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Vital Signs
 Taking Vital Signs
 Vital signs may include:
 Respirations, Pulse, Oxygen saturation, Temperature, Blood pressure, Pain
 __________________________
 Check suspicious condition
 Monitor existing condition
 Limitations
 May or may not detect important physiologic changes
 Indicate further investigation
 Normal does not equal ______________
 Temperature
 Cellular metabolism requires a stable core, or “deep body,” temperature of a mean of 37.2° C (99° F)
 Body maintains steady temperature through a thermostat, or feedback mechanism, regulated in
hypothalamus of brain
 Thermostat balances heat production (from metabolism, exercise, food digestion, external factors) with
heat loss (through radiation, evaporation of sweat, convection, conduction)
 Various routes of temperature measurement reflect body’s core temperature
 Celsius vs Fahrenheit
 Most facilities document in celsius (universal)
 Fahrenheit to Celsius (°F - 32) x 5/9 = °C
 Celsius to Fahrenheit (°C × 9/5) + 32 = °F
 °F to °C Deduct 32, then multiply by 5, then divide by 9 °
 C to °F Multiply by 9, then divide by 5, then add 32
 Variables affecting Temperature
 Circadian (________________) Rhythms
 Trough occurs in early morning hours and peak occurring in late afternoon to early evening
 Hormones (progesterone)
 Age (infant, elderly)
 Exercise
 Stress
 Environment
 Temperature Routes
 Oral
 37° C (98.6° F), with a range of 35.8° C to 37.3° C (96.4° F to 99.1° F)
 Convenient, accessible
 Right or left posterior sublingual pocket
 Accuracy varies ingestions of hot/cold drinks immediately prior to assessment
 Wait 15-20 minutes
 Rectal
 0.4° C to 0.5° C (0.7° F to 1° F) higher than oral
 Considered most accurate
 Invasive and uncomfortable
 Used in infants and children
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

Use gloves, probe covers, and lubrication
Risk for __________________________
 Insert only ½-1 inch
 Check setting on digital thermometer
 Axillary
 0.4° C to 0.5° C (0.7° F to 1° F) lower than oral
 Safe and noninvasive
 Placement and position of thermometer tip affects reading
 Middle of armpit with arm down at side
 Wait at least 15 minutes after bathing or exercising
 Tympanic (calibrated to oral or rectal scales)
 Convenient, safe, fast
 Research inconclusive of accuracy
 Technique affects reading
 Temporal Artery
 Scans the forehead area for the temporal artery
 Easy to Use
 Non-invasive
 Ideal for all age groups
 Clinically proven to be more accurate than tympanic
thermometry
 Assessment of Pulses
 May evaluate carotid, brachial, radial, femoral, popliteal,
posterior tibial, dorsalis pedis
 Apical pulse
 Pulse Characteristics
 Rate: Number of beats in 1 minute
 Influenced by blood pressure, age, gender, activity,
emotions, pain, environment, medications, and disease
 Adult: ___________________ bpm
 May take for 30 seconds x2
 Most accurate rate is measured apically using a stethoscope for a 60 second count period
 Infants –use brachial or apical
 Rhythm: Regular vs Irregular
 Second most important observation
 Symmetry: Right vs Left
 Amplitude: Pulse strength
 Absent to bounding
 If not palpable, try a ____________ ultrasonic stethoscope
 Graded
 Grading Pulses
Grade
Findings
0
Absent pulse
1+
Weak and thready
2+
Normal
3+
Full and bounding
(Some agencies use a four-point scale)
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 Respirations
 One inspiration and one expiration = 1 breath
 Adult = _________________ breaths per minute
 In adults, frequently taken with pulse
 Pulse for 30 sec, Respirations for 30 sec
 Discreetly observe client’s breathing
 In babies, taken with stethoscope
 If chief complaint is respiratory, client is an infant, or you have difficulty assessing rate, take for a full
60 seconds
 May vary with anxiety, crying, excitement, fever, exercise, medications, altitude, and age
 Oxygen Saturation
 Oxygen saturation (SO2) measures the percentage of hemoglobin binding sites in the bloodstream
occupied by oxygen.
 Pulse oximeter = device
 Normal = 95% - 100%
 Less than 92% = hypoxia
 Standing order in most facilities is to start _____________ of oxygen via nasal cannula
 Pulse Oximeter
 Need to be calibrated
 Place probe on tip of finger/toe/ear
 Reading will vary if:
 Finger/toenail has polish on it
 Extremity is cold/decreased circulation
 Skin is not intact
 Probe is placed over jewelry
 Record number/check orders
 Blood Pressure
 Force exerted by blood on the arterial walls
 Blood pressure is expressed in a ratio of systolic/diastolic (120/80)
 Systolic Blood Pressure: pressure exerted on the arterial wall when the heart ventricles are contracting
 Diastolic Blood Pressure: pressure exerted on the arterial wall when the ventricles are relaxed
 Factors Affecting Blood Pressure
 Age
 Gender
 Race
 Diurnal rhythm
 Weight
 Exercise
 Emotions
 Stress
 Cardiac Output
 Peripheral Vascular Resistance
 Blood Volume
 Viscosity
 Elasticity of Walls
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 American Heart Association recommended blood pressure levels
BP Category
Systolic
Diastolic
Normal
less than 120
less than 80
Prehypertension
120–139
or 80–89
High (HYPERTENSION)
Stage 1
140–159
or ____________
Stage 2
160 or higher or 100 or higher
 Hypertension
 Due to:
 Thickened arteries, inelastic arteries
 Smoking
 Obesity
 Lack of exercise
 Hypercholesterolemia
 Stress
 Hypotension
 Low blood pressure <___________________
 This is relative…
 Orthostatic Hypotension
 Measured supine, sitting, then standing
 Wait 1 -3 minutes between positions
 Decrease in SBP of more than 20 points (this again, is relative)
 Equipment
 Sphygmomanometer
 Aneroid: Dial
 Mercury
 Electronic Sphygmomanometers
 Stethoscope
 Bell vs Diaphragm Side
 Doppler Ultrasound stethoscope
 Stethoscopes
 Tubing
 Eartips
 Chestpiece
 ______________ – low pitch
 Diaphragm – High pitch
 How to work your stethoscope
 If you have a double sided:
 If you have a one sided:
 Ear Placement
 Correct:
 Hold the headset in front of you with the eartips pointing away
 Once the eartips are in your ears, they should point forward
 Incorrect – Eartips back
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 Blood pressure cuff
 Blood pressure cuff
 Cuff size important
 Bladder width should be about _____________% of the arm circumference
 Cuff too narrow: False-high blood pressure
 Cuff too wide: False-low blood pressure
 Korotkoff’s sounds
 Phase 1: systolic BP –first sound heard, sharp tapping
 Phase 2: swishing/swooshing (can be an absence of sound)
 Phase 3: tapping, softer than phase 1
 Phase 4: softer blowing muffled, last sound is diastolic BP
 Phase 5: silence
 Methods
 Direct (insertion of catheter into an artery)
 Indirect
 Auscultatory – usual method
 Palpatory – used to determine initial reading, used when unable to auscultate BP
 Site Choice
 Either arm, using brachial artery
 When not to use a particular limb
 Use thigh when arms unavailable (burns or injuries to both arms)
 Use opposite arm in cases of:
 Mastectomy with lymph node dissection
 IV infusion
 Fistula
 Do not take over _______________________
 Do not use forearm
 Implementation
 Position appropriately
 Have sit quietly for 5 minutes
 Extend arm and support at heart level, palm up
 Make sure client does not have legs crossed
 Wrap deflated cuff around upper arm – apply center of the bladder directly over the brachial artery - one
inch above antecubital space
 Determining a Target Pressure
 Perform a preliminary palpatory determination of SBP if this is an initial examination
 Palpate the brachial artery
 Pump up cuff until you no longer feel the brachial pulse, note pressure on sphygmomanometer
 Release cuff, wait 1 – 2 minutes (avoids false ____________ readings)
 Implementation
 Position stethoscope appropriately
 Auscultate the patient’s blood pressure
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
Pump up cuff until sphygmomanometer reads 30 mm Hg above the point where the brachial pulse
disappeared
 Release valve carefully so that the pressure decreases at the rate of 2-3 mmHg per second
 Try to identify 5 phases
 Deflate cuff rapidly and completely
 Remove cuff
 Document data (even numbers)
 SBP/DBP = 106/68
 Record RA (right arm) or LA (left arm), RL (right leg) or LL
 Erroneously High BP
 Bladder cuff too narrow
 Arm unsupported
 Insufficient rest before the assessment
 Repeating assessment too quickly
 Cuff wrapped unevenly
 Assessing immediately after a meal, smoking, caffeine containing beverage
 Assessing when client has pain
 Erroneously Low BP
 Bladder cuff too wide
 Deflating cuff too quickly (low SBP)
 Arm above level of heart
 Failure to identify auscultatory gap
 Sources of Pain
 Visceral pain – large interior organs
 Deep somatic pain – blood vessels, joints, muscles, bones
 Cutaneous pain – skin surface
 ________________ pain – Originates from a different location than felt
 Types of Pain
 Acute pain
 Short term
 Self-limiting
 Follows a predictable trajectory
 Dissipates after injury heals
 Chronic pain
 Continues for 6 months or longer
 Types are malignant (cancer-related) and nonmalignant
 Does not stop when injury heals
 Pain Assessment
 Pain assessment questions
 Where is your pain?
 When did your pain start?
 What does your pain feel like?
 How much pain do you have now?
 What makes the pain better or worse?
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 Pain Assessment Tools
 Initial pain assessment
 Brief pain inventory
 Short-Form McGill Pain Questionnaire
 Pain rating scales
 Numeric rating scales
 Descriptor scale
 Charting
 Vitals:
 128/86 LA sitting
 37.2°C orally
 Apical pulse 82 regular, Radial pulses +3, symmetrical and regular at 80
 O2 sat 98% on room air
 RR = 16
 Pain = 0 on 0-10 scale
 Can also use a graphing flow sheet