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Vital Signs
A window into patient health
Vital Signs
Defined
• Various determinations that provide
information about basic body
conditions of the patient.
Four Main Vital Signs
1.
2.
3.
4.
Temperature
Pulse
Respirations
Blood Pressure
The “fifth” vital sign
• Many health professionals regard
the degree of pain as the fifth vital
sign.
• Patients are asked to rate their
degree of pain on a scale of 1-10, 1
being minimal pain and 10 being
severe pain.
Additional Vital Signs
• Skin color Temperature, color, and
condition)
• Pupils(PERRL) Pupils are equal,
round, and reactive to light
• Level of consciousness (AVPU)
– Alert AOX4 alert and oriented to person,
place, time, and event
– Verbal
– Pain
– Unconscious
• It is essential that vital signs be
accurate as they are often the first
indication of disease or abnormality
in the patient.
Pulse
Pulse defined
• The pressure of the blood pushing
against the wall of an artery as the
heart beats and rests. (the throbbing
of an artery caused by the
contractions of the heart.
Major Pulse Sites
• Temporal (side of the forehead)
• Carotid (at the neck)
• Brachial (inner aspect of the forearm at
the antecubital space)
• Radial (inner aspect of the wrist, above
the thumb)
• Femoral (at the inner aspect of the upper
thigh)
• Popliteal (behind the knee)
• Dorsalis Pedis (at the top of the foot arch)
Figure. 3 to the left shows the common sites where
the pulse is felt.
1.
2.
Temporal artery at the temple above and to the
outer side of the eye
2. Carotid artery on the side of the neck
3. Brachial artery on the inner side of the biceps
3.
4. Radial artery on the radial bone side of the wrist
5. Femoral artery in the groin
4.
5.
6. Popliteal artery behind the knee
7. Posterior tibial pulse behind the inner ankle
8. Dorsalis pedis artery on the upper front part
(anteriosuperior aspect) of the foot
6.
7.
8.
There is one pulse per heart beat, and so the pulse rate is used
as an easy method for counting the heart rate.
Pulse is usually taken over
the radial artery
Pulse rate is measured as the
number of beats per minute and
vary depending on age, and gender
• Adults: 60-90 BPM
• Children >1 : 70-110 BPM
• Infants:100-160 BPM
Rhythm as well as rate is
also noted
• Regular
• Irregular
• Regularly irregular
• Arrhythmia is an irregular or abnormal
rhythm usually caused by a defect in the
electrical conduction pattern of the heart.
Volume (strength or intensity)
•
•
•
•
Strong
Weak
Thready
Bounding
Apical Pulse
• Pulse count taken over the apex of
the heart with a stethoscope
– Stethoscope is an instrument used to
listen to internal body sounds
– Actual heartbeat is heard and counted
– Two sounds will be heard Lubb (sound
of valve opening Dupp sound of valve
closing
– Each lubb-dupp counts as one heart
beat
Reasons for taking an
apical pulse
•
•
•
•
Pt c irregular heartbeats
Hardening of the arteries
Weak or rapid radial pulses
Infants or children
Placement of Stethoscope
• Bell or diaphragm should be placed
over the apex of the heart
• Apex located 2-3 inches to the left of
the sternum
• At the line drawn down from the
center of the clavicle (midclavicular
line)
• Fifth intercostal space
Method
•
•
•
•
Position stethoscope correctly
Listen for one full minute
Note rate rhythm and volume
Record all information
– Ex: 1/13/09 1335 AP 84 strong and
regular
Pulse Deficit
• Occurs with some heart conditions
• Heart is weak and does not pump
enough blood to produce a pulse
• Tachycardia (not enough time to
adequately fill the heart, heart does
not always produce a distal pulse)
• In these cases apical pulse is higher
Method to Determine Pulse
Deficit
• 1 Person measure apical pulse 1
person measure radial pulse at the
same time
• Subtract radial from apical
Factors that ↑ Pulse
•
•
•
•
•
•
Exercise
Stimulant drugs
Excitement
Nervous tension
Fever
Shock
Factors That ↓ Pulse
•
•
•
•
•
Sleep
Depressant drugs
Heart disease
Coma
Physical training
Normal Rates
• Infant 80-160
• Child 70-110
• Adult 60-100
Respirations
Respirations are another vital sign
you must observe, count, and record
accurately.
Respiration Defined
• Respiration is the process of taking
in oxygen (O2) and expelling carbon
dioxide (CO2) from the lungs and
respiratory tract.
• One respiration consists of one
inspiration (breathing in) and one
expiration (breathing out)
Ventilation:
The mechanics of breathing.
• During inhalation the diaphragm
contracts and moves downward, the
intercostal muscles contract moving
the thoracic cage upward and out.
• During exhalation the diaphragm
relaxes and moves upward, the
intercostal muscles relax returning
the thoracic inward and down.
Normal Rates
• Adult (12-20)
• Child (16-25)
• Infant (30-50)
• In addition to rate the character and
rhythm of respirations should be
noted.
Character refers to the depth and quality
(or ease) of respiration. Words to
describe character include:
•
•
•
•
•
Deep
Shallow
Labored
Difficult
Stertorous (abnormal sounds like
snoring)
http://www.cvmbs.colostate.edu/clinsci/callan/breath_sounds.htm
http://www.wilkes.med.ucla.edu/lungintro.htm
http://www.emsvillage.com/education_center/breath_sounds/index.cfm
Rhythm refers to the regularity of
respirations or equal spacing of
breaths.
• Regular
• Irregular
Terminology
• Dyspnea-difficult or labored
breathing
• Apnea-absence of respirations
(usually temporary)
• Tachypnea- respiratory rate above
25 bpm
• Bradypnea- slow respiratory rate, usually
below 10 bpm
• Orthopnea-severe dyspnea in which
breathing is difficult in any position other
than sitting erect or standing.
• Cheyne Stokes- periods of dyspnea
followed by periods of apnea; frequently
noted in a dying patient
• Rales- bubbling or noisy (wet) sounds
caused by fluids or mucus in the air
passages.
• Wheezing-difficult breathing with a highpitched whistling or sighing sound heard
during expiration; caused by a narrowing
of bronchioles (as seen in asthma) and/or
obstruction or mucus accumulation in the
bronchi.
• Cyanosis-a dusky, bluish discoloration of
the skin, lips, and/or nail beds as a result
of ↓ O2 and ↑ CO2 in the bloodstream.
• Respirations must be counted in
such a way that the patient is
unaware of the procedure. Because
respirations are partly under
voluntary control the patient may
alter the way they are breathing if
they are aware respirations are
being counted.
• Leave your hand on the pulse site
while you count respirations. The
patient will think you are still
counting the pulse, and will be less
likely to alter their respiratory rate.
Temperature
• Temperature is the measurement of
the balance between heat lost and
heat produced by the body.
Heat Loss
• Perspiration
• Respiration
• Excretion (urine and feces)
Heat Production
• Metabolism of food
• Muscle and gland activity
Homeostasis
• A constant state of fluid balance
known as homeostasis is the ideal
state in the human body. The rate of
chemical reactions in the body are
regulated by body temperature.
Therefore, if the body temperature is
too high or too low the body’s fluid
balance is affected.
Factors that lead to ↑ Temp
•
•
•
•
•
Illness
Infection
Exercise
Excitement
High environmental temperatures
Factors that lead to ↓ Temp
•
•
•
•
•
•
Starvation/Fasting
Sleep
Decreased muscle activity
Mouth breathing
Certain diseases
Cold environmental temps.
Variations in Temperature
• Accelerated metabolism ↑ Temp
• Slow metabolism ↓ Temp
• Time of day (↓ am after rest ↑ pm
after daily activity)
• Parts of body where temperature is
taken.
Ways to measure
temperature
1.
2.
3.
4.
Oral (mouth)
Rectal (rectum)
Axillary (armpit)
Aural (ear)
Oral
• The most common, convenient, and
comfortable method of obtaining a
temperature.
• Average temperature 98.6° F (37° C)
• Normal range of temperature
97.6-99.6°F (36.5-37.5°C)
Rectal
• Temperature taken in the rectum.
• Clinical thermometer is left in place
for 3-5 minutes
• Internal method and is most
accurate
• Average temp 99.6°F (37.6°C)
• Normal range 98.6-100.6°F
37-38.1°C
Axillary
• Taken in the armpit or groin
• Thermometer is inserted between two
folds of skin
• External temps (less accurate)
• Clinical thermometer held in place 10
minutes
• Average temp 97.6°F (36.4°C)
• Normal range 96.6-98.6°F or 36-37°C
Aural
• Taken with a special thermometer
that is placed in the ear or auditory
canal.
• Detects and measures the thermal,
infrared energy radiating from blood
vessels in the tympanic membrane,
or eardrum
• Because this is a core temperature
measurement there is no range
Conversions
• From °F to °C
.5556(F-32) or 5/9(F-32)
• From °C to °F
(C*1.8)+32 or (C*9/5)+32
Extremes in Body Temperatures
Hypothermia
• Core body temperature < 95°F
(35°C)
• Caused by prolonged exposure to
cold
• Death occurs if body temp drops
below 93° F (33.9°C) for a period of
time
Pyrexia (fever)
• Elevated body temperature >101°F
(38.3°C) measured rectally
• Febrile means a fever is present
• Afebrile means no fever is present
• Fever is usually caused by infection
or injury
Hyperthermia
• Occurs when the body temperature
exceeds 104°F (40°C) measured rectally
• Caused by prolonged exposure to hot
temperatures, brain damage, and serious
infections
• Temperatures above 106°F (41.1°C) can
lead to convulsions, brain damage, and
death.
Recording a Temperature
• To record a temperature, write 986 instead
of 98.6°. This reduces the possibility of
making an error in reading.
• Be sure to indicate how the temp. was
measured
• 986 is an oral reading
• 986 (R) is a rectal reading
• 986 (Ax) is an axillary reading
• 986 (T) is an aural reading
Factors that can influence
a temperature reading
• Eating
• Drinking
• Smoking
** If a patient has done any of the
above you must wait 15 minutes
before taking an oral temperature.
Specific Heat Disorders
What is sweating?
Sweating occurs as sodium (salt) is
transported to the skin. Because “water
follows sodium” water is deposited on
the skin surface evaporation occurs,
aiding in the cooling process.
Sweating Cont…..
Since sweating involves not only
the loss of water, but also the loss
of electrolytes (sodium),
intermittent cramping of skeletal
muscle may occur.
Signs and Symptoms of
Dehydration
• Nausea, vomiting, and abdominal
distress
• Vision disturbances
• Decreased urine output
• Poor skin turgor
• Signs of hypovolemic shock
Thirst is a poor indication of the degree of
dehydration present
Heat (muscle) Cramps
Acute painful spasms of the
voluntary muscles following
strenuous activity in a hot
environment without adequate
fluid or salt intake.
Signs and Symptoms
• Present with cramps in fingers, arms
legs, or abdominal muscles
• Mentally alert with a feeling of
weakness
• May feel dizzy or faint
• Vital signs stable
• Skin moist and warm
Treatment
• Remove patient from the environment
• Place in a cool environment (shade or air
conditioning)
• Administer a sports drink or 4tsp of salt
dissolved in 1 gallon of water.
• Massage painful muscles
• Apply cool moist cloth over forehead and over
cramped muscles
Heat Exhaustion
A moderate heat illness; an acute
reaction to heat exposure.
Signs and Symptoms
•
•
•
•
•
•
Increased body temperature ( >100 F)
Skin cool and clammy with heavy perspiration
Breathing rapid and shallow
Weak pulse
May develop diarrhea and muscle cramps
Patient may feel weak
Signs and Symptoms
Cont...
•
•
•
•
•
•
May lose consciousness
Headache
Anxiety
Paresthesia (numbness)
Impaired judgement
Psychosis
Treatment
• Call 911
• Remove patient from the
environment.
• Place the patient in a supine
position.
• Administer oral saline or a sports
drink (administer fluids only if patient
is conscious)
Tx. Cont….
• Remove some clothing from the
patient and fan. If the patient begins
to shiver stop fanning
• Treat for shock
Symptoms should resolve with fluids,
rest, and supine posturing with
knees elevated. If they do not,
consider that the symptoms may be
due to an increased core body
temperature which is predictive of
impending heat stroke.
Heatstroke
Acute dangerous reaction to heat
exposure, characterized by a body
temperature usually above 105° F
and central nervous system
disturbances.
Signs and Symptoms
•
•
•
•
Cessation of sweating
Skin that is hot and dry
Very high core temperature
Deep respirations that become
shallow, rapid at first but may later
slow
• Rapid full pulse, may slow later
Signs and Symptoms
• Hypotension with low or absent
diastolic reading
• Confusion, disorientation, or
unconsciousness
• Possible seizures
Tx
• Call 911
• Remove pt from the environment
• Initiate rapid active cooling, remove
clothing cover the patient with
sheets soaked in TEPID water.
Avoid over cooling target core temp
102°F
Tx. Cont….
• Administer fluid therapy if and only if
pt is able to swallow
Dehydration in Heat
Disorders
Dehydration often goes hand in hand
with heat disorders because it
inhibits vasodilation therefore
thermolysis.