Chapter 18 Vital Signs Copyright © The McGraw-Hill Companies, Inc.

Chapter 9 2 Vital Signs most important measurements you will obtain when you evaluate or assess a client’s condition.

Copyright © The McGraw-Hill Companies, Inc. Chapter 9 3 Temperature Body temperature (T) is one of the first assessments done. Temperature Ranges – Normal adult temperature is 98.6ºF, or 37ºC. – Normal range can be from 96.8ºF to 100.4ºF, or 36ºC to 38ºC.

Copyright © The McGraw-Hill Companies, Inc. Chapter 9 4 Temperatures can vary due to: Time of day. Allergic reaction. Illness. Stress. Exposure to heat or cold.

Copyright © The McGraw-Hill Companies, Inc. Chapter 9 5 Temperature Sites Oral – within the mouth or under the tongue. Axillary – in the armpit. Tympanic – in the ear canal. Rectal – through the anus, in the rectum. Other sites include on the skin or in the blood.

Copyright © The McGraw-Hill Companies, Inc. Chapter 9 6 Pulse A wave of blood flow created by a contraction of the heart. Name these pulses. Click HERE to check answers.HERE A. B. D. E. F. C.G. H.

Copyright © The McGraw-Hill Companies, Inc. Chapter 9 7 Pulse Sites A. Temporal B. Femoral C. Popliteal D. Posterior tibial E. Carotid F. Brachial G. Radial H. Dorsalis pedis A. B. D. E. F. C.G. H.

Copyright © The McGraw-Hill Companies, Inc. Chapter 9 8 Characteristics of the Pulse Pulse Rate – Assessed as beats per minute, or BPM. – Counted for 30 seconds. – Tachycardia – a pulse rate faster than normal. – Bradycardia – a pulse rate slower than normal.

Copyright © The McGraw-Hill Companies, Inc. Chapter 9 9 Pulse Rhythm – the pattern of the heartbeats. – Measure for one for minute if irregular. – When documenting pulse rhythm, record as regular or irregular. Click Pictures for Sounds RhythmRegular Irregular

Copyright © The McGraw-Hill Companies, Inc. Chapter 9 10 Respiration Respiration (R) is the act of breathing. Respiratory Rate (RR) – Observe the client’s chest movement upward and outward for a complete minute. – Children under 7 years of age use abdominal breathing. – Auscultation with a stethoscope may be necessary on clients who are aware that you are counting their respiratory rate.

Copyright © The McGraw-Hill Companies, Inc. Chapter 9 11 Characteristics of Respiration Rate of Respiration – the number of breaths per minute. – Normal range is 12 to 20 breaths per minute for an adult. – Rate will vary with age and size of client. An increased respiratory rate is called hyperventilation. A decrease in respiratory rate and depth is called hypoventilation.

Copyright © The McGraw-Hill Companies, Inc. Chapter 9 12 Rhythm of Respiration – should be regular. Quality of Respiration – Can be shallow or deep.

Copyright © The McGraw-Hill Companies, Inc. Chapter 9 13 Blood Pressure Blood pressure (BP) is the pressure or tension exerted on the arterial walls as blood pulsates through them. Systolic blood pressure (SBP) – pressure exerted on the arteries during the contraction phase of the heartbeat. Diastolic blood pressure (DBP) – the resting pressure on the arteries as the heart relaxes between contractions.

Copyright © The McGraw-Hill Companies, Inc. Chapter 9 14 Blood Pressure (cont.) Expected Blood Pressure Values – Expected SBP – 100 to 140 mm Hg. – Expected DBP – 60 to 90 mm Hg. – Hypotension – when the blood pressure drops below expected levels. – Hypertension – high blood pressure. – Prehypertension – classified by the American Heart Association as SBP 120 to 139 mm Hg or DBP 80 to 89 mm Hg.

Copyright © The McGraw-Hill Companies, Inc. Chapter 9 15 Apply Your Knowledge Where would one measure tympanic temperature? Answer: Tympanic temperature is measured in the ear canal.

Copyright © The McGraw-Hill Companies, Inc. Chapter 9 16 Vital Signs Procedures

Copyright © The McGraw-Hill Companies, Inc. Chapter 9 17 Order of Performance Perform the least invasive vital sign first. Use this order if possible: – Respiratory rate. – Pulse. – Temperature. – Blood pressure.

Copyright © The McGraw-Hill Companies, Inc. Chapter 9 18 Documenting and Reporting Check for common abbreviations in chart. – VS (vital signs) – T P R BP (temperature, pulse, respiratory rate, blood pressure) – RR (respiratory rate) Record results properly. Report information to your supervisor. – Vital signs outside the expected range. – Vital signs significantly different from previous results.

Copyright © The McGraw-Hill Companies, Inc. Chapter 9 19 Apply Your Knowledge List the order for taking vital signs. Answer: 1.Respiratory rate. 2.Pulse. 3.Temperature. 4.Blood pressure.

Copyright © The McGraw-Hill Companies, Inc. Chapter 9 20 STOP

Copyright © The McGraw-Hill Companies, Inc. Patient Assessment Measuring Pulse & Respiration

Copyright © The McGraw-Hill Companies, Inc. Objectives Students will: – Identify normal and abnormal V/S measurements. – Measure and record vital signs according to industry standards. – Measure and record height and weight according to industry standards. – Explain why urine, stool, and sputum specimens are collected. – Explain the rules for collecting different specimens – Describe the seven warning signs of cancer

Copyright © The McGraw-Hill Companies, Inc. Vital Signs Are important indicators of health Detect changes in normal body function May signal life-threatening conditions Provide information about responses to treatment

Copyright © The McGraw-Hill Companies, Inc. Vital Signs Temperature Pulse Respirations Blood Pressure

Copyright © The McGraw-Hill Companies, Inc. Vital Signs Are Measured: – Upon admission – As often as required by the person’s condition – Before & after surgery and other procedures – After a fall or accident – When prescribed drugs that affect the respiratory or circulatory system – When there are complaints of pain, dizziness, shortness of breath, chest pain – As stated on the care plan

Copyright © The McGraw-Hill Companies, Inc. When Measuring Vital Signs Usually taken with the person sitting or lying The person is at rest Always report: – A change from a previous measurement – Vital signs above or below the normal range – If you are unable to measure the vital signs

Copyright © The McGraw-Hill Companies, Inc. Pulse The pressure of blood pushing against the wall of an artery as the heart beats and rests. Measured for one minute while noting: – rate - beats per minute – rhythm - regular or irregular – volume - strength or intensity - described as strong, weak, thready, bounding

Copyright © The McGraw-Hill Companies, Inc. Pulse Rhythm and Force of the pulse Rhythm-time interval between each beat, Rhythm should be regular. Irregular pulse- beats are not everly spaced or when beats are skipped Force-related to pulse strengh

Copyright © The McGraw-Hill Companies, Inc. Pulse Sites Most Commonly Used: Carotid – during CPR Apical – use stethoscope Brachial – for Blood Pressure Radial - to count pulse Femoral – assessment and procedures Popliteal – assessment Dorsalis Pedis – assessment

Copyright © The McGraw-Hill Companies, Inc. Normal Ranges AgePulse per Minute Birth to 1 year years years years years & older Bradycardia – Under 60 beats per minute Tachycardia – Over 100 beats per minute

Copyright © The McGraw-Hill Companies, Inc. Factors that Affect Pulse Factors that  pulse Exercise Stimulant drugs Excitement Fever Shock Nervous tension Factors that  pulse Sleep Depressant drugs Heart disease Coma

Copyright © The McGraw-Hill Companies, Inc. Taking a Pulse The radial pulse is used for routine vital signs It is felt by placing the first two or three fingers of one hand against the radial artery. Count the pulse for one minute.

Copyright © The McGraw-Hill Companies, Inc. Respirations Process of breathing air into (inhalation) and out of (exhalation) the lungs. (Respiration Rate) Oxygen enters the lungs during inhalation. Carbon dioxide leaves the lungs during exhalation. The chest rises during inhalation and falls during exhalation. Normal rate breaths per minute

Copyright © The McGraw-Hill Companies, Inc. Assessing Respiration Respirations is measured when the person is at rest. Rate may change is patient is aware that it is being counted. To prevent this, count respirations right after taking a pulse. Keep your fingers or stethoscope over the pulse site. To count respirations, watch the chest rise and fall.

Copyright © The McGraw-Hill Companies, Inc. Assessing Respiration Character and quality of respirations is also assessed: – Deep (diaphragmatic breathing) – Shallow (hypopnea) – Labored or difficult ( dyspnea) – Noises – wheezing, stertorous (a heavy, snoring type of sound) – Moist or rattling sounds Apnea – absence of respirations Cheyne-Stokes – periods of dyspnea followed by periods of apnea; often noted in the dying patient Rales – bubbling or noisy sounds caused by fluids or mucus in the air passages

Copyright © The McGraw-Hill Companies, Inc. Patient Assessment Measuring BP, Ht and Wt

Copyright © The McGraw-Hill Companies, Inc. Objectives Students will: – Identify normal and abnormal V/S measurements. – Measure and record vital signs according to industry standards. – Measure and record height and weight according to industry standards. – Explain why urine, stool, and sputum specimens are collected. – Explain the rules for collecting different specimens – Describe the seven warning signs of cancer

Copyright © The McGraw-Hill Companies, Inc. Vital Signs Are important indicators of health Detect changes in normal body function May signal life-threatening conditions Provide information about responses to treatment

Copyright © The McGraw-Hill Companies, Inc. Vital Signs Temperature Pulse Respirations Blood Pressure

Copyright © The McGraw-Hill Companies, Inc. Vital Signs Are Measured: – Upon admission – As often as required by the person’s condition – Before & after surgery and other procedures – After a fall or accident – When prescribed drugs that affect the respiratory or circulatory system – When there are complaints of pain, dizziness, shortness of breath, chest pain – As stated on the care plan

Copyright © The McGraw-Hill Companies, Inc. When Measuring Vital Signs Usually taken with the person sitting or lying The person is at rest Always report: – A change from a previous measurement – Vital signs above or below the normal range – If you are unable to measure the vital signs

Copyright © The McGraw-Hill Companies, Inc. Blood Pressure Measure of the pressure blood exerts on the walls of arteries Blood pressure is controlled by: – The force of heart contractions weakened heart  drop in BP – The amount of blood pumped with each heartbeat loss of blood  drop in BP – How easily the blood flows through the blood vessels Narrowing of vessels  increase in BP Dilatation of vessels  decrease in BP

Copyright © The McGraw-Hill Companies, Inc. Factors that Affect Blood Pressure Factors that  blood pressure Excitement, anxiety, nervous tension Stimulant drugs Exercise and eating Factors that  blood pressure Rest or sleep Depressant drugs Shock Excessive loss of blood

Copyright © The McGraw-Hill Companies, Inc. Measuring BP A sphygmomanometer is used to measure BP – Aneroid – has a round dial and needle – Mercury – has a column of mercury – Electronic – automated device BP is measured in millimeters (mm) of mercury (Hg). The systolic pressure is recorded over the diastolic pressure.

Copyright © The McGraw-Hill Companies, Inc. Contraindications for Taking BP Measurement of BP at the brachial artery is a generally benign procedure. However, there are some circumstances in which obtaining readings from a particular arm my not be appropriate: -Presence of an arterial-venous shunt -Recent axillary node dissection -Any deformity or surgical history that interferes with proper access or blood blow to the upper arm. If these relative contraindications are present, BP should be assessed in the opposite arm. There may also be pre-existing conditions that can interfere with the accuracy or interpretation of readings, such as aortic coarctation, arterial-venous malformation, occlusive arterial dz, or the presence of an antecubital bruit. If neither arm can be used, then measurement of blood pressure in a leg may be indicated.

Copyright © The McGraw-Hill Companies, Inc. Normal Range of Blood Pressure Systolic: Pressure on the walls of arteries when the heart is contracting. Normal range – less than 120 mm Hg Diastolic: Constant pressure when heart is at rest Normal range – less than 80 mm Hg Hypertension—BP that remains above a systolic of 140 mm Hg or a diastolic of 90 mm Hg Hypotension—Systolic below 90 mm Hg and/or a diastolic below60 mm Hg

Copyright © The McGraw-Hill Companies, Inc. Measuring Height and Weight Used to determine if patient is underweight or overweight Height and weight charts are used as averages Weight greater or less than 20% considered normal BMI or Body Mass Index a statistical measure of body weight based on a person's weight and height. BMI from 18.5 to 24.9 is considered normal

Copyright © The McGraw-Hill Companies, Inc.

Measuring Height and Weight General Guidelines: Use the same scale every day Make sure the scale is balanced before use Weigh the patient at the same time each day Remove jacket, robe, and shoes before weighing OBSERVE SAFETY PRECAUTIONS! Prevent injury from falls and the protruding height lever. Some people are weight conscious. Make only positive comments when weighing patients

Copyright © The McGraw-Hill Companies, Inc. Types of Scales Clinical scales contain a balance beam and measuring rod. Bed scales or chair scales are used for patients unable to stand Infant scales come in balanced, aneroid, or digital. – When weighing an…keep slightly over but not touching the infant. – A tape measure is used to measure infant height.

Copyright © The McGraw-Hill Companies, Inc. Converting Weight to Metric Measurement To convert multiply by: Grams to ounces Grams to pounds Kilograms to pounds Ounces to grams Pounds to grams Pounds to Kilograms

Copyright © The McGraw-Hill Companies, Inc. Converting Height Converting inches to centimeters is simple…just take the number of inches and multiply it by So for example, 8 inches would be 20.3 cm (8 x 2.54= 20.3) 20.3 / 2.54 = foot = 12 inches