion (decorticate) Abnormal extension (decerebrate) No response	6 5 4 3 2 1
Best response - 15 Comatose patient - 8 or less Total unresponsiveness - 3

Fig. 1.6: Glucometer

Glucometer: Equipment used to measure Blood Glucose.

Table 1.12 Factors affecting vital signs

Vital signs	Increased	Decreased
Heart rate	Acute/chronic pain Exercise Fear and anxiety Pulmonary embolism Hypo/hyperkalemia Hypo/hyperglycemia Leukemia Tamponade Hyper/hyponatremia Pulmonary embolism	Beta-blockers Calcium channel blockers Narcotics Acute myocardial infarction Spinal injury Hypo/hypocalcemia Acute myocardial infarction
Respiratory rate	Acute pain Exercise Fear and anxiety Tamponade Acute myocardial infarction Pulmonary embolism Hyperglycemia Leukemia Hyper/hyponatremia	Spinal injury Beta-blockers Calcium channel blockers Narcotics
Systolic blood pressure	Acute pain Anxiety Hypoglycemia Hyponatremia Hyperkalemia	Beta-Blockers Calcium channel blockers Narcotics Hypo/hypocalcemia Hypernatremia Hypokalemia Pulmonary embolism 11
Temperature	Fever Spinal injury Exercise Pulmonary embolism Hyperglycemia Leukemia Hypernatremia	Hypoglycemia Narcotics Hypothermia

Chapter Notes

Vital or Cardinal Signs1