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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?
