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Chapter 15 Vital Signs © 2009 Delmar, Cengage Learning 15:1 Measuring and Recording Vital Signs (VS) • Record information about the basic body conditions – Abnormalities from homeostasis • Main vital signs (VS) – – – – Temperature Pulse Respiration Blood pressure © 2009 Delmar, Cengage Learning Other Assessments • Pain—patients asked to rate on scale of 1 to 10 (1 is minimal and 10 is severe) © 2009 Delmar, Cengage Learning Other Assessments • Color of skin – – – – – Pallor Cyanosis Jaundice Erythema Ecchymosis © 2009 Delmar, Cengage Learning Other Assessments • Size of pupils and reaction to light © 2009 Delmar, Cengage Learning Other Assessments • Level of consciousness © 2009 Delmar, Cengage Learning Other Assessments • Response to stimuli © 2009 Delmar, Cengage Learning Vital Sign Readings • Accuracy is essential – Must know how to accomplish task with various equipment – Never guess or report false readings • Report abnormality or change – Severe abnormalities indicate life-threatening conditions • If unable to get reading, ask another person to check © 2009 Delmar, Cengage Learning 15:2 Measuring and Recording Temperature • Temperature: Measures balance between heat lost and heat produced in the body – Thermal activity • Heat produced by metabolism of food and by muscle and gland activity • Heat lost through perspiration, respiration, and excretion © 2009 Delmar, Cengage Learning 15:2 Measuring and Recording Temperature • Conversion between Fahrenheit and Celsius temperature F C: C = (F - 32) x (5/9 or 0.5556) C F: F = (C x 9/5 or 1.8) + 32 • Practice: – 102o F to C – 19o C to F 212o F to C 37o C to F © 2009 Delmar, Cengage Learning Variations in Body Temperature • Normal range – 97-100o F, 36.1-37.8o C • Causes of variations – Size/shape of individual, time of day, part of body, metabolic activity © 2009 Delmar, Cengage Learning Variations in Body Temperature • Temperature measurements — oral, rectal (often used on infants/children), axillary or groin, aural, and temporal • Normal: – Oral: 98.6o F – Rectal: 99.6o F Axillary: 97.6o F Aural/Temporal: no normal range © 2009 Delmar, Cengage Learning Variations in Body Temperature Abnormal conditions affecting temperature Increase: Illness and infection Exercise, excitement, fear High environmental temperatures Decrease: Starvation or fasting Sleep Sedation Mouth breathing Cold environmental temperatures © 2009 Delmar, Cengage Learning Variations in Body Temperature • Abnormal conditions – Hypothermia: body temperature < 95o F – Fever: elevated above 101o F • Pyrexia, Febrile, Afebrile – Hyperthermia: body temperature > 104o F © 2009 Delmar, Cengage Learning Thermometers • Clinical thermometers – – – – – Glass: contains mercury, analog Electronic: digital reading, quicker results Tympanic: use infrared energy Temporal: measures temporal artery Plastic or paper: disposable • Reading thermometers and recording results – Read in 1o increments, labeled by site • R, Ax,, A, 986 (continues) © 2009 Delmar, Cengage Learning © 2009 Delmar, Cengage Learning Thermometers (continued) • Avoid factors that could alter or change temperature – Examples??? • Cleaning glass clinical thermometers – Clean with alcohol wipe or soap/cool water • Paper/plastic sheath on glass thermometer – Used to prevent transmission of disease – Dispose of properly – Still wipe with alcohol pad © 2009 Delmar, Cengage Learning 15:3 Measuring and Recording Pulse • Pulse: Pressure of the blood pushing against the wall of an artery as the heart beats and rests (continues) © 2009 Delmar, Cengage Learning 15:3 Measuring and Recording Pulse • Major arterial or pulse sites – – – – – – – Temporal Carotid Brachial Radial Femoral Popliteal Dorsal Pedal (continues) © 2009 Delmar, Cengage Learning 15:3 Measuring and Recording Pulse • • • • Must note 3 different factors of the pulse: Pulse rate (beats per min) Pulse rhythm (regular or irregular) Pulse volume (strong, weak, thready, bounding) (continues) © 2009 Delmar, Cengage Learning 15:3 Measuring and Recording Pulse • Pulse rate – adult 60-100 bpm, varies – Bradycardia: slow pulse rate, < 60 bpm – Tachycardia: fast pulse rate, >100 bpm • Pulse rhythm – spacing between beats – Regular vs. irregular – Arrythmia: abnormal heart rhythm • Pulse volume – strength/intensity of the pulse – Strong vs. weak, thready, bounding (continues) © 2009 Delmar, Cengage Learning Measuring and Recording Pulse Factors that change pulse rate Increase: Exercise Stimulant drugs Excitement Fear Fever Shock Nervous tension Decrease: Sleep Depressant drugs Heart disease Coma Physical training © 2009 Delmar, Cengage Learning Measuring and Recording Pulse (continued) Basic principles for taking radial pulse: 1. Patient positioned comfortably, palm down 2. Use tip of index/middle fingers to locate pulse on thumb side of wrist 3. First beat counted starts with zero 1. 2. 3. 4. 10 sec x 6 15 sec x 4 30 sec x 2 60 sec © 2009 Delmar, Cengage Learning Measuring and Recording Pulse (continued) • Recording information: – Include rate, rhythm, volume Example: P 82 regular and strong (rate)(rhythm)(volume) © 2009 Delmar, Cengage Learning 15:4 Measuring and Recording Respirations • Respiration: Measures the breathing of a patient • Process of taking in oxygen and expelling carbon dioxide from the lungs and respiratory tract (continues) © 2009 Delmar, Cengage Learning 15:4 Measuring and Recording Respirations • One respiration: one inspiration (breathing in) and one expiration (breathing out) (continues) © 2009 Delmar, Cengage Learning Measuring and Recording Respirations (continued) • Normal respiratory rate – Adults: 12-20 breaths per minute – Children: 16-30 per minute – Infants: 30-50 per minute © 2009 Delmar, Cengage Learning Measuring and Recording Respirations • Must note 3 different factors: • Rate (breaths per minute) • Character (depth and quantity) • Rhythm (regularity) © 2009 Delmar, Cengage Learning Measuring and Recording Respirations (continued) • Character of respirations – refers to depth and quality – Deep vs. shallow, labored, moist, difficult, noisy • Rhythm of respirations – refers to spacing between breaths – Regular (or even) vs. irregular © 2009 Delmar, Cengage Learning Measuring and Recording Respirations (continued) • Abnormal respirations – Dyspnea: difficulty breathing – Apnea: absence of respirations – Tachypnea: rapid, shallow > 25/min – Bradypnea: slow <10/min © 2009 Delmar, Cengage Learning Measuring and Recording Respirations (continued) • Abnormal respirations – Orthopnea: severe dyspnea in any position besides sitting or standing – Cheyne-Stokes: abnormal breathing pattern, periods of dyspnea and apnea – Rales: bubbling or noisy sounds caused by fluid © 2009 Delmar, Cengage Learning Measuring and Recording Respirations (continued) • Voluntary control of respirations – Respiration can be controlled if consciously thought about – Important to keep the patient unaware breathing is being assessed – Do not tell the patient you are counting respirations © 2009 Delmar, Cengage Learning Measuring and Recording Respirations (continued) • Record information – Rate, character, rhythm • Ex: A child with R 22, shallow, labored, and regular would suffer from? • Ex: An adult with R 8, deep, regular would suffer from? © 2009 Delmar, Cengage Learning 15:5 Graphing Temperature (TPR) • Graphic sheets are special records used for recording TPR • Presents a visual diagram (easier to follow) • Uses – hospitals or long care facilities (continues) © 2009 Delmar, Cengage Learning 15:5 Graphing TPR • Color codes – Temperature in blue – Pulse in red – Respirations in green • Factors affecting vital signs are often noted on the graph – Surgeries, medications, day & time, etc. (continues) © 2009 Delmar, Cengage Learning Graphing TPR (continued) • Graphic charts are legal records – – – – Must be legible and neat Completed in ink Use straightedge to connect lines HIPAA act! • To correct an error: cross out in red ink and correct, initial next to correction © 2009 Delmar, Cengage Learning Graphing TPR (continued) • Basic principles for completing: – – – – – – Fill in patient information accurately Fill in dates, times (mm/dd/yyyy, __:__am/pm) Adm = admission (first measurement) Following days are numbered PO = after surgery PP = post partum (after delivery) © 2009 Delmar, Cengage Learning © 2009 Delmar, Cengage Learning 15:7 Measuring and Recording Blood Pressure • 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 (mmHg) on a sphygmomanometer (continues) © 2009 Delmar, Cengage Learning Measuring and Recording Blood Pressure (continued) • Systolic pressure: pressure when left ventricle contracts and pushes blood to arteries – Normal is <120 mmHg (range of 100-120 mmHg) – First sound heard during reading of sphygmomanometer © 2009 Delmar, Cengage Learning Measuring and Recording Blood Pressure (continued) • Diastolic pressure: constant pressure when left ventricle is at rest, or between contractions – Normal is < 80 mmHg (range of 60-80 mmHg) – Last sound heard during reading of sphygmomanometer © 2009 Delmar, Cengage Learning Measuring and Recording Blood Pressure (continued) • Blood pressure is read as a fraction • Systolic pressure / Diastolic pressure – Ex: (120/80 mmHg) © 2009 Delmar, Cengage Learning Measuring and Recording Blood Pressure (continued) • Pulse pressure: difference between systolic & diastolic pressure – Important indicator of health and tone of arterial walls – Normal range is 30-50 mmHg – The pulse pressure should be approximately one third of the systolic reading (120 - 80 = 40) © 2009 Delmar, Cengage Learning Measuring and Recording Blood Pressure (continued) • Hypertension—high blood pressure – Prehypertension (120-139 mmHg / 80-89 mmHg) – Systolic > 140 mmHg / Diastolic > 90 mmHg • Hypotension—low blood pressure – Systolic < 90 mmHg / Diastolic < 60 mmHg (continues) © 2009 Delmar, Cengage Learning Measuring and Recording Blood Pressure (continued) • Factors influencing blood pressure readings (high or low) – – – – – Force of heartbeat Resistance of arterial system Elasticity of the arteries Volume of blood in arteries Position of the patient (standing vs sitting vs lying down) (continues) © 2009 Delmar, Cengage Learning Measuring and Recording Blood Pressure (continued) Increased BP Decrease BP Excitement, anxiety, nervous tension Pain Obesity Stimulant drugs Exercise and eating Smoking Rest or sleep Depressant drugs Shock Dehydration Hemorrhage fasting © 2009 Delmar, Cengage Learning Measuring and Recording Blood Pressure (continued) • Types of sphygmomanometers – Mercury: uses a column of mercury in a tube to measure the pressure (discouraged by OSHA) – Aneroid: uses a round gauge to measure pressure • Each line on gauge = 2 mmHg • Measure at eye level, deflated cuff should read zero – Electronic: measures pressure automatically • Shows reading on a digital display (continues) © 2009 Delmar, Cengage Learning © 2009 Delmar, Cengage Learning Measuring and Recording Blood Pressure (continued) • Factors to follow for accurate readings – Patient should sit quietly for at least five minutes before BP is taken – Two readings should be taken and averaged • Minimum wait of 30 seconds between readings – Arm should be rested on a flat surface & free of restrictions © 2009 Delmar, Cengage Learning Measuring and Recording Blood Pressure (continued) • How to measure blood pressure – Cuff should be placed above the crook of the elbow, with arrow pointing over brachial artery – Place the bell/diaphragm of stethoscope directly over brachial artery in the antecubital fossa • Hold as securely as possible with index/middle fingers – Inflate cuff to 150-180 mmHg – Deflate slowly and listen for heart sounds • First sound = Systolic Blood Pressure (Top #) • When sound disappears = Diastolic Blood Pressure (Bottom #) © 2009 Delmar, Cengage Learning © 2009 Delmar, Cengage Learning © 2009 Delmar, Cengage Learning Measuring and Recording Blood Pressure (continued) • Record all required information – Date, time, BP, signature/initials • Do not discuss the reading with the patient; it’s the doctor’s responsibility – Could cause personal reaction to patient © 2009 Delmar, Cengage Learning Blood Pressure Practice Blood Pressure Practice © 2009 Delmar, Cengage Learning