Unit 14 Vital Signs

Janet. J. Nelson RN, CMA

14:1 Measuring andRecording Vital Signs (VS)

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Main vital signs (VS) Temperature

Oral Rectal Axillary Temporal Tympanic

Pulse Rate Rhythm Volume

oRespiration Rate Rhythm Character

oBlood pressure Systolic diastolic

Other Assessments3

Pain – patients asked to rate on scale of 1 to 10 (1 is minimal and 10 is severe)

Pulse oximetryColor of skinSize of pupils and reaction to lightLevel of consciousnessResponse to stimuli

VS Readings

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Accuracy is essential

Report abnormality or change immediately

If unable to get reading, ask another person to check

14:2 Measuring andRecording Temperature

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Measures balance between heat lost and heat produced in the body

Heat produced by metabolism of food and by muscle and gland activity

Homeostasis: constant state of fluid balance

Conversion between Fahrenheit and CelsiusWhere do you find the formulas???

Variations in BodyTemperature

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Normal range

What can causes of variations? Increase/decrease

Temperature measurements – oral, rectal,

axillary or groin, tympanic and temporal

NORMAL TEMPERATURES7

ORAL 98.6 degrees =/- 1 degree

RECTAL 99.6 =/- 1 degree

AXILLARY 97.6 =/- 1 degree

TYMPANIC core temperature but thermometer can be set to read as oral, rectal

TEMPORAL SCAN core temp (same as rectal)

ABNORMAL CONDITIONS8

Hypothermia

Fever Intermittent Remittent Relapsing Constant

Hyperthermia

Thermometers 9

Clinical thermometers Glass Electronic Tympanic Temporal Scan Plastic or paper

Reading thermometers and recording results Date Time in military time (no colons) T & Temperature. Fly the fraction Indicate if it is R, Ax, T, or TA

Thermometers(continued)

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Avoid factors that could alter or change temperature

Wait 15 minutes for oral temp

THINGS TO REMEMBER WITH TEMPS

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ORAL- Check eating, drinking, smoking. It is understood the temp is oral unless otherwise indicated.

RECTAL-Insert electronic thermometer ½-3/4 inch for peds and 1 inch for adult. Pt to lie on left side (Sims) Never with bradycardia. Record with a R. What are some contraindications for rectal temp?

AXILLARY-Dry axillary area. Record with AX When would you use axillary temp?

TYMPANIC (Aural) TEMPERATURES

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Ear canal is not straight. You need to straighten the ear canal in an adult by pulling up & back on the ear.

Infant Tympanic Temps.

An infants ear needs to be pulled straight back

REMEMBER that earwax (cerumen) can obstruct the infrared rays coming from the tympanic membrane

Hearing aides need to be removed and wait 20 min.

If bathing or swimming wait 20 min

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TEMPORAL ARTERY TEMPERATURES

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High-resolution infrared image of a person’s temporal artery being scanned with the TAT-5000 Temporal Artery Thermometer. The measurement is obtained by swiping the thermometer probe across the forehead and behind the ear.

14:3 Measuring andRecording Pulse

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Pressure of the blood pushing against the wall of an artery as the heart beats and rests.

Major arterial or pulse sites

Pulse rate Adults 60-90 Child (>7yr) 72-90 Child 1-7yr 80-120 Infant 90-140

Measuring andRecording Pulse (continued)

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Pulse volume…What does this mean? Bounding Thready

Factors that change pulse rate…Like what?Basic principles for taking radial pulseRecording information: Date, time

(military), P rate, any abnormalities, your first initial, last name & title.

Pulse Tachycardia

Bradycardia

14:4 Measuring andRecording Respirations

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Measures the inspiration and expiration= one breath

Normal respiratory rate. What cause this to vary?

Adults 14-18 (20)

Rhythm :o Dyspnea Apnea Cheynes Stokes

Tachypnea Bradypnea

Measuring and Recording Respirations (continued)

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Character of respirations Rales Hyperventilation Hypoventilation Orthopnea Wheezing

RESPIRATIONS ARE UNDER VOLUNTARY CONTROL….So what does that mean?

Record information; date, time (military), R rate, any abnormalities, your first initial, last name and title.

14:5 Graphing TPR

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Graphic sheets are special records used for recording TPR

Presents a visual diagramUsesColor codesFactors affecting VS are often noted on the

graph

Graphing TPR(continued)

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Graphic charts are legal recordsTo correct an errorBasic principles for completing

14:6 Measuring andRecording Apical Pulse

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Pulse count taken at the apex of the heartReasons for taking an apical pulseProtect the patient’s privacy and

avoid exposureHeart soundsAbnormal sounds or beats

Measuring and Recording Apical Pulse (continued)

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Pulse deficitUse the stethoscopePlacement of stethoscopeMeasuring apical pulseRecord all information

14:7 Measuring andRecording Blood Pressure

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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 on an instrument called a sphygmomanometer

Measurements read at two points http://www.pennmedicine.org/encyclopedia/em_DisplayAnima

tion.aspx?gcid=000013&ptid=17

Measuring and RecordingBlood Pressure (continued)

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Systolic pressureDiastolic pressurePulse pressureHypertension – high blood pressureHypotension – low blood pressureFactors influencing

blood pressure readings

NEW RECOMMENDATIONS FROM AHA

SYSTOLIC LESS THAN 120

DIASTOLIC LESS THAN 80

Measuring and RecordingBlood Pressure (continued)

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Individual factors can all influence blood pressure readings

Blood pressure is recorded as fractionsTypes of sphygmomanometers

Mercury Aneroid Electronic

Manometers

Measuring and RecordingBlood Pressure (continued)

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Factors to follow for accurate readings Pt sit quietly with arm at heart level Width of cuff about same diameter as arm Support forearm on surface Do NOT use thumb on stethoscope Place stethoscope medial antecubital space Cuff on bare skin Determine plapatory systolic pressure…wait 30-

60sec and blow up to +30 mm/HgRecord all required information. Write BP in

fraction.Do not reveal the reading to the patient

How many errors can you find in this picture?

Procedure for BP

ID patient and explain procedureObtain palpatory systolic pressureWait 30+ secInflate cuff 30 mm/Hg over palpatory systolic

pressure.Listen and remember the first number you hear

and last number you hear. In case of a child the diastolic is the where the sound changes.

Finish with patient and record date, time, BP systolic/diastolic, name and title.