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Chapter 15
Vital Signs
© 2009 Delmar, Cengage Learning
15:1 Measuring and Recording
Vital Signs (VS)
• Record information about the basic body
conditions
– Abnormalities from homeostasis
• Main vital signs (VS)
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Temperature
Pulse
Respiration
Blood pressure
© 2009 Delmar, Cengage Learning
Other Assessments
• Pain—patients asked to rate on scale of
1 to 10 (1 is minimal and 10 is severe)
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Other Assessments
• Color of skin
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Pallor
Cyanosis
Jaundice
Erythema
Ecchymosis
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Other Assessments
• Size of pupils and reaction to light
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Other Assessments
• Level of consciousness
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Other Assessments
• Response to stimuli
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Vital Sign Readings
• Accuracy is essential
– Must know how to accomplish task with various
equipment
– Never guess or report false readings
• Report abnormality or change
– Severe abnormalities indicate life-threatening
conditions
• If unable to get reading, ask another
person to check
© 2009 Delmar, Cengage Learning
15:2 Measuring and Recording
Temperature
• Temperature: Measures balance between
heat lost and heat produced in the body
– Thermal activity
• Heat produced by metabolism of food and
by muscle and gland activity
• Heat lost through perspiration, respiration,
and excretion
© 2009 Delmar, Cengage Learning
15:2 Measuring and Recording
Temperature
• Conversion between Fahrenheit and Celsius
temperature
F C: C = (F - 32) x (5/9 or 0.5556)
C F: F = (C x 9/5 or 1.8) + 32
• Practice:
– 102o F to C
– 19o C to F
212o F to C
37o C to F
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Variations in Body Temperature
• Normal range
– 97-100o F, 36.1-37.8o C
• Causes of variations
– Size/shape of individual, time of day, part of body,
metabolic activity
© 2009 Delmar, Cengage Learning
Variations in Body Temperature
• Temperature measurements — oral, rectal
(often used on infants/children), axillary
or groin, aural, and temporal
• Normal:
– Oral: 98.6o F
– Rectal: 99.6o F
Axillary: 97.6o F
Aural/Temporal: no normal range
© 2009 Delmar, Cengage Learning
Variations in Body Temperature
Abnormal conditions affecting temperature
Increase:
Illness and infection
Exercise, excitement, fear
High environmental
temperatures
Decrease:
Starvation or fasting
Sleep
Sedation
Mouth breathing
Cold environmental
temperatures
© 2009 Delmar, Cengage Learning
Variations in Body Temperature
• Abnormal conditions
– Hypothermia: body
temperature < 95o F
– Fever: elevated above 101o F
• Pyrexia, Febrile, Afebrile
– Hyperthermia: body
temperature > 104o F
© 2009 Delmar, Cengage Learning
Thermometers
• Clinical thermometers
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Glass: contains mercury, analog
Electronic: digital reading, quicker results
Tympanic: use infrared energy
Temporal: measures temporal artery
Plastic or paper: disposable
• Reading thermometers and recording results
– Read in 1o increments, labeled by site
• R, Ax,, A, 986
(continues)
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© 2009 Delmar, Cengage Learning
Thermometers
(continued)
• Avoid factors that could alter or change
temperature
– Examples???
• Cleaning glass clinical thermometers
– Clean with alcohol wipe or soap/cool water
• Paper/plastic sheath on glass thermometer
– Used to prevent transmission of disease
– Dispose of properly
– Still wipe with alcohol pad
© 2009 Delmar, Cengage Learning
15:3 Measuring and Recording Pulse
• Pulse: Pressure of the blood pushing
against the wall of an artery as the heart
beats and rests
(continues)
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15:3 Measuring and Recording Pulse
• Major arterial or pulse
sites
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Temporal
Carotid
Brachial
Radial
Femoral
Popliteal
Dorsal Pedal
(continues)
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15:3 Measuring and Recording Pulse
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Must note 3 different factors of the pulse:
Pulse rate (beats per min)
Pulse rhythm (regular or irregular)
Pulse volume (strong, weak, thready, bounding)
(continues)
© 2009 Delmar, Cengage Learning
15:3 Measuring and Recording Pulse
• Pulse rate – adult 60-100 bpm, varies
– Bradycardia: slow pulse rate, < 60 bpm
– Tachycardia: fast pulse rate, >100 bpm
• Pulse rhythm – spacing between beats
– Regular vs. irregular
– Arrythmia: abnormal heart rhythm
• Pulse volume – strength/intensity of the pulse
– Strong vs. weak, thready, bounding
(continues)
© 2009 Delmar, Cengage Learning
Measuring and Recording Pulse
Factors that change pulse rate
Increase:
Exercise
Stimulant drugs
Excitement
Fear
Fever
Shock
Nervous tension
Decrease:
Sleep
Depressant drugs
Heart disease
Coma
Physical training
© 2009 Delmar, Cengage Learning
Measuring and Recording Pulse
(continued)
Basic principles for taking radial pulse:
1. Patient positioned comfortably, palm down
2. Use tip of index/middle fingers to locate
pulse on thumb side of wrist
3. First beat counted starts with zero
1.
2.
3.
4.
10 sec x 6
15 sec x 4
30 sec x 2
60 sec
© 2009 Delmar, Cengage Learning
Measuring and Recording Pulse
(continued)
• Recording information:
– Include rate, rhythm,
volume
Example:
P 82 regular and strong
(rate)(rhythm)(volume)
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15:4 Measuring and Recording
Respirations
• Respiration: Measures the breathing of a patient
• Process of taking in oxygen and expelling
carbon dioxide from the lungs and
respiratory tract
(continues)
© 2009 Delmar, Cengage Learning
15:4 Measuring and Recording
Respirations
• One respiration: one inspiration (breathing
in) and one expiration (breathing out)
(continues)
© 2009 Delmar, Cengage Learning
Measuring and Recording Respirations
(continued)
• Normal respiratory rate
– Adults: 12-20 breaths per minute
– Children: 16-30 per minute
– Infants: 30-50 per minute
© 2009 Delmar, Cengage Learning
Measuring and Recording Respirations
• Must note 3 different factors:
• Rate (breaths per minute)
• Character (depth and quantity)
• Rhythm (regularity)
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Measuring and Recording Respirations
(continued)
• Character of respirations – refers to depth
and quality
– Deep vs. shallow, labored, moist, difficult, noisy
• Rhythm of respirations – refers to spacing
between breaths
– Regular (or even) vs. irregular
© 2009 Delmar, Cengage Learning
Measuring and Recording Respirations
(continued)
• Abnormal respirations
– Dyspnea: difficulty breathing
– Apnea: absence of respirations
– Tachypnea: rapid, shallow > 25/min
– Bradypnea: slow <10/min
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Measuring and Recording Respirations
(continued)
• Abnormal respirations
– Orthopnea: severe dyspnea in any
position besides sitting or standing
– Cheyne-Stokes: abnormal breathing
pattern, periods of dyspnea and apnea
– Rales: bubbling or noisy sounds caused by
fluid
© 2009 Delmar, Cengage Learning
Measuring and Recording Respirations
(continued)
• Voluntary control of respirations
– Respiration can be controlled if consciously thought
about
– Important to keep the patient unaware breathing is being
assessed
– Do not tell the patient you are counting respirations
© 2009 Delmar, Cengage Learning
Measuring and Recording Respirations
(continued)
• Record information
– Rate, character, rhythm
• Ex: A child with R 22, shallow, labored, and
regular would suffer from?
• Ex: An adult with R 8, deep, regular would
suffer from?
© 2009 Delmar, Cengage Learning
15:5 Graphing Temperature (TPR)
• Graphic sheets are special records used for
recording TPR
• Presents a visual diagram (easier to follow)
• Uses – hospitals or long care facilities
(continues)
© 2009 Delmar, Cengage Learning
15:5 Graphing TPR
• Color codes
– Temperature in blue
– Pulse in red
– Respirations in green
• Factors affecting vital signs are often noted
on the graph
– Surgeries, medications, day & time, etc.
(continues)
© 2009 Delmar, Cengage Learning
Graphing TPR
(continued)
• Graphic charts are legal records
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Must be legible and neat
Completed in ink
Use straightedge to connect lines
HIPAA act!
• To correct an error: cross out in red ink and
correct, initial next to correction
© 2009 Delmar, Cengage Learning
Graphing TPR
(continued)
• Basic principles for completing:
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Fill in patient information accurately
Fill in dates, times (mm/dd/yyyy, __:__am/pm)
Adm = admission (first measurement)
Following days are numbered
PO = after surgery
PP = post partum (after delivery)
© 2009 Delmar, Cengage Learning
© 2009 Delmar, Cengage Learning
15:7 Measuring and Recording
Blood Pressure
• Blood 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 (mmHg)
on a sphygmomanometer
(continues)
© 2009 Delmar, Cengage Learning
Measuring and Recording
Blood Pressure
(continued)
• Systolic pressure: pressure when left ventricle
contracts and pushes blood to arteries
– Normal is <120 mmHg (range of 100-120 mmHg)
– First sound heard during reading of sphygmomanometer
© 2009 Delmar, Cengage Learning
Measuring and Recording
Blood Pressure
(continued)
• Diastolic pressure: constant pressure when left
ventricle is at rest, or between contractions
– Normal is < 80 mmHg (range of 60-80 mmHg)
– Last sound heard during reading of sphygmomanometer
© 2009 Delmar, Cengage Learning
Measuring and Recording
Blood Pressure
(continued)
• Blood pressure is read as a fraction
• Systolic pressure / Diastolic pressure
– Ex: (120/80 mmHg)
© 2009 Delmar, Cengage Learning
Measuring and Recording
Blood Pressure
(continued)
• Pulse pressure: difference between systolic
& diastolic pressure
– Important indicator of health and tone of arterial walls
– Normal range is 30-50 mmHg
– The pulse pressure should be approximately one third of
the systolic reading (120 - 80 = 40)
© 2009 Delmar, Cengage Learning
Measuring and Recording
Blood Pressure
(continued)
• Hypertension—high blood pressure
– Prehypertension (120-139 mmHg / 80-89 mmHg)
– Systolic > 140 mmHg / Diastolic > 90 mmHg
• Hypotension—low blood pressure
– Systolic < 90 mmHg / Diastolic < 60 mmHg
(continues)
© 2009 Delmar, Cengage Learning
Measuring and Recording
Blood Pressure
(continued)
• Factors influencing blood pressure
readings (high or low)
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Force of heartbeat
Resistance of arterial system
Elasticity of the arteries
Volume of blood in arteries
Position of the patient
(standing vs sitting vs lying down)
(continues)
© 2009 Delmar, Cengage Learning
Measuring and Recording
Blood Pressure
(continued)
Increased BP
Decrease BP
Excitement, anxiety, nervous
tension
Pain
Obesity
Stimulant drugs
Exercise and eating
Smoking
Rest or sleep
Depressant drugs
Shock
Dehydration
Hemorrhage
fasting
© 2009 Delmar, Cengage Learning
Measuring and Recording
Blood Pressure
(continued)
• Types of sphygmomanometers
– Mercury: uses a column of mercury in a tube to measure
the pressure (discouraged by OSHA)
– Aneroid: uses a round gauge to measure pressure
• Each line on gauge = 2 mmHg
• Measure at eye level, deflated cuff should read zero
– Electronic: measures pressure automatically
• Shows reading on a digital display
(continues)
© 2009 Delmar, Cengage Learning
© 2009 Delmar, Cengage Learning
Measuring and Recording
Blood Pressure
(continued)
• Factors to follow for accurate readings
– Patient should sit quietly for at least five minutes before
BP is taken
– Two readings should be taken and averaged
• Minimum wait of 30 seconds between readings
– Arm should be rested on a flat surface & free of
restrictions
© 2009 Delmar, Cengage Learning
Measuring and Recording
Blood Pressure
(continued)
• How to measure blood pressure
– Cuff should be placed above the crook of the elbow, with
arrow pointing over brachial artery
– Place the bell/diaphragm of stethoscope directly over
brachial artery in the antecubital fossa
• Hold as securely as possible with index/middle fingers
– Inflate cuff to 150-180 mmHg
– Deflate slowly and listen for heart sounds
• First sound = Systolic Blood Pressure (Top #)
• When sound disappears = Diastolic Blood Pressure (Bottom #)
© 2009 Delmar, Cengage Learning
© 2009 Delmar, Cengage Learning
© 2009 Delmar, Cengage Learning
Measuring and Recording
Blood Pressure
(continued)
• Record all required information
– Date, time, BP, signature/initials
• Do not discuss the reading with the patient;
it’s the doctor’s responsibility
– Could cause personal reaction to patient
© 2009 Delmar, Cengage Learning
Blood Pressure Practice
Blood Pressure Practice
© 2009 Delmar, Cengage Learning