Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Chapter 38 Vital Signs and...

Copyright ©2012 Delmar, Cengage Learning. All rights reserved.

Chapter 38

Vital Signs and Measurements


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


Height and Weight

• Additional infant measurements taken to ensure proper growth and development– Length of extremities– Circumference of head– Circumference of abdomen or chest


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


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


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


Temperature

• Factors affecting temperature– Metabolic rate– Time of date– Amount of activity

• Normal temperature may vary– Temperature above normal: febrile– Temperature below normal: afebrile


Thermometers

• Disposable• Electronic (battery operated)• Digital• Tympanic infrared• Temporal artery


Oral Temperature


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


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


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


Tympanic (Aural) Temperature

• Thermometers are easy, safe, and fast• When documenting, record (Tym) following

reading


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


Temperature Conversions

• Fahrenheit to Celsius

• Celsius to Fahrenheit


Pulse

• Palpated in arteries close to body surface and lie over bone or firm structures

• Can be felt in several locations on the body


Pulse Sites

• Radial – Most frequently used when measuring pulse rate

• Apical• Brachial

– Used to palpate and auscultate blood pressure• Carotid

– Palpated during CPR


Pulse Sites

• Femoral• Dorsal pedalis• Popliteal

– These three sites are palpated to evaluate circulation in the lower extremities


Pulse

• Pulse rates– Normal range is 60-100 beats per minute– Influenced by

• Exercise• Age• Gender• Size• Physical condition of body


Pulse

• Pulse characteristics– Volume

• Normal, full or bounding, weak, thready

– Quality• Arrythmia, pulse lacks a specific rhythm• Intermittent


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


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


Pulse Oximetry

• Small device used to measure pulse and arterial oxygen saturation in blood

• Clip attached to patient’s finger


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


Respirations

• Abnormal respirations– Hyperventilation– Dyspnea– Rales (noisy breathing)– Apnea, absence of breathing– Cheyne-Stokes


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


Normal Blood Pressure

• Systolic pressure– 100-120 mm Hg

• Diastolic pressure– 60-80 mm Hg


Abnormal Blood Pressure

• Hypertension– Consistent readings above 140/90– Idiopathic (essential hyptertension)– Primary, secondary, malignant

• Hypotension– Consistent readings below 90/60

Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Chapter 38 Vital Signs and...

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