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Chapter 14 Vital Signs Objectives • List the four main vital signs • Convert Fahrenheit temperatures to Celsius, or Celsius to Fahrenheit • Read a clinical thermometer to the nearest two-tenths of a degree • Measure and record oral temperature accurately • Measure and record rectal temperature accurately • Measure and record axillary temperature accurately • Measure and record tympanic (aural) temperature accurately Objectives • Count and record respirations to an accuracy within + or – 1 respirations per minute • Measure and record apical pulse to an accuracy within + or – 2 beats per minute • Measure and record blood pressure to an accuracy within + or – 2 mm Hg • State the normal range for oral temperature, axillary temperature, rectal temperature, pulse, respirations, systolic and diastolic blood pressure • Define, pronounce, and spell all the key terms Chapter 14:1 Measuring and Recording Vital Signs Vital signs: • Defined as “various determinations that provide information about the basic body conditions of the patient” • 4 main vital signs + pain Temperature • Measurement of the balance between heat lost and heat produced by the body • Can be measured in the oral, rectal, axillary, or aural areas • Most reported in Fahrenheit but many are now reporting in Celsius Conversion Formulas Fahrenheit temperature to Celsius: • Subtract 32 from the Fahrenheit temperature and then multiply the result by 5/9 or 0.5556 • EX: • 98.6 degrees (F) • 98.6 – 32 = 66.6 X 0.5556 = 37 degrees (C) Conversion Formula Celsius temperature to Fahrenheit Multiply the (C) temperature by 9/5 or 1.8 And then add 32 degrees EX: 16 degrees (C) X 1.8 = 28.8 + 32 = 60.8 degrees (F) Pulse • Pressure of the blood felt against the wall of an artery as the heart contracts and relaxes, or beats – Rate: number of beats/min – Rhythm: regularity – Volume: strength • Any abnormality can indicate disease Respirations • Reflect the breathing rate of the patient – Count: number – Rhythm: regularity – Character: type • Abnormal respirations usually indicate that a health problem or disease is present Blood Pressure • The force exerted by the blood against the arterial walls when the heart contracts or relaxes • Two readings: 1. Systolic-measurement of blood pressure taken when the heart is contracting and forcing blood into the arteries 2. Diastolic-measurement of blood pressure taken when the heart is at rest: Measure of constant pressure in the arteries Chapter 14:2 Measuring and Recording Temperature • Constant state of fluid balance = homeostasis • Rates of chemical reactions in the body are regulated by body temperature • Normal body temperature is 97 – 100 degrees (F) or 36.1 – 37.8 (C) Variations of body temperatures • Individual differences • Time of day • Body sites – Oral – – – – Rectal Axillary and groin Aural Temporal Increased Body Temperature • • • • • • • Illness Infection Exercise Excitement High environment temperature Fever (pyrexia)-temp >101 Hyperthermia-body temp >104 – Treat quickly – Body temp>106 = seizures, coma, death Decreased Body Temperature • • • • • Starvation or fasting Sleep Decreased muscle activity Mouth breathing Exposure to cold temperatures in the environment • Certain diseases • Hypothermia-body temp <95 – Temp <93 = death Types of Thermometers • Clinical • Glass • Contains mercury or alcohol with red dye • Different types Types of Thermometers • Electronic Thermometers • Can be used for oral, rectal, axillary, and/or groin temperatures • Blue and Red probes • Disposable covers used to prevent cross contamination • Will usually register the temperature in about 60 seconds Types of Thermometers • Tympanic thermometers • Specialized that record the aural temperature in the ear • Disposable plastic covers are used • Temp recorded within 1-2 seconds Reading & Recording Temperature • Always recorded to the next nearest two-tenths of a degree • Recording Temperature • Eating, drinking, or smoking can alter temperature in the mouth • Thermometers must be cleaned thoroughly after use • Know your facilities procedure for cleaning Chapter 14:3 Measuring and Recording Pulse • Can be felt at different arterial sites on the body – Temporal – Carotid – Brachial – Radial – Femoral – Popliteal – Dorsalis Pedis Normal Pulse Rates • Vary among individuals, depending on age, sex, and body size Adults -general range of 60 – 90 beats/min Children -over 7: 70 – 90 beats/min -age 1 – 7: 80 – 110 beats/min Infants -100 -160 beats/min Pulse • Bradycardia-Rate under 60 beats/min • Tachycardia-Rate over 100 beats/min (except in children) • Any variations of extremes in pulse rates should be reported immediately • Rhythm-regularity – Regular or irregular (arrythmia) • Volume-strength/intensity – Strong, weak, thready, bounding Factors that change pulse rates Increased or accelerated: • Exercise • Stimulant drugs • Excitement • Fever • Shock • Nervous tension • Other similar factors Decreased or slower: • Sleep • Depressant drugs • Heart disease • Coma • Physical training • Other similar factors Chapter 14:4 Measuring and Recording Respirations • Respiration: the process of taking in O2 and expelling CO2 from the lungs and respiratory tract • Normal: 14-18 breaths/min (adult) 16-30 breaths/min (children) 30-50 breaths/min (infants) Respirations • Character: • Refers to depth and quality of respirations – – – – – – – – – Dyspnea Apnea Tachypnea Bradypnea Orthopnea Cheyne-Stokes Rales Wheezing Cyanosis Respirations • Must be counted in such a way that the patient is unaware of the procedure • Leave your hand on the pulse site while counting respirations Chapter 14:5 Graphing TPR • Graphic Sheets: • Special records used for recording TPR • The graphics are a medical record, so it must be neat, legible, and accurate • Double check your charting to be sure they are accurate Chapter 14:6 Measuring and Recording Apical Pulse • Pulse count taken with a stethoscope at the apex of the heart • Actual heartbeat is heard and counted • Usually ordered by physician for patients with arrythmias, hardening of the arteries, or weak, or rapid radial pulses **Important that you protect the patient’s privacy. Avoid exposing the patient. Apical Pulse • Two separate heart sounds are heard • “lubb-dupp” counts as one heartbeat • Caused by the closing of the valves of the heat as blood flows through the chambers of the heart • Located at the 5th intercostal space and midclavicular line • Any abnormal sounds should be reported immediately Pulse Deficit • Conditions that occurs with some heat conditions • Most accurate: • Have one person should check the apical pulse while a second person checks another pulse site (usually the radial) • Subtract the rate of the radial pulse from the rate of the apical pulse. The difference is the pulse deficit Chapter 14:7 Measuring and Recording Blood Pressure • Read in mm Hg on a sphygmomanometer • Systolic – Normal: 120 mm Hg – Normal Range: 100-140 mm Hg • Diastolic – Normal: 80 mm Hg – Normal range: 60 – 90 mm Hg Pulse Pressure • Difference between the systolic and diastolic pressure • Important indicator of the health and tone of arterial walls • Normal range in adults: 30 to 50 mm Hg Hypertension • High blood pressure (HBP or HTN) • pressures > 140 mm Hg (systolic) • pressures > 90 mm Hg (diastolic) Common Causes: • Stress • Anxiety • Obesity • High-salt intake • Aging • Kidney disease • Thyroid deficiency • Vascular conditions (arteriosclerosis) * If not treated, can lead to CVA, kidney disease, and/or heart disease Hypotension • Low blood pressure • Pressures < 100 mm Hg (systolic) • Pressures < 60 mm Hg (diastolic) May occur with: • Heart failure • Dehydration • Depression • Severe burns • Hemorrhage • Shock Orthostatic Hypotension • Postural • Occurs when there is a sudden drop in both systolic and diastolic pressure when an individual moves for a lying to a sitting or standing positions • Caused by the inability of blood vessels to compensate quickly to the change in position • Symptoms: • Dizziness, or blurred vision • Last a few seconds until vessels compensate Factors that Influence BP readings: • • • • Force of the heartbeat Resistance of the arterial system Elasticity of the arteries Volume of the blood in the arteries Recording BP • Recorded as a fraction • Systolic (top number) • Diastolic (bottom number)