Vital Signs
Mrs. Jessica Dean, RN, BSN
Daily Objectives:
1. List the four main vital signs: temperature,
pulse, respirations, blood pressure
2. Recognize common terminology and
abbreviations used in documenting and
discussing vital signs.
3. Compare the methods and contraindications
of measuring oral, tympanic, axillary, and
rectal temperatures
Vital Signs
• Vital signs: various determinations that
provide information about the basic body
conditions of the patient
• Four main vital signs
1.
2.
3.
4.
Temperature
Pulse
Respiration
Blood pressure
5th vital sign
• Degree of pain frequently regarded as the fifth
vital sign
– Patients are asked to rate their level of pain on a
scale of 1 to 10
– 1 indicates minimal pain and 10 indicates severe
pain
Other important vital signs:
• Color of the skin
• Size of the pupils in the eyes and their
reaction to light
• Level of consciousness
• Patient’s response to stimuli
• Health assistant may have responsibility of
measuring and recording vital signs
– Not able to reveal information to the patient
– Physician will decide if information should be told
to patient
• Accuracy is essential
– Abnormal vital signs are often the first indication
of a disease or an abnormality
– Never guess or report an inaccurate reading
• Report any abnormality or change in vital sign
to your supervisor immediately
• If you have difficulty obtaining a correct
reading for any vital sign, ask another
individual to check the reading
• Temperature: the balance between heat
lost and heat produced by the body
Heat
• Heat is lost through perspiration, respiration,
and excretion
• Heat is produced by the metabolism of food
and muscle and gland activity
• Homeostasis: constant state of fluid balance,
ideal health state in the human body
• If body temperature is too high or low,
the body’s fluid balance is affected.
Temperature Range
• 97-100 degrees F
• 36.1-37.8 degrees C
Body temperature variations
• Individual differences
• Time of day
• Parts of the body where temp is taken
Oral Temperature
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•
•
•
•
Oral- mouth
Leave in place 3-5 minutes
Normal 98.6
Range: 97.6- 99.6 degrees F
Most common, convenient, and comfortable
method for obtaining a temperature
Rectal Temperature
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•
•
•
•
Rectal= Rectum
Leave in place 3-5 minutes
MOST ACCURATE of all methods
Normal temp= 99.6F
Range 98.6-100.6 degrees F
Axillary Temperature
•
•
•
•
•
•
Axillary= armpit
May also be taken in the groin area
Hold in place for 10 minutes
External temperature, less accurate
Normal 97.6F
Range 96.6-98.6F
Aural Temperature
• Aural= ear
• Detects and measures thermal, infrared
energy radiating from the tympanic
membrane (eardrum)
• No normal range= core body temp
• Most record in less than 2 seconds
• Fast and convenient method
Temporal temperatures
• Temporal= temple
• Measures the temperature in the temporal
artery to provide an accurate measurement of
blood temperature
• Easy to use and produces very accurate results
Daily Objectives:
1. Identify the different types of thermometers
2. Define fever, hypothermia, and
hyperthermia and the effects on the human
body
3. Accurately assess an oral temperature using
a clinical thermometer.
Increased Body Temp
• Illness
• Infection
• Exercise
• Excitement
• High environmental
temperature
Decreased Body
Temperature
• Starvation or
fasting
• Sleep
• Decreased muscle
activity
• Exposure to cold
temperature
• Certain diseases
Hypothermia
• Hypothermia: low body temperature
• Below 95 degrees F, rectally
• Caused by prolonged exposure to cold
• Death usually occurs at 93 degrees F for a
period of time
Fever
• Fever: elevated body temperature
• Above 100.4F, rectally
• Usually caused by infection or injury
Hyperthermia
• Hyperthermia: body temperature exceed 104
degrees, rectally
• Caused by prolonged exposure to hot
temperatures, brain damage, serious
infections
• Body temp above 106F leads to convulsions
and death
Clinical Thermometers
• Slender glass tube containing mercury
• Expands when exposed to heat
– Glass oral thermometer
• Long, slender bulb or blue tip
– Security oral thermometer
• Shorter, rounder bulb marked with blue tip
– Rectal thermometer
• Short, stubby, rounded bulb, marked with red tip
Thermometers
• Oral thermometer
• Security oral
thermometer
• Rectal
Thermometers, cont
• Electronic Thermometers
– Registers the temp in a few seconds
– Disposable covers are used
– Can be used orally, rectally, axillary, and/or groin
temperature
• Blue= oral
• Red= rectal
Thermometers, cont
• Tympanic thermometers
– Record temperature aurally
– Read within 1-2 seconds
Thermometers, cont
• Plastic or paper thermometer
– Contain special chemical dots or strips that change
color when exposed to specific temperatures
– Used and then discarded
• Electronic and tympanic are easy to read
because of digital displays
• Glass clinical thermometers take some
practice
– Read at the point where mercury line ends
– Each short line represents .2 of a degree
Writing temperature
• Always write with little number for the tenth
degree
• If oral, doesn’t need to be indicated
• If rectal, place (R) beside recording
• If axillary, place (Ax) beside recording
• If Tympanic, place (T) beside recording
• Eating or drinking hot or cold liquids and/or
smoking can alter the temperature in the
mouth
• No eating, drinking, smoking for 15 minutes
prior to taking temperature
• Follow agencies policy for cleaning and caring
for thermometer
• It is NOT your job to tell the patient the
temperature reading. That is the physician's
responsibility!
Daily Objectives:
1. Identify the sites for assessing the pulse.
2. Recognize the normal and abnormal values
and characteristics of pulse
Pulse
• Pulse: the pressure of the blood pushing
against the wall of an artery as the heart
beats and rests
Pulse, cont
• More easily felt in arteries that lie fairly close
to the skin and can be pressed against a bone
by the fingers
Arterial Sites
• Temporal-side of the forehead
• Carotid- at the neck
• Brachial- inner aspect of forearm at the
antecubital space (crease of elbow)
• Radial-wrist area
• Femoral- inner aspect of the upper thigh
• Popliteal- behind the knee
• Dorsalis Pedis- top of the foot arch
Pulse sites
• Usually taken
over the radial
artery
Pulse Rate
• Measured as the number of beats per minute
• Vary among individuals, depending on age,
sex, and body size
Pulse Rate, cont
• Adults: 60-90 beats per minute (bpm)
– Adult men: 60-70 bpm
– Adult female: 65-80 bpm
• Children over 7: 70-90 bpm
• Children 1-7: 80-110 bpm
• Infants: 90 to 160 bpm
Pulse Rate, cont
• Bradycardia: rates under 60 bpm
• Tachycardia: rates over 100 bpm (except in
children)
Pulse
• Rhythm: regularity of the pulse, or the spacing
of the beats
– Regular or irregular
• Volume: strength or intensity of the pulse
– Strong, weak, thready, or bounding
• http://depts.washington.edu/physdx/heart/de
mo.html
Factors Increasing Pulse Rate
• Exercise
• Fever
• Stimulant drugs
• Nervous tension
• Excitement
Factors Decreasing Pulse Rate
• Sleep
• Heart disease
• Depressant drugs
• Coma
Apical Pulse
• Apical Pulse: taken with a stethoscope at the
apex of the heart
• Actual heart beat is heard and counted
• Taken in children due to rapid pulse and
difficult to count radially
Daily Objectives
1. Recognize the normal and abnormal values
and characteristics of respirations for infants,
children, and adults.
2. Recognize common terminology and
abbreviations used in documenting and
discussing respirations.
Respirations
• Respirations: process of taking in oxygen and
expelling carbon dioxide from the lungs and
respiratory tract
Respirations, cont
• One respiration consists of one
inspiration and one expiration
Respiratory Rate
• Adults: 12-20 breaths per minute
• Children: 16-25 breaths per minute
• Infants: 30-50 breaths per minute
Respiratory Rate, cont
• Character: the depth and quality of
respirations
– Deep, shallow, labored, difficult, stertorous
(snoring), moist
• Rhythm: the regularity of respiration or equal
spacing between breaths
– Regular or irregular
Abnormal Respirations
• Dyspnea: difficult or labored
breathing
• Apnea: absence of respirations
Abnormal Respirations
• Cheyne-Stokes respirations: periods of
dyspnea followed by periods of apnea,
frequently seen in the dying patient
• Rales: bubbling or noisy sounds caused
by fluids or mucus in the air passages
Respirations
• Count in a way that the patient is unaware of
the procedure
• Do not tell the patient you are counting
respirations
• http://www.wilkes.med.ucla.edu/lungintro.ht
m
Daily Objectives
1. Identify the sites for assessing the blood
pressure
2. List the effects of high and low blood
pressure on the body
3. Recognize normal and abnormal values and
characteristics of blood pressure for adults,
children, and infants
Blood Pressure
• Blood Pressure: measurement of the pressure that
the blood exerts on the walls of the arteries during
the various stages of heart activity.
• Sphygmomanometer: instrument used to measure
blood pressure
Blood Pressure
• Two types of blood pressure
– Systolic: occurs in the walls of the arteries when
the heart is contracting and pushing blood into
the arteries
– Diastolic: the constant pressure in the walls of the
arteries when the heart is at rest or between
contractions
Systolic Pressure
• Normal reading= 120 millimeters mercury
(120 mm Hg)
• Normal range= from 100 to 140 mm Hg
• Noted as the reading on the
sphygmomanometer gauge when the first
sound is heard
Diastolic Pressure
• Normal reading= 80 mm Hg
• Normal range= from 60 to 90 mm Hg
• Noted as the reading on the
sphygmomanometer gauge when the sound
stops or becomes very faint
Recording Blood Pressure
• Recorded as a fraction
• Systolic reading is top number or numerator
• Diastolic is bottom number or denominator
• Example: Systolic of 120 and diastolic of 80 is 120/80
Prehypertension
• Warning that high blood pressure will develop
unless steps are taken to prevent it
• Indicated by pressure readings
– Systolic: 120-139
– Diastolic: 80-89
• Treatment:
– Proper nutrition
– Regular exercise program
Hypertension
( high blood pressure)
• Indicated when pressures are greater than
140mm Hg systolic and 90mm Hg diastolic
• Often called the “silent killer” because many
individuals do not have any signs or symptoms
of disease
• If not treated, can lead to stroke, kidney
disease, and/or heart disease
Hypotension
(low blood pressure)
• Indicated when pressures are less than 90mm
Hg systolic and 60 mmHg diastolic
• Occurs with heart failure, dehydration,
depression, severe burns, hemorrhage, and
shock
– Orthostatic hypotension: sudden drop in both
systolic and diastolic pressure when move from
lying to a sitting or standing position
Factors influencing blood pressure readings
• Force of the heartbeat
• Resistance of the
arterial system
• Elasticity of the arteries
• Volume of the blood in
the arteries
Factors increasing blood pressure
•
•
•
•
•
•
Excitement
Anxiety
Nervous tension
Stimulant drugs
Exercise
eating
Factors decreasing blood pressure
•
•
•
•
•
Rest
Sleep
Depressant drugs
Shock
Excessive loss of blood
Factors causing miscellaneous
readings
• Lying down (usually lower)
• Sitting position
• Standing position (usually highest)
Daily Objectives:
• Identify and Demonstrate correct techniques
for assessing blood pressure.
Types of
sphygmomanometers
• Two main types are used
–Mercury sphygmomanometer
–Aneroid sphygmomanometer
Mercury sphygmomanometer
• Contains a long column
of mercury
• Each line on gauge
represents 2 mm of
mercury
• Must be placed on a
flat, level surface
• Level of mercury should
be at zero when viewed
at eye level if
manometer is
calibrated correctly
Aneroid sphygmomanometer
• Does not have a column
of mercury- just round
gauge
• Calibrated in millimeters
of mercury
• Each line on gauge
represents 2mm of
mercury pressure
• Gauge should be
positioned at eye level
for correct readings
Factors to follow for accurate readings
(American Heart recommendations)
• Patient should sit quietly for at least 5 minutes
before the blood pressure is taken
• Two separate readings should be taken and averaged
• Minimum wait of 30 seconds between readings
Factor to follow, cont
• Size and placement of sphygmomanometer cuff
– Cuff contains a rubber bladder
• Bladder fills with air as cuff is inflated
• Applies pressure to arteries to stop blood flow
– Cuffs that are too narrow or too wide cause
inaccurate readings
• Width of cuff should be approximately the same
diameter of patient’s arm
• Small cuff results in falsely high reading
• Large cuff may cause falsely low reading
• Patient should be seated or lying comfortably
• Arm must be fee of any constricting clothing and cuff
should be applied to bare arm
• Deflated cuff should be placed on arm with the
center of rubber bladder directly over the brachial
artery
• Lower edge of the cuff should be 1 to 1.5 in above
the antecubital area (bend of the elbow)
– Forearm should be supported on a flat surface
– Area of the arm covered by the cuff should be at
heart level
Palpatory Systolic pressure
•
•
•
•
•
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Should be determined to avoid overinflation of cuff
Position cuff correctly on arm
Locate radial pulse and keep fingers on pulse
Inflate the cuff until radial pulse disappears
Inflate the cuff 30mm Hg above this point
Slowly release the pressure on the cuff while
watching the gauge
• Note the reading on the gauge when radial pulse is
felt again= palpatory systolic pressure
• Deflate the cuff completely to 0mm Hg
• Wait 30-60 seconds to allow blood flow to
resume completely
• Ask the patient to raise the arm and flex the
fingers to promote blood flow
• When you are ready to measure blood
pressure, inflate the cuff to 30mm Hg above
the palpatory systolic pressure
• Place the stethoscope bell/diaphragm
correctly
– Place bell/diaphragm directly over the brachial
artery at the antecubital area
– Hold it securely but with as little pressure as
possible
• Make sure the earpieces of the stethoscope
are pointed forward while they are placed in
the ears to ensure accurate sound
• Record all information
Blood Pressure Demonstration
• http://www.merlot.org/merlot/viewMaterial.htm?id=80803