vital signs vital signs are important indicators of health states of the body vitals signs defined...
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VITAL SIGNS
Vital SignsVital signs are important
indicators of health states of the body
Vitals Signs Defined as: various determinations that provide basic body conditions of the patient
Four Main Vital Signs• Temperature
• Pulse
• Respirations
• Blood Pressure
Additional Vital Signs• Degree of Pain: scale 1 – 10
• Color of skin
• Size of pupils & reaction to light
• Level of consciousness
• Response to stimuli
They are usually the first sign of disease or abnormality in the patient.
Healthcare WorkersAs a healthcare worker it is your
responsibility to measure and record the vital sign of a patient.
However it is not your responsibility to reveal this information to the patient – Physician’s responsibility.
Temperature• Temperature is the
measurement of balance of heat lost and heat produced in the body
• Can be measured: • mouth (oral)
• Rectum (rectal)
• Armpit (axillary)
• Ear (aural)
• Too high or too low can be a sign of disease or infection
TemperatureMost temperatures are measured
in Fahrenheit Scale
However many healthcare facilities are now using Celsius Scale
Temperature ConversionFahrenheit to Celsius:Subtract 32 from F temp, than
multiply by 5/9 or 0.5556
IE: 212 Degrees F – 32 = 180 180 X 5/9 or 0.5556 = 100 C
Temperature ConversionCelsius to Fahrenheit:Multiply Celsius Temp by 9/5 or
1.8 and than add 32.
IE: 37 degrees Celsius X 9/5 or 1.8 = 66.6
66.6 + 32 = 98.6 F
TemperatureNormal ranges vary:
97 – 100 degrees F (98.6)
36.1 – 37.8 degrees C (37)
Temps vary during the day and where
you take them
TemperatureOral – taken in the mouth with
thermometer, 3 – 5 minutesRectal – taken in rectum, 3-5
minutesAxillary – taken under the armpit,
10 minutesAural – Special thermometer is
placed in the ear and measures thermal infrared energy from blood vessels in the ear.
Temperature IndicationsHypothermia – low temp, below
95 F
• Prolonged exposure to cold
• Death occurs below 93 F
Fever – above 101 F, infection or injury
Hyperthermia – above 104 F
• Gets above 106, convulsions/brain damage/death
PulsePulse is the pressure of the blood
felt against the artery wall as the heart contracts & relaxes (beats)
What gets recorded:
• Rate
• Rhythm
• Volume
Pulse• Rate – refers to the number of
beats per minute
• Rhythm – refers to regularity of the beats
• Volume – refers to the strengthPulse is usually taken over the radial artery
Pulse MeasurementThe pulse of a patient can be
measured at various sites.
• Radial – inner aspect of wrist above the thumb
• Brachial – Inner aspect of elbow
• Femoral – inner aspect of upper thigh
• Popliteal – behind the knee
• Dorsalis Pedis – top of arch of foot
Pulse RatesPulse rates vary by age, sex,
body size and physical condition.
Adults: 60- 90 Beats per minute-bpm
Adult men: 60- 70 bpmAdult Women: 65- 85 bpmInfants: 100 – 160 bpm
Bradycardia – pulse under 60 bpmTachycardia – pulse over 100 bpm
except infants
RespirationsRespirations reflect the breathing
rate of the patient
• Also note the regularity – rhythm
• Character – type (deep, shallow)
RespirationsNormal rate is 14 – 18 breaths per
minute (sometimes 12 – 20)
• Children slightly faster: 16 – 25
• Infants: 30 – 50
Words used to describe breathing are also used – labored, shallow, deep, difficulty
Breathing TerminologyDyspnea – difficult or laboredApnea – Absence of respiration Tachypnea – rate above 25Bradypnea – below 10Orthopnea – very, very difficult in
any other position other than sitting
Cheyne-Stokes – periods of dyspnea followed by Apnea
Breathing TerminologyRales – bubbling or noisy sounds
caused by mucus or fluid in lungs
Wheezing - difficulty in breathing along with high pitched whistling during expiration
Cyanosis – a dusky, bluish discoloration of the skin, lips and/or nail beds as a result of decreased oxygen and increase carbon dioxide in blood
Measuring Breathing• Best done with the patient
unaware that you are doing it.
• Count respirations after performing pulse check.
• Continue holding wrist and count each inspiration/expiration as one.
Blood PressureBlood pressure is the force
exerted by the blood against the artery walls when the heart contracts and relaxes.
• Two readings are recorded• Systolic - contraction
• Diastolic - relaxation
Measuring Blood PressureInstrument: sphygmomanometerNormal Systolic is 120 mm Hg
range from 100 – 140 mm Hg
Normal Diastolic is 80 mm Hgrange from 60 – 90 mm Hg
Hypertension – BP to highHypotension – BP to low
Measuring Blood Pressure• Roll up patient sleeve to 5”
above elbow
• Position arm palm up and supported
• Wrap deflated cuff 1 -1.5 “ above elbow (Center of bladder of cuff should be over brachial artery)
Measuring Blood PressureSystolic Pressure: tighten valve
pump up until pulse is no longer heard, slowly release pressure and record pressure when pulse is first heard.
Diastolic Pressure: Continue slowly releasing valve and note when pulse disappears or when there is a significant change in sound.
Additional Vital SignsApical Pulse – Taken by a
stethoscope at the apex of the heart.
• Actual heartbeat is heard and counted
• Used when radial pulse is weak as in diseased arteries or infants when pulse is to rapid to count