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Chapter 38
Vital Signs and Measurements
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Height and Weight
• Mensurations: the process of measuring
• Purpose
– The baseline for all measurements to follow
– Can provide information about treatment
• Obtained at the beginning of the visit
– May not be taken at all visits
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Height and Weight
• Additional infant measurements taken to
ensure proper growth and development
– Length of extremities
– Circumference of head
– Circumference of abdomen or chest
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Body Mass Index
• Numerical correlation between height and
weight
• May be documented in patient’s chart
• There are a number of ways to determine BMI
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Vital Signs
• Measure body functions essential to life
• Four vital indicators, TPR and B/P
– Temperature: body’s ability to control heat
– Pulse: rate, volume, and rhythm of the heart
– Respirations: rate and quality of breathing
– Blood pressure: force of the heart and condition of
the blood vessels
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Temperature
• The balance between heat production and
heat loss
– Heat is produced when food is changed to energy
– Heat is lost through perspiration, breathing, and
elimination of waste
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Temperature
• Factors affecting temperature
– Metabolic rate
– Time of date
– Amount of activity
• Normal temperature may vary
– Temperature above normal: febrile
– Temperature below normal: afebrile
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Thermometers
•
•
•
•
•
Disposable
Electronic (battery operated)
Digital
Tympanic infrared
Temporal artery
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Oral Temperature
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Oral Temperature
• Contraindications
– Infants and young children
– Certain respiratory conditions
– Confused, disoriented, or unstable patients
– Oral injuries or dental problems
– Recent oral surgery
– Facial paralysis
– Nasal obstruction, sinus congestion, or colds
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Rectal Temperature
• Very accurate method for measurement
• Indicated for babies and young children
• When documenting, record (R) following
reading
• Normal rectal temperature is one degree
above normal oral temperature
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Axillary Temperature
• Least accurate method for measurement
• Indicated when oral and rectal temperatures
are undesirable
• When documenting, record (Ax) following
reading
• Normal axillary temperature is one degree
below normal oral temperature
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Tympanic (Aural) Temperature
• Thermometers are easy, safe, and fast
• When documenting, record (Tym) following
reading
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Temporal Artery Temperature
• Very accurate method for measurement
• Appropriate for all ages, infant through older
adult
• When documenting, record (TA) following
reading
• Normal TA temperature is one degree above
normal oral temperature
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Temperature Conversions
• Fahrenheit to Celsius
• Celsius to Fahrenheit
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Pulse
• Palpated in arteries close to body surface and
lie over bone or firm structures
• Can be felt in several locations on the body
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Pulse Sites
• Radial
– Most frequently used when measuring pulse rate
• Apical
• Brachial
– Used to palpate and auscultate blood pressure
• Carotid
– Palpated during CPR
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Pulse Sites
• Femoral
• Dorsal pedalis
• Popliteal
– These three sites are palpated to evaluate
circulation in the lower extremities
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Pulse
• Pulse rates
– Normal range is 60-100 beats per minute
– Influenced by
•
•
•
•
•
Exercise
Age
Gender
Size
Physical condition of body
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Pulse
• Pulse characteristics
– Volume
• Normal, full or bounding, weak, thready
– Quality
• Arrythmia, pulse lacks a specific rhythm
• Intermittent
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Measuring Radial Pulse
• Patient should be sitting or laying down
– The arm should be well-supported
• Use the tips of your fingers
– Do not use the thumb
• Typically count for 30 seconds, multiply by 2
– Count for 60 seconds if pulse is irregular
– Measure respirations at the same time
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Measuring Apical Pules
• Indicated for
– Instances when radial pulse is not appropriate
– Infants and small children
– Patients with heart conditions
• Listen to heart at its apex with a stethoscope
– Palpate at fifth intercostal space
• Count for 60 seconds
• Document using [Ap] to indicate apical site
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Pulse Oximetry
• Small device used to measure pulse and
arterial oxygen saturation in blood
• Clip attached to patient’s finger
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Respirations
• Combination of inspiration (inhale) and
expiration (exhale)
• Normal respiration rate is 16-20 per minute
• Observe rate and quality of respirations
– Should be quiet, effortless, and regularly spaced
– Breathing should be through the nose
– Depth of respiration: normal, shallow, or deep
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Respirations
• Abnormal respirations
– Hyperventilation
– Dyspnea
– Rales (noisy breathing)
– Apnea, absence of breathing
– Cheyne-Stokes
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Blood Pressure
• Measured in the brachial artery of the arm in
the antecubital space
– Uses stethoscope and sphygmomanometer to
measure
• Blood pressure phases
– Systole, contraction phase
– Diastole, relaxation phase
• Expressed as a fraction, systolic/diastolic
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Normal Blood Pressure
• Systolic pressure
– 100-120 mm Hg
• Diastolic pressure
– 60-80 mm Hg
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Abnormal Blood Pressure
• Hypertension
– Consistent readings above 140/90
– Idiopathic (essential hyptertension)
– Primary, secondary, malignant
• Hypotension
– Consistent readings below 90/60
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