VITAL SIGNS

Vital Signs

Various factors that provide information about the basic body conditions of the patient.

4 Main VS Temperature Pulse Respirations Blood Pressure

Other Vital Signs Pain

Scale - 0 to 10 Pts are asked to rate their level of pain on the 0 –

10 scale

Skin color Size of the pupil & reaction to light Level of consciousness Patients response to stimuli Pulse oximetry reading

Pulse

The pressure of the blood felt against the wall of an artery as the heart contracts and relaxes

Rate - # of beats per minute Rhythm – refers to regularity Volume – refers to strength

Pulse Usually taken on the radial or carotid artery Pulse is taken on an artery

Temporal – sides of the forehead Carotid – sides of the neck Brachial – inner aspect of forearm at the

antecubital space Radial – inner aspect of the wrist, above thumb Femoral – inner aspect of the upper thigh Popliteal – behind the knee Dorsalis pedis – top of the foot arch

Pulse Bradycardia – pulse <60 bpm Tachycardia – pulse >100 bpm

(except in children)

Rhythm refers to the regularity of the pulse (the spacing of the beats) Regular Irregular - arrhythmia

Usually caused by a defect in the electrical conduction pattern

Pulse Volume – strength or intensity

Strong Weak Thready Bounding

Factors that alter pulse rate Increase pulse: exercise, stimulant drugs,

excitement, fever, shock, nervous tension (stress) Decrease pulse: sleep, depressant drugs, heart

disease, coma, physical training

Respirations The process of taking in O2 and expelling

CO2 from the lungs and respiratory tract

1 breath consists of 1 inspiration and 1 expiration (exhalation)

Normal range:12–20 breaths/minute in adults

Respiration Character – depth & quality

Deep Shallow Labored Difficult Stertorous (abnormal sounds like snoring) Moist

Regularity Regular Irregular

Respirations

Dyspnea – difficult or labored breathing Apnea – absence of respirations Tachypnea – RR >20 bpm Bradypnea – RR <12 bpm Orthopnea – severe dyspnea in which

breathing is very difficult in any position other than sitting erect or standing

Respirations Cheyne-Stokes Respirations – periods of

dyspnea followed by periods of apnea; frequently noted in the dying pt

Rales – bubbling or noisy sounds caused by fluids or mucus in the air passages

Wheezing – dyspnea with high pitched whistling or sighing sounds during expiration; caused by narrowing bronchioles and/or obstruction or mucus accumulation in the bronchi

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Respirations

Cyanosis – a dusky, bluish discoloration of the skin, lips, and/or nail beds as a result of ↓O2 and ↑CO2 in the bloodstream

RR should be counted in a way that the pt is unaware of the procedure RR is partially voluntary controlled

Apical Pulse Taken with a stethoscope at the apex of

the heart Use diaphragm (flat, flexible disk) Actual heartbeat is heard & counted

Pulse Deficit – take the apical then the radial pulse, then subtract the radial from the apical = difference is the pulse deficit

Occurs with pts with heart conditions Heart is weak & does not pump enough

blood to produce a pulse

Temperature

A measurement of the balance between heat lost and heat produced

Heat is lost thru perspiration, respiration, & excretion (urine & feces)

Heat is produced by the metabolism of food; and by muscle and gland activity

Temperature

Homeostasis – constant state of fluid balance

The rates of chemical reactions in the body are regulated by body temp. If body temp is too high or too low the

body’s fluid balance is affected

Temperature Measured:

Oral O Rectal R Axillary Ax Aural (ear) T

aka tympanic; in auditory canal

A low or high reading can indicate disease

Temperature

Normal range 96.6 to 100.6 F depending on route used Individuals have different body temps

Depends on the body’s processes Time of day

Lower in am, after resting Higher in pm or after activity or food intake

Parts of the body vary O-98.6 R-99.6 Ax-97.6

Temperature

Factors that lead to ↑ body temp Illness, infection, exercise, excitement,

environmental temp

Factors that lead to ↓ body temp Starvation/fasting, sleep, ↓ muscle

activity, mouth breathing, environmental temp, certain diseases

Temperature Hypothermia – body temp <95oF rectally

Death usually occurs if temp <93oF rectally

Hyperthermia – body temp >104oF rectally Prolonged exposure will cause brain damage or

serious infection >106oF will lead to convulsions, brain damage, or

death

Temperature

Fever – elevated body temp >101oF rectally Febrile – fever is present Afebrile - no fever is present, WNL (within normal

limits)

Clinical Thermometer Glass with mercury or alcohol w/red dye

If breaks, mercury can evaporate & create toxic vapor, attacking CNS

Never vacuum or sweep to clean – use a mercury spill kit

Red – rectal Blue – oral or axillary

Temperature

Factors that can alter temp in mouth Eating, drinking (hot or cold), smoking Wait at least 15 min before taking temp

Clean thermometers in disinfectant solution

Blood Pressure

BP – measurement of the pressure that the blood exerts on the walls of the arteries during the various stages of heart activity (contraction and relaxation)

BP is read in mm of Hg (mercury)

Sphygmomanometer is the medical name

Blood Pressure

Systolic BP Pressure occurs in the walls of the

arteries when the left ventricle of the heart is contracting and pushing blood into the arteries

Normal range 100 to 120 mm Hg

Blood Pressure

Diastolic BP The constant pressure in the walls of the

arteries when the left ventricle of the heart is at rest, or between contractions. Blood has moved forward into the capillaries and veins, so the volume of blood in the arteries has decreased.

Normal range 60 – 80 mm Hg http://familymedicine.osu.edu/products/p

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Blood Pressure

Pulse Pressure The difference between Systolic BP and

Diastolic BP Important indicator of the health and

tone of the arterial walls Normal range 30 – 50 mm Hg

120/80 120 – 80 = 40 pulse pressure

Blood Pressure

Hypertension (HTN) – High BP; 140/90 or higher Causes: stress, anxiety, obesity, high

Na intake, aging, kidney disease, thyroid deficiency, vascular conditions (arteriosclerosis)

HTN not treated will lead to kidney failure, stroke, heart disease

Blood Pressure

Prehypertension- BP in the range of 120/80 - 139/89

Don’t have “high blood pressure” but at risk for developing HTN if lifestyle changes do not occur.

Blood Pressure Hypotension – low BP; less than 90/60

May occur with heart failure, dehydration, depression, severe burns, hemorrhage, and shock

Orthostatic or Postural Hypotension Sudden drop in both SBP & DBP when a person

changes positions Caused by the inability of blood vessels to

compensate quickly to positional change SS ; lightheaded, dizziness, blurred vision

Blood Pressure Factors that ↑ BP

Excitement, anxiety, nervous tension Stimulant drugs Exercise & eating Smoking

Factors that ↓ BP Rest or sleep Depressant drugs Shock Excessive loss of blood Fasting (starvation)

As a class practice reading the computerized blood pressures

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After each reach reading discuss if BP is in normal range or not

PRACTICE BLOOD PRESSURE