Transcript Vital Signs

Vital Signs
What are they and why are they so
important?
Vital Signs
• Important indicators that provide information
about the basic body conditions of the patient
• Four main vital signs: temperature, pulse,
respirations, and blood pressure
Temperature
• Definition – a measurement of the balance
between heat lost and heat produced by the
body
Temperature
– Heat is produced by the metabolism of food and
muscle, and gland activity
– Heat is lost through perspiration, respiration, and
excretion
– Homeostasis (constant state of fluid balance) is
the ideal state in the human body
• Normal temperature range is 97 to 100 degrees
Fahrenheit or 36.1 to 37.8 degrees Celsius
Temperature
– Aseptic technique for handling
– Oral measurement – mouth; 3-5 min
– Rectal measurement – rectum; 3-5 min
– Axillary measurement – armpit; 10 min
– Aural measurement – ear; less than 2 sec
Temperature
– Hypothermia – very low body temperature, below 95
degrees Fahrenheit measured rectally
– Factors that lead to decreased body temperature:
starvation or fasting, decreased muscle activity,
mouth breathing, exposure to cold environmental
temperatures and certain diseases
– Hyperthermia – body temperatures exceeds 104
degrees Fahrenheit measured rectally
– Factors that lead to increased body temperature:
illness, infection, exercise, excitement, and high
environmental temperatures
Temperature
– Usually measured on Fahrenheit scale, but may
see Celsius scale
– Convert Fahrenheit to Celsius temperature,
subtract 32 from the Fahrenheit temperature and
then multiply the result by 5/9 or 0.5556.
– Convert Celsius to Fahrenheit temperature,
multiply the Celsius temperature by 9/5 or 1.8 and
then add 32 to the total.
Temperature
– Equipment used for measurement
• Clinical thermometer – slender glass tube containing
mercury, which expands when exposed to heat
• Electronic thermometer – usually battery operated unit
registering temperature in about 60 sec on digital
display screen
• Tympanic thermometer – specialized electronic
thermometer measuring temperature in the auditory
canal in 1 to 2 sec on display screen
Temperature
– Conditions requiring modifications
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Oral - eating, drinking, or smoking
Rectal – diarrhea
Axillary or groin – moisture or rubbing
Aural – incorrect positioning of pinna
Recording or documenting - T
– Cleaning equipment
Pulse
• Definition- the pressure of the blood felt
against the wall of an artery as the heart
contracts and relaxes, or beats
• Felt in arteries that lie fairly close to the skin and can
be pressed against a bone by the fingers
Pulse
– Pulse sites
• Temporal – at side of forehead
• Carotid – at neck
• Brachial – at inner aspect of forearm at antecubital
space
• Radial – at inner aspect of wrist above thumb; most
common site
• Femoral – at inner aspect of upper thigh
• Popliteal – behind knee
• Dorsalis pedis – at top foot arch
Pulse
– Measured in number of beats per minute
• Rate – number of beats per minute
• Rhythm – regularity; regular or irregular
• Volume – strength; strong, weak, thready, or bounding
Pulse
– Pulse rates vary depending on age, sex, and body
size
• Adults – 60 – 90 bpm
– Men – 60 – 70 bpm
– Women – 65 – 80 bpm
• Children over 7 years – 70 – 90 bpm
• Children 1 to 7 years – 80 – 100 bpm
• Infants – 100 – 160 bpm
Pulse
–Bradycardia – pulse under 60
bpm
–Tachycardia – pulse over 100
bpm
–Arrhythmia – irregular or
abnormal rhythm
Pulse
• Factors that may change pulse rate
– Increased – exercise, stimulant drugs, excitement,
fever, shock, and nervous tension
– Decreased – sleep, depressant drugs, heart
disease, coma, and physical training
• Document findings - P
Respirations
• Definition- the process of taking in oxygen and
expelling carbon dioxide from the lungs and
respiratory tract
• One respiration consists of one inspiration and
one expiration
Respirations
– The breathing rate of the patient
• Rate – number of respirations per minute =
– Adults – 12 –20 rpm
– Children – 16 – 25 rpm
– Infants – 30 –50 rpm
• Rhythm – regularity = regular or irregular
• Character – type; depth and quality = deep, shallow,
labored, difficult, stertorous, and moist
Respirations
– Abnormal respirations
• Dyspnea- difficult or labored breathing
• Apnea – absence of breathing
• Tachypnea – respiratory rate above 25 rpm
• Bradypnea – respiratory rate below 10 rpm
• Orthopnea – difficult breathing in any
position other than sitting erect or standing
Respirations
Abnormal respirations continued
• Cheyne-Stokes respirations – periods of
dyspnea followed by periods of apnea =
frequently seen in dying patients
• Rales – bubbling or noisy sounds caused
by fluids or mucus in the air passages
Respirations
• Must be counted in such a way that
patient is unaware of the procedure
as respirations are partially under
voluntary control
• Leave hand on pulse site while
counting respirations
• Document findings - R
Blood Pressure
• Definition– force exerted by the heart against
the arterial walls when the heart contracts or
relaxes
• Read in millimeters (mm) of mercury (Hg)
Blood Pressure
– Two types of measurements
• Systolic – pressure in the walls of the arteries when the
heart is contracting and pushing blood into the arteries
– Reading shows greatest pressure
– Normal reading is 120 mm Hg
– Normal range is 100 to 140 mm Hg
• Diastolic – constant pressure in the walls of the arteries
when the heart is at rest or between contractions
– Reading shows least pressure
– Normal reading is 80 mm Hg
– Normal range is 60 to 90 mm Hg
Blood Pressure
–Pulse pressure – difference between
systolic and diastolic pressure
• Important indicator of health and tone of
arterial walls
• Normal range in adults 30 to 50 mm Hg
Blood Pressure
–Hypertension – high blood pressure
• Systolic greater than 140 mm Hg
• Diastolic greater than 90 mm Hg
• Causes – stress, anxiety, obesity, high-salt
intake, aging, kidney disease, thyroid
deficiency and vascular conditions
Blood Pressure
–Hypotension – low blood pressure
• Systolic less than 100 mm Hg
• Diastolic less than 60 mm Hg
• Causes – heart failure, dehydration,
depression, severe burns, hemorrhage,
and shock
Blood Pressure
– Factors influencing blood pressure readings
• Force of heartbeat
• Resistance of the arterial system
• Elasticity of the arteries
• Volume of the blood in the arteries
Blood Pressure
– Factors increasing blood pressure
• Excitement, anxiety, nervous tension
• Stimulant drugs
• Exercise and eating
– Factors decreasing blood pressure
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Rest or sleep
Depressant drugs
Shock
Excessive loss of blood
– Factors causing miscellaneous readings
• Lying down
• Sitting position
• Standing position
Blood Pressure
– Recorded as a fraction
• Systolic is numerator = top number
• Diastolic is denominator = bottom number
– Sphygmomanometer instrument used to measure
blood pressure = B/P cuff
• Mercury – long column; 2mm marks
• Aneroid – face scale; 2mm marks
• Parts: cuff, bladder, control valve, bulb, tubing,
measurement scale
• Stethoscope: earpieces, diaphragm, bell and tubing
– Document findings – B/P
Apical Pulse
• Definition– pulse count taken at the apex of the
heart with a stethoscope
– Stethoscope amplifies the actual heart beat
– Usually ordered on patients with irregular heartbeats,
hardening of the arteries, or weak or rapid radial
pulses, and infants
– Two separate heart sounds are heard while listening
to the heartbeat = “lubb-dupp” caused by closing of
heart valves as blood flows through chambers of the
heart
– Each lubb-dupp counts as ONE heartbeat
Apical Pulse
– Pulse deficit – heart condition in which heart is
weak and does not pump enough to blood to
produce a pulse or heart beats too fast and there
is not enough time for the heart to fill with blood
• The heart does not produce a pulse during each beat
• Apical pulse rate is higher than the pulse rate at the
other pulse sites on the body
• Most accurate determination of pulse deficit calculated
by two persons at the same time
– Document findings - AP
Documentation
• Graphing vitals
–Graphic sheets used for recording vitals
–Visual diagram of variations in patient’s
vital signs
–Must be neat, legible, and accurate
–Correct errors carefully