vital signs. vital signs temperature breathing +pulse oximeter pulse blood pressure pain (5 th vs)

VITAL SIGNS

Vital Signs• Temperature

• Breathing+Pulse Oximeter

• Pulse

• Blood pressure

• Pain (5th VS)

TEMPERATURE

Skin temperature - taken by placing the back of your hand on the patient’s skin

Equipment – thermometer for accurate temperature reading/measurement

• Shell Temperature

• Core Temperature

Temperature• Normal: 98.6 ° F (37°C)

• Hypothermia: 95°F (35°C)

• Hyperthermia – excessively high core temp. > 105 = brain damage

• Routes– Oral– Axillary– Rectal – Tympanic – Temporal, etc.

Placement – rear sublingual pocket at base of tongue

PULSE

Pressure wave that is felt as the heart contracts

PULSE-Assess… Rate - number of beats per minute

– 60-100 bpm– Rate varies with age and other factors– Do not use your thumb– Tachycardia - > 100 bpm– Bradycardia - < 60 bpm

The Pulse

Rhythm - The pattern of pulsations and pauses between themRegular/Irregulararrhythmia, sinus arrhythmia

Quality /Volume-Force of the contraction of the heartStrongWeakGrading of pulse volume: 0-3+/4+

Pulse Assessment Locations

• Carotid

• Brachial

• Radial

• Femoral

• Popliteal

• Dorsalis pedis

• Posterior tibial

PULSE

If peripheral pulse is not palpable, assess carotid pulseUse caution. Avoid excess pressure

on geriatricsNever attempt to assess carotid

pulse on both sides at one time

Measuring Pulse

Radial

Palpate thumb side of wrist with two to three fingers, do not press too hard or it will obliterate.

Count 30 seconds and multiply by 2. If irregular, count for one full minute. If unable to find, measure apical pulse.

Radial site

Apical pulse

• Site: fifth intercostal space midclavicular line

• The apical pulse is considered more accurate than the radial pulse

• the sound of each heartbeat is obvious and distinct when listening to the apical pulse

• Pulse deficit – difference between apical and radial rate

Apical site: Left 5th ICS Midclavicular Line

Counting Apical Pulse• Apical• Place stethoscope on chest under clothing

• Auscultate apex of the heart below left nipple

• Move around a little at a time until heart beat clearly heard

• If difficulty finding apical pulse, have patient lean forward while sitting, or turn to left side when lying down

• Lub-dub is one beat• Always count for one full minute

RESPIRATIONS(Breathing)

Assessed by observing the patients chest rise and fall

Rate - Count # of breaths for 1 minute

Ventilation – one inhalation and one expiration

QUALITY (and)

Determined while assessing the rate

DEPTH EvenShallowDeep

EFFORTLaboredUnlabored

Types of Respirations

• Eupnea

• Tachypnea

• Bradypnea

• Hyperventilation

• Dyspnea

• Orthopnea

• Apnea

Pressure of circulating blood against the walls of arteries

BLOOD PRESSURE

Blood pressure• Systolic pressure - the

pressure exerted against the walls of the arteries during the contraction of the heart

• Diastolic pressure - pressure that is constantly present within the arterial walls as the heart relaxes and fills with blood

• Pulse pressure - normal range of pulse pressure-– 30 to 50.

Blood Pressure

There are two methods of obtaining blood pressureAuscultation - listen for the systolic

and diastolic soundsPalpation - In certain situations, the

systolic blood pressure may be measured by feeling for return of pulse with deflation of the cuff

Korotkoff Sounds• Korotkoff I- onset of faint but clear tapping

sounds which gradually increase in pitch and intensity

• Korotkoff II- murmur or swishing like sound

• Korotkoff III- distinct, loud tapping sounds without the murmurs

• Korotkoff IV- lower-pitched distinct, abrupt muffling sound with a soft, blowing quality

• Korotkoff V- cessation /disappearance of sound

• Auscultatory gap

• Orthostatic Hypotension

Measuring BP

QUESTIONS?