1. VITAL SIGNS

2. VITAL SIGNS INCLUDE: TEMPERATURE PULSE RESPIRATIONS BLOOD PRESSURE
VITAL SIGNS MUST BE MEASURED, REPORTED, AND RECORDED ACCURATELY
IF YOU ARE NOT SURE OF A MEASUREMENT, RECHECK IT

3. VITAL SIGNS ARE TAKEN: WHEN A PERSON IS IN A HEALTH CARE FACILITY
SEVERAL TIMES A DAY FOR HOSPITALIZED PATIENTS
BEFORE AND AFTER SURGERY
AFTER SOME PROCEDURES
BEFORE MEDICATIONS ARE GIVEN THAT AFFECT THE RESPIRATORY OR CIRCULATORY SYSTEM
WHENEVER THE PERSON COMPLAINS OF PAIN, SHORTNESS OF BREATH, RAPID HEART RATE, OR NOT FEELING WELL
WITH THE PERSON AT REST IN A LYING OR SITTING POSITION (TILT BLOOD PRESSURES)

4. A CHANGE IN ONE VITAL SIGN WILL CAUSE A CHANGE IN THE OTHERS
FACTORS THAT AFFECT
VITAL SIGNS
ILLNESS
EMOTIONS – ANGER, FEAR, ANXIETY, PAIN
EXERCISE AND ACTIVITY
AGE
SEX
ENVIRONMENT - WEATHER
FOOD AND FLUID INTAKE
MEDICATIONS
TIME OF DAY – ↓ IN THE MORNING, ↑ IN THE AFTERNOON/EVENING
NOISE
A CHANGE IN ONE VITAL SIGN WILL CAUSE A CHANGE IN THE OTHERS

5. REPORT THE VITAL SIGNS TO THE NURSE IF:
ANY VITAL SIGN IS CHANGED FROM A PREVIOUS MEASUREMENT
VITAL SIGNS ARE ABOVE THE NORMAL RANGE
VITAL SIGNS ARE BELOW THE NORMAL RANGE

6. REPORTING AND RECORDING
VITAL SIGNS
MANY AGENCIES HAVE TEMP BOARDS OR TPR BOOKS
RECORD VITAL SIGN MEASUREMENTS AS SOON AS POSSIBLE
CARRY A SMALL NOTEBOOK IN YOUR POCKET SO YOU CAN RECORD THEM AS YOU TAKE THEM
ABBREVIATIONS
TEMPERATURE – T
PULSE – P
RESPIRATIONS – R
BLOOD PRESSURE - BP

7. BODY TEMPERATURE BODY TEMPERATURE IS THE AMOUNT OF HEAT IN THE BODY
IT IS A BALANCE BETWEEN THE AMOUNT OF HEAT PRODUCED AND THE AMOUNT OF HEAT LOST
HEAT IS PRODUCED BY :
THE CONTRACTION OF MUSCLES DURING EXERCISE
THE BREAKDOWN OF FOOD DURING DIGESTION
THE ENVIRONMENTAL TEMPERATURE
HEAT IS LOST THROUGH :
URINE FECES
RESPIRATIONS PERSPIRATION

8. TEMPERATURE MEASUREMENT SITES
BODY TEMPERATURE IS MEASURED IN ONE OF FOUR AREAS OF THE BODY
THE MOUTH – ORAL
THE RECTUM – RECTAL
THE AXILLA (UNDERARM) – AXILLARY
THE EAR – TYMPANIC
WE NOW ALSO HAVE THE TEMPORAL SITE - FOREHEAD
MOST TEMPERATURES ARE TAKEN ORALLY
RECTAL TEMPERATURES ARE THE MOST ACCURATE
AXILLARY TEMPERATURES ARE THE LEAST ACCURATE

9. NORMAL BODY TEMPERATURE
SITE NORMAL RANGE
ORAL ° ° TO 99.6 °
RECTAL ° ° TO °
AXILLARY ° ° TO 98.6 °
TYMPANIC ° °
TEMPORAL ° °

10. TYPES OF THERMOMETERS GLASS THERMOMETER
A SMALL HOLLOW GLASS TUBE THAT CONTAINS MERCURY OR A MERCURY-FREE SUBSTANCE IN A BULB AT ONE END.WHEN HEATED THE MERCURY RISES IN THE TUBE.
Pear – shaped tip

11. READING A GLASS THERMOMETER
THE SCALE IS MARKED FROM 94° TO 108°
THE LONG LINES REPRESENT ONE DEGREE
THE SHORT LINES REPRESENT TWO TENTHS OF A DEGREE
ONLY EVERY OTHER DEGREE IS MARKED WITH A NUMBER

12. ELECTRONIC THERMOMETER
BATTERY OPERATED
HAVE AN ORAL PROBE AND A RECTAL PROBE
DISPOSABLE PROBE COVER IS PLACED ON THE PROBE
THE TEMPERATURE REGISTERS IN ABOUT 30 SECONDS

13. DISPOSABLE ORAL THERMOMETER
DIGITAL THERMOMETER
USE A DISPOSABLE SHEATH
DISPOSABLE ORAL THERMOMETER

14. TYMPANIC THERMOMETER INFANTS – PULL THE EAR STRAIGHT BACK
MEASURES THE TEMPERATURE IN THE TYMPANIC MEMBRANE (EARDRUM)
FAST AND ACCURATE - 1 TO 3 SECONDS
INFANTS – PULL THE EAR STRAIGHT BACK
ADULTS AND CHILDREN OVER ONE YEAR –
PULL THE EAR UP AND BACK

15. GUIDELINES FOR TAKING AN
ORAL TEMPERATURE
DO NOT TAKE AN ORAL TEMPERATURE ON:
AN INFANT OR YOUNG CHILD ( UNDER AGE 6)
AN UNCONSCIOUS PATIENT
A PATIENT THAT HAS HAD ORAL SURGERY OR AN INJURY TO THE FACE, NECK, NOSE, OR MOUTH
A PERSON RECEIVING OXYGEN
A PATIENT WITH A NASOGASTRIC TUBE IN PLACE
A PATIENT WHO IS CONFUSED OR RESTLESS
A PATIENT WHO IS PARALYZED ON ONE SIDE OF THE BODY
HAS A HISTORY OF SEIZURES
A PATIENT WHO BREATHES THROUGH THE MOUTH

16. TAKING AN AXILLARY TEMPERATURE
TAKEN ONLY WHEN NO OTHER SITE CAN BE USED
MAKE SURE THE UNDERARM IS CLEAN AND DRY
THE ARM IS HELD CLOSE TO THE BODY
YOU NEED TO HOLD THE THERMOMETER IN PLACE WHILE THE TEMPERATURE IS BEING TAKEN
THE THERMOMETER IS LEFT IN PLACE FOR 10 MINUTES

17. TAKING A PULSE THE PULSE IS:
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
MORE EASILY FELT IN ARTERIES THAT COME CLOSE TO THE SKIN AND CAN BE GENTLY PRESSED AGAINST A BONE
THE PULSE SHOULD BE THE SAME IN ALL PULSE SITES ON THE BODY
THE PULSE IS AN INDICATION OF HOW THE CARDIOVASCULAR SYSTEM IS MEETING THE BODY’S NEEDS
THE PULSE RATE IS AFFECTED BY MANY FACTORS – AGE, FEVER, EXERCISE, FEAR. ANGER, ANXIETY, EXCITEMENT, HEAT, POSITION, AND PAIN.
MEDICATIONS CAN BE TAKEN THAT EITHER INCREASE OR DECREASE A PERSON’S PULSE RATE.

18. PULSE
SITES

19. WE ALSO OBSERVE THE FORCE (STRENGTH) OF THE HEARTBEAT.
COUNTING A PULSE
WE USUALLY COUNT A PULSE FOR 30 SECONDS AND MULTIPLY THE NUMBER TIMES 2 TO GET THE PULSE RATE FOR 1 MINUTE
WE NOTE THE RHYTHM (PATTERN) OF THE HEART BEAT – IF THE HEART BEAT IS IRREGULAR WE COUNT THE PULSE FOR A FULL MINUTE
WE ALSO OBSERVE THE FORCE (STRENGTH) OF THE HEARTBEAT.
DOES THE PULSE FEEL :
STRONG FULL BOUNDING
WEAK THREADY FEEBLE

20. RADIAL PULSE MOST COMMON SITE USED FOR TAKING A PULSE
CAN BE TAKEN WITHOUT DISTURBING OR EXPOSING THE PERSON
PLACE THE FIRST TWO OR THREE FINGERS OF ONE HAND AGAINST THE RADIAL ARTERY
THE RADIAL ARTERY IS ON THE THUMB SIDE OF THE WRIST
DO NOT USE YOUR THUMB TO TAKE A PERSON’S PULSE
USE GENTLE PRESSURE
COUNT THE PULSE FOR 30 SECONDS AND MULTIPLY BY TWO

21. USING A STETHOSCOPE
ALWAYS CLEAN THE EARPIECES OF THE STETHOSCOPE WITH ALCOHOL BEFORE AND AFTER USE
WARM THE DIAPHRAGM IN YOUR HAND BEFORE PLACING IT ON THE PERSON
HOLD THE DIAPHRAGM IN PLACE OVER THE ARTERY
DO NOT LET THE TUBING STRIKE AGAINST ANYTHING WHILE THE STETHOSCOPE IS BEING USED

22. APICAL PULSE TAKEN WITH A STETHOSCOPE
COUNTED BY PLACING THE STETHOSCOPE OVER THE HEART
COUNTED FOR ONE FULL MINUTE
THE HEART BEAT NORMALLY SOUNDS LIKE A LUB-DUB. EACH LUB-DUB IS COUNTED AS ONE HEARTBEAT.
DO NOT COUNT THE LUB AS ONE HEARTBEAT AND THE DUB AS ANOTHER.
THE APICAL PULSE IS TAKEN ON PATIENTS WHO HAVE HEART DISEASE , AN IRREGULAR PULSE RATE, OR TAKE MEDICATIONS THAT CAN AFFECT THE HEART.

23. REPORT ABNORMAL HEART RATES TO THE NURSE IMMEDIATELY
NORMAL ADULT PULSE RATE IS – 60 TO 100 bpm
TACHYCARDIA – HEART RATE OVER 100 bpm
BRADYCARDIA – HEART RATE BELOW 60 bpm
REPORT ABNORMAL HEART RATES TO THE NURSE IMMEDIATELY

24. COUNTING RESPIRATIONS
ONE RESPIRATION CONSISTS OF ONE INSPIRATION AND ONE EXPIRATION
THE CHEST RISES DURING INSPIRATION (BREATHING IN) AND FALLS DURING EXPIRATION (BREATHING OUT)
COUNT EACH TIME THE CHEST RISES
COUNT FOR 30 SECONDS AND MULTIPLY X 2
DO NOT LET THE PERSON KNOW YOU ARE COUNTING THEIR RESPIRATIONS
COUNT AFTER TAKING THE PULSE – KEEP YOUR FINGERS ON THE PULSE SITE
NORMAL RESPIRATORY RATE FOR ADULT IS 12 – 20 BREATHS PER MIN.

25. ABNORMAL RESPIRATIONS
TACHYPNEA – RESPIRATORY RATE OVER 20
BRADYPNEA – RESPIRATORY RATE BELOW 12
DYSPNEA – SHORTNESS OF BREATH – DIFFICULTY IN BREATHING
APNEA – NO BREATHING
HYPERVENTILATION – FAST AND DEEP RESPIRATIONS
HYPOVENTILATION – SLOW AND SHALLOW RESPIRATIONS

26. BLOOD PRESSURE
THE MEASUREMENT OF THE AMOUNT OF FORCE THE BLOOD EXERTS AGAINST THE ARTERY WALLS
SYSTOLIC PRESSURE – PRESSURE EXERTED WHEN THE HEART MUSCLE IS CONTRACTING
DIASTOLIC PRESSURE – PRESSURE EXERTED WHEN THE HEART MUSCLE IS RELAXING BETWEEN BEATS
BLOOD PRESSURE IS RECORDED AS A FRACTION WITH THE SYSTOLIC PRESSURE ON TOP AND THE DIASTOLIC PRESSURE ON THE BOTTOM
SYSTOLIC SYSTOLIC /DIASTOLIC
DIASTOLIC 120/80
BP IS MEASURED IN MM (MILLIMETERS) OF HG (MERCURY)

27. ABNORMAL BLOOD PRESSURE
AVERAGE ADULT SYSTOLIC RANGE – 100 TO 140
AVERAGE ADULT DIASTOLIC RANGE – 60 TO 90
ABNORMAL BLOOD PRESSURE
HYPERTENSION – MEASUREMENTS ABOVE THE NORMAL SYSTOLIC OR DIASTOLIC PRESSURES
HYPOTENSION – MEASUREMENTS BELOW THE NORMAL SYSTOLIC OR DIASTOLIC PRESSURES

28. FACTORS THAT AFFECT BLOOD PRESSURE
AGE – BLOOD PRESSURE INCREASES AS A PERSON GROWS OLDER.
GENDER – WOMEN USUALLY HAVE LOWER BLOOD PRESSURE THAN MEN
BLOOD VOLUME – SEVERE BLEEDING LOWERS THE BLOOD PRESSURE
STRESS – HEART RATE AND BLOOD PRESSURE INCREASE AS PART OF THE BODY’S RESPONSE TO STRESS
PAIN – INCREASES BLOOD PRESSURE
EXERCISE – INCREASES HEART RATE AND BLOOD PRESSURE
WEIGHT – BLOOD PRESSURE IS HIGHER IN OVERWEIGHT PERSONS
RACE – BLACK PERSONS GENERALLY HAVE HIGHER BLOOD PRESSURE THAN WHITE PERSONS DO
DIET – A HIGH-SODIUM DIET INCREASES THE FLUID VOLUME IN THE BODY WHICH INCREASES BLOOD PRESSURE
MEDICATIONS – CAN BE TAKEN TO RAISE OR LOWER BLOOD PRESSURE
POSITION – BLOOD PRESSURE IS LOWER WHEN LYING DOWN

29. USING BLOOD PRESSURE
EQUIPMENT

30. GUIDELINES FOR MEASURING
BLOOD PRESSURE
DO NOT TAKE A BLOOD PRESSURE ON AN ARM WITH AN IV, A CAST, OR A DIALYSIS SHUNT.
DO NOT TAKE A BLOOD PRESSURE ON THE SIDE THAT A PERSON HAS HAD BREAST SURGERY ON.
MEASURE BLOOD PRESSURE WITH THE PERSON SITTING OR LYING.
APPLY THE CUFF TO THE BARE UPPER ARM. DO NOT APPLY THE CUFF OVER CLOTHING.
MAKE SURE THE CUFF IS SNUG.
USE A LARGE CUFF IF NECESSARY.
MAKE SURE THE ROOM IS QUIET.
IF YOU DO NOT HEAR THE BLOOD PRESSURE, WAIT 30 TO 60 SECONDS AND TRY AGAIN. IF YOU STILL CAN NOT HEAR IT OR ARE UNSURE OF YOUR READINGS, HAVE THE NURSE CHECK YOUR MEASUREMENTS.

31. MEASURING WEIGHT AND HEIGHT
Standing, chair, and lift scales are used.
Measuring weight and height
The person only wears a gown or pajamas.
The person voids before being weighed.
Weigh the person at the same time of day.
Use the same scale.
Balance the scale at zero before weighing the person.

32. PAIN Pain means to ache, hurt, or be sore.
Pain is a warning from the body.
Pain is personal.
Types of pain
Acute pain – felt suddenly from an injury, disease, trauma, or surgery
Chronic pain – lasts longer than 6 months. Pain can be constant or occur on and off.
Radiating pain – felt at the site of tissue damage and in nearby areas.
Phantom pain – felt in a body part that is no longer there.

33. Signs and symptoms
Location – Where is the pain?
Onset and duration – When did the pain start?
Intensity – Rate the pain on a scale of 1 to 10, with 10 as the most severe
Description – Can you use words to describe the pain?
Factors causing pain – What were you doing when the pain started?
Vital signs – Take the person’s vital signs when they complain of pain.
Other signs and symptom
Body responses - ↑ vital signs, nausea, pale skin, sweating, vomiting
Behaviors – crying, groaning, holding affected body part, irritability, restlessness