Download Vital Signs

Vital Signs
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Cardinal signs, reflects body’s physiological status
Provides information critical to evaluate homeostatic
balance
Five critical assessments
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Temperature
Pulse
Respiration
Blood Pressure (B/P)
(Now also checking the oxygen saturation)
Frequency
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Vital signs are taken at regular intervals depending on unit policy and
patient condition. These times may be:
• Every 8hrs
• Every 4 hrs
• Every 2 hrs
• Every hour
• Every 5-30 minutes
• Depending on condition of client or medication administration
Vital signs indicate a positive or negative change in clients condition
If vital signs are out of range or different from previous recordings, repeat &
if using mechanical equipment find a different machine
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Factors influencing Vital Signs:
– Age
Gender Medications
– Race
Heredity
Environment
– Pain
Stress Metabolism
– Lifestyle Exercise
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Components of Vital Signs:
• Temperature- regulated by hypothalamus; shows balance
between heat gained and heat loss
Temperature
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Temperature- measured by thermometer
– Oral, rectal, ,axillary, tympanic, heat sensitive
tape
– Electric probe with disposal cover
– Always designate where temperature is taken as
O, R, A, T, tape
– Register temperature as C (Centigrade) or F
(Fahrenheit)
-Mercury thermometers no longer used
Temperature-measured by thermometer
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Oral Electronic with disposal cover
Tympanic- electric probe used in ear
Oral, rectal, axillary
Heat sensitive tape
Temperature variations:
– Newborn 36.5-37 C axillary
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Infants 3 months 99.4*F axillary
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1 yr 99.7*F axillary
After 4-5 yrs old can be taken orally
or ear based device
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Temperature variations
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Newborns 36.5-37oC
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1 year 99.7oF temp taken axillary
4-5 year old taken orally or tympanic
13 years 97.8oF
Elderly range between 96.6o to 98.3oF
– Taken orally, axillary it unable to close mouth may also
use tympanic or heat sensitive tape
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Pulse
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Pulse – an index of the heart’s rate and rhythm, shows
heart action
– Need to evaluate:
 Rate- number of pulsation in one minute
 Rhythm- pattern, even or regular; regular irregular;
irregular irregular
 Quality- fullness or strength- reflex stroke volume
maybe bounding, very strong, weak/ thready,
absent
Common Terms
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Pulse rate may increase or decrease for various reasons (exercise, drugs, lack of
oxygen, medical conditions=dehydration, hemorrhage, etc)
Tachycardia pulse over 100 BPM.
Bradycardia pulse below 60 BPM
Pulse located:
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Carotid- avoid pressuring too hard decreases blood flow to brain
Apical
Brachial ( site for auscultation of B/P)
Ulnar-near pinky finger
Radial- easy access near thumb
Femoral
Popliteal (behind knee)
Posterior Tibial-evaluate circulation lower extremities
Dorsalis Pedis- evaluate circulation lower extremities
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Pulses should be felt against bone and using pads of 3 middle
fingers
DO NOT USE YOUR THUMB
NEED A WATCH WITH SECOND HAND
Client should be either in supine or sitting position
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Infants and Children
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Newborn= 80-180/min
Toddler=80-110/min
School age= 50-90/min
Adolescent= 50-90/min
Blood Pressure
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Blood pressure (B/P)- is the force of blood against
arterial wall
Pulse pressure is the difference between the systolic and
diastolic pressure (normal 30-50 mm HG
Equipment: Stethoscope ( bell and diaphragm);
sphygmomanometer
Make sure B/P cuff size is based on circumference of the
limb
When unable to take B/P on arm can take on thigh
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Factors affecting B/P
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Cardiac output
Peripheral vascular resistance
Elasticity & Distensibility of arteries
Blood volume
Blood Viscosity
Hormones & Enzymes
Chemoreceptors
Age, sex, weight
Body position
Activity
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Normal adult B/P ranges below 120(systolic) and less
than 80(diastolic), varies with different people
Hypertensive B/P is defined as 140 mmHG or greater
systolic; and/ or 90mmHG or greater diastolic
Systolic pressure- give data about the condition of the
heart and great arteries
Diastolic pressure- data about the arteriolar or peripheral
vascular resistance
Allow 1 to 2 minutes between taking B/P again
Respirations
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Respiration is the process of bringing oxygen to the
body tissue ( Inspiration) and removing carbon
dioxide (expiration)
Normal rate of adult 12-18 breaths/min.
Newborn 30- (40-60) breaths/min.
Older children 20-26 breaths/min.
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Common Terms
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Tachypnoea rate over 24 breaths/min.
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Bradypnea rate less than 10 breaths/min
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Apnoea absence of breathing
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Dyspnoea difficulty breathing
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Need to assess pattern, rate and depth of clients breathing
Rhythm- pattern between inspiration and expiration
Quality effort required to breathe
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Factors affecting respiration
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Age
Drugs
Stress
Emotions
Body position
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Respirations:
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Newborn- 30-60/min
Toddler=24-32/min
School age- 18-26/min
Adolescent- 16-20/min
Adults- 12-20/min