Vital Signs By: Cindy Quisenberry

Vital Signs Vital signs usually include: Temperature Pulse (heart rate) Respirations Blood pressure (BP) Some agencies consider “pain” to be a vital sign (the “5th vital sign”)

Vital Signs Vital signs reflect three body processes regulation of body temperature, breathing, and heart function. A person’s vital signs vary within certain limits. Affected by: Sleep Activity Eating Weather Noise Exercise Drugs Anger Fear Anxiety Pain Illness

Vital Signs Vital signs show even minor changes in the person’s condition. Vital signs tell about responses to treatment. Vital signs often signal life-threatening events.

Vital Signs Accuracy is ESSENTIAL when you measure, record, and report vital signs. If unsure of your measurements, promptly ask your instructor, supervisor, etc. to take them again. Report at once to your supervisor immediately: Any vital sign that is changed from a prior measurement. Vitals above or below the normal range.

Temperature The amount of heat in the body. It is a balance between the amount of heat produced and the amount lost by the body. Produced as cells use food for energy Lost through the skin, breathing, urine, and feces Temperature is lower in the morning and higher in the afternoon and evening. Measured using the Fahrenheit (F) and Centigrade or Celsius (C).

Temperature Temperature sites are: Mouth Rectum Axilla (armpit) Tympanic membrane (ear) Temporal artery (forehead)

Temperature Temperature sites are: Baseline Normal range: Mouth Rectum Axilla (armpit) Tympanic membrane (ear) Temporal artery (forehead) Baseline 98.6° F 99.6° F 97.6° F Normal range: 97.6-99.6° F 98.6-100.6° F 96.6-98.6° F 98.6° F 99.6° F Note: * Older persons have lower body temperatures than younger persons. An oral temperature of 98.6° F may signal fever in an older person.

Temperature Types of Thermometers: Glass – a hollow glass tube with a bulb (tip) at the end. Device is filled with a substance, when heated the substance expands and rises in the tube. Electronic – battery powered; temperature is shown on the front of the device Oral or rectal probes Tympanic membrane Temporal artery

pulse The beat of the heart felt at an artery as a wave of blood passes through the artery. A pulse is felt every time the heart beats. Temporal Carotid Brachial Radial Femoral Popliteal Posterior tibial Dorsalis pedis

Adult pulse rate (Heart rate) Heart rate (pulse rate) – the number of heart beats or pulses felt in 1 minute. Normal adult heart rate is 60-100 beats per minute. A rate of less than 60 or more than 100 is considered abnormal. Report abnormal heart rates.

Children’s heart rate Children > 7 years of age: 70-100 beats/minute Children 1-7: range of 80-100 beats/minute Infants: 100-160 beats/minute

heart rate What is Bradycardia? What is Tachycardia?

pulse Rhythm and Force: Rhythm should be regular (pulse are felt in a pattern) The same time interval occurs between beats. An irregular pulse occurs when the beats are not evenly spaced or beats are skipped. Force relates to pulse strength A forceful pulse is easy to feel. It is described as strong, full, or bounding. Hard to feel pulses are described as weak, thready, or feeble.

Apical pulse The apex of the heart is at the tip of the heart, just below the left nipple; felt over the heart. This pulse is taken with a stethoscope. Taken for persons who: Have heart disease Have irregular rhythms Take drugs that affect the heart.

respirations Respirations means breathing air into (inhalation) and out of (exhalation) the lungs. Each respiration involves 1 inhalation (inspiration) and 1 exhalation (expiration). Respirations are normally quiet, effortless, and regular. Both sides of the chest should rise and fall equally.

Adult respirations The healthy adult has 12-20 breaths per minute. If the rate is above 24 or less than 12, it should be reported. Respirations are usually counted right after taking the pulse. (Keep your fingers or stethoscope over the pulse site while counting the respiratory rate.)

Children’s respirations Children’s respiratory rates are slightly faster than those of adults and average 16-30 breaths/minute. Infants: 30-50 breaths/minute

respirations Check the rate, the character and rhythm of respirations. Character refers to the depth and quality of respirations. Deep Shallow Labored Difficult

respirations What is Dyspnea? What is Apnea? What is Tachypnea? What is Bradypnea? What is Orthopnea? Cheyne-Stokes – abnormal breathing pattern characterized by periods of dyspnea followed by periods of apnea Rales – bubbling, crackling, or noisy sounds caused by fluids or mucus in the air passages

respirations Wheezing – difficulty breathing with a high-pitched whistling or sighing sound during expiration; caused by a narrowing of bronchioles (as seen in asthma) and/or obstruction or mucus accumulation in the bronchi What is Cyanosis?

Blood pressure The amount of force exerted against the walls of an artery by the blood. The period of heart muscle contraction is called systole. The period of heart muscle relaxation is called diastole.

Blood pressure Systolic pressure is the pressure in the arteries when the heart contracts. It is the higher pressure. Diastolic pressure is the pressure in the arteries when the heart is at rest. It is the lower pressure.

Blood pressure Normal blood pressure – systolic < 120; diastolic < 80 Normal Range – systolic 100-120; diastolic 60-80 Prehypertensive – systolic 120-139; diastolic 80-89 Hypertension Stage 1 – systolic 140-159; diastolic 90-99 Hypertension Stage 2 – systolic 160 or higher; diastolic 100 or higher Hypertensive Crisis – systolic > 180; diastolic > 110

Blood pressure Prior to taking BP you need the following information: When to measure BP (VS’s qid?) What arm to use The person’s normal BP range Position of the patient when taking the BP What size cuff to use

pain Means to ache, hurt, or be sore. Pain is a warning from the body. It differs for each person. What one person calls sore, another may call aching.

pain Types of pain Acute – is felt suddenly from injury, disease, trauma, or surgery. Chronic (persistent) – lasts for a long time or occurs off and on Radiating – felt at the site of tissue damage and in nearby areas (ie: myocardial infarction) Phantom – felt in a body part that is no longer there

pain Assessment Location Onset and duration Intensity (rate on a scale from 0-10) Description (ie: stabbing, etc.) Factors that cause pain – precipitating factors Factors affecting pain – What makes it better, what makes it worse? Vital signs Other signs and symptoms (ie: dizzy, nauseated, vomiting, etc.)

pain Wong-Baker Scale