Vital Signs Chapter 15

Vital Signs Various factors that provide information about the basic body conditions of the patient 4 Main Vital Signs 1.Temperature 2.Pulse 3.Respirations 4.Blood Pressure

Other Vital Signs Pain Scale 0 to 10 Patients are asked to rate their level of pain on the 0-10 scale (relative to the patient) Skin Color Size of pupils and reaction to light Level of consciousness Patient’s response to stimuli Pulse oximeter reading

Temperature A measurement of the balance between heat lost and heat produced Measured: Oral (O) Rectal (R) Axillary (Ax) Aural (ear) (T) aka tympanic A low or high reading can indicate disease

Temperature Normal range 96.6 to F depending on route used Individuals have different body temperatures Time of day Lower in am, after resting Higher in the pm or after activity or food intake Parts of the body vary O – 98.6 R – 99.6 Ax – 97.6

Temperature Hypothermia – body temp < 95  F rectally Death usually occurs if temp < 93  F rectally Hyperthermia – body temp > 104  F rectally Prolonged exposure will cause brain damage or serious infection > 106  F will lead to convulsions, brain damage, or death

Temperature Clinical thermometer Red – rectal Blue – oral or axillary

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 forehead Carotid – sides of the neck Brachial – inner aspect of forearm Radial – inner aspect of the wrist Femoral – inner aspect of the upper thigh Popliteal – behind the knee Doralis Pedis – top of the foot arch

Pulse Bradycardia – pulse < 60 bpm Tachycardia – pulse > 100 bpm (except in children) Normal Ranges: Newborn baby to 160 bpm Baby aged from 1 to 12 months - 80 to 140 bpm Baby/toddler aged from 1 to 2 years - 80 to 130 bpm Toddler/young child aged 2 to 6 years - 75 to 120 bpm Child aged 7 to 12 years - 75 to 110 bpm Adults – bpm

Respirations Normal ranges: Adults: breaths per minute Newborns up to 6 months old: breaths per minute Infants 6-12 months old: breaths per minute Toddlers and Children 1-5 years old: breaths per minute Children 6-12 years old: breaths per minute Adults: breaths per minute

Respirations 1 breath consists of 1 inspiration and 1 expiration 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 should be counted in a way that the patient is unaware of the procedure

Blood Pressure The measurement of the pressure that the blood exerts on the walls of the arteries during the various stages of heart activity BP is read in mm of Hg Medical name: Sphygmomanometer SYSTOLIC: Top number in reading Normal range 100 to 120 mm Hg DIASTOLIC: Bottom number in reading Normal range 60 to 80 mm Hg

Blood Pressure

Height and Weight They are important because they provide necessary information in performing and evaluating: Lab tests Calculating dosages of medication Monitor patients who have cancer and are on chemotherapy Monitor patients who have edema (swelling) due to heart, kidney, or other diseases

Height and Weight For those patients who require daily weights: Use the same scale each day Make sure the scale is balanced before weighing a patient Weigh the patient at the same time each day Make sure the patient is wearing the same amount of clothing each day

Balance Beam Scale Bed Scale Chair Scale Wheelchair Scale Infant Scale

Pulse Oximeter Normal is over 96% O2 saturation Levels below 96% can indicated a respiratory or cardiovascular abnormality (congenital heart disease, sickle cell anemia, asthma, etc)