VITAL SIGNS

Vitals Signs

•4 types(TPR & BP)– Temperature– Pulse– Respirations– Blood Pressure

•Degree of Pain is frequently regarded as the 5th VS(pain scale 0-5)

•Color of the skin, size of the pupils in the eyes and their reaction to light, level of consciousness, and patient’s response to stimuli•VS provide information about the basic body conditions of the patient

**Earliest indicators of change in the body

Temperature

• Balance between heat production and heat loss in the body• Disturbances such as hypothermia (low temp) or pyrexia (fever) affects the

body’s fluid balance• Factors affecting Temperature: Time of day(usually lower in morning), age,

environmental temperature, exercise, menstrual cycleBody heat is created by - exercise

food ingestion muscle tension hormones external factors such as clothing, blankets, etc. illness and infection excitement

Heat loss occurs by - sweating/dilation of blood vesselsrespirationsexcretion(urine and feces)***Starvation/fasting, sleep, decrease muscle activity, mouth breathing, & cold temperatures cause decrease in body temp

Types of thermometers• Glass

• Electronic

• Topical/temp strip

Temporal artery

Normal Temperature Ranges –

Axillary (under the armpit) **less accurate Taken for 5-10 minutes with glass or electronic thermometer

96.6F - 98.6F (1 degree less than oral)

Oral

Taken for 3 - 5 minutes with glass, paper, or electronic thermometer 97.6F - 99.6F

(fever is anything over 100.6F oral)

Rectal “core” **most accurateTaken 3-5 min with electronic or glass thermometer after inserting

the thermometer 1 1/2 - 3 inches in the rectum 98.6 F- 100.6F (1 degree higher than oral)

Tympanic(the ear) “core”Taken 1-2 sec with electronic thermometer

96.4F to 100.4F

CLASSIFICATIONS OF FEVERS

Slight= 99.6-101.0 F 37.5-38.3 C

Moderate= 101.0-102.0 F 38.3-38.8 C

Severe= 102.0-104.0 F 38.8-40.0 C

Dangerous= 104.0-105.0 F 40.0-40.5 C

Fatal= Over 106.0 F 41.1 C

HypothermiaLow body temp below 95F rectallyCan be caused by prolonged exposure to coldDeath usually occurs if temp drops below 93F rectally

Fevers/ Febrile (Pyrexia)Usually 100.4-101 orally is considered a fever Usually caused by infection or injuryAfebrile means no fever is present or the temperature is within the normal range.

Symptoms of Infection:elevated temperaturechilling sensationmalaise - feel ‘blah’no appetite

Hyperthermia Body temp exceeds 104F rectallyCaused by prolonged exposure to hot temp, brain damage, or serious infectionsImmediate action to lower tempTemp above 106F can quickly lead to convulsions, brain damage, and death.

Treatment for fever:•Tepid baths•Reduce room temp and amount of bedding•Force fluids•High calorie diet•Medications if necessary•**Fluctuations of 2-3 degrees increases metabolic rate and pulse rate (10 beats/degree)

Before taking an oral temperature:Ask the patient - “Have you had anything to eat, drink or smoke in the last 15 minutes?”

(If they have, wait 15 minutes to take the temp)

Oral temps are not taken on – patients under the age of 4 or 5

patients who mouth breathe or have nasal congestion patients with a nasogastric tube

patients on Oxygen patients who have had face/neck/nose/mouth injuries or surgery patients who are confused, restless, delirious, or unconscious

patients who are paralyzed on one side of the body patients who has sore mouth

Report all temperatures over 100.6F or 37.9C Immediately!!

Rectal temps are used for infants and children under 3 yrs old and when the oral site cannot be used.

Rectal temps are not taken on – patients who have had any rectal surgery/injurypatient with inflamed hemorrhoidspatients with bleeding from the rectumpatients who have diarrheapatients who have heart diseasepatients who are confused or agitated

Tympanic Membrane (ear) are not taken on-patients who have an ear disorderpatients who have ear drainage

Which method would you choose?

-infants and children under the age of six

-patients with respiratory complications that result in mouth breathing or use of supplemental oxygen

-confused, disoriented, or emotionally unstable patients

-patients with nasal obstruction

Calculations

PULSEPOINTS

Antecubital

How to evaluate a pulse

• Find pulse point• Feel with pads of first two fingers• No thumb • Make sure you feel it well• Time (count) for 30 seconds and multiply

by 2• If irregular you MUST count for a full

minute

CHARACTERISTICS OF PULSE

VOLUMEStrong, weak, thready, or bounding

RHYTHMRegular or irregular

RATEBeats/minute

EXAMPLE RECORDING PULSE: Date, Time, P 82 strong and regular, Your signature & title

Pulse - heart rate/minute(beat of the heart that is felt through the walls of arteries)**Most often taken at the radial artery

*usually taken for 30 seconds and multiplied by 2, unless the heart rate is irregular **if the heart rate is irregular, the pulse must be taken Apically (at the apex of the heart in the chest) with a stethoscope for 1 Full minute

Normal Adult pulse: 60 - 100 beats per minute Children: 70-110 beats/min.

Infants: 100-160 beats/min

-Slow pulse rate less than 60/ minute = Bradycardia, and must immediately be reported-Rapid heart rate over 100/ minute = Tachycardia, and must be reported

**You must note the Rate, Strength of the pulse(volume) and Rhythm and document this

Apical Pulse

• Most accurate• Use for irregularity• Use in infants & children (difficult to count rapid radial

pulse)• Auscultated(listen) NOT palpated(felt) – full minute• Stethoscope required• Apex – left, 5th intercostal space of ribs at middle of left

clavicle. (2 to 3 inches to the left of the breastbone below the left nipple)

EXAMPLE RECORDING: Date, Time, AP 84 strong and regular, Your signature & title.

Heart Sounds

Lubb – S1 – Apex – valves between chambers closing (bicuspid and tricuspid)

Dupp – S2 – 2nd intercostal space at the sternal borders – pulmonary and aortic semilunar valves closing

Abnormal Sounds

• S3

• S4

• Murmurs

• Rubs

What may cause an increase in pulse?

• Exercise

• Emotion (excitement, nervous, tension, stress)• Disease(infection, cardio-vascular disease)

• Medications

• Fever

• Shock

• Age: younger=faster

How about a decrease in pulse?

• Medications

• Depression

• Sleep

• Physical fitness

• Heart disease

• Coma

• Larger size

• Age

Pulse Defecit

• Apical – radial = pulse deficit

• Requires 2 medical professionals

• Measure for full minute

• Discrepancy means trouble (weak heart, tachycardia)

Respirations - number of breaths per minute -represented by 1 Inspiration (breathe in) + 1 Expiration (breathe out)

Normal range for Adult Respirations: 12 - 20 breaths / minute Children: 16-25 breaths/min. Infants 30-50 breaths/min

**You must document the symmetry of the chest on inspiration, depth, rhythm and any abnormal sounds heard

Use words such as deep, shallow, labored, moist, difficult, & stertorous (abnormal sounds like snoring)

Slow respirations less than 12/min = BradypneaRapid respirations over 20/min = Tachypnea

Abnormal sounds:1. rales - moist crackling sounds(fluid in air passages)2. rhonchi - noisy breathing3. stridor - ‘crowing’ on inspiration (usually will see the chest

caving in with inspiration)4. wheezing - whistling noises with inspiration or expiration(narrow

bronchioles (asthma)

Types of Breathing:Eupnea - normal breathingDyspnea – difficulty/ labored breathingOrthopnea - difficulty breathing while lying downApnea - no breathingSterterous - noisy breathing that sounds like snoringCheyne Stokes breathing - periods of deep labored

breaths(dyspnea), followed by very short or no breaths(apnea), and repeat in cycles (occurs shortly before death)

Kussmaul breathing: heavy labored breathing with a fruity odor

Cyanotic- dusky, bluish discoloration of the skin, lips, nail beds.

Counting Respirations1. Stay in the pulse measuring position.

2. Watch the chest rise and fall. Determine the quality…1. Depth (deep or shallow)2. Rhythm (regular or irregular)

3. Count respirations by 30 seconds and multiply by 2

Let the patient think you are still taking pulse while counting! (Patients may breathe faster or slower when they are aware of this procedure)

EXAMPLE RECORDING: Date, Time, R 18 deep and regular, Your signature and title

Blood Pressure Evaluates…

• The condition of the heart

• The amount of blood forced from the heart and contraction

• The condition of the arteries

• The volume and viscosity (thickness) of the blood

Blood Pressure pressure exerted on the walls of arteries when the blood is pumped out of the heart (Systolic BP), and the pressure left when the heart is at rest (Diastolic BP).

Factors affecting Blood Pressure:Agepaindiseasesalt consumptionalcohol and drugsexerciseemotions

Equipment

• Sphygmomanometer• Stethoscope• Pen • Paper

Measured in millimeters(mm) of mercury(Hg) BP is normally measured in the brachial artery on the antecubital area (fold of arm opposite elbow).

SystolicDiastolic

• Systolic pressure- top number– The contraction phase of the heart.– The period of highest pressure.

• Diastolic pressure –bottom number– The relaxation phase of the heart.– The period of lowest pressure.

What Should Normal BP Be?

• Normal BP is:– Systolic pressure less than 140– Diastolic pressure less than 90– Ideally both are less than 120/80

• Pre-hypertension >120 / >80• Hypertension BP is when the systolic

pressure is over 140 and/or diastolic is over 90. There are mild, moderate, and severe cases.

Hypertension - **Can cause a stroke (Cerebral vascular accident / CVA)

**High blood pressure also damages the kidneys, heart and retina of the eyes

Hypotension - a sustained systolic BP less than 90mm or diastolic BP less than 60mm

**only dangerous with symptoms of shock:

rapid weak pulse cold, clammy, pale/blue skin anxious

dizziness

Factors that affect blood pressure

• Diseases

• Emotional status

• Techniques and equipment

• Position

• Activity level

• Medication

• Diet (caffeine, sodium)

Pulse Pressure

• Difference between systolic and diastolic (subtraction)

• Systolic – Diastolic = Pulse Pressure

• Normal 30-50 mmHg

Sounds of blood pressure - Korotkoff Sounds

tappingswishingknockingmuffledsilence

Steps to Finding Blood Pressure

B/P PREP

Expose upper arm- palm up.

Identify brachial artery.

Place middle of cuff bladder over the brachial artery.

Wrap cuff smoothly & snugly.

Palpate the brachial or radial artery & inflate cuff. Note on the dial where you no longer feel pulse. Add 30 to this number to determine how high to pump up the cuff.

OBTAINING THE BLOOD PRESSURE1.Patient should be resting for 5 minutes prior to taking the reading2.You must document the position the patient was in (sitting/lying) *Do not take the BP standing unless ordered that way3. Use the correct size cuff4. Use the brachial artery5. Palpate the brachial artery and inflate the cuff 30mm above

where the pulse disappeared. Deflate the cuff slowly(2-4mm/sec). Where you feel the pulse return, will be approximately what the systolic BP will be.

6.Note the number on the dial you first hear a beat(systolic number).7. Keep listening and note the last number you hear a sound or until the sound disappears (diastolic number).8. Deflate completely before re-inflating the cuff. Wait 30 seconds if you must recheck.9. Once the cuff is inflated, immediately start slowly deflating or venous congestion will occur and the reading will be inaccurate

Recording

• BP systolic/diastolic

• Example: BP 120/80 L arm sitting