Vital Signs and Measurements Chapter 38 Vital Signs and Measurements

Height and Weight Mensurations: the process of measuring Purpose The baseline for all measurements to follow Can provide information about treatment Obtained at the beginning of the visit May not be taken at all visits

Height and Weight Additional infant measurements taken to ensure proper growth and development Length of extremities Circumference of head Circumference of abdomen or chest

Body Mass Index Numerical correlation between height and weight May be documented in patient’s chart There are a number of ways to determine BMI

Vital Signs Measure body functions essential to life Four vital indicators, TPR and B/P Temperature: body’s ability to control heat Pulse: rate, volume, and rhythm of the heart Respirations: rate and quality of breathing Blood pressure: force of the heart and condition of the blood vessels

Temperature The balance between heat production and heat loss Heat is produced when food is changed to energy Heat is lost through perspiration, breathing, and elimination of waste

Temperature Factors affecting temperature Normal temperature may vary Metabolic rate Time of date Amount of activity Normal temperature may vary Temperature above normal: febrile Temperature below normal: afebrile

Thermometers Disposable Electronic (battery operated) Digital Tympanic infrared Temporal artery

Oral Temperature

Oral Temperature Contraindications Infants and young children Certain respiratory conditions Confused, disoriented, or unstable patients Oral injuries or dental problems Recent oral surgery Facial paralysis Nasal obstruction, sinus congestion, or colds

Rectal Temperature Very accurate method for measurement Indicated for babies and young children When documenting, record (R) following reading Normal rectal temperature is one degree above normal oral temperature

Axillary Temperature Least accurate method for measurement Indicated when oral and rectal temperatures are undesirable When documenting, record (Ax) following reading Normal axillary temperature is one degree below normal oral temperature

Tympanic (Aural) Temperature Thermometers are easy, safe, and fast When documenting, record (Tym) following reading

Temporal Artery Temperature Very accurate method for measurement Appropriate for all ages, infant through older adult When documenting, record (TA) following reading Normal TA temperature is one degree above normal oral temperature

Temperature Conversions Fahrenheit to Celsius Celsius to Fahrenheit

Pulse Palpated in arteries close to body surface and lie over bone or firm structures Can be felt in several locations on the body

Pulse Sites Radial Apical Brachial Carotid Most frequently used when measuring pulse rate Apical Brachial Used to palpate and auscultate blood pressure Carotid Palpated during CPR

Pulse Sites Femoral Dorsal pedalis Popliteal These three sites are palpated to evaluate circulation in the lower extremities

Pulse Pulse rates Normal range is 60-100 beats per minute Influenced by Exercise Age Gender Size Physical condition of body

Pulse Pulse characteristics Volume Quality Normal, full or bounding, weak, thready Quality Arrythmia, pulse lacks a specific rhythm Intermittent

Measuring Radial Pulse Patient should be sitting or laying down The arm should be well-supported Use the tips of your fingers Do not use the thumb Typically count for 30 seconds, multiply by 2 Count for 60 seconds if pulse is irregular Measure respirations at the same time

Measuring Apical Pules Indicated for Instances when radial pulse is not appropriate Infants and small children Patients with heart conditions Listen to heart at its apex with a stethoscope Palpate at fifth intercostal space Count for 60 seconds Document using [Ap] to indicate apical site

Pulse Oximetry Small device used to measure pulse and arterial oxygen saturation in blood Clip attached to patient’s finger

Respirations Combination of inspiration (inhale) and expiration (exhale) Normal respiration rate is 16-20 per minute Observe rate and quality of respirations Should be quiet, effortless, and regularly spaced Breathing should be through the nose Depth of respiration: normal, shallow, or deep

Respirations Abnormal respirations Hyperventilation Dyspnea Rales (noisy breathing) Apnea, absence of breathing Cheyne-Stokes

Blood Pressure Measured in the brachial artery of the arm in the antecubital space Uses stethoscope and sphygmomanometer to measure Blood pressure phases Systole, contraction phase Diastole, relaxation phase Expressed as a fraction, systolic/diastolic

Normal Blood Pressure Systolic pressure Diastolic pressure 100-120 mm Hg Diastolic pressure 60-80 mm Hg

Abnormal Blood Pressure Hypertension Consistent readings above 140/90 Idiopathic (essential hyptertension) Primary, secondary, malignant Hypotension Consistent readings below 90/60