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CHAPTER 11
Vital Signs
Discussion
What does the term vital mean?
• The term vital means essential or necessary.
What readings or measurements are commonly
considered vital signs?
• Vital signs are a patient’s body temperature, pulse,
respirations, and blood pressure.
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Temperature
• A patient’s temperature is
a measure of his or her
body heat
• Pyrexia (fever) is caused
by the body heating up to
try to protect itself
• Body temperature is
regulated by the
hypothalamus in the brain
• Heat generated in a fever
is defense against toxins
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Temperature
• Converting temperature
• F = 9/5 *(C) + 32
• C = (F – 32)
1.8
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Where to Take a Temperature
•
•
•
Locations where body temperature
can be taken
– Oral
– Rectal
– Axillary
– Tympanic
– Temporal
Taking an oral temperature is the
most common method
– Exceptions: Pt receiving O2,
agitated or unconscious pt,
children <4
Rectal and temporal artery
temperatures provide most accurate
measurements
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Thinking Further
Myth or Fact?
It is common for a patient’s temperature to change
slightly (by 1°F) during the day.
FACT
• Fact: A patient’s temperature may change slightly
due to exertion, how much he or she eats or
drinks, or the external temperature.
• Fact: The normal, or average, temperature for an
adult is 98.6°F (37°C).
• Hypothermia = Temperature below 95 F
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Tympanic Thermometers
• A tympanic thermometer
measures the temperature
on the eardrum
• They are usually
battery-operated and
have a digital display
• Placement of the
thermometer is very
important to get an
accurate reading
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Temporal Artery Thermometers
• Temporal artery thermometers
measure the temperature of
arteries on either side of the
head
• These thermometers are
usually handheld, infrared
scanners with a digital display
• A forehead thermometer strip
can also be used to measure
temporal artery temperature
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Pulse
• A pulse is the pressure of
the blood against the wall
of an artery as the heart
beats
• The pulse tells you how
well the cardiovascular
system is working
• It is particularly important
if a patient has a heart or
respiratory condition
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Critical Thinking
Is it important for you to know your normal
resting pulse rate? Why or why not?
• Being able to report your normal resting pulse
rate to a nurse or doctor could be important for
comparison purposes if you become ill or injured.
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Pulse Locations
• Three commonly used
pulse locations
– Radial pulse
– Apical pulse
– Carotid pulse
• The radial pulse is
located on the radial
artery at the wrist
• The apical pulse is taken
by using a stethoscope
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Pulse Locations
•
•
•
•
Temporal pulse
Brachial pulse
Femoral pulse
Popliteal pulse
– Behind the knee
• Dorsalis pedis pulse
– Important for fractures or
dislocation of lower
extremities
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Parts of a Stethoscope
• Various components
– A diaphragm that detects
high frequency sounds
– A bell that can detect lowfrequency sounds
• When listening to lung
sounds, start at clavicle
and move down on front
and back of the patient
• Always disinfect the
earpieces, diaphragm, and
bell before use
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Pulse Rate Measurements
• Pulse rate is measured by
counting the number of
beats in one minute
• Average resting pulse rates
are established for different
age groups
• Bradycardia: a slow pulse
rate of less than 60 beats
per minute
• Tachycardia: a fast pulse rate
of over 100 beats per minute
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Lung sounds
• Clear and equal bilaterally
• Rales/crackles
– Fluid or congestion in lower lobes
• CPAP or diuretic
• Wheezing
– Bronchoconstriction
• “Expiratory is first”, “Inspiratory is worse”
– Bronchodilators, steroids
• Stridor
– High-pitched sound due to obstruction of airflow
• https://www.easyauscultation.com/lung-sounds
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Respiration
• The rate of respiration is
the measurement of a
patient’s breathing cycle
• Count number of
respirations in 15 seconds
and multiply by 4
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Measuring Respirations
• To determine rate of respiration,
record the number of full
breaths taken in one minute
• It is best to count the respiration
rate immediately after the pulse
• Switch from taking the pulse to
counting respirations without
mentioning the change
• This will prevent the patient
from subconsciously altering
his or her breathing
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Understanding Respiratory Rates
• A normal adult respiratory
rate is 12 to 20 breaths per
minute
• Infants: 30-60 breaths/min
• Children: 18-30 breaths/min
• Observing how well the
patient is breathing is
important
• Note the regularity,
expansion of the chest, and
depth of respiration
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Using a Pulse Oximeter
• A pulse oximeter measures
how well oxygen is being
used in the body
• A pulse oximeter is applied
to the patient’s finger
• It uses infrared light that
passes through the body
tissue
• Ensure device is properly
placed and pt’s fingers are not
too cold
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Thinking Further
What is a normal reading for oxygen in the blood?
• 95 percent to 100 percent
• A reading below 85 percent is considered too low
and is called hypoxia.
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Blood Pressure
• Blood pressure is a measure of
the force of the blood pushing
against the body’s arterial walls
• Hypotension can mean the body
is not getting enough oxygen and
nutrients
• Hypertension may place too much
pressure on the walls of the
arteries and increase risk of
stroke
• Hypotension and hypertension
may indicate or cause certain
diseases or conditions
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Measuring Blood Pressure
• Two pressure levels are
measured as the heart beats
• Systolic: the heart muscle
contracts
• Diastolic: the heart muscle
relaxes
• These levels are measured
using a stethoscope and a
sphygmomanometer
• The two pressures are recorded
as a fraction, such as 120/80
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https://www.youtube.com/watch?v
=Gmic13mvsgo
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Factors Affecting Blood Pressure
• Blood pressure can vary
for several reasons
–
–
–
–
–
–
Diet
Weight
Exercise
Race
Time of reading
Body position
• Orthostatics
– Cigarettes, alcohol,
drugs, and medication
– Stress, fear, or pain
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Taking a Patient’s Blood Pressure
• For a manual blood pressure
measurement, you will
need a stethoscope and
a sphygmomanometer
• Have patients relax for a
few minutes before taking
their blood pressure
• Systolic/Palp
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Height and Weight
• Tracking height and
weight determines the
following
– Nutritional status
– Medication dosages
– General health status
• Height and weight are
used to calculate ideal
body weight and body
mass index (BMI)
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Measuring Height
• Height should be measured
in feet (′) and inches (″) or in
centimeters (cm)
• If the patient is able to walk,
height can be measured by
having the patient stand on
a scale
• If the patient is bedridden, a
tape measure can be used
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Measuring Weight
• A patient’s weight is often
used to calculate
medication dosages
• Weight should be
measured at the same
time each day
• A balance or digital scale
can be used
• A lift or a bed scale may be
needed for some patients
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Blood Glucose Level
• BGL is measured in mg/dL
• BGL should be measured
on the side of the finger,
not the pad of the finger
• Normal reading:
– 80-140 mg/dL
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