Post on 22-Dec-2015
Outward signs of what is occurring inside the body
Also give valuable information about the patient’s condition
They are taken on every patient you assess.
Vital Signs
Pulse Blood pressure (BP) Respirations Skin Condition Pupillary Respons Capillary refill (for children < 6yo)
What are the vital signs?
Initial set of vial signs are called baseline vital signs
Must be repeated periodically◦Observe trends!
Vital signs – take them when?
The “waves” felt as blood is pumped by the heart
Measures the heart rate and quality Feel for the pulse and an artery near the
skin surface Most often measured at the radial artery.
Pulse
Normal pulse rate◦ 60-100 beats per minute (bpm) at rest◦ >100 bpm – tachycardia◦ <60 bpm – bradycardia
Regular PulseMeasure over 15 seconds x 4 or 30 seconds x 2
Irregular pulseMeasure for a full minute
Pulse Rates
Tachycardia◦Temporary tachycardia FearActivitySome medicationSudafed is a common culprit!
Abnormal Pulses
Bradycardia◦ Seasoned athletes may normally have pulses
from 40-50 bpm◦ Some medications may depress pulse rate
Beta blockers
A pulse consistently under 50 or greater than 120 is a problem!
Abnormal pulses
Normal/fullWeak/threadyStrong/boundingRegular vs irregularRegularly irregular vs. irregularly irregular
Pulse Quality
A complete pulse measurement must include: Rate, strength, regularity
For example:◦Pulse rate of 120, thready and regulary irregular
Reporting pulse
Often overlooked, yet it’s an early and EASY tipoff that the respiratory system is impaired.
Normal respiratory rate in an adult◦ 12-20 breaths per minute◦ One respiration cycle is one inhalation and one
exhalation◦ Can measure for 30 seconds X 2◦ Best to measure for a full minute
Respiratory Rate
Bradypnea: < 12 breaths per minute Tachypnea: > 20 breaths per minute Apnea: absence of breathing Hyperpnea: Very deep respiration Hyperventilation: Hyperpnea and tachypnea Cheyne-Stokes: alternating between apnea
and tachypnea Hypoxia: Inadequate oxygenation
Respiratory Rate - Terms
Blood pressure is the force of blood against the arterial walls.
Responsible for the flow of blood.
Blood pressure is the result of:- The pumping action of the heart.
- Resistance of the blood vessels.
- Volume of blood.
Blood pressure also depends on: Distance from the heart.
Would B/P in the legs be lower or higher than in the arm?
Blood Pressure is Elevated by:
Sex and age of the patient.
Exercise, eating, emotions
Stimulants Obesity Arteriosclerosis Diabetes Pain Heredity factors Some drugs
Blood Pressure is: Recorded as an improper fraction. 120/80 Numerator equals systolic pressure, the first
sound you will hear. Denominator equals diastolic pressure, the
last sound you will hear.
Blood Pressure Sounds are: Auscultated through a stethoscope Sounds are correlated with the readings on
a sphygmomanometer. Blood pressure is recorded in millimeters of
mercury. (mm Hg)
Blood Pressure Variations Determine baseline- From medical record
- From systolic palpated pressure Hypertension – High blood pressure Hypotension – Low blood pressure Orthostatic hypotension – decrease in B/P with position change from supine to erect.
Aneroid Sphygmomanometer
Use the proper size cuff Undersized cuff artificially raises blood
pressure Oversized cuff artificially lowers blood
pressure
The "ideal" cuff should have a bladder length that is 80% and a width that is at least 40% of arm circumference (a length-to-width ratio of 2:1).
Positioning for BP Ideally have the patient seated and their
arm at heart level. Make sure that they do not have any tight clothing which may constrict their arm.
Locate the brachial pulse
Palpate in the antecubital fossa for the point of maximal pulsation of the
brachial artery.
Positioning of Blood Pressure Cuff Cuff applied directly over skin (not through
clothes) ◦ Clothes artificially raises blood pressure
Center inflatable bladder over brachial artery Position lower cuff border 1 inch above
antecubital space
Estimation of systolic pressure The examiner should assess the estimated
systolic pressure. To do this, palpate the patient’s radial pulse. Now inflate the cuff until you feel the exact point when the pulse disappears. The point on the manometer at this moment represents the estimated systolic pressure.
Assessment of systolic & diastolic pressure
Place your stethoscope over the brachial artery area. Now inflatean extra 30mmHg worth of pressure above the estimate systolic pressure (e.g. if the estimate systolic pressure was 120mmHg – inflate the cuff to 150mmHg).
Now slowly release the pressure in the cuff by using the valve.
The pressure should be reduced at a rate of 2-3mmHg per second. The point where
consecutive tapping noises (i.e. Korotkoff phase 1) occur you should read off the pressure on the manometer – i.e. the
systolic pressure.
When the consecutive heart beat sounds finally
disappear (i.e. Korotkoff phase 5), read off the measurement on the
manometer. This represents the diastolic
pressure.
Trouble-shooting
False high reading- Cuff too small- Cuff too loose- Slow cuff release
- Column or dial not at eye level - Anxiety or recent exercise
False low reading- Incorrect position of arm…be sure
to position at the level of the heart - Failure to notice auscultatory gap:
Sounds fade out for 10 to 15 mm Hg then return
– Inaudibility of low volume sounds – Column or dial not at eye level
Blood pressure values• Systolic normal range 90 –
140 mm Hg Diastolic normal range 60 –
90 mm Hg Pulse pressure: difference
betweensystolic & diastolic pressure,
approximately 40 mm Hg
Blood pressure readings…
Use same arm for
readings• Do not take B/P
on arm with: – An IV – Paralysis – Injury – A – V shunt – Edema
Temperature
Body temperature (T) is one of the first assessments done.
Temperature Ranges◦ Normal adult temperature is 98.6ºF, or
37ºC.◦ Normal range can be from 96.8ºF to
100.4ºF, or 36ºC to 38ºC.
Temperature (cont.)
Temperature Ranges (cont.)◦ Temperatures can vary due to:
Time of day. Allergic reaction. Illness. Stress. Exposure to heat or cold.
Temperature (cont.)
Temperature Sites◦ Oral – within the mouth or under the
tongue.◦ Axillary – in the armpit.◦ Tympanic – in the ear canal.◦ Rectal – through the anus, in the
rectum.◦ Other sites include on the skin or in
the blood.
Temperature (cont.)
Types of Thermometers◦Electronic Thermometers Measure temperature
through a probe at the end of the device.
Hold as close as possible to the area where you wish to measure the temperature.