OA 11.1
• Define: vital signs. What are they used for?
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Chapter 15
Vital Signs
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15:1 Measuring and Recording
Vital Signs (VS)
• Record information about the basic body
conditions
– Abnormalities from homeostasis
• Main vital signs (VS)
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Temperature
Pulse
Respiration
Blood pressure
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Other Assessments
• Pain—patients asked to rate on scale of
1 to 10 (1 is minimal and 10 is severe)
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Other Assessments
• Color of skin
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Pallor
Cyanosis
Jaundice
Erythema
Ecchymosis
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Other Assessments
• Size of pupils and reaction to light
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Other Assessments
• Level of consciousness
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Other Assessments
• Response to stimuli
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VS Readings
• Accuracy is essential
– Must know how to accomplish task with various
equipment
– Never guess or report false readings
• Report abnormality or change
– Severe abnormalities indicate life-threatening
conditions
• If unable to get reading, ask another
person to check
© 2009 Delmar, Cengage Learning
OA 11.4
• What information can be gathered from
measuring vital signs?
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15:2 Measuring and Recording
Temperature
• Measures balance between heat lost and heat
produced in the body
– Thermal activity
• Heat produced by metabolism of food and
by muscle and gland activity
• Heat lost through perspiration, respiration,
and excretion
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15:2 Measuring and Recording
Temperature
• Conversion between Fahrenheit and Celsius
temperature
F  C: C = (F-32) x 0.5556
C  F: F = (C x 9/5) + 32
• Practice:
– 102o F to C
– 19o C to F
212o F to C
37o C to F
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Variations in Body Temperature
• Normal range
– 97-100o F, 36.1-37.8o C
• Causes of variations
– Size/shape of individual, time of day, part of body,
metabolic activity
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Variations in Body Temperature
• Temperature measurements — oral, rectal
(often used on infants/children), axillary
or groin, aural, and temporal
• Normal:
– Oral: 98.6o F
– Rectal: 99.6o F
Axillary: 97.6o F
Aural/Temporal: no normal range
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Variations in Body Temperature
Abnormal conditions affecting temperature
Increase:
• Illness and infection
• Exercise, excitement,
fear
• High environmental
temperatures
Decrease:
• Starvation or fasting
• Sleep
• Sedation
• Mouth breathing
• Cold environmental
temperatures
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Variations in Body Temperature
• Abnormal conditions
– Hypothermia: body temperature < 95o F
– Fever: elevated above 101o F
• Pyrexia, Febrile, Afebrile
– Hyperthermia: body temperature > 104o F
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Thermometers
• Clinical thermometers
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Glass: contains mercury, analog
Electronic: digital reading, quicker results
Tympanic: use infrared energy
Temporal: measures temporal artery
Plastic or paper: disposable
• Reading thermometers and recording results
– Read in 1o increments, labeled by site
• R, Ax, Gr, A
(continues)
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© 2009 Delmar, Cengage Learning
Thermometers
(continued)
• Avoid factors that could alter or change
temperature
– Examples???
• Cleaning thermometers
– Clean with alcohol wipe or soap/water
• Paper/plastic sheath on glass thermometer
– Used to prevent transmission of disease
– Dispose of properly
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OA 11.5
• List 3 factors that would affect your body
temperature right now.
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15:3 Measuring and Recording Pulse
• Pressure of the blood pushing against the
wall of an artery as the heart beats and
rests
(continues)
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15:3 Measuring and Recording Pulse
• Major arterial or pulse
sites
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Temporal
Carotid
Brachial
Radial
Femoral
Popliteal
Dorsal Pedal
(continues)
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15:3 Measuring and Recording Pulse
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Must note 3 different factors of the pulse:
Pulse rate
Pulse rhythm
Pulse volume
(continues)
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15:3 Measuring and Recording Pulse
• Pulse rate – adult 60-80 bpm, varies
– Bradycardia: slow pulse rate, < 60 bpm
– Tachycardia: fast pulse rate, >100 bpm
• Pulse rhythm – spacing between beats
– Regular vs. irregular
– Arrythmia: abnormal heart rhythm
• Pulse volume – strength/intensity of the pulse
– Strong vs. weak, thready, bounding
(continues)
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Measuring and Recording Pulse
Factors that change pulse rate
Increased:
• Exercise
• Stimulant drugs
• Excitement
• Fear
• Fever
• Shock
• Nervous tension
Decreased:
• Sleep
• Depressant drugs
• Heart disease
• Coma
• Physical training
© 2009 Delmar, Cengage Learning
Measuring and Recording Pulse
(continued)
Basic principles for taking radial pulse:
1. Patient positioned comfortably, palm down
2. Use tip of index/middle fingers to locate
pulse on thumb side of wrist
3. First beat counted starts with zero
1.
2.
3.
4.
10 sec x 6
15 sec x 4
30 sec x 2
60 sec
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Measuring and Recording Pulse
(continued)
• Recording information:
– Include rate, rhythm,
volume
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15:4 Measuring and Recording
Respirations
• Measures the breathing of a patient
• Process of taking in oxygen and expelling
carbon dioxide from the lungs and
respiratory tract
(continues)
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15:4 Measuring and Recording
Respirations
• One respiration: one inspiration (breathing
in) and one expiration (breathing out)
(continues)
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Measuring and Recording Respirations
(continued)
• Normal respiratory rate
– Adults: 12-20 breaths per minute
– Children: 16-25 per minute
– Infants: 30-50 per minute
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Measuring and Recording Respirations
(continued)
• Character of respirations – refers to depth
and quality
– Deep vs. shallow, labored, moist, difficult, noisy
• Rhythm of respirations – refers to spacing
between breaths
– Regular (or even) vs. irregular
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Measuring and Recording Respirations
(continued)
• Abnormal respirations
– Dyspnea: difficulty breathing
– Apnea: absence of respirations
– Tachypnea: rapid, shallow > 25/min
– Bradypnea: slow <10/min
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Measuring and Recording Respirations
(continued)
• Abnormal respirations
– Orthopnea: severe dyspnea in any
position besides sitting or standing
– Cheyne-Stokes: abnormal breathing
pattern, periods of dyspnea and apnea
– Rales: bubbling or noisy sounds
caused by fluid
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Measuring and Recording Respirations
(continued)
• Voluntary control of respirations
– Respiration can be controlled if consciously thought
about
– Important to keep the patient unaware breathing is being
assessed
– Do not tell the patient you are counting respirations
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Measuring and Recording Respirations
(continued)
• Record information
– Rate, character, rhythm
• Ex: A child with R 22, shallow, labored, and
regular would suffer from?
• Ex: An adult with R 8, deep, regular would
suffer from?
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15:5 Graphing TPR
• Graphic sheets are special records used for
recording TPR
• Presents a visual diagram (easier to follow)
• Uses – hospitals or long care facilities
(continues)
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15:5 Graphing TPR
• Color codes
– Temperature in blue
– Pulse in red
– Respirations in green
• Factors affecting VS are often noted on
the graph
– Surgeries, medications, day & time, etc.
(continues)
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Graphing TPR
(continued)
• Graphic charts are legal records
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Must be legible and neat
Completed in ink
Use straightedge to connect lines
HIPAA act!
• To correct an error: cross out in red ink and
correct, initial next to correction
© 2009 Delmar, Cengage Learning
Graphing TPR
(continued)
• Basic principles for completing:
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Fill in patient information accurately
Fill in dates, times (mm/dd/yyyy, __:__am/pm)
Adm = admission (first measurement)
Following days are numbered
PO/PP = after surgery
PP = post partum (after delivery)
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© 2009 Delmar, Cengage Learning
OA 11.12
• What is blood pressure?
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15:7 Measuring and Recording
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 (mmHg)
on a sphygmomanometer
(continues)
© 2009 Delmar, Cengage Learning
Measuring and Recording
Blood Pressure
(continued)
• Systolic pressure: pressure when left
ventricle contracts
– Normal is <120 mmHg (range of 100-120 mmHg)
– First sound heard during reading of sphygmomanometer
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Measuring and Recording
Blood Pressure
(continued)
• Diastolic pressure: constant pressure when
left ventricle relaxes
– Normal is < 80 mmHg (range of 60-80 mmHg)
– Last sound heard during reading of sphygmomanometer
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Measuring and Recording
Blood Pressure
(continued)
• Blood pressure is read as a fraction
• Systolic pressure / Diastolic pressure
– Ex: (120/80 mmHg)
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Measuring and Recording
Blood Pressure
(continued)
• Pulse pressure: difference between systolic
& diastolic pressure
– Important indicator of health and tone of arterial walls
– Normal range is 30-50 mmHg
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Measuring and Recording
Blood Pressure
(continued)
• Hypertension—high blood pressure
– Prehypertension (120-139 mmHg / 80-89 mmHg)
– Systolic >140 mmHg / Diastolic >90 mmHg
• Hypotension—low blood pressure
– Systolic <90 mmHg / Diastolic <60 mmHg
(continues)
© 2009 Delmar, Cengage Learning
Measuring and Recording
Blood Pressure
(continued)
• Factors influencing blood pressure readings
(high or low)
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Force of heartbeat
Resistance of arterial system
Elasticity of the arteries
Volume of blood in arteries
Position of the patient
(standing vs sitting vs lying down)
(continues)
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Measuring and Recording
Blood Pressure
Increased BP
(continued)
• Excitement, anxiety, nervous
tension
• Pain
• Obesity
• Stimulant drugs
• Exercise and eating
• Smoking
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Decrease BP
Rest or sleep
Depressant drugs
Shock
Dehydration
Hemorrhage
fasting
© 2009 Delmar, Cengage Learning
Measuring and Recording
Blood Pressure
(continued)
• Types of sphygmomanometers
– Mercury: uses a column of mercury in a tube to measure
the pressure (discouraged by OSHA)
– Aneroid: uses a round gauge to measure pressure
• Each line on gauge = 2 mmHg
• Measure at eye level, deflated cuff should read zero
– Electronic: measures pressure automatically
• Shows reading on a digital display
(continues)
© 2009 Delmar, Cengage Learning
© 2009 Delmar, Cengage Learning
Measuring and Recording
Blood Pressure
(continued)
• Factors to follow for accurate readings
– Patient should sit quietly for at least five minutes before
BP is taken
– Two readings should be taken and averaged
• Minimum wait of 30 seconds between readings
– Arm should be rested on a flat surface & free of
restrictions
© 2009 Delmar, Cengage Learning
Measuring and Recording
Blood Pressure
(continued)
• How to measure blood pressure
– Cuff should be placed above the crook of the elbow, with
arrow pointing over brachial artery
– Place the bell/diaphragm of stethoscope directly over
brachial artery in the antecubital fossa
• Hold as securely as possible with index/middle fingers
– Inflate cuff to 150-180 mmHg
– Deflate slowly and listen for heart sounds
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© 2009 Delmar, Cengage Learning
© 2009 Delmar, Cengage Learning
Measuring and Recording
Blood Pressure
(continued)
• Record all required information
– Date, time, BP, signature/initials
• Do not discuss the reading with the patient;
it’s the doctor’s responsibility
– Could cause personal reaction to patient
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