VITAL SIGNS
Vitals Signs
• 4 types(TPR & BP)
– Temperature
– Pulse
– Respirations
– Blood Pressure
• Degree of Pain is frequently regarded as the 5th VS(pain
scale 0-5)
• Color of the skin, size of the pupils in the eyes and their reaction to light,
level of consciousness, and patient’s response to stimuli
• VS provide information about the basic body conditions of the patient
**Earliest indicators of change in the body
Temperature
• Balance between heat production and heat loss in the body
• Disturbances such as hypothermia (low temp) or pyrexia (fever) affects the
body’s fluid balance
• Factors affecting Temperature: Time of day(usually lower in morning),
age, environmental temperature, exercise, menstrual cycle
Body heat is created by - exercise
food ingestion
muscle tension
hormones
external factors such as clothing, blankets, etc.
illness and infection
excitement
Heat loss occurs by - sweating/dilation of blood vessels
respirations
excretion(urine and feces)
***Starvation/fasting, sleep, decrease muscle
activity, mouth breathing, & cold temperatures
cause decrease in body temp
Types of thermometers
• Glass
• Electronic
• Topical/temp strip
Temporal artery
Normal Temperature Ranges –
Axillary (under the armpit) **less accurate
Taken for 5-10 minutes with glass or electronic thermometer
96.6F - 98.6F (1 degree less than oral)
Oral
Taken for 3 - 5 minutes with glass, paper, or electronic thermometer
97.6F - 99.6F
(fever is anything over 100.6F oral)
Rectal “core” **most accurate
Taken 3-5 min with electronic or glass thermometer after inserting the
thermometer 1 1/2 - 3 inches in the rectum
98.6 F- 100.6F (1 degree higher than oral)
Tympanic(the ear) “core”
Taken 1-2 sec with electronic thermometer
96.4F to 100.4F
CLASSIFICATIONS OF FEVERS
Slight=
Moderate=
Severe=
Dangerous=
Fatal=
99.6-101.0 F
101.0-102.0 F
102.0-104.0 F
104.0-105.0 F
Over 106.0 F
37.5-38.3 C
38.3-38.8 C
38.8-40.0 C
40.0-40.5 C
41.1 C
Hypothermia
Low body temp below 95F rectally
Can be caused by prolonged exposure to cold
Death usually occurs if temp drops below 93F rectally
Fevers/ Febrile (Pyrexia)
Usually 100.4-101 orally is considered a fever
Usually caused by infection or injury
Afebrile means no fever is present or the temperature is within the
normal range.
Symptoms of Infection:
elevated temperature
chilling sensation
malaise - feel ‘blah’
no appetite
Hyperthermia
Body temp exceeds 104F rectally
Caused by prolonged exposure to hot temp, brain damage, or
serious infections
Immediate action to lower temp
Temp above 106F can quickly lead to convulsions, brain damage,
and death.
Treatment for fever:
• Tepid baths
• Reduce room temp and amount of bedding
• Force fluids
• High calorie diet
• Medications if necessary
• **Fluctuations of 2-3 degrees increases
metabolic rate and pulse rate (10 beats/degree)
Before taking an oral temperature:
Ask the patient - “Have you had anything to eat, drink or smoke in the last 15
minutes?”
(If they have, wait 15 minutes to take the temp)
Oral temps are not taken on –
patients under the age of 4 or 5
patients who mouth breathe or have nasal congestion
patients with a nasogastric tube
patients on Oxygen
patients who have had face/neck/nose/mouth injuries or surgery
patients who are confused, restless, delirious, or unconscious
patients who are paralyzed on one side of the body
patients who has sore mouth
Report all temperatures over 100.6F or 37.9C Immediately!!
Rectal temps are used for infants and children under 3 yrs old and when the oral
site cannot be used.
Rectal temps are not taken on –
patients who have had any rectal surgery/injury
patient with inflamed hemorrhoids
patients with bleeding from the rectum
patients who have diarrhea
patients who have heart disease
patients who are confused or agitated
Tympanic Membrane (ear) are not taken onpatients who have an ear disorder
patients who have ear drainage
Which method would you choose?
-infants and children under the age of six
-patients with respiratory complications that result in
mouth breathing or use of supplemental oxygen
-confused, disoriented, or emotionally unstable patients
-patients with nasal obstruction
Calculations
PULSE
POINTS
Antecubital
How to evaluate a pulse
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•
•
•
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Find pulse point
Feel with pads of first two fingers
No thumb
Make sure you feel it well
Time (count) for 30 seconds and multiply
by 2
• If irregular you MUST count for a full
minute
CHARACTERISTICS
OF PULSE
RATE
Beats/minute
RHYTHM
Regular or irregular
VOLUME
Strong, weak, thready, or
bounding
EXAMPLE RECORDING PULSE: Date, Time, P 82 strong and regular, Your signature
& title
Pulse - heart rate/minute
(beat of the heart that is felt through the walls of arteries)
**Most often taken at the radial artery
*usually taken for 30 seconds and multiplied by 2, unless the heart rate is
irregular
**if the heart rate is irregular, the pulse must be taken Apically
(at the apex of the heart in the chest) with a stethoscope for 1 Full minute
Normal Adult pulse:
Children:
Infants:
60 - 100 beats per minute
70-110 beats/min.
100-160 beats/min
-Slow pulse rate less than 60/ minute = Bradycardia, and must immediately be reported
-Rapid heart rate over 100/ minute = Tachycardia, and must be reported
**You must note the Rate, Strength of the pulse(volume) and Rhythm and
document this
Apical Pulse
• Most accurate
• Use for irregularity
• Use in infants & children (difficult to count rapid radial
pulse)
• Auscultated(listen) NOT palpated(felt) – full minute
• Stethoscope required
• Apex – left, 5th intercostal space of ribs at middle of left
clavicle. (2 to 3 inches to the left of the breastbone
below the left nipple)
EXAMPLE RECORDING: Date, Time, AP 84 strong and regular, Your
signature & title.
Heart Sounds
Lubb – S1 – Apex – valves between
chambers closing (bicuspid and
tricuspid)
Dupp – S2 – 2nd intercostal space at
the sternal borders – pulmonary and
aortic semilunar valves closing
Abnormal Sounds
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•
•
•
S3
S4
Murmurs
Rubs
What may cause an increase in
pulse?
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Exercise
Emotion (excitement, nervous, tension, stress)
Disease(infection, cardio-vascular disease)
Medications
Fever
Shock
Age: younger=faster
How about a decrease in pulse?
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•
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•
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Medications
Depression
Sleep
Physical fitness
Heart disease
Coma
Larger size
Age
Pulse Defecit
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Apical – radial = pulse deficit
Requires 2 medical professionals
Measure for full minute
Discrepancy means trouble (weak heart,
tachycardia)
Respirations - number of breaths per minute
-represented by 1 Inspiration (breathe in) + 1 Expiration (breathe out)
Normal range for Adult Respirations: 12 - 20 breaths / minute
Children: 16-25 breaths/min.
Infants 30-50 breaths/min
**You must document the symmetry of the chest on inspiration, depth, rhythm
and any abnormal sounds heard
Use words such as deep, shallow, labored, moist, difficult, & stertorous
(abnormal sounds like snoring)
Slow respirations less than 12/min = Bradypnea
Rapid respirations over 20/min = Tachypnea
Abnormal sounds:
1. rales - moist crackling sounds(fluid in air passages)
2. rhonchi - noisy breathing
3. stridor - ‘crowing’ on inspiration (usually will see the chest
caving in with inspiration)
4. wheezing - whistling noises with inspiration or expiration(narrow
bronchioles (asthma)
Types of Breathing:
Eupnea - normal breathing
Dyspnea – difficulty/ labored breathing
Orthopnea - difficulty breathing while lying down
Apnea - no breathing
Sterterous - noisy breathing that sounds like snoring
Cheyne Stokes breathing - periods of deep labored
breaths(dyspnea), followed by very short or no breaths(apnea), and
repeat in cycles (occurs shortly before death)
Kussmaul breathing: heavy labored breathing with a fruity odor
Cyanotic- dusky, bluish
discoloration of the
skin, lips, nail beds.
Counting Respirations
1.
Stay in the pulse measuring position.
2.
Watch the chest rise and fall. Determine the quality…
1.
2.
3.
Depth (deep or shallow)
Rhythm (regular or irregular)
Count respirations by 30 seconds and multiply by 2
Let the patient think you are still taking pulse while counting!
(Patients may breathe faster or slower when they are aware
of this procedure)
EXAMPLE RECORDING: Date, Time, R 18 deep and regular, Your
signature and title
Blood Pressure Evaluates…
• The condition of the heart
• The amount of blood forced from the heart
and contraction
• The condition of the arteries
• The volume and viscosity (thickness) of
the blood
Blood Pressure
pressure exerted on the walls of arteries when the blood is
pumped out of the heart (Systolic BP), and the pressure left when
the heart is at rest (Diastolic BP).
Factors affecting Blood Pressure:
Age
pain
disease
salt consumption
alcohol and drugs
exercise
emotions
Equipment
•
•
•
•
Sphygmomanometer
Stethoscope
Pen
Paper
Measured in millimeters(mm) of mercury(Hg)
BP is normally measured in the brachial artery on the
antecubital area (fold of arm opposite elbow).
Systolic
Diastolic
• Systolic pressure- top number
– The contraction phase of the heart.
– The period of highest pressure.
• Diastolic pressure –bottom number
– The relaxation phase of the heart.
– The period of lowest pressure.
What Should Normal BP Be?
• Normal BP is:
– Systolic pressure less than 140
– Diastolic pressure less than 90
– Ideally both are less than 120/80
• Pre-hypertension >120 / >80
• Hypertension BP is when the systolic
pressure is over 140 and/or diastolic is
over 90. There are mild, moderate, and
severe cases.
Hypertension **Can cause a stroke (Cerebral vascular accident / CVA)
**High blood pressure also damages the kidneys, heart and retina of the
eyes
Hypotension -
a sustained systolic BP less than 90mm or diastolic BP less
than 60mm
**only dangerous with symptoms of shock:
rapid weak pulse
cold, clammy, pale/blue skin
anxious
dizziness
Factors that affect blood pressure
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•
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Diseases
Emotional status
Techniques and equipment
Position
Activity level
Medication
Diet (caffeine, sodium)
Pulse Pressure
• Difference between systolic and diastolic
(subtraction)
• Systolic – Diastolic = Pulse Pressure
• Normal 30-50 mmHg
Sounds of blood pressure - Korotkoff Sounds
tapping
swishing
knocking
muffled
silence
Steps to Finding Blood
Pressure
B/P PREP
Expose upper arm- palm up.
Identify brachial artery.
Place middle of cuff bladder over the
brachial artery.
Wrap cuff smoothly & snugly.
Palpate the brachial or radial artery &
inflate cuff. Note on the dial where you
no longer feel pulse. Add 30 to this
number to determine how high to pump
up the cuff.
OBTAINING THE BLOOD PRESSURE
1.Patient should be resting for 5 minutes prior to taking the reading
2.You must document the position the patient was in (sitting/lying)
*Do not take the BP standing unless ordered that way
3. Use the correct size cuff
4. Use the brachial artery
5. Palpate the brachial artery and inflate the cuff 30mm above
where the pulse disappeared. Deflate the cuff slowly(2-4mm/sec).
Where you feel the pulse return, will be approximately what the systolic BP
will be.
6.Note the number on the dial you first hear a beat(systolic number).
7. Keep listening and note the last number you hear a sound or until the sound
disappears (diastolic number).
8. Deflate completely before re-inflating the cuff. Wait 30 seconds if you must
recheck.
9. Once the cuff is inflated, immediately start slowly deflating or
venous congestion will occur and the reading will be inaccurate
Recording
• BP
systolic/diastolic
• Example:
BP 120/80 L arm sitting