1. Chapter 15
Vital Signs

2. 15:1 Measuring and Recording Vital Signs (VS)
Record information about the basic body conditions
Main vital signs (VS)
Temperature
Pulse
Respiration
Blood pressure

3. Other Assessments
Pain—patients asked to rate on scale of 1 to 10 (1 is minimal and 10 is severe)
Color of skin
Size of pupils and reaction to light
Level of consciousness
Response to stimuli

4. VS Readings Accuracy is essential Report abnormality or change
If unable to get reading, ask another person to check

5. Measuring and Recording Temperature
Measures balance between heat lost and heat produced in the body
Heat produced by metabolism of food and by muscle and gland activity
Homeostasis: constant state of balance in the body
Conversion between Fahrenheit and Celsius temperature

6. Variations in Body Temperature
Normal range
Causes of variations
Temperature measurements—oral, rectal (often used on infants/children), axillary or groin, aural, and temporal
Abnormal conditions affecting temperature

7. Thermometers Clinical thermometers
Glass
Electronic
Tympanic
Temporal
Plastic or paper
Reading thermometers and recording results

8. Thermometers Avoid factors that could alter or change temperature
Cleaning thermometers
Paper/plastic sheath on glass thermometer

9. Measuring and Recording Pulse
Pulse: Pressure of the blood pushing against the wall of an artery as the heart beats and rests
Major arterial or pulse sites:
Temporal, carotid, brachial, radial, femoral, popliteal & dorsalis pedis
Pulse rate
Adult men bpm
Adult women bpm
Children over 7yrs- 90 bpm
Children 1-7yrs bpm
Infants bpm
Pulse rhythm- regularity of beat
Pulse volume- strength or intensity of pulse

10. Measuring and Recording Pulse
Arrhythmia- irregular or abnormal rhythm, usually caused by a defect in the electrical conduction pattern of the heart
Factors that change pulse rate:
exercise
Stimulant or depressant drugs
Excitement
Fever
Shock
Nervous tension
Sleep
Depression
Heart disease
Coma
Basic principles for taking radial pulse
Recording information

11. Measuring and Recording Respirations
Measures the breathing of a patient
Respiration: Process of taking in oxygen and expelling carbon dioxide from the lungs and respiratory tract
One respiration: one inspiration (breathing in) and one expiration (breathing out)

12. Measuring and Recording Respirations
Normal respiratory rate:
Adults: breaths per minute
Children: breaths per minute
Infants: breaths per minute
Character of respirations- the depth and quality of respiration
Rhythm of respirations- regularity of respirations
Abnormal respirations:
Dyspnea- difficult or labored breathing
Apnea- absence or respirations, usually temporary
Tachypnea- respiratory rate above 25 respirations per minute
Bradypnea- slow rate, usually below 10 respirations per minute
Orthopnea- severe dyspnea in any position other than sitting erect
Cheyne-Stokes- periods of dyspnea followed by apnea (often in the dying)
Rales- bubbling or noisy sounds caused by fluids or mucus
Wheezing- difficult breathing with whistling
Cyanosis- dusky, bluish discoloration of the skin, lips and nail beds
Voluntary control of respirations
Record information

13. Graphing TPR Graphic sheets are special records used for recording TPR
Presents a visual diagram
Uses: most often in hospitals and long-term care facilities
Color codes: EX: temperature in blue ink, pulse in red ink and inspirations in green ink
Factors affecting VS are often noted on the graph: surgery, medications and antibiotics
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14. Graphing TPR
Graphic charts are legal records: must be legible, neat and accurate
To correct an error- cross out error with red ink and initialed

15. Measuring and Recording Apical Pulse
Apical Pulse- count taken at the apex of the heart with a stethoscope
Reasons for taking an apical pulse: patients with irregular heartbeats, hardening of the arteries, or weak or rapid radial pulse
Protect the patient’s privacy and avoid exposure
Heart sounds: lubb-dubb; sounds of the heart valves opening and closing in the heart
Abnormal sounds or beats
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16. Measuring and Recording Apical Pulse
Pulse deficit: check the apical pulse while a second person checks the radial pulse; subtract the radial pulse from apical pulse for difference
Use the stethoscope
Placement of stethoscope: 2-3” to left of breastbone
Measuring apical pulse
Record all information

17. Measuring and Recording Blood Pressure
Blood Pressure- Measurement of the pressure the blood exerts on the walls of the arteries during the various stages of heart activity
Measured in millimeters of mercury on a sphygmomanometer
120/80 mm Hg
Measurements read at two points:
Systolic pressure- occurs in the walls of the arteries when the left ventricle of the heart is contracting and pushing blood in the arteries
Diastolic pressure- the constant pressure in the walls of the arteries when the left ventricle of the heart is at rest, or between contractions
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18. Measuring and Recording Blood Pressure
Pulse pressure: the difference between systolic and diastolic pressure
Hypertension—high blood pressure; >140/90
Hypotension—low blood pressure; < 100/60
Factors influencing blood pressure readings (high or low):
Force of the heartbeat
Resistance of the arterial system
Elasticity of the arteries
Volume of the blood in arteries
Excitement, anxiety, nervous tension, shock
Stimulant and depressant drugs
Exercise and eating or fasting
Rest or sleep
Lying down, standing up or sitting position

19. Measuring and Recording Blood Pressure
Individual factors can all influence blood pressure readings
Types of sphygmomanometers
Mercury
Aneroid- no mercury but calibrated in mmHg
Electronic

20. Measuring and Recording Blood Pressure
Factors to follow for accurate readings: size and placement of sphygmomanometer
Record all required information
Do not discuss the reading with the patient; it’s the doctor’s responsibility

21. Summary Vital signs are major indicators of body function
Accuracy of measurement and recording of vital signs
The health care worker needs to be alert and report any abnormalities