Vital SignsProvide Support to Meet Personal

Care Needs

Updated by Jo Lewis BHS

Fiona O’Toole & Josie Ashmore

PERSONAL CARE WORKERS ROLE

• RecordAccording to workplace protocol

• Report Supervisor

GP

VITAL SIGNS

• Most frequent measurements taken by health care professionals

• Temperature, Pulse, Blood Pressure and Respiration’s

• Indicators of health status - measure the effectiveness of circulatory, respiratory, neural and endocrine body functions

• Alteration in vital signs may signal the need for further intervention

TEMPERATURE

• Oral Via Mouth, rarely used • Axilla Per Axilla (underarm)

Used infrequently• Tympanic Most common• Temple Recent introduction

Oral

Oral: • No longer used in Residential Care,

may still be used in home setting

• 3 minutes • Under tongue, lips closed• No hot or cold drinks beforehand

Per Axilla

ArmpitPreviously most common in aged

careUsed now if tympanic/temple not

available• 3 minutes• Skin surfaces to touch bulb• Record as p/a

Tympanic

• Most commonly used in aged care• As per instructions for each type• Apply cover• Pull the ear lobe up and backwards

to straighten the ear canal. • Insert into canal• Wait for beep

THE PULSE

• The bounding of blood flow we can feel at various points around our body

• Indicator of effective circulation• For our cells to function normally we

need continuous blood flow and volume• Blood flows around the body in a

continuous circuit, pumped by the heart

• Cardiac output = volume of blood pumped by the heart in one minute

• Changes in heart rate alter how well the heart pumps - leads to changes in BP

• As heart rate increases less time for heart to fill -less volume reduces BP

• As heart rate decreases filling time increases - normalises BP

Assessing the Pulse

• Any artery can be used to assess pulse rate

• Radial and carotid easiest• Carotid best in emergency situation -

heart will pump blood to brain for as long as possible

• When cardiac output drastically reduces peripheral pulses difficult to feel

Carotid pulse

Personal Care Workers

Use only the radial pulse point

Pulse points in the bodyRadial and apical locations most commonly used

Equipment needed:

• Watch with second hand

• Pen

• Documentation as per organisation

protocol

Factors which might affect pulse rate

• Age

• Exercise

• Position changes

• Medications

• Temperature

• Emotional distress/anxiety/fear

The steps for taking a radial pulse

• Collect equipment• Explain to client• Wash hands• Provide privacy if required• Place client’s forearm alongside or

across lower chest or abdomen (lying)• Bend client’s forearm at 90 deg angle

and support lower arm on chair• Make sure palm is facing downward

Steps for taking a radial pulse

• Place the tips of your first two fingers over the groove along the thumb side (radial side) of the client’s wrist

• Do not use your thumb!!!!• Lightly compress against the radius to

feel a pumping sensation• Determine the strength of the pulse - Is it strong, thready, bounding or weak ?

Work out the rate

• After pulse can be felt regularly, look at watch’s second hand and begin to count rate

• If pulse is regular count for 30 seconds and multiply by 2 (x2)

• If pulse is irregular, count rate for 60 seconds

Things to consider

• Rate• Rhythm - regular, regularly

irregular, irregularly irregular• Strength

Factors influencing pulse rates

• Exercise• Temperature - fever and heat• Drugs• Loss of blood (haemorrhage)• Postural changes - sitting or

standing• Lung conditions - poor oxygenation

Normal ranges

• INFANT - 120-160 bpm

• TODDLER - 90-140 bpm

• SCHOOLAGE - 75-100 bpm

• ADOLESCENT - 60-90 bpm

• ADULT - 60-100 bpm

Respiration• Our survival depends on the ability of O2

and CO2 to be removed from the cells

• Respiration exchanges gases between the atmosphere and the blood and cells

• Ventilation = the movement of gases in and out of the lungs

• Regulated by the respiratory centre in our brain

Normal breathing• Chest wall gently rises and falls• Abdominal cavity rises and falls due to

diaphragmatic movement• No use of accessory muscles - intercostal,

muscles in neck and shoulders• Accurate measurement necessary as

breathing tied to numerous body systems• Look at rate and depth

Normal rates

• Newborn - 30-60 • Infant - 30-50• Toddler - 25-35• Child - 20-30• Adolescent - 16-20• Adult - 12-20

How to assess respiration• Equipment: watch, Obs chart, pen• Explain to client ????• Make sure chest is visible-place client arm over

abdomen/ or your arm• Observe complete cycle (insp and exp)• Begin to count rate• If regular count for 30 seconds and multiply

by 2 (x2)• If irregular, less than 12 or more than 20

count for full minute

• Note depth of respirations, skin color and effort

• Replace linen• Wash hands• Record on obs chart• Report abnormal findings

Other terms you might hear• Bradypnea - slow breathing

• Tachypnea - fast breathing• Apnoea - no breathing for several

seconds• Hyperventilation - fast rate and depth• Hypoventilation - slow rate and depth• Cheyne-stoke’s respiration - irregular -

apnoea - hyperventilation - shallower - apnoea

Blood pressure

The force applied to the inside of our artery by the blood pulsing from our heart

Blood pressure

Can be affected by:• Effectiveness of heart pumping• Resistance in extremities• Blood volume• Thickness of the blood• Elasticity of arteries and blood

vessels

Systolic v’s Diastolic BP

• Systolic pressure = peak maximum pressure when heart contraction forces blood into aorta (major blood vessel to body)

• Diastolic pressure = the amount of blood left in the ventricles of the heart when they relax between contractions

Factors influencing BP

• Age• Stress• Race• Medications• Time of day• Gender

Common conditions of BP

•Hypertension high BP

•Hypotension low BP

•Postural hypotension dropping of

BP when rising to an upright

position

Normal values

Category Systolic Diastolic

Optimal < 120 mm hg <80 mm hg

Normal <130mm hg < 85 mm hg

Hypertension >140 mm hg –

180 mmhg

> 90 – 110 mm hg

Severe Hypertension

> 180 mm hg > 110 mm hg

Equipment needed

• Sphygmomanometer and cuff• Stethoscope• Obs chart and pen

Getting started

• Gather equipment• Explain to client - rest 5 min if

anxious• Select appropriate cuff size - S - XL• Client can lie or sit or stand• Wash hands• Expose extremity by removing

constricting clothes

• Palpate the brachial pulse (arm)• Place cuff about 2.5 cm above

pulse site • Making sure cuff is fully deflated wrap evenly and snugly around extremity (use arrow to centre on cuff)

• Position the manometer < 1m away from you so you can see it

• Place stethoscope pieces in ears and ensure sounds are clear and not muffled

• ? Estimate systolic pressure (30 mmHg >)• Relocate pulse and place bell of the

stethoscope over it (don’t cover it with clothing/cuff

Steps cont….

• Close valve of pressure bulb clockwise until tight

• Rapidly inflate cuff to 30 mmHg than palpated/previous BP

• SLOWLY release bulb pressure valve allow mercury to fall at a rate of 2-3 mmHg per second

Listen carefully...

• Listen for the first thumping sound and note the measurement on the manometer (systolic reading)

• Sound increases in intensity• Continue to deflate cuff and sound

will become muffled/dampened and note the measurement again (diastolic reading)

• Continue to deflate cuff gradually - listen for 10-20 mmHg after the last sound - let the rest of the air escape quickly

• Remove cuff • Assist client to comfortable position,

wash hands• Document reading on obs chart• Notify of abnormalities

What if the BP is abnormal ?

• Repeat the process

• Check on other arm

• Ask client how they feel

• Compare old readings

• Get someone else to check reading