1. Measuring and Recording Vital Signs

2. Vital Signs Four main: Accuracy essential: Temperature Pulse
Respiration
Blood pressure
Accuracy essential:
Abnormal vital signs often first indication of disease or abnormality
Never guess if having difficulty

3. Other Vital Signs Pain (scale of 1-10) Skin color
Red=heat
Blue=lack of oxygen
Yellow=jaundice
Pupil reaction (smaller with light)
Level of consciousness/Response to Stimuli
Glasgow Coma Scale
Eye, verbal and motor response

5. Temperature
Measurement of balance between heat lost and heat produced in body
Heat loss:
Perspiration
Respiration
Excretion
Heat produced:
Metabolism of food
Muscle & gland activity

6. Temperature Homeostasis: Constant state of fluid balance
Ideal health state
Rate of chemical reactions regulated by body temp
Fluid balance affected by body temp

7. Temperature Variations: Individual differences Time of day
Higher metabolism-higher temp
Slower metabolism-lower temp
Time of day
Lower in AM
Higher after muscular activity & food intake

8. Temperature Parts of body: Oral temp Rectal temp
Most common & convenient
Normal: F (37 C)
Thermometer left 3-5 minutes
Rectal temp
Normal: F
Most accurate

9. Temperature Part of body, cont Axillary or groin temp Aural temp
Normal: F
Thermometer left 10 minutes
An external temp & least accurate
Aural temp
Detects & measures thermal energy radiating from eardrum
A core temp-accurate

10. Temperature Factors Causing Increased Temp
Illness and infection
Exercise and/or excitement
High temps in environment
Factors Causing Decreased temp
Starvation or fasting
Decrease muscle activity
Cold temps in environment

11. Abnormal conditions: Hypothermia: Hyperthermia: Fever:
Body temp below 95 F
Caused by prolonged exposure to cold
Hyperthermia:
Body temp exceeds 104 F
Caused by prolonged exposure to hot temps, brain damage or serious infection
Fever:
Elevated body temp
Usually above 101 F
Usually caused by infection or injury

12. Clinical Thermometers
Oral and Rectal:
Oral has long, slender bulb and/or blue tip
Rectal has short, stubby, rounded bulb & may be marked with red tip

13. Clinical Thermometers
Electronic:
Used to take all temps
Prevents contamination from patient to patient

14. Clinical Thermometers
Tympanic (aural):
Measures thermal, infrared energy radiating from eardrum
A core temp-accurate

15. Factors Affecting Temperature
Eating
Drinking hot or cold liquids
Smoking
Wait 15 minute before taking temp

16. Pulse
*The regular expansion of an artery caused by the ejection of blood into the arterial system by the contractions of the heart
*More easily felt in arteries that lie close to skin and pressed against bone

17. Taking the Pulse
Measured by index, middle, and ring fingers over pulse point.
Do not take with the thumb, since it has a pulse of its own.
Count for 30 seconds and multiply by 2, or count for 60 seconds

18. Major Pulse Sites Temporal: side of forehead Carotid: side of neck
Brachial: inner aspect of elbow
Radial: inner aspect of wrist
Femoral: inner aspect upper thigh
Popliteal: behind knee
Dorsalis pedis: top of foot arch

20. Factors to be Noted Pulse rate Noted as number beats per minute
Varies due to age, sex, body size
Adult:
Men:
Women:
Children >7:
Children 1-7:
Infants:
Bradycardia: pulse <60
Tachycardia: pulse>100

21. Factors to be Noted Pulse rhythm Pulse volume
Refers to regularity of pulse or spacing of beats
Described as regular or irregular
Pulse volume
Describes strength or intensity of pulse
Described by strong or weak; thready or bounding

22. Factors Affecting Pulse Rate
Increased rates:
Exercise/excitement
Stimulant drugs
Shock
Nervous tension
Decreased rates:
Sleep
Depressant drugs
Coma

23. Measuring and Recording Respirations
Breathing rate of patient per minute
Taken by watching rise & fall of chest
One respiration: one inhale, one exhale
Normal rates:
Adults:
Children:
Infants:

24. Factors to be Noted Rate Character Rhythm
Refers to depth & quality of respirations
Described as deep, shallow, labored, moist, difficult
Rhythm
Regularity or equal spacing between breaths
Described as regular or irregular

25. Abnormal Respirations
Dyspnea
Difficult or labored breathing
Apnea
Absence of respirations
Cheyne-Stokes
Periods of dyspnea followed by periods of apnea
Rales
Bubbling or noisy sounds caused by fluids or mucus in air passages

26. Control of Respirations
Partially under voluntary control
If pt aware, may breathe faster or slower
Tips when counting:
Don’t tell
Keep hand on pulse site while measuring respirations so will think still counting pulse

27. Apical Pulse Taken at apex of heart Ordered for: Irregular heart beats
Hardening of arteries
Weak or rapid radial pulses
Infants & children

28. Apical Pulse-Heart Sounds
2 separate sounds-”lubb-dupp”
Each “lubb-dupp” counts as one heart beat
Report abnormal sounds or beats

29. Pulse Deficit Taken when: Accuracy essential:
Heart too weak to produce pulse
Tachycardia-not enough time for refill-no pulse produced
Accuracy essential:
One person measure apical pulse
2nd person measures radial pulse
Subtract radial from apical pulse=pulse deficit

30. Blood Pressure
Measurement of pressure exerted on arterial walls as heart contracts or relaxes
If arteries are hardened or narrowed, heart has to work harder to pump blood & pressure will be higher
Measured in mmHg
Instrument: sphygmomanometer

31. Measurement of B/P Systolic pressure Diastolic pressure
Pressure when heart contracting & pushing blood into arteries
Normal range: 100 to 140 mmHg
Diastolic pressure
Constant pressure in arteries when heart at rest
Normal range: 60 to 90 mm Hg

32. Measurement of BP The first sound is the systolic blood pressure
The second sound is the diastolic pressure
Person should be comfortably seated or lying down
Should have rested for minutes prior to the reading
Arms that are paralyzed, injured, have an IV or shunt should not be used
Infant blood pressures can be taken on the leg, but adults must use the arm
Electronic blood pressure equipment can be used

33. Measurement of BP Excess air should be squeezed out of the cuff
Cuff should be placed snugly on upper arm.
Gauge should be easily visualized
Valve should be closed, but easily able to be opened
Find brachial artery and put diaphragm of stethoscope over the site. Pump cuff to 120 mm Hg and listen for the heart beat. If it is heard, pump another 30 mm Hg and listen again. When the pulse is no longer heard, then pump another 30 mm Hg and slowly deflate, listening for the two measurements.

34. Factors Influencing B/P
Force of heartbeat
Resistance of arterial system
Elasticity of arteries
Volume of blood in arteries

35. Individual Factors Influencing B/P
Increase:
Excitement, anxiety, nervous tension
Stimulant drugs
Exercise and eating
Decrease:
Rest or sleep
Depressant drugs
Excessive blood loss

36. Recording B/P
Written as fraction:
Systolic over diastolic
120/80 mmHg

37. B/P Cuffs
Contains rubber bladder that applies pressure to arteries to stop blood flow
Correct size important:
Width=diameter of pt’s arm
Too narrow: false high reading
Too large: false low reading