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Vital Signs
© 2009 Delmar, Cengage Learning
14:1 Measuring and Recording
Vital Signs (VS)
• Vital Signs are defined as various
determinations that provide basic information
about the basic conditions of the patient
• The 4 main vital signs (VS)
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Temperature (T)
Pulse (P)
Respiration (R)
Blood pressure (BP)
© 2009 Delmar, Cengage Learning
Other Assessments on Patients
• Pain—patients asked to rate on scale of
1 to 10 (1 is minimal and 10 is severe)
• Color of skin
• Size of pupils and reaction to light
• Level of consciousness
• Response to stimuli
© 2009 Delmar, Cengage Learning
VS Readings
• Accuracy is essential
• Report abnormality or change
• If unable to get reading, ask another
person to check
• As a health care worker, it is your
responsibility to measure and record the VS
of your patients
© 2009 Delmar, Cengage Learning
14:2 Measuring and Recording
Temperature
• Measures balance between heat lost and heat
produced in the body
• Heat produced by metabolism of food and
by muscle and gland activity
• Homeostasis: constant state of balance in
the body
• Conversion between Fahrenheit and
Celsius temperature
© 2009 Delmar, Cengage Learning
Variations in Body Temperature
• Normal range 97- 100 degrees Fahrenheit
• Causes of variations –individual differences,
time of day, body sites
• Temperature measurements—oral, rectal
(often used on infants/children), axillary (arm
pit) or groin, aural (ear), and temporal
(forehead-is measuring the temp in the
temporal artery)
© 2009 Delmar, Cengage Learning
Causes of Increased Body Temperature
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Illness
Infection
Exercise
Excitement
High temperatures in the environment
© 2009 Delmar, Cengage Learning
Causes of Decreased Body Temperature
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Starvation or fasting
Sleep
Decreased muscle activity
Mouth breathing
Exposure to cold temperatures in the
environment
• Certain diseases
© 2009 Delmar, Cengage Learning
Thermometers
• Clinical thermometers – are used to record
temperatures
– Glass – consists of a slender glass tube containing
mercury or alcohol with red dye, which expands when
exposed to heat
– Electronic – registers the temp on a viewer in a few
seconds
– Tympanic – records aural temp in the ear
– Temporal – measures the temp in the temporal artery of
the forehead
– Plastic or paper - contain special chemical dots/strips that
(continues)
change color when exposed to specific temps
© 2009 Delmar, Cengage Learning
Thermometers
(continued)
• Reading thermometers and recording results:
* Electronic & tympanic thermometers are
easily read because of digital displays
* Mercury thermometers should be held at eye
level & rotated slowly to find the mercury
Examples of how to record a temperature:
98.6 is an oral reading
99.6 (R) is a rectal reading
97.9 (Ax) is an axillary reading
98.6 (A) is an aural reading
© 2009 Delmar, Cengage Learning
Cleaning Thermometers
• Must be cleaned after each use
• The procedure will vary with different
agencies and thermometers
• Glass thermometers are cleaned with water
and soaked in a disinfectant solution (70%
alcohol) for a minimum of 30 minutes before
using again
• Electronic/digital thermometers use a probe
or sheath that is discarded after each use
© 2009 Delmar, Cengage Learning
14:3 Measuring and Recording Pulse
• Pressure of the blood pushing against the
wall of an artery as the heart beats and rests
• Major arterial or pulse sites
• Pulse rate
• Pulse rhythm
• Pulse volume
(continues)
© 2009 Delmar, Cengage Learning
Measuring and Recording Pulse
(continued)
• Factors that change pulse rate
• Basic principles for taking radial pulse
• Recording information
© 2009 Delmar, Cengage Learning
14:4 Measuring and Recording
Respirations
• Measures the breathing of a patient
• Process of taking in oxygen and expelling
carbon dioxide from the lungs and
respiratory tract
• One respiration: one inspiration (breathing
in) and one expiration (breathing out)
(continues)
© 2009 Delmar, Cengage Learning
Measuring and Recording Respirations
(continued)
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Normal respiratory rate
Character of respirations
Rhythm of respirations
Abnormal respirations
Voluntary control of respirations
Record information
© 2009 Delmar, Cengage Learning
14:5 Graphing TPR
• Graphic sheets are special records used for
recording TPR (temp., pulse, resp.)
• Presents a visual diagram
• Used most often in hospitals and long term
care facilities
• Factors affecting VS are often noted on
the graph - - examples include surgery,
medications that lower temperature such as
aspirin and antibiotics
(continues)
© 2009 Delmar, Cengage Learning
Graphing TPR
(continued)
• Graphic charts are legal
records – so it must be
neat, legible, and
accurate
• To correct an error
mark a single line
through the error and
initial beside it
© 2009 Delmar, Cengage Learning
14:6 Measuring and Recording
Apical Pulse
• Pulse count taken at the apex of the heart
with a stethoscope
• Reasons for taking an apical pulse – pts with
irregular heart beats, hardening of the
arteries, weak or rapid radial pulses
• Protect the patient’s privacy and
avoid exposure
• 2 heart sounds “lubb-dupp” = 1 heart beat
(continues)
• Abnormal sounds or beats should be
reported immediately
© 2009 Delmar, Cengage Learning
Measuring and Recording Apical Pulse
(continued)
• Pulse deficit – a condition that occurs with
some heart conditions – when the apical
pulse rate is higher than the pulse rate on
other sites on the body
• Use the stethoscope : diaphragm side
• Placement of stethoscope : 2-3in. to the left
of the breast bone
• Measuring apical pulse : count for 1 full min.
• Record all information
© 2009 Delmar, Cengage Learning
14:7 Measuring and Recording
Blood Pressure
• Measurement of the pressure the blood exerts
on the walls of the arteries during the various
stages of heart activity
• Measured in millimeters of mercury on
a sphygmomanometer
• Measurements read at two points
(continues)
© 2009 Delmar, Cengage Learning
Measuring and Recording
Blood Pressure
(continued)
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Systolic pressure
Diastolic pressure
Pulse pressure
Hypertension—high blood pressure
Hypotension—low blood pressure
Factors influencing blood pressure readings
(high or low)
(continues)
© 2009 Delmar, Cengage Learning
Measuring and Recording
Blood Pressure
(continued)
• Individual factors can all influence blood
pressure readings
• Types of sphygmomanometers
– Mercury
– Aneroid
– Electronic
(continues)
© 2009 Delmar, Cengage Learning
Measuring and Recording
Blood Pressure
(continued)
• Factors to follow for accurate readings
• Record all required information
• Do not discuss the reading with the patient;
it’s the doctor’s responsibility
© 2009 Delmar, Cengage Learning
Summary
• Vital signs are major indicators of
body function
• Accuracy of measurement and recording
of vital signs
• The health care worker needs to be alert
and report any abnormalities
© 2009 Delmar, Cengage Learning