1. Vital Signs and Measurements
Chapter 38
Vital Signs and Measurements

2. Height and Weight Mensurations: the process of measuring Purpose
The baseline for all measurements to follow
Can provide information about treatment
Obtained at the beginning of the visit
May not be taken at all visits

3. Height and Weight
Additional infant measurements taken to ensure proper growth and development
Length of extremities
Circumference of head
Circumference of abdomen or chest

4. Body Mass Index Numerical correlation between height and weight
May be documented in patient’s chart
There are a number of ways to determine BMI

5. Vital Signs Measure body functions essential to life
Four vital indicators, TPR and B/P
Temperature: body’s ability to control heat
Pulse: rate, volume, and rhythm of the heart
Respirations: rate and quality of breathing
Blood pressure: force of the heart and condition of the blood vessels

6. Temperature The balance between heat production and heat loss
Heat is produced when food is changed to energy
Heat is lost through perspiration, breathing, and elimination of waste

7. Temperature Factors affecting temperature Normal temperature may vary
Metabolic rate
Time of date
Amount of activity
Normal temperature may vary
Temperature above normal: febrile
Temperature below normal: afebrile

8. Thermometers Disposable Electronic (battery operated) Digital
Tympanic infrared
Temporal artery

9. Oral Temperature

10. Oral Temperature Contraindications Infants and young children
Certain respiratory conditions
Confused, disoriented, or unstable patients
Oral injuries or dental problems
Recent oral surgery
Facial paralysis
Nasal obstruction, sinus congestion, or colds

11. Rectal Temperature Very accurate method for measurement
Indicated for babies and young children
When documenting, record (R) following reading
Normal rectal temperature is one degree above normal oral temperature

12. Axillary Temperature Least accurate method for measurement
Indicated when oral and rectal temperatures are undesirable
When documenting, record (Ax) following reading
Normal axillary temperature is one degree below normal oral temperature

13. Tympanic (Aural) Temperature
Thermometers are easy, safe, and fast
When documenting, record (Tym) following reading

14. Temporal Artery Temperature
Very accurate method for measurement
Appropriate for all ages, infant through older adult
When documenting, record (TA) following reading
Normal TA temperature is one degree above normal oral temperature

15. Temperature Conversions
Fahrenheit to Celsius
Celsius to Fahrenheit

16. Pulse
Palpated in arteries close to body surface and lie over bone or firm structures
Can be felt in several locations on the body

17. Pulse Sites Radial Apical Brachial Carotid
Most frequently used when measuring pulse rate
Apical
Brachial
Used to palpate and auscultate blood pressure
Carotid
Palpated during CPR

18. Pulse Sites Femoral Dorsal pedalis Popliteal
These three sites are palpated to evaluate circulation in the lower extremities

19. Pulse Pulse rates Normal range is 60-100 beats per minute
Influenced by
Exercise
Age
Gender
Size
Physical condition of body

20. Pulse Pulse characteristics Volume Quality
Normal, full or bounding, weak, thready
Quality
Arrythmia, pulse lacks a specific rhythm
Intermittent

21. Measuring Radial Pulse
Patient should be sitting or laying down
The arm should be well-supported
Use the tips of your fingers
Do not use the thumb
Typically count for 30 seconds, multiply by 2
Count for 60 seconds if pulse is irregular
Measure respirations at the same time

22. Measuring Apical Pules
Indicated for
Instances when radial pulse is not appropriate
Infants and small children
Patients with heart conditions
Listen to heart at its apex with a stethoscope
Palpate at fifth intercostal space
Count for 60 seconds
Document using [Ap] to indicate apical site

23. Pulse Oximetry
Small device used to measure pulse and arterial oxygen saturation in blood
Clip attached to patient’s finger

24. Respirations
Combination of inspiration (inhale) and expiration (exhale)
Normal respiration rate is per minute
Observe rate and quality of respirations
Should be quiet, effortless, and regularly spaced
Breathing should be through the nose
Depth of respiration: normal, shallow, or deep

25. Respirations Abnormal respirations Hyperventilation Dyspnea
Rales (noisy breathing)
Apnea, absence of breathing
Cheyne-Stokes

26. Blood Pressure
Measured in the brachial artery of the arm in the antecubital space
Uses stethoscope and sphygmomanometer to measure
Blood pressure phases
Systole, contraction phase
Diastole, relaxation phase
Expressed as a fraction, systolic/diastolic

27. Normal Blood Pressure Systolic pressure Diastolic pressure
mm Hg
Diastolic pressure
60-80 mm Hg

28. Abnormal Blood Pressure
Hypertension
Consistent readings above 140/90
Idiopathic (essential hyptertension)
Primary, secondary, malignant
Hypotension
Consistent readings below 90/60