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Chapter 18�Vital Signs

We will take some notes and then practice T, Pulse, Resp

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Vital Signs

most important measurements you will obtain when you evaluate or assess a client’s condition.

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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.

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Temperatures can vary due to:

Time of day.
Allergic reaction.
Illness.
Stress.
Exposure to heat or cold.

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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.

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Pulse

A wave of blood flow created by a contraction of the heart.

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Name these pulses.

Click HERE to check answers.

A.

B.

D.

E.

F.

C.

G.

H.

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Pulse Sites

A. Temporal

B. Femoral

C. Popliteal

D. Posterior tibial

E. Carotid

F. Brachial

G. Radial

H. Dorsalis pedis

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A.

B.

D.

E.

F.

C.

G.

H.

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Characteristics of the Pulse

Pulse Rate

Assessed as beats per minute, or BPM.
Counted for 30 seconds.
Tachycardia – a pulse rate faster than normal.
Bradycardia – a pulse rate slower than normal.

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Pulse Rhythm

the pattern of the heartbeats.
Measure for one for minute if irregular.
When documenting pulse rhythm, record as regular or irregular.

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Click Pictures for Sounds

Rhythm

Regular

Irregular

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Respiration

Respiration (R) is the act of breathing.
Respiratory Rate (RR)

Observe the client’s chest movement upward and outward for a complete minute.
Children under 7 years of age use abdominal breathing.
Auscultation with a stethoscope may be necessary on clients who are aware that you are counting their respiratory rate.

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Characteristics of Respiration

Rate of Respiration – the number of breaths per minute.

Normal range is 12 to 20 breaths per minute for an adult.
Rate will vary with age and size of client.

An increased respiratory rate is called hyperventilation.
A decrease in respiratory rate and depth is called hypoventilation.

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Rhythm of Respiration – should be regular.
Quality of Respiration

Can be shallow or deep.

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Blood Pressure

Blood pressure (BP) is the pressure or tension exerted on the arterial walls as blood pulsates through them.
Systolic blood pressure (SBP) – pressure exerted on the arteries during the contraction phase of the heartbeat.
Diastolic blood pressure (DBP) – the resting pressure on the arteries as the heart relaxes between contractions.

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Blood Pressure (cont.)

Expected Blood Pressure Values

Expected SBP – 100 to 140 mm Hg.
Expected DBP – 60 to 90 mm Hg.
Hypotension – when the blood pressure drops below expected levels.
Hypertension – high blood pressure.
Prehypertension – classified by the American Heart Association as SBP 120 to 139 mm Hg or DBP 80 to 89 mm Hg.

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Apply Your Knowledge

Where would one measure tympanic temperature?

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Answer:

Tympanic temperature is measured in the ear canal.

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Vital Signs Procedures

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Order of Performance

Perform the least invasive vital sign first.
Use this order if possible:

Respiratory rate.
Pulse.
Temperature.
Blood pressure.

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Documenting and Reporting

Check for common abbreviations in chart.

VS (vital signs)
T P R BP (temperature, pulse, respiratory rate, blood pressure)
RR (respiratory rate)

Record results properly.
Report information to your supervisor.

Vital signs outside the expected range.
Vital signs significantly different from previous results.

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Apply Your Knowledge

List the order for taking vital signs.

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Answer:

Respiratory rate.
Pulse.
Temperature.
Blood pressure.

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STOP

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Patient Assessment��Measuring Pulse & Respiration

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Objectives

Students will:

Identify normal and abnormal V/S measurements.
Measure and record vital signs according to industry standards.
Measure and record height and weight according to industry standards.
Explain why urine, stool, and sputum specimens are collected.
Explain the rules for collecting different specimens
Describe the seven warning signs of cancer

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Vital Signs

Are important indicators of health
Detect changes in normal body function
May signal life-threatening conditions
Provide information about responses to treatment

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Vital Signs

Temperature
Pulse
Respirations
Blood Pressure

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Vital Signs Are Measured:

Upon admission
As often as required by the person’s condition
Before & after surgery and other procedures
After a fall or accident
When prescribed drugs that affect the respiratory or circulatory system
When there are complaints of pain, dizziness, shortness of breath, chest pain
As stated on the care plan

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When Measuring Vital Signs

Usually taken with the person sitting or lying
The person is at rest
Always report:

A change from a previous measurement
Vital signs above or below the normal range
If you are unable to measure the vital signs

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Pulse

The pressure of blood pushing against the wall of an artery as the heart beats and rests.
Measured for one minute while noting:

rate - beats per minute
rhythm - regular or irregular
volume - strength or intensity - described as strong, weak, thready, bounding

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Pulse

Rhythm and Force of the pulse

Rhythm-time interval between each beat, Rhythm should be regular. Irregular pulse- beats are not everly spaced or when beats are skipped

Force-related to pulse strengh

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Pulse Sites

Most Commonly Used:

Carotid – during CPR
Apical – use stethoscope
Brachial – for Blood Pressure
Radial - to count pulse
Femoral – assessment and procedures
Popliteal – assessment
Dorsalis Pedis – assessment

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Normal Ranges

Age	Pulse per Minute
Birth to 1 year	80-190
2 years	80-160
6 years	75-120
10 years	70-110
12 years & older	60-100

Bradycardia – Under 60 beats per minute

Tachycardia – Over 100 beats per minute

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Factors that Affect Pulse

Factors that 🡹 pulse

Exercise
Stimulant drugs
Excitement
Fever
Shock
Nervous tension

Factors that 🡻 pulse

Sleep
Depressant drugs
Heart disease
Coma

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Taking a Pulse

The radial pulse is used for routine vital signs
It is felt by placing the first two or three fingers of one hand against the radial artery.
Count the pulse for one minute.

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Respirations

Process of breathing air into (inhalation) and out of (exhalation) the lungs.

(Respiration Rate)

Oxygen enters the lungs during inhalation.
Carbon dioxide leaves the lungs during exhalation.
The chest rises during inhalation and falls during exhalation.

Normal rate 12-20 breaths per minute

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Assessing Respiration

Respirations is measured when the person is at rest.
Rate may change is patient is aware that it is being counted.
To prevent this, count respirations right after taking a pulse.

Keep your fingers or stethoscope over the pulse site.

To count respirations, watch the chest rise and fall.

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Assessing Respiration

Character and quality of respirations is also assessed:

Deep (diaphragmatic breathing)
Shallow (hypopnea)
Labored or difficult ( dyspnea)
Noises – wheezing, stertorous (a heavy, snoring type of sound)
Moist or rattling sounds

Apnea – absence of respirations
Cheyne-Stokes – periods of dyspnea followed by periods of apnea;

often noted in the dying patient

Rales – bubbling or noisy sounds caused by fluids or mucus in

the air passages

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Patient Assessment��Measuring BP, Ht and Wt

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Objectives

Students will:

Identify normal and abnormal V/S measurements.
Measure and record vital signs according to industry standards.
Measure and record height and weight according to industry standards.
Explain why urine, stool, and sputum specimens are collected.
Explain the rules for collecting different specimens
Describe the seven warning signs of cancer

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Vital Signs

Are important indicators of health
Detect changes in normal body function
May signal life-threatening conditions
Provide information about responses to treatment

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Vital Signs

Temperature
Pulse
Respirations
Blood Pressure

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Vital Signs Are Measured:

Upon admission
As often as required by the person’s condition
Before & after surgery and other procedures
After a fall or accident
When prescribed drugs that affect the respiratory or circulatory system
When there are complaints of pain, dizziness, shortness of breath, chest pain
As stated on the care plan

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When Measuring Vital Signs

Usually taken with the person sitting or lying
The person is at rest
Always report:

A change from a previous measurement
Vital signs above or below the normal range
If you are unable to measure the vital signs

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Blood Pressure

Measure of the pressure blood exerts on the walls of arteries

Blood pressure is controlled by:

The force of heart contractions

weakened heart 🡪 drop in BP

The amount of blood pumped with each heartbeat

loss of blood 🡪 drop in BP

How easily the blood flows through the

blood vessels

Narrowing of vessels 🡪 increase in BP
Dilatation of vessels 🡪 decrease in BP

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Factors that Affect Blood Pressure

Factors that 🡹 blood pressure

Excitement, anxiety, nervous tension
Stimulant drugs
Exercise and eating

Factors that 🡻 blood pressure

Rest or sleep
Depressant drugs
Shock
Excessive loss of blood

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Measuring BP

A sphygmomanometer is used to measure BP

Aneroid – has a round dial and needle
Mercury – has a column of mercury
Electronic – automated device

BP is measured in millimeters (mm) of mercury (Hg).

The systolic pressure is recorded over the diastolic pressure.

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Contraindications for Taking BP

Measurement of BP at the brachial artery is a generally benign procedure. However, there are some circumstances in which obtaining readings from a particular arm my not be appropriate:

-Presence of an arterial-venous shunt

-Recent axillary node dissection

-Any deformity or surgical history that interferes with proper access or blood blow to the upper arm.

If these relative contraindications are present, BP should be assessed in the opposite arm. There may also be pre-existing conditions that can interfere with the accuracy or interpretation of readings, such as aortic coarctation, arterial-venous malformation, occlusive arterial dz, or the presence of an antecubital bruit. If neither arm can be used, then measurement of blood pressure in a leg may be indicated.

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Normal Range of Blood Pressure

Systolic: Pressure on the walls of arteries when the heart is contracting.

Normal range – less than 120 mm Hg

Diastolic: Constant pressure when heart is at rest

Normal range – less than 80 mm Hg

Hypertension—BP that remains above a systolic

of 140 mm Hg or a diastolic of 90 mm Hg

Hypotension—Systolic below 90 mm Hg and/or a diastolic below60 mm Hg

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Measuring Height & Weight

Chapter 20 page 709

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Measuring Height and Weight

Used to determine if patient is underweight or overweight
Height and weight charts are used as averages
Weight greater or less than 20% considered normal

BMI or Body Mass Index a statistical measure of body weight based on a person's weight and height.
BMI from 18.5 to 24.9 is considered normal

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Measuring Height and Weight

General Guidelines:

Use the same scale every day
Make sure the scale is balanced before use
Weigh the patient at the same time each day
Remove jacket, robe, and shoes before weighing
OBSERVE SAFETY PRECAUTIONS!
Prevent injury from falls and the protruding height lever.
Some people are weight conscious.
Make only positive comments when weighing patients

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Types of Scales

Clinical scales contain a balance beam and measuring rod.
Bed scales or chair scales are used for patients unable to stand
Infant scales come in balanced, aneroid, or digital.

When weighing an…keep slightly over but not touching the infant.
A tape measure is used to measure infant height.

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Converting Weight to Metric Measurement

To convert multiply by:

Grams to ounces 0.0353

Grams to pounds 0.0022

Kilograms to pounds 2.2046

Ounces to grams 28.35

Pounds to grams 453.592

Pounds to Kilograms 0.4536

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Converting Height

Converting inches to centimeters is simple…just take the number of inches and multiply it by 2.54. So for example, 8 inches would be 20.3 cm (8 x 2.54= 20.3)
20.3 / 2.54 = 7.99
1foot = 12 inches

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Measuring Height & Weight

Applying our knowledge