Vital Signs

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

DeepShallowLabored Normal

Quality of Respirations

Blood Pressure

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?

Pumping Action of the HeartSystolic Phase-SystoleVentricles ContractBlood flows to the body

Pumping Action of the HeartDiastolic Phase – Diastole

Heart relaxes

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 lowered by:

Fasting Rest Depressants Weight loss Loss of blood or shock Diuretics

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.

Equipment

Stethoscope

Stethoscope

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).

Mercury Sphygmomanometer

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).

Korotkoff Sounds

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.

Temperature (cont.)

Types of Thermometers (cont.)◦ Glass Thermometers

Mercury rises in a glass tube until its level matches the temperature.

Bulb shapes– Long tip – for oral use. – Security tip – for oral

and rectal use.– Rounded tip – for rectal.