Vital signs/ Anthropometric Measurements Dr. Jennifer Lucy

Vital sign Vital signs are physical signs that indicate an individual is alive Includes heart beat, respiratory rate, temperature, blood pressures and recently oxygen saturation.

Vital sign Signs may be observed, measured, and monitored Assess an individual's level of physical functioning.

Vital sign Before measurements, patient should sit for five minutes.

Observation Does the patient seem anxious, in pain, upset? Remember, anxiety can affect vital sign results

Temperature Vital signs

Temperature Babies and young children tend to have higher temperatures Elderly clients tend to have lower, hence a 97.9 might be a fever.

Temperature Body temperature of affected by Gender Recent activity Food and fluid consumption Menstrual cycle.

Normal Temperature Fahrenheit/Celcius Normal Range: 97.8 F – 99 F equivalent to 36.5 C-37.2 C

Oral Oral ( do not take after food or smoking for 30 mins Place probe under tongue Second most accurate route after rectal Converting F to C -30 then divide by 2 C to F x2 + 30

Temperature ( Rectal ) Rectal temperatures tend to be 1° higher than when taken by mouth. Position patient in Sims ( left side lying position Insert probe 1 inch for patients over 6 months old ½ inch for under patients under 6 months old

Temperature ( Axillary) Axillary temperatures can be taken under the arm. Temperatures taken by this route tend to be 0.3 to 0.4° (Fahrenheit) lower than those temperatures taken by mouth.

Tympanic ( Aural) Measure’s body's core temperature For patients over 3 years gently pull pinna up and out For under three years gently pull pinna down and back .

Temporal Measures infrared heatwaves across skin of forehead

Fever A fever is indicated when body temperature rises above 99.0 orally or 99.8° F rectally.

Hypothermia/ Hyperthermia Hypothermia is defined as a drop in body temperature below 96° F. Hyperthermia is defined as a rise in body temperature above 104 F.

Respiratory rates Vital signs

What is the respiratory rate? The respiration rate is the number of breaths a person takes per minute.

Respiratory Rate Try to do this as surreptitiously as possible. Observing the rise and fall of the patient's hospital gown while you appear to be taking their pulse.

Respiratory Rate Breaths should be counted for at 30 second then times by 2 if regular Count for one minute if irregular

Respiratory Rate Respiration rates may increase with fever , illness or pain

Respiratory Rate Normal respiration rates at rest range from 12 to 20 breaths per minute. 12 20

Abnormal Respiratory Rate Bradypnea under 12 breaths per minute Tachypnea over 20 breaths per minute under 12 breaths over 20 breaths

Pulse Vital signs

Pulse rate The normal pulse for healthy adults ranges from 60 to 100 beats per minute.

Pulse rate The pulse rate may fluctuate and increase with exercise, illness, injury, and emotions. Girls ages 12 and older and women, in general, tend to have faster heart rates than do boys and men.

Pulse rate Athletes, such as runners, may have heart rates in the 50's and experience no problems.

Radial pulse You feel the beats by firmly pressing on the arteries, which are located close to the surface of the skin at certain points of the body.

How to check your carotid pulse The carotid pulse can be found on the side of the lower neck,.

Pulse: Quantity Regular Pulse Irregular Measure the rate of the pulse (recorded in beats per minute). Count for 30 seconds and multiply by 2 (or 15 seconds x 4) Measure for a full minute Regular Pulse Irregular

Pulse: Regularity Is the time between beats constant?. Irregular rhythms, are quite common.

Brady / Tachycardia Below 60: Bradycardia Above 100: Tachycardia

Average Heart rate by Age New born 120-160bpm Infant ( 1 to 12 months) 80-140bpm Toddler (1-3 years) 80-130bpm Preschool (3-5-years )80-120bpm School age ( 6-15) 70-100bpm Adult ( over 15 years) 60-100bpm

Blood pressure Vital signs

Preparation for measurement Patient should abstain from eating, drinking, smoking and taking drugs that affect the blood pressure 30 mins before measurement. 

Position of the Patient Sitting position Arm and back are supported. Feet should be resting firmly on the floor Feet not dangling. 

Equipment needed to measure blood pressure Adult Cuff size Indications for large cuff or thigh cuff Upper arm circumference >34 cm Indications for forearm cuff (with radial palpation) Upper arm circumference >50 cm

Blood Pressure If cuff is too small, the readings will be artificially elevated. The opposite occurs if the cuff is too large. Clinics should have at least 2 cuff sizes available, normal and large.

Cuff position Patient's arm slightly flexed at elbow Push the sleeve up, wrap the cuff around the bare arm

In order to measure the Blood Pressure (Cuff Position) Cuff applied directly over skin (Clothes artificially raises blood pressure ) Position lower cuff border about 2 inches above antecubital Center inflatable bladder over brachial artery

What Abnormal Results Mean

Blood pressure for adult Physician will want to see multiple blood pressure measurements over several days or weeks before making a diagnosis of hypertension and initiating treatment.

Blood pressure (mm Hg) Normal blood pressure Systolic 100 to 119 Diastolic 60 to 79 Pre hypertension Systolic 120 to 139 Diastolic 80 to 89

Hypertension High blood pressure greater than 139-89..

Hypertension Stages STAGE ONE ( Primary) Systolic140-159 Diastolic 90-99 STAGE TWO Systolic 160 or higher Diastolic 100 or higher

Hypertensive Crisis Systolic 180 or above Diastolic 110 or above

Hypotensive stage Systolic less than 90 Diastolic less than 60

Blood pressure may be affected by many different conditions Cardiovascular disorders Neurological conditions Kidney and urological disorders

Blood pressure may be affected by many different conditions Preclampsia in pregnant women Psychological factors such as stress, anger, or fear Eclampsia

PALPABLE B/P Feel for radial pulse Inflate cuff Feel when pulse is no longer palpable Add 30 That is your starting point when you do B/P

Oxygen Saturation Vital signs

Oxygen Saturation Oxygen Saturation provides important information about oxygen perfusion Normal levels 90-100% Make sure patient has no nail polish on Make sure hand is flat on table Capillary refill should be less than 3 seconds.

Height Procedure Place paper towel on scale Place scale at Zero Point Remove shoes Stand straight Measure client Convert 5 feet 6 inches to inches 5 ft x12=60inches +6=66 inches 66 inches x 2.54= 167.64cm

Weight Place paper towel on scale Place scale on zero Guide client onto scale Read scale Convert weight from lbs to kg by multiplying pounds by 0.45 140lbx0.45=63kg. For kg to pounds Multiply kg by 2.2 83kgx2.2=183lb

Pediatric Anthropometric Measurement Birth to 3 years Head Circumference Lay baby on back in supine position Zero mark is placed at forehead. Bring around head just above the ears Length Gently extend leg Measure length from head to foot Weight Set scale Remove diaper Place in middle of scale

Body Mass Index Take height and weight Calculate BMI BMI Values Normal18.5-24.9 Underweight<18.5 Overweight>25-29.9 Obese>30

Pain Scale 0 – Pain free. Mild Pain – Nagging, annoying, but doesn't really interfere with daily living activities. 1 – Pain is very mild, barely noticeable. Most of the time you don't think about it. 2 – Minor pain. Annoying and may have occasional stronger twinges. 3 – Pain is noticeable and distracting, however, you can get used to it and adapt. Moderate Pain – Interferes significantly with daily living activities. 4 – Moderate pain. If you are deeply involved in an activity, it can be ignored for a period of time, but is still distracting. 5 – Moderately strong pain. It can't be ignored for more than a few minutes, but with effort you still can manage to work or participate in some social activities. 6 – Moderately strong pain that interferes with normal daily activities. Difficulty concentrating.

Severe Pain – Disabling; unable to perform daily living activities. 7 – Severe pain that dominates your senses and significantly limits your ability to perform normal daily activities or maintain social relationships. Interferes with sleep. 8 – Intense pain. Physical activity is severely limited. Conversing requires great effort. 9 – Excruciating pain. Unable to converse. Crying out and/or moaning uncontrollably. 10 – Unspeakable pain. Bedridden and possibly delirious. Very few people will ever experience this level of pain.

Pain scale pictures