© 2009 Delmar, Cengage Learning
Vital Signs
© 2009 Delmar, Cengage Learning
14:1 Measuring and RecordingVital Signs (VS)
• Vital Signs are defined as various determinations that provide basic information about the basic conditions of the patient
• The 4 main vital signs (VS)– Temperature (T)
– Pulse (P)
– Respiration (R)
– Blood pressure (BP)
© 2009 Delmar, Cengage Learning
Other Assessments on Patients
• Pain—patients asked to rate on scale of 1 to 10 (1 is minimal and 10 is severe)
• Color of skin
• Size of pupils and reaction to light
• Level of consciousness
• Response to stimuli
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VS Readings
• Accuracy is essential
• Report abnormality or change
• If unable to get reading, ask another person to check
• As a health care worker, it is your responsibility to measure and record the VS of your patients
© 2009 Delmar, Cengage Learning
14:2 Measuring and Recording Temperature
• 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 balance in the body
• Conversion between Fahrenheit and Celsius temperature
© 2009 Delmar, Cengage Learning
Variations in Body Temperature
• Normal range 97- 100 degrees Fahrenheit
• Causes of variations –individual differences, time of day, body sites
• Temperature measurements—oral, rectal (often used on infants/children), axillary (arm pit) or groin, aural (ear), and temporal (forehead-is measuring the temp in the temporal artery)
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Causes of Increased Body Temperature
• Illness
• Infection
• Exercise
• Excitement
• High temperatures in the environment
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Causes of Decreased Body Temperature
• Starvation or fasting
• Sleep
• Decreased muscle activity
• Mouth breathing
• Exposure to cold temperatures in the environment
• Certain diseases
© 2009 Delmar, Cengage Learning
Thermometers
• Clinical thermometers – are used to record temperatures– Glass – consists of a slender glass tube containing mercury
or alcohol with red dye, which expands when exposed to heat
– Electronic – registers the temp on a viewer in a few seconds
– Tympanic – records aural temp in the ear
– Temporal – measures the temp in the temporal artery of the forehead
– Plastic or paper - contain special chemical dots/strips that change color when exposed to specific temps (continues)
© 2009 Delmar, Cengage Learning
Thermometers(continued)
• Reading thermometers and recording results:
* Electronic & tympanic thermometers are easily read because of digital displays
* Mercury thermometers should be held at eye level & rotated slowly to find the mercury
Examples of how to record a temperature:
98.6 is an oral reading
99.6 (R) is a rectal reading
97.9 (Ax) is an axillary reading
98.6 (A) is an aural reading
© 2009 Delmar, Cengage Learning
Cleaning Thermometers
• Must be cleaned after each use
• The procedure will vary with different agencies and thermometers
• Glass thermometers are cleaned with water and soaked in a disinfectant solution (70% alcohol) for a minimum of 30 minutes before using again
• Electronic/digital thermometers use a probe or sheath that is discarded after each use
© 2009 Delmar, Cengage Learning
14:3 Measuring and Recording Pulse
• Pressure of the blood pushing against the wall of an artery as the heart beats and rests
• Major arterial or pulse sites
• Pulse rate
• Pulse rhythm
• Pulse volume
(continues)
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Measuring and Recording Pulse (continued)
• Factors that change pulse rate
• Basic principles for taking radial pulse
• Recording information
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14:4 Measuring and Recording Respirations
• Measures the breathing of a patient
• Process of taking in oxygen and expelling carbon dioxide from the lungs and respiratory tract
• One respiration: one inspiration (breathing in) and one expiration (breathing out)
(continues)
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Measuring and Recording Respirations (continued)
• Normal respiratory rate
• Character of respirations
• Rhythm of respirations
• Abnormal respirations
• Voluntary control of respirations
• Record information
© 2009 Delmar, Cengage Learning
14:5 Graphing TPR
• Graphic sheets are special records used for recording TPR (temp., pulse, resp.)
• Presents a visual diagram
• Used most often in hospitals and long term care facilities
• Factors affecting VS are often noted on the graph - - examples include surgery, medications that lower temperature such as aspirin and antibiotics (continues)
© 2009 Delmar, Cengage Learning
Graphing TPR(continued)
• Graphic charts are legal records – so it must be neat, legible, and accurate
• To correct an error mark a single line through the error and initial beside it
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14:6 Measuring and RecordingApical Pulse
• Pulse count taken at the apex of the heart with a stethoscope
• Reasons for taking an apical pulse – pts with irregular heart beats, hardening of the arteries, weak or rapid radial pulses
• Protect the patient’s privacy and avoid exposure
• 2 heart sounds “lubb-dupp” = 1 heart beat• Abnormal sounds or beats should be reported
immediately (continues)
© 2009 Delmar, Cengage Learning
Measuring and Recording Apical Pulse (continued)
• Pulse deficit – a condition that occurs with some heart conditions – when the apical pulse rate is higher than the pulse rate on other sites on the body
• Use the stethoscope : diaphragm side
• Placement of stethoscope : 2-3in. to the left of the breast bone
• Measuring apical pulse : count for 1 full min.
• Record all information
© 2009 Delmar, Cengage Learning
14:7 Measuring and RecordingBlood Pressure
• 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 a sphygmomanometer
• Measurements read at two points
(continues)
© 2009 Delmar, Cengage Learning
Measuring and Recording Blood Pressure
(continued)
• Systolic pressure
• Diastolic pressure
• Pulse pressure
• Hypertension—high blood pressure
• Hypotension—low blood pressure
• Factors influencing blood pressure readings (high or low) (continues)
© 2009 Delmar, Cengage Learning
Measuring and RecordingBlood Pressure
(continued)
• Individual factors can all influence blood pressure readings
• Types of sphygmomanometers– Mercury
– Aneroid
– Electronic
(continues)
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Measuring and RecordingBlood Pressure
(continued)
• Factors to follow for accurate readings
• Record all required information
• Do not discuss the reading with the patient; it’s the doctor’s responsibility
© 2009 Delmar, Cengage Learning
Summary
• Vital signs are major indicators of body function
• Accuracy of measurement and recording of vital signs
• The health care worker needs to be alert and report any abnormalities
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