Vital Signs

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Chapter 15

• Vital Signs

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151 Measuring and RecordingVital Signs (VS)

• Record information about the basic body
  conditions
• Main vital signs (VS)
• Temperature
• Pulse
• Respiration
• Blood pressure

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Other Assessments

• Painpatients 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

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VS Readings

• Accuracy is essential
• Report abnormality or change
• If unable to get reading, ask another person to
  check

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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

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Variations in Body Temperature

• Normal range
• Causes of variations
• Temperature measurementsoral, rectal (often used
  on infants/children), axillary or groin, aural,
  and temporal
• Abnormal conditions affecting temperature

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Thermometers

• Clinical thermometers
• Glass
• Electronic
• Tympanic
• Temporal
• Plastic or paper
• Reading thermometers and recording results

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Thermometers

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

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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- 60-70 bpm
• Adult women- 65-80 bpm
• Children over 7yrs- 90 bpm
• Children 1-7yrs- 80-110 bpm
• Infants- 100-160 bpm
• Pulse rhythm- regularity of beat
• Pulse volume- strength or intensity of pulse

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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

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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)

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Measuring and Recording Respirations

• Normal respiratory rate
• Adults 14-18 breaths per minute
• Children 16-25 breaths per minute
• Infants 30-50 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

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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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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

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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 patients 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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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

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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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Measuring and Recording Blood Pressure

• Pulse pressure the difference between systolic
  and diastolic pressure
• Hypertensionhigh blood pressure gt140/90
• Hypotensionlow blood pressure lt 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

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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

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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 its
  the doctors responsibility

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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