Vital Signs

Most important measurements you will obtain from Pt Temp, pulse, respirations, and blood pressure These are all vital to life, thus vital signs Variances indicate a possible underlying issue not seen with the naked eye

Temperature Body temp is a good indicator for Pt assessment Normal temp is considered 98.6 or 37 C There is a range for a normal temp from 96.8-100.4 F or 36.0-38.0 C ºC * 1.8000+ 32.00 = F So 32 F would be 0 C

Range in temp is related to 5 factors Time of day- temp usually lower in the am and higher in the pm Allergic reaction Illness Stress Exposure to heat or cold

When temp gets above 100.4 F or 38 C you would document or chart this as the Pt being febrile If temp is within norms you would document afebrile When taking a temp, ensure that the pt hasn’t been drinking hot fluid, been wrapped up in blankets, or other means of giving a false high temp.

There are a few places on the body you can get an accurate temp Orally- within the mouth or under the tongue Axillary- in the armpit also known as axilla Tympanic- within the ear canal Rectal- through the rectum or anus

Contraindication of oral temperature: • Infants and children. • Unconscious patients. • Inflammation or surgery of mouth. • Persistent frequent coughing. • Mouth breathing patients.

Contraindication of rectal temperature: • Patients with surgical operation in the rectum or perineal region. • Disease or inflammation of the rectum. • Diarrhea Hemorrhoids

Pulse A pulse is a wave of blood flow created by a contracting heart You will check a pulse by palpating or feeling it on a Pt Sometime we would listen or ausculate by using a stethoscope or vital sign machine

Pulse Locations Most common are radial, brachial, and apical Radial is located on the inside of the Pt wrist, near the thumb Note: your thumb can have a pulse or it’s own so don’t mistake your pulse for your Pt

The brachial is adults is found in the antecubital (AC) The brachial in children it is found in the middle of the inside of the arm

The apical pulse is ausculated with a stethoscope on the chest Note anatomically were the apex of the heart is It is located on the Pt left side of sternum and under the fifth and sixth intercostal space Apical-radial pulse occurs due to obstruction, trauma, abnormal heart rate, or disorder

Characteristics of pulse Rate, Rhythm, Volume, Bilateral presence Assessed in Beats per min or BPM Counted for 15-60 seconds Rates vary for age, gender underlying medical condition, medication As we age our pulse decreases Women tend to have faster pulses

Pulse per Age group Newborn= 120-160 1-12 months= 80-140 1-6 year= 80-120 6-adolescence= 75-110 Adult= 72-80 Late adulthood= 60-80

Tachycardia Fast HR Physical or emotional stress, infection, pain, exercise etc… Lack of oxygen or low bp

Bradycardia Slow HR Physically fit Certain medications Severe lack of oxygen or bp Symptomatic

Pulse Rhythm Pattern of heartbeats Should be regular Irregular rates are referred to as an arrhythmia or dysrhythmia When you document pulse rhythm you should record it as regular or irregular.

EKG Electrocardiogram Measures electric cardiac voltage Doesn’t measure muscle contraction just the electrical activity Known as a 12-lead

Normal Sinus Rhythm

Sinus Tachycardia

Sinus Bradycardia

Respiration Act of breathing Exchange of oxygen and carbon dioxide Difference between respiration and ventilation When counting resp. you will count one inhalation and one exhalation as one this is a complete breath

Respiration- is the actual gas exchange that takes place within the lungs Ventilation- is the process of moving air in and out of the lungs The air we breath has only 21% oxygen and when we exhale we breath out 14% oxygen Thus in CPR when we do mouth to mouth our Pt is still receiving O2 during breaths

Most common way to assess resp. is to observe chest rise and fall Children under 7 are known as belly breathers hence the healthcare worker will observe the child's belly to obtain resp. rate Belly breathing in adults is an ominous sign or indicates resp. distress

Rate of resp. This is number of breaths a minute Counted for full min Normal range is 12-20 bpm Ventilation again refers to movement of air in and out of the lungs An increase in ventilation is documented as hyperventilation

Causes of hyperventilation Physical/mental stress such as infection, exercise, anxiety Increase in body temp. Lack of oxygen and reduced or no blood pressure

Rhythm of resp. should be regular and a quiet process Should hear no auditory indicators Apnea is another word for not breathing

Blood pressure Amount of pressure or tension exerted on the arterial walls Systolic blood pressure(top #)- pressure exerted on the arteries during the contraction of the heart. This # is higher of the two because pressure should be higher during the heart beat Diastolic (lower #)- is the resting pressure on the arteries as the heart relaxes between contractions

When you document bp it should look like 120/80 Bp is measured in mm of mercury Expected systolic readings are between 100 and 140 mm Hg Expected diastolic readings are between 60 and 90 mm Hg

A systolic reading of 120-130 mm Hg and a diastolic reading of 80-89 mm Hg is classified as prehypertension When the bp drops below normal levels(hypotension) the body attempts to raise the pressure

Shock When a traumatic injury occurs and there is substantial blood loss the body is classified as going into shock Compensated shock Non-compensated shock

Symptoms of shock Change in LOC/AMS Increase in HR and Resp. Weak irregular thready pulse Diaphoretic skin

Compensated Shock The bodies attempt to reverse the shock process Elevated Bp, HR, Resp As the body loses blood volume the harder it is on the body to maintain homeostatis This stage however can be reversed with rapid transport or acute medical care, thermoregulation of Pt, and volume replacement

Decompensated Shock This stage is the failing of the body systems The increase in body vitals seen with compensated are no longer present Lowered bp, diminished HR and Resp. are all classic signs of impending death

Sites for bp Bp can be obtained from any artery Brachial- taken from upper arm, most common site for routine vitals for adults and older children Radial-taken on lower arm, possible site for infants or Pt who have large upper arms Popliteal-taken on the thigh, alternate to arms due to trauma, disease, mastectomy

Orthostatic hypotension-occurs when the Pt with normal bp develops symptoms and low bp upon rising to an upright position

Pulse Ox Pulse ox measures oxygen saturation Probe with LED and photo sensor Probe requires highly vascular area to detect the degree of oxygenation Earlobe, finger, toe, bridge of nose