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Vital Signs - Chapter 9 VITAL SIGNS
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Vital Signs - Chapter 9 Vital Signs The most important measurements obtained when assessing a client’s condition. Temperature Pulse Respirations Blood Pressure Vital Signs – Drastic changes of these signs can lead to death These signs are ‘vital to life’ – thus the terms ‘vital signs’ Vital signs – good indicator of body’s ability to maintain homeostasis May affect Vital Signs – age, activity, nutrition, emotions, fitness, meds, illness 5th Vital Sign - pain – rating pain on a scale of 1-0 (1=1min to 10=severe) Other signs – skin color; pupil size; reaction to light; LOC; response to stimuli
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Body Temperature - defined
Vital Signs - Chapter 9 Body Temperature - defined Measurement of the balance between heat lost and heat produced in the body The measurement of core body heat.
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TEMPERATURE The first assessment taken
Vital Signs - Chapter 9 TEMPERATURE The first assessment taken Normal adult temp – 98.6°F (37°C) Normal range – 96.8°F to 100.4°F (36.0° ° C) Variations may be due to Time of day Allergic reaction Illness/Infection Stress Exposure to heat or cold Variations – time of day – temps usually lower in the morning/higher in the evening exposure to heat or cold – higher out in sun; lower when exposed to cold air FORMULA Conversion F to C/C to F Fahrenheit to Celcius °F – 32 ÷ 1.8 = °C Celcius to Fahrenheit °C x = °F
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TEMPERATURE High Temps above 100.4°F (38.0°C) Hyperthermia Hypothermia
Vital Signs - Chapter 9 TEMPERATURE High Temps above 100.4°F (38.0°C) Documented as febrile (fever) Normal temperature range – afebrile Hyperthermia Temperatures above 104°F Death & Convulsions Hypothermia Temperatures below 95°F Death Pyrexia – aka Fever caused by an infection or injury Death occurs if body temp drops below 93°F Fever = body temp (101°F rectally)
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TEMPERATURE SITES Oral Tympanic Rectal (most accurate) Axillary
Vital Signs - Chapter 9 TEMPERATURE SITES Oral Normal °F Range – 97.6 – 99.6°F Axillary Normal – 97.6°F Range – 96.6 – 98.6°F Tympanic Rectal (most accurate) Normal – 99.6°F Range – 98.6 – 100.6°F Oral – in the mouth/under the tongue - most common, convenient & comfortable (3-5 minutes) Mercury thermometers are read by degrees – and 2/10 of a degree Axillary – in the arm pit (aka axilla) Abbrev = Ax - charting (10 min) Remove clothing Hold thermometer in place Tympanic – in the ear canal (aural) Abbrev = T - charting Rectal – through the anus/rectum – internal & most accurate Abbrev = R - charting (3-5 min) Always hold thermometer in place while taking temp Use a lubricant with rectal temps
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THERMOMETER TYPES Two basic types –
Vital Signs - Chapter 9 THERMOMETER TYPES Two basic types – Electronic/Digital – measures temperature through a probe Glass – contain mercury in the bulb Rounded tip – rectal use Long tip – oral use Security tip – both oral & rectal assessments Electronic – make sure probe is as close as possible to area where you wish to measure the temperature disposable plastic covers – prevent contamination Glass – may be colored red – rectal; blue – oral & axillary aka Clinical Thermometer
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PULSE Auscultation - listening for sounds
Vital Signs - Chapter 9 PULSE A wave of blood flow created by contractions of the heart The amount of blood pumped from the left ventricle of the heart to the artery being assessed Pulse is checked by palpating - to feel OR Auscultation - listening for sounds Contractions of the heart = heart beats
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Vital Signs - Chapter 9 PULSE SITES (points) Named according to bones or other structures near where they are located Most Common Sites Radial – inside of wrist Brachial – Adults – antecubital space (bend of the elbow) Children – middle of the inside of upper arm Apical – auscultated with a stethoscope placed on the chest wall Apical pulse – often used when assessing infants & young children Adults – must be taken before certain drugs – may slow heart rate Used when an apical-radial pulse deficit is being assessed this occurs when there is a difference in the rate of the radial & apical pulse Apical pulse – higher – indicating the heartbeats are not reaching the radial artery Obstruction, trauma, abnormal heartbeat or other disorder may cause the deficit Taken – b/c illness, atherosclerosis, weak/rapid radial pulse, Dr’s orders
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Vital Signs - Chapter 9 Pulse Sites (points) Named according to bones or other structures near where they are located Other Sites Carotid – alongside the trachea toward the ear Temporal – front edge of ears Femoral – in the groin or crease between thigh & abdomen Popliteal – behind the knee, toward the midline Dorsalis pedis – dorsal side of the foot Posterior tibial – behind the medial malleolus Carotid – on pt/client not having a heartbeat during CPR; found more often when pulse is weak or BP is low Temporal – pressure here could slow bleeding from the scalp Femoral – most commonly used for invasive procedures; used as a site to slow bleeding in the leg Popliteal – used for assessing BP in the leg Dorsalis pedis & Posterior tibial - used during neurovascular checks of the feet to verify circulation
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PULSE CHARACTERISTICS
Vital Signs - Chapter 9 PULSE CHARACTERISTICS Pulse assessment characteristics include Rate – BPM Tachycardia – pulse rate faster than 100 bpm Bradycardia – pulse rate slower than 60 bpm Normal Rages Infants bpm Children – 1 to 7 yrs – bpm Children 7 yrs – bpm Adults bpm Rate – beats per minute (bpm); count for 15, 20, 30, 60 seconds Tachycardia – causes: physical/mental stress – infection, pain, exercise Bradycardia – causes: physically fit athletes; taking meds for the heart; a severe lack of oxygen or BP Normal range varies with age & gender adult men – bpm adult women – bpm age pulse rate Physically fit – pulse is on low side
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Pulse Characteristics
Vital Signs - Chapter 9 Pulse Characteristics Pulse assessment characteristics include Rhythm – pattern of heartbeats (regularity) Regular or Irregular Arrhythmia or Dysrhythmia – irregular heartbeat Must be counted for a full minute Medications Heart dysfunction Lack of oxygen
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Pulse Characteristics
Vital Signs - Chapter 9 Pulse Characteristics Pulse assessment characteristics include Volume – the strength of the pulse Measurement as it presses against the arterial wall and against your fingertips when palpating Rating Scale 0 – Absent, unable to detect 1 – Thready or weak, difficult to palpate, easily obliterated by light pressure from fingertips 2 – Strong or normal, easily found & obliterated by strong pressure from fingertips 3 – Bounding or full, difficult to obliterate with fingertips Volume = strength - intensity Thready or weak pulse – may indicate decreased circulation – obstruction of the artery, weak contraction of the heart, low blood pressure Bounding pulse – may indicate high blood pressure or strong contractions of the heart What affects pulse rate and quality??? body temp emotions activity level health of the heart
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Pulse Characteristics
Vital Signs - Chapter 9 Pulse Characteristics Pulse assessment characteristics include Bilateral Presence – found on both sides of the body; having the same rate, rhythm, and volume Unilateral – found on one side of the body
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Vital Signs - Chapter 9 RESPIRATIONS The act of breathing; the exchange of oxygen and carbon dioxide from the air into the lungs Breathing in – inspiration & Breathing out – expiration Assessment Rate Rhythm Quality Respiratory Rate Observing the client’s chest movement for one minute Quality – character – depth & quality of respirations deep - shallow - labored - difficult
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Vital Signs - Chapter 9 Respirations Respiratory Rate – the number of breaths per minute – counted for one full minute Suggested normal rates – 12 – 20 breaths/minute Ventilation – movement of air in & out of lungs Hyperventilation – increased respiratory rate Hypoventilation – decreased respiration rate Rates decrease with an increase in size & age Hyperventilation causes: Physical/mental stress – infection, exercise, anxiety Increase in body temp Lack of oxygen or low blood pressure Hypoventilation causes: Pain medications & alcohol Decrease in body temp Severe lack of oxygen & no blood pressure Children – respiration slightly faster than adults bpm – ave Infants – bpm
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Respirations Respiratory Rhythm Abnormal respiration – Cheyne-Stokes
Vital Signs - Chapter 9 Respirations Respiratory Rhythm Should be regular Abnormal respiration – Cheyne-Stokes Periods of dyspnea followed by periods of apnea Apnea – no breathing
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Respirations Quality of respiration is seen in volume & effort
Vital Signs - Chapter 9 Respirations Quality of respiration is seen in volume & effort Volume – the amount of air taken into the lungs and exhaled from the lungs Documented as shallow or deep Effort – the amount of work the client uses in order to breath Muscle use seen in the neck, chest & abdomen is an indication of labored or difficult breathing Dyspnea – difficult or labored breathing Tachypnea – respirations over 25/min Bradypnea – slow respirations - 10 Orthopnea – severe dyspnea – breathing is difficult in any position other than sitting erect or standing Rales – bubbling or noisy sounds – fluids/mucus in air passages Wheezing – difficult breathing with high-pitched whistling or sighing Cyanosis – bluish discoloration of skin, lips &/or nailbed
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Vital Signs - Chapter 9 Measuring Methods If using a mercury thermometer, measure the pulse and respiration while waiting for the temperature If using another method of measuring the temperature, complete the temperature - then measure the pulse and respiration Keep your fingers on the pulse while measuring the respiration Chart in this order: Temperature – Pulse - Respiration
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Vital Signs - Chapter 9 BLOOD PRESSURE Blood Pressure – the amount of pressure or tension exerted on the arterial walls as blood pulsates through them Systolic pressure – the pressure exerted on the arteries during the contraction phase of the heartbeat Diastolic pressure – the resting pressure on the arteries as the heart relaxes between contractions Measured in millimeters (mm) of mercury (Hg) Systolic pressure – should be higher because pressure should be higher in the blood vessels when the heart is contracting Factors that may affect Blood Pressure Lying down (usually lower B/P) Sitting position Standing position (usually higher B/P) Increase in Blood Pressure Excitement, anxiety, nervous tension Stimulant drugs Exercise and eating Decrease in Blood Pressure Rest and sleep Depressant drugs Excessive loss of blood
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Blood Pressure Normal Systolic readings Normal Diastolic readings
Vital Signs - Chapter 9 Blood Pressure Normal Systolic readings Between mm Hg Normal Diastolic readings Between mm Hg Prehypertension Readings Systolic – mm Hg Diastolic – mm Hg Hypotension – lower than normal BP – body attempts to raise the BP – see signs of shock or a lack of blood flow to the body’s tissues Signs of shock: change in level of consciousness (LOC); increased heart rate & respiration weak, thready pulse pale, sweaty skin
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Blood Pressure Readings
Vital Signs - Chapter 9 Blood Pressure Readings American Heart Association recommendations Patient should sit quietly for at least 5 minutes before the B/P is taken Two separate readings should be taken and averaged Minimum wait of 30 seconds between readings Follow these recommendations for an accurate reading Proper Cuff Size – s/b the same diameter as the arm Small cuffs result in falsely high readings Large cuff may cause falsely low readings
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BLOOD PRESSURE SITES Blood pressure can be obtained from any artery.
Vital Signs - Chapter 9 BLOOD PRESSURE SITES Blood pressure can be obtained from any artery. Need a pulse site Safest & most convenient sites Brachial – most common for routine VS for adults/children Radial – possible site for infants or clients with very large upper arms Popliteal/Femoral – behind the knee/thigh – used because of trauma, disease, medical treatments to the arm, or recent mastectomy Dorsalis pedis/Posterior Tibial – lower leg – common use for infants
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BLOOD PRESSURE EQUIPMENT
Vital Signs - Chapter 9 BLOOD PRESSURE EQUIPMENT Sphygmomanometer – the instrument used to measure BP sphygmo – pulse mano – pressure meter – measure Commonly referred to as the BP cuff Types of Sphygmomanometers Mercury Aneroid Electronic (no stethoscope needed)
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VITAL SIGNS PROCEDURES
Vital Signs - Chapter 9 VITAL SIGNS PROCEDURES Perform the least invasive first Invasive – invading someone’s personal space or inserting a needle into the skin Noninvasive – actions that do not intrude – a simple observation Temperature Pulse Respiration Blood Pressure Temperature & Pulse & Respiration are commonly taken at the same time
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Vital Sign Procedures Documentation & Reporting
Vital Signs - Chapter 9 Vital Sign Procedures Documentation & Reporting Check on the chart for VS or T P R BP Always record in this order 98.6 – 72 – 16 – 145/69 Always report information to the supervisor if it falls outside of the normal range for the client or if the VS is significantly different from the previous recorded result Respirations may also be abbreviated RR
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