VITAL SIGNS
Vital Signs
• Temperature
• Breathing
+Pulse Oximeter
• Pulse
• Blood pressure
• Pain (5th VS)
TEMPERATURE
Skin temperature - taken by placing the
back of your hand on the patient’s skin
Equipment – thermometer for accurate
temperature reading/measurement
• Shell Temperature
• Core Temperature
Temperature
• Normal: 98.6 ° F (37°C)
• Hypothermia: 95°F (35°C)
• Hyperthermia – excessively high core
temp. > 105 = brain damage
• Routes
– Oral
– Axillary
– Rectal
– Tympanic
– Temporal, etc.
Placement – rear sublingual pocket
at base of tongue
PULSE
Pressure wave that is
felt as the heart
contracts
PULSE-Assess…
 Rate - number of beats per minute
– 60-100 bpm
– Rate varies with age and other factors
– Do not use your thumb
– Tachycardia - > 100 bpm
– Bradycardia - < 60 bpm
The Pulse
Rhythm - The pattern of pulsations and pauses
between them
Regular/Irregular
arrhythmia, sinus arrhythmia
Quality /Volume-Force of the contraction of the heart
Strong
Weak
Grading of pulse volume: 0-3+/4+
Pulse Assessment Locations
•
•
•
•
•
•
•
Carotid
Brachial
Radial
Femoral
Popliteal
Dorsalis pedis
Posterior tibial
PULSE
If peripheral pulse is not palpable,
assess carotid pulse
Use caution. Avoid excess pressure
on geriatrics
Never attempt to assess carotid
pulse on both sides at one time
Measuring Pulse
Radial
Palpate thumb side of wrist with two to three
fingers, do not press too hard or it will
obliterate.
Count 30 seconds and multiply by 2. If
irregular, count for one full minute. If
unable to find, measure apical pulse.
Radial site
Apical pulse
• Site: fifth intercostal space midclavicular
line
• The apical pulse is considered more
accurate than the radial pulse
• the sound of each heartbeat is obvious
and distinct when listening to the apical
pulse
• Pulse deficit – difference between apical
and radial rate
Apical site: Left 5th ICS
Midclavicular Line
Counting Apical Pulse
• Apical
• Place stethoscope on chest under clothing
• Auscultate apex of the heart below left
nipple
• Move around a little at a time until heart
beat clearly heard
• If difficulty finding apical pulse, have patient
lean forward while sitting, or turn to left side
when lying down
• Lub-dub is one beat
• Always count for one full minute
RESPIRATIONS
(Breathing)
 Assessed by observing the
patients chest rise and fall
Rate - Count # of breaths for
1 minute
Ventilation – one inhalation
and one expiration
QUALITY (and)
Determined while
assessing the rate
DEPTH
Even
Shallow
Deep
EFFORT
Labored
Unlabored
Types of Respirations
•
•
•
•
Eupnea
Tachypnea
Bradypnea
Hyperventilation
• Dyspnea
• Orthopnea
• Apnea
BLOOD PRESSURE
Pressure of circulating
blood against the walls of
arteries
Blood pressure
• Systolic pressure - the
pressure exerted against the
walls of the arteries during
the contraction of the heart
• Diastolic pressure pressure that is constantly
present within the arterial
walls as the heart relaxes and
fills with blood
• Pulse pressure - normal
range of pulse pressure– 30 to 50.
Blood Pressure
There are two methods of
obtaining blood pressure
Auscultation - listen for the systolic
and diastolic sounds
Palpation - In certain situations, the
systolic blood pressure may be
measured by feeling for return of
pulse with deflation of the cuff
Korotkoff Sounds
• Korotkoff I- onset of faint but clear tapping
sounds which gradually increase in pitch and
intensity
• Korotkoff II- murmur or swishing like sound
• Korotkoff III- distinct, loud tapping sounds
without the murmurs
• Korotkoff IV- lower-pitched distinct, abrupt
muffling sound with a soft, blowing quality
• Korotkoff V- cessation /disappearance of sound
• Auscultatory gap
• Orthostatic Hypotension
Measuring BP
QUESTIONS?