© 2009 Delmar, Cengage Learning Chapter 15 Vital Signs

© 2009 Delmar, Cengage Learning

Chapter 15

Vital Signs


15:1 Measuring and RecordingVital Signs (VS)

• Record information about the basic body conditions– Abnormalities from homeostasis

• Main vital signs (VS)– Temperature

– Pulse

– Respiration

– Blood pressure


Other Assessments

• Pain—patients asked to rate on scale of 1 to 10 (1 is minimal and 10 is severe)


Other Assessments

• Color of skin– Pallor

– Cyanosis

– Jaundice

– Erythema

– Ecchymosis


Other Assessments

• Size of pupils and reaction to light


Other Assessments

• Level of consciousness


Other Assessments

• Response to stimuli


Vital Sign Readings

• Accuracy is essential– Must know how to accomplish task with various

equipment

– Never guess or report false readings

• Report abnormality or change– Severe abnormalities indicate life-threatening

conditions

• If unable to get reading, ask another person to check


15:2 Measuring and Recording Temperature

• Temperature: Measures balance between heat lost and heat produced in the body– Thermal activity

• Heat produced by metabolism of food and by muscle and gland activity

• Heat lost through perspiration, respiration, and excretion


15:2 Measuring and Recording Temperature

• Conversion between Fahrenheit and Celsius temperature

F C: C = (F - 32) x (5/9 or 0.5556)

C F: F = (C x 9/5 or 1.8) + 32• Practice:

–102o F to C 212o F to C

–19o C to F 37o C to F


Variations in Body Temperature

• Normal range– 97-100o F, 36.1-37.8o C

• Causes of variations– Size/shape of individual, time of day, part of body,

metabolic activity



• Temperature measurements — oral, rectal (often used on infants/children), axillary or groin, aural, and temporal

• Normal:– Oral: 98.6o F Axillary: 97.6o F– Rectal: 99.6o F Aural/Temporal: no normal range



Increase:

Illness and infection

Exercise, excitement, fear

High environmental temperatures

Decrease:

Starvation or fasting

Sleep

Sedation

Mouth breathing

Cold environmental temperatures

Abnormal conditions affecting temperature



• Abnormal conditions– Hypothermia: body

temperature < 95o F

– Fever: elevated above 101o F• Pyrexia, Febrile, Afebrile

– Hyperthermia: body temperature > 104o F


Thermometers

• Clinical thermometers– Glass: contains mercury, analog

– Electronic: digital reading, quicker results

– Tympanic: use infrared energy

– Temporal: measures temporal artery

– Plastic or paper: disposable

• Reading thermometers and recording results– Read in 1o increments, labeled by site

• R, Ax,, A, 986

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Thermometers(continued)

• Avoid factors that could alter or change temperature– Examples???

• Cleaning glass clinical thermometers– Clean with alcohol wipe or soap/cool water

• Paper/plastic sheath on glass thermometer– Used to prevent transmission of disease

– Dispose of properly

– Still wipe with alcohol pad


15:3 Measuring and Recording Pulse

• Pulse: Pressure of the blood pushing against the wall of an artery as the heart beats and rests

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• Major arterial or pulse sites– Temporal

– Carotid

– Brachial

– Radial

– Femoral

– Popliteal

– Dorsal Pedal

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• Must note 3 different factors of the pulse:• Pulse rate (beats per min)

• Pulse rhythm (regular or irregular)

• Pulse volume (strong, weak, thready, bounding)

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• Pulse rate – adult 60-100 bpm, varies– Bradycardia: slow pulse rate, < 60 bpm

– Tachycardia: fast pulse rate, >100 bpm

• Pulse rhythm – spacing between beats– Regular vs. irregular

– Arrythmia: abnormal heart rhythm

• Pulse volume – strength/intensity of the pulse– Strong vs. weak, thready, bounding

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Measuring and Recording Pulse

Increase:

Exercise

Stimulant drugs

Excitement

Fear

Fever

Shock

Nervous tension

Decrease:

Sleep

Depressant drugs

Heart disease

Coma

Physical training

Factors that change pulse rate


Measuring and Recording Pulse (continued)

Basic principles for taking radial pulse:

1.Patient positioned comfortably, palm down

2.Use tip of index/middle fingers to locate pulse on thumb side of wrist

3.First beat counted starts with zero1. 10 sec x 6

2. 15 sec x 4

3. 30 sec x 2

4. 60 sec


Measuring and Recording Pulse (continued)

• Recording information:– Include rate, rhythm,

volume

Example:

P 82 regular and strong

(rate)(rhythm)(volume)


15:4 Measuring and Recording Respirations

• Respiration: Measures the breathing of a patient

• Process of taking in oxygen and expelling carbon dioxide from the lungs and respiratory tract

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15:4 Measuring and Recording Respirations

• One respiration: one inspiration (breathing in) and one expiration (breathing out)

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Measuring and Recording Respirations (continued)

• Normal respiratory rate– Adults: 12-20 breaths per minute

– Children: 16-30 per minute

– Infants: 30-50 per minute


Measuring and Recording Respirations

• Must note 3 different factors:• Rate (breaths per minute)

• Character (depth and quantity)• Rhythm (regularity)



• Character of respirations – refers to depth and quality– Deep vs. shallow, labored, moist, difficult, noisy

• Rhythm of respirations – refers to spacing between breaths– Regular (or even) vs. irregular



• Abnormal respirations

– Dyspnea: difficulty breathing

– Apnea: absence of respirations

– Tachypnea: rapid, shallow > 25/min

– Bradypnea: slow <10/min



• Abnormal respirations

– Orthopnea: severe dyspnea in any position besides sitting or standing

– Cheyne-Stokes: abnormal breathing pattern, periods of dyspnea and apnea

– Rales: bubbling or noisy sounds caused by fluid



• Voluntary control of respirations– Respiration can be controlled if consciously thought

about

– Important to keep the patient unaware breathing is being assessed

– Do not tell the patient you are counting respirations



• Record information– Rate, character, rhythm

• Ex: A child with R 22, shallow, labored, and regular would suffer from?

• Ex: An adult with R 8, deep, regular would suffer from?


15:5 Graphing Temperature (TPR)

• Graphic sheets are special records used for recording TPR

• Presents a visual diagram (easier to follow)

• Uses – hospitals or long care facilities

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15:5 Graphing TPR

• Color codes

– Temperature in blue

– Pulse in red

– Respirations in green

• Factors affecting vital signs are often noted on the graph– Surgeries, medications, day & time, etc.

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Graphing TPR(continued)

• Graphic charts are legal records– Must be legible and neat

– Completed in ink

– Use straightedge to connect lines

– HIPAA act!

• To correct an error: cross out in red ink and correct, initial next to correction


Graphing TPR(continued)

• Basic principles for completing:– Fill in patient information accurately

– Fill in dates, times (mm/dd/yyyy, __:__am/pm)

– Adm = admission (first measurement)

– Following days are numbered

– PO = after surgery

– PP = post partum (after delivery)



15:7 Measuring and RecordingBlood Pressure

• Blood Pressure: Measurement of the pressure the blood exerts on the walls of the arteries during the various stages of heart activity

• Measured in millimeters of mercury (mmHg) on a sphygmomanometer

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Measuring and Recording Blood Pressure

(continued)

• Systolic pressure: pressure when left ventricle contracts and pushes blood to arteries– Normal is <120 mmHg (range of 100-120 mmHg)

– First sound heard during reading of sphygmomanometer



(continued)

• Diastolic pressure: constant pressure when left ventricle is at rest, or between contractions– Normal is < 80 mmHg (range of 60-80 mmHg)

– Last sound heard during reading of sphygmomanometer



(continued)

• Blood pressure is read as a fraction

• Systolic pressure / Diastolic pressure– Ex: (120/80 mmHg)



(continued)

• Pulse pressure: difference between systolic & diastolic pressure– Important indicator of health and tone of arterial walls

– Normal range is 30-50 mmHg

– The pulse pressure should be approximately one third of the systolic reading (120 - 80 = 40)



(continued)

• Hypertension—high blood pressure– Prehypertension (120-139 mmHg / 80-89 mmHg)

– Systolic > 140 mmHg / Diastolic > 90 mmHg

• Hypotension—low blood pressure– Systolic < 90 mmHg / Diastolic < 60 mmHg

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(continued)

• Factors influencing blood pressure readings (high or low)– Force of heartbeat

– Resistance of arterial system

– Elasticity of the arteries

– Volume of blood in arteries

– Position of the patient(standing vs sitting vs lying down)

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(continued)

Increased BPExcitement, anxiety, nervous

tension

Pain

Obesity

Stimulant drugs

Exercise and eating

Smoking

Decrease BPRest or sleep

Depressant drugs

Shock

Dehydration

Hemorrhage

fasting


Measuring and RecordingBlood Pressure

(continued)

• Types of sphygmomanometers– Mercury: uses a column of mercury in a tube to measure

the pressure (discouraged by OSHA)

– Aneroid: uses a round gauge to measure pressure• Each line on gauge = 2 mmHg

• Measure at eye level, deflated cuff should read zero

– Electronic: measures pressure automatically• Shows reading on a digital display

(continues)




(continued)

• Factors to follow for accurate readings– Patient should sit quietly for at least five minutes before

BP is taken

– Two readings should be taken and averaged• Minimum wait of 30 seconds between readings

– Arm should be rested on a flat surface & free of restrictions



(continued)

• How to measure blood pressure– Cuff should be placed above the crook of the elbow, with

arrow pointing over brachial artery

– Place the bell/diaphragm of stethoscope directly over brachial artery in the antecubital fossa

• Hold as securely as possible with index/middle fingers

– Inflate cuff to 150-180 mmHg

– Deflate slowly and listen for heart sounds• First sound = Systolic Blood Pressure (Top #)

• When sound disappears = Diastolic Blood Pressure (Bottom #)





(continued)

• Record all required information– Date, time, BP, signature/initials

• Do not discuss the reading with the patient; it’s the doctor’s responsibility– Could cause personal reaction to patient


Blood Pressure Practice

Blood Pressure Practice

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© 2009 Delmar, Cengage Learning Chapter 15 Vital Signs