Vital Signs

ByPamela

Sommers

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• Vital signs are objective guideposts that provide data to determine a persons state of health

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• The four vital signs are

• Temperature

• Pulse

• Respiration

• Blood Pressure

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TEMPERATURE

• Body temperature is maintained within a fairly constant range by the hypothalamus, which is located in the brain. The hypothalamus functions as the body’s thermostat

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• The purpose of measuring body temperature is to establish the patient’s baseline temperature and to monitor any abnormalities.

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Temperature Range

• The normal temperature range is 97* to 99* Fahrenheit

• The average temperature is 98.6* Fahrenheit

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Temp Alterations

• Body temp. that fall between 99* F and 100.4* F is termed as a low grade fever.

• Body temp. that is above 100.4* F is termed as a normal fever

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• Temperature that reaches 105.8* F is a serious condition

• Temperature that reaches 109.4* F is generally fatal

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Oral Body Temp

• Step 1: Sanitize your hands.• Step 2: Use the thermometer that is

color coded blue for oral temps only• Step 3: If using an electronic

thermometer make sure you put a plastic sheath over the thermometer to prevent spreading microorganisms

• Step 4: Place the thermometer under the patients tongue (make sure the patients mouth stays closed) hold it there until the machine beeps.

• Remove the thermometer from the mouth and discard the plastic sheath

• The temperature reading will show up on the machine.

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Axillary Body Temp

• Step 1: Sanitize your hands• Step 2: Use the thermometer that is

color coded blue for oral temps only• Step 3: If using an electronic

thermometer make sure you put a plastic sheath over the thermometer to prevent spreading microorganisms

• Step 4: Place the thermometer under the patients arm pit (make sure it is dry) close the arm, securing the thermometer, hold it there until the machine beeps.

• Remove the thermometer from the arm pit and discard the plastic sheath

• The temperature reading will show up on the machine.

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Rectal Temp

• Step 1: Sanitize your hands and wear a pair of gloves

• Step 2: Use the thermometer that is color coded red for rectal temps only

• Step 3: If using an electronic thermometer make sure you put a plastic sheath over the thermometer to prevent spreading microorganisms

• Step 4: Lubricate the thermometer and gently insert it in the patients rectum

• Step 5: For adults insert it approximately 1 inch, for children 5/8 of an inch and infants ½ inch; hold the thermometer in place until the machine beeps.

• Gently remove the thermometer and discard the sheath

• The temperature reading will show up on the machine

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Tympanic Temp• Step 1: Sanitize your hands• Step 2: Place a cover over the probe.

This protects the lens and provides infection control

• Step 3: Hold the thermometer in your dominate hand

• Step 4: With your non-dominate hand straighten the patients external ear

• For adults and children older than 3 yrs. Gently pull the upper part of the outer ear upward and back

• For children younger than 3yrs pull the lower part of the outer ear downward and back

• Insert the probe gently into the patients ear canal. Seal the probe tightly without causing discomfort. Wait for the beep.

• Gently remove the probe and discard the plastic sheath

• The temperature reading will show up on the machine.

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Pulse

• The purpose of measuring the pulse is to establish the patient’s baseline pulse rate and access the pulse rate following special procedures and medications

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• The pulse is measured by applying moderate pressure with the sensitive pads located on the tips of the three middle fingers

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• Place your three middle fingers on the radial artery which is located on the inner portion of the wrist just above the thumb. Count how many heart beats you feel in one minute.

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Pulse Range

• Normal pulse rate varies depending on age.

• For the healthy adult the normal resting pulse ranges from 60 to 100 beats per minute

• Tachycardia is characterized as a fast heart rate which is more than 100 beats per minute. This may indicate a patient having some sort of heart disease or the person just finished with vigorous exercise

• Bradycardia is characterized as an abnormally low heart rate which is fewer than 60 beats per minute. This may occur during sleep or with trained athletes.

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Respiration

• The purpose of respiration is to provide for the exchange of oxygen and carbon dioxide between the atmosphere and the blood. Oxygen is taken into the body to be used for vital body processes, and carbon dioxide is given off as a waste product

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• Each respiration is divided into two phases

• 1. inhalation, which is breathing in.

• 2. exhalation, which is breathing out

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You need to watch the chest rise and fall as the person breaths. You will count for one minute how many times the chest falls. This will be how many respirations the patient has per minute

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Respiration Range

• The respiration for a healthy adult ranges from 12 to 20 respirations per minute

• Tachypnea is characterized as an abnormal increase in respirations which is more than 20 respirations per minute

• Bradypnea is characterized as an abnormal decrease in respirations which is less than 12 respirations per minute

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Blood Pressure

• Blood pressure is a measurement of the pressure or force exerted by the blood on the wall of the arteries in the heart. It varies by age, gender and medications just to mention an few.

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Measuring Blood Pressure

Step 1: Sanitize your hands and select the proper cuff size

Step 2: Place the cuff on the patients upper arm approximately one inch above the bend of the elbow. Keep the arm extended.

Step 3: Place the chest piece of the Stethoscope directly on the bend of the arm of the brachial artery.

Step 4: Using the bulb inflate the cuff to approximately 180-200. Gently release the pressure

Listen carefully. Watch the pressure gage on the B/P Cuff. You will record the first clear tapping sound which is the systolic pressure, then you will record the last tapping sound which is the diastolic pressure.

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B/P Ranges

• Blood pressure less than 120/80 is considered normal according to the National Heart, Lung, and Blood Institute

• Blood pressure between 120/80-139/89 is considered prehypertension.

• Blood pressure above 139/80 is considered high blood pressure or hypertension.

• Blood pressure below 95/60 is considered low blood pressure or hypotension