• Are important indicators of health
• Detect changes in normal body function
• May signal life-threatening conditions
• Provide information about responses to treatment

• Temperature
• Pulse
• Respirations
• Blood Pressure
• Oxygen level per protocol – Pulse
Oximeter

As often as required by the person’s condition or physician’s orders.
Examples:
– Upon admission
– Before & after surgery and other procedures
– After a fall or accident
– When prescribed drugs that affect the respiratory or circulatory system
– When there are complaints of pain, dizziness, shortness of breath, chest pain.

• Usually taken with the person sitting or lying
• The person is at rest
• Always report:
– A change from a previous measurement
– Vital signs above or below the normal range
– If you are unable to measure the vital signs

• Measurement of balance between heat lost and produced by the body.
– Heat is produced by:
• Metabolism of food
• Muscle and gland activity
– Heat may be lost through:
• Perspiration, Respiration, Excretion
• Measured with the Fahrenheit (F) or Celsius or Centigrade (C) scales

• Factors that  body temperature
• Illness
• Infection
• Exercise
• Excitement
• High temperatures in the environment
• Temperature is usually higher in the evening
• Factors that  body temperature
• Starvation or fasting
• Sleep
• Decreased muscle activity
• Exposure to cold in the environment

• Oral - by mouth – most common method
– May be affected by hot or cold food, smoking, oxygen, chewing gum
– Wait 15 minutes or use alternate site
• Rectal - in the rectum -most accurate site
– Do not use if patient has rectal surgery or bleeding
• Axillary - under arm – less reliable site
– Used when other sites are inaccessible
– Do not use immediately after bathing

• Tympanic or aural - in the ear
– Measures in 1 to 3 seconds
• Temporal Artery – temporal artery on the forehead
• Record route temperature was taken
• O - Oral
• R - Rectal
• T – Tympanic
• A – Axillary

Oral 98.6 ( 97.6 - 99.6)
Rectal 99.6 (98.6 - 100.6)
Axillary 97.6 (96.6 - 98.6)
Typmanic 98.6 (98.6 - 100.6)
Temporal 99.6 (98.6 - 100.6)
Hypothermia – temperature below normal
Hyperthermia – temperature above normal

• Electronic: Used orally, rectally, or axillary.
Must use disposable probe covers.
• Tympanic: Placed in auditory canal and must use disposable cover.
• Strips: Strip that contains special chemicals or dots that change colors.

• The pressure of blood pushing against the wall of an artery as the heart beats and rests.
• Measured for one minute while noting:
Rate - beats per minute
Rhythm - regular or irregular
Volume - strength or intensity - described as strong, weak, thready, bounding

Most Commonly Used:
• Carotid
• Apical
• Brachial
• Radial
(most common site to check pulse)
• Femoral
• Popliteal
• Dorsalis Pedis
• Posterior tibial artery

Age
Birth to 1 year
2 years
6 years
10 years
12 years & older
Pulse per Minute
80-190
80-160
75-120
70-110
60-100
Bradycardia – Under 60 beats per minute
Tachycardia – Over 100 beats per minute

• Factors that  pulse • Factors that  pulse
• Exercise
• Stimulant drugs
• Excitement
• Fever
• Shock
• Nervous tension
• Sleep
• Depressant drugs
• Heart disease
• Coma

• Process of breathing air into ( inhalation ) and out of ( exhalation ) the lungs.
• Oxygen enters the lungs during inhalation.
• Carbon dioxide leaves the lungs during exhalation.
• The chest rises during inhalation and falls during exhalation.
• Normal rate 12-20 breaths per minute

• Respirations are measured when the person is at rest.
• Rate may change if patient is aware that it is being counted.
• To prevent this, count respirations right after taking a pulse.
• Keep your fingers or stethoscope over the pulse site.
• To count respirations, watch the chest rise and fall.

• Character and quality of respirations is also assessed:
– Deep
– Shallow
– Labored or difficult
– Noises – wheezing, stertorous (a heavy, snoring type of sound)
– Moist or rattling sounds
• Dyspnea – difficult or labored breathing
• Apnea – absence of respirations
• Cheyne-Stokes – periods of dyspnea followed by periods of apnea; often noted in the dying patient
• Rales – bubbling or noisy sounds caused by fluids or mucus in the air passages

• Measure of the pressure blood exerts on the walls of arteries
• Blood pressure is controlled by:
– The force of heart contractions
• weakened heart  drop in BP
– The amount of blood pumped with each heartbeat
• loss of blood  drop in BP
– How easily the blood flows through the blood vessels
• Narrowing of vessels  increase in BP
• Dilatation of vessels  decrease in BP

Factors that  blood pressure
• Excitement, anxiety, nervous tension
• Stimulant drugs
• Exercise and eating
Factors that  blood pressure
• Rest or sleep
• Depressant drugs
• Shock
• Excessive loss of blood

• A sphygmomanometer is used to measure
BP
– Aneroid – has a round dial and needle
– Mercury – has a column of mercury
– Electronic – automated device
• BP is measured in millimeters (mm) of mercury (Hg).
• The systolic pressure is recorded over the diastolic pressure
.

• Systolic : Pressure on the walls of arteries when the heart is contracting.
• Diastolic : Constant pressure when heart is at rest
• Hypertension —BP that remains above a systolic of 140 mm Hg or a diastolic of 90 mm Hg
• Hypotension —Systolic below 90 mm Hg and/or a diastolic below60 mm Hg

• Used to determine if patient is underweight or overweight
• Height and weight charts are used as averages
• BMI or Body Mass Index a statistical measure of body weight based on a person's weight and height.
• BMI from 18.5 to 24.9 is considered normal

General Guidelines:
• Use the same scale every day
• Make sure the scale is balanced before use
• Weigh the patient at the same time each day
• Remove jacket, robe, and shoes before weighing
• OBSERVE SAFETY PRECAUTIONS!
• Prevent injury from falls and the protruding height lever.
• Some people are weight conscious.
• Make only positive comments when weighing patients

• Clinical scales: balanced manually or digital with an attached or detached measuring rod for height.
• Bed scales or Chair scales: used for patients unable to stand
• Infant scales: balanced manually or digital
– When weighing an infant…keep one hand slightly over but not touching the infant
– A tape measure is used to measure infant height.