1. VITAL SIGNS

2. VOCABULARY – CH 18 pg. 529 Homeostasis Rate Respiration Rhythm
Blood Pressure
Oral
Rectal
Fahrenheit
Aural
Axillary
Arrhythmia
Rate
Rhythm
Apex
Stethoscope
Tachycardia
Bradycardia
Systolic Pressure
Diastolic Pressure
Hypertension
Hypotension

3. 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

4. OTHER VITAL SIGNS PAIN COLOR THE PATIENTS SKIN
SIZE OF THEIR PUPILS AND THEIR REACTION TO LIGHT
LEVEL OF CONSCIOUSNESS
PATIENTS RESPONSE TO STIMULUS

5. VITAL SIGNS ARE TAKEN:
WHEN A PERSON IS ADMITTED TO A HEALTH CARE FACILITY
SEVERAL TIMES A DAY FOR HOSPITALIZED PATIENTS
BEFORE AND AFTER SURGERY
AFTER SOME NURSING 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. NORMAL BODY TEMPERATURE
SITE NORMAL RANGE
ORAL ° ° TO °
RECTAL ° ° TO °
AXILLARY ° ° TO °
TYMPANIC ° °
TEMPORAL ° °

12. ABNORMAL BODY TEMPERATURE
Fever is not an illness. Its actually an important part of the bodys defense against infection.
Infants develop high fevers with minor viral illnesses.
Older adults loses some thermoregulatory control and its not the first symptom of infection.
Most bacteria thrives at temp. Raising it can give your body the advantage.
The fever activates the body’s immune system to make more white blood cells and antibodies.
Most common causes:
Viral & bacterial infection
Colds or flu like illnesses
Soar/strep throat
Ear infection
Acute bronchitis
Upper respiratory infections

13. FACTORS THAT INFLUENCE TEMPERATURE
Increase Temp.
Exercise
Digestion of food
Environmental Temp.
Illness
Infection
Excitement
Anxiety
Decrease Temp.
Sleeping
Fasting
Exposure to cold
Certain Illnesses
Decreased muscle activity
Mouth breathing
Depression

14. 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.
No used very often due to the chance of mercury poison if it would break.
Pear – shaped tip

15. 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

16. 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

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

18. TYMPANIC THERMOMETER FAST AND ACCURATE - 1 TO 3 SECONDS
MEASURES THE TEMPERATURE IN THE TYMPANIC MEMBRANE
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

19. ORAL TEMPERATURE RINSE WITH COLD WATER CHECK FOR BREAKS AND CHIPS
SHAKE DOWN SO THE MERCURY IS BELOW THE LINES AND NUMBERS
PLACE A DISPOSABLE COVER ON
PLACE UNDER THE PERSON’S TONGUE
LEAVE IN PLACE FOR 2 – 3 MINUTES
IF THE PERSON HAS BEEN EATING, DRINKING, OR SMOKING, WAIT 15 MINUTES BEFORE TAKING TEMPERATURE

20. 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 AN INJURY TO THE FACE, NECK, NOSE, OR MOUTH
A PERSON RECEIVING OXYGEN
A PATIENT WHO IS CONFUSED OR RESTLESS
HAS A HISTORY OF SEIZURES
A PATIENT WHO BREATHES THROUGH THE MOUTH

21. TAKING A RECTAL TEMPERATURE
LUBRICATE THE THERMOMETER BEFORE INSERTING INTO THE RECTUM
PLACE THE PERSON IN A SIDE-LYING POSITION
INSERT THE THERMOMETER 1 INCH INTO THE RECTUM
HOLD THE THERMOMETER IN PLACE FOR 2 MINUTES
REMOVE THE DISPOSABLE COVER AND READ THE THERMOMETER

22. GUIDELINES FOR TAKING A RECTAL TEMPERATURE
DO NOT TAKE A RECTAL TEMPERATURE ON:
A PERSON WHO HAS HAD RECTAL SURGERY OR RECTAL INJURY
IF THE PERSON HAS DIARRHEA
IF THE PERSON IS CONFUSED OR AGITATED
IF THE PERSON HAS HEART DISEASE ( STIMULATES THE VAGUS NERVE WHICH SLOWS THE HEART RATE )

23. 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 3 MINUTES

24. PULSE
THE PULSE IS:
CAUSED BY PRESSURE OF THE BLOOD PUSHING AGAINST THE WALL OF AN ARTERY AS THE HEART CONTRACTS AND RELXES.
A PULSE IS FELT EVERY TIME THE HEART BEATS
THE PULSE SHOULD BE THE SAME IN ALL PULSE SITES ON THE BODY
THE PULSE IS AN INDICATION OF HOW WELL THE BLOOD IS CIRCULATING THROUGH THE BODY.
FACTORS THAT AFFECT PULSE RATE-
AGE
FEVER
EXERCISE
MEDICATION
ILLNESS
SLEEP
EMOTIONS- FEAR. ANGER, ANXIETY, EXCITEMENT
HEAT, POSITION, AND PAIN.

25. PULSE CHARACTERISTICS
NORMAL PULSE RATE
RATE- number of pulse beats per minute.
RHYTHM- Regularity of the beats.
VOLUME- Strength or pressure felt with each beat.
Before Birth
At Birth
First Year
Childhood Years
Adult

26. PULSE RATES
Resting HR: Measured during rest, one indication of CV function.
During PT Session: measuring CV systems capacity to provide blood flow during physical stress.
After PT Session: measuring the CV systems ability to recover.

27. PULSE
SITES

28. 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

29. 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

30. 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.
THE APICAL PULSE IS TAKEN ON PATIENTS WHO HAVE HEART DISEASE , AN IRREGULAR PULSE RATE, OR TAKE MEDICATIONS THAT CAN AFFECT THE HEART.

31. 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

32. APICAL - RADIAL PULSE
THE APICAL AND RADIAL PULSE RATES SHOULD BE EQUAL
SOMETIMES THE HEART BEAT IS NOT STRONG ENOUGH TO CREATE A PULSE IN THE RADIAL ARTERY
THIS WOULD CAUSE THE RADIAL PULSE TO BE LESS THAN THE APICAL PULSE
ONE PERSON COUNTS THE APICAL WHILE THE OTHER PERSON COUNTS THE RADIAL
THE DIFFERENCE IN PULSES IS CALLED THE PULSE DEFICIT

33. REPORT ABNORMAL HEART RATES TO THE NURSE IMMEDIATELY
NORMAL ADULT PULSE RATE IS – 60 TO 100 BEATS PER MIN.
TACHYCARDIA – HEART RATE OVER 100
BRADYCARDIA – HEART RATE BELOW 60
REPORT ABNORMAL HEART RATES TO THE NURSE IMMEDIATELY

34. 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.

35. 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

36. BLOOD PRESSURE
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
BP IS RECORDED AS A FRACTION WITH THE SYSTOLIC ON TOP AND THE DIASTOLIC PRESSURE ON THE BOTTOM
SYSTOLIC /DIASTOLIC
120/80
BP IS MEASURED IN MM (MILLIMETERS) OF HG (MERCURY)

37. 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

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

39. PARTS OF BP CUFF & STETHOSCOPE

40. USING BLOOD PRESSURE
EQUIPMENT

41. GUIDELINES FOR MEASURING
BLOOD PRESSURE
DO NOT TAKE A BP ON AN ARM WITH AN IV OR CAST.
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 & CORRECT SIZE.
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.

42. PROCEDURE FOR MEASURING BLOOD PRESSURE
CLEAN THE STETHOSCOPE EARPIECES AND DIAPHRAGM WITH ALCOHOL.
LOCATE THE BRACHIAL PULSE. THIS IS WHERE THE STETOSCOPE WILL BE PLACED.
WRAP THE CUFF SNUGLY ABOVE THE ELBOW WITH THE ARROW POINTING TO THE
PLACE THE DIAPHRAGM OF THE STETHOSCOPE FLAT ON THE PULSE SITE, HOLDING IT IN PLACE WITH THE INDEX AND MIDDLE FINGERS OF ONE HAND.
LOCATE THE RADIAL PULSE.
CLOSE THE VALVE ON THE BP CUFF BY TURNING IT TO THE RIGHT (CLOCKWISE).

43. PROCEDURE FOR MEASURING BLOOD PRESSURE
7. INFLATE THE CUFF UNTIL YOU CAN NO LONGER FEEL THE RADIAL PULSE. ,THEN INFLATE THE CUFF 30 MM HG BEYOND THIS POINT.
8. DEFLATE THE CUFF SLOWLY BY OPENING THE VALVE SLIGHTLY AND TURNING IT COUNTERCLOCKWISE (TO THE LEFT) WITH YOUR THUMB AND INDEX FINGER. ALLOW THE AIR TO ESCAPE SLOWLY WHILE LISTENING FOR A PULSE SOUND.
9. NOTE THE READING AT WHICH YOU HEAR THE FIRST CLEAR, REGULAR PULSE SOUND. THIS NUMBER IS THE SYSTOLIC PRESSURE.
10. CONTINUE LISTENING UNTIL THE SOUND DISAPPEARS. THIS IS THE DIASTOLIC PRESSURE. NOTE THIS READING.
11. OPEN THE VALVE COMPLETELY TO DEFLATE THE CUFF. REMOVE THE CUFF FROM THE PATIENT.

44. 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.

45. 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.

46. 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