Vital Signs 2009 Delmar Cengage Learning 14 1

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Vital Signs © 2009 Delmar, Cengage Learning

Vital Signs © 2009 Delmar, Cengage Learning

14: 1 Measuring and Recording Vital Signs (VS) • Vital Signs are defined as

14: 1 Measuring and Recording Vital Signs (VS) • Vital Signs are defined as various determinations that provide basic information about the basic conditions of the patient • The 4 main vital signs (VS) – – Temperature (T) Pulse (P) Respiration (R) Blood pressure (BP) © 2009 Delmar, Cengage Learning

Other Assessments on Patients • Pain—patients asked to rate on scale of 1 to

Other Assessments on Patients • Pain—patients asked to rate on scale of 1 to 10 (1 is minimal and 10 is severe) • Color of skin • Size of pupils and reaction to light • Level of consciousness • Response to stimuli © 2009 Delmar, Cengage Learning

VS Readings • Accuracy is essential • Report abnormality or change • If unable

VS Readings • Accuracy is essential • Report abnormality or change • If unable to get reading, ask another person to check • As a health care worker, it is your responsibility to measure and record the VS of your patients © 2009 Delmar, Cengage Learning

14: 2 Measuring and Recording Temperature • Measures balance between heat lost and heat

14: 2 Measuring and Recording Temperature • Measures balance between heat lost and heat produced in the body • Heat produced by metabolism of food and by muscle and gland activity • Homeostasis: constant state of balance in the body • Conversion between Fahrenheit and Celsius temperature © 2009 Delmar, Cengage Learning

Variations in Body Temperature • Normal range 97 - 100 degrees Fahrenheit • Causes

Variations in Body Temperature • Normal range 97 - 100 degrees Fahrenheit • Causes of variations –individual differences, time of day, body sites • Temperature measurements—oral, rectal (often used on infants/children), axillary (arm pit) or groin, aural (ear), and temporal (forehead-is measuring the temp in the temporal artery) © 2009 Delmar, Cengage Learning

Causes of Increased Body Temperature • • • Illness Infection Exercise Excitement High temperatures

Causes of Increased Body Temperature • • • Illness Infection Exercise Excitement High temperatures in the environment © 2009 Delmar, Cengage Learning

Causes of Decreased Body Temperature • • • Starvation or fasting Sleep Decreased muscle

Causes of Decreased Body Temperature • • • Starvation or fasting Sleep Decreased muscle activity Mouth breathing Exposure to cold temperatures in the environment • Certain diseases © 2009 Delmar, Cengage Learning

Thermometers • Clinical thermometers – are used to record temperatures – Glass – consists

Thermometers • Clinical thermometers – are used to record temperatures – Glass – consists of a slender glass tube containing mercury or alcohol with red dye, which expands when exposed to heat – Electronic – registers the temp on a viewer in a few seconds – Tympanic – records aural temp in the ear – Temporal – measures the temp in the temporal artery of the forehead – Plastic or paper - contain special chemical dots/strips (continues) that change color when exposed to specific temps © 2009 Delmar, Cengage Learning

Thermometers (continued) • Reading thermometers and recording results: * Electronic & tympanic thermometers are

Thermometers (continued) • Reading thermometers and recording results: * Electronic & tympanic thermometers are easily read because of digital displays * Mercury thermometers should be held at eye level & rotated slowly to find the mercury Examples of how to record a temperature: 98. 6 is an oral reading 99. 6 (R) is a rectal reading 97. 9 (Ax) is an axillary reading 98. 6 (A) is an aural reading © 2009 Delmar, Cengage Learning

Cleaning Thermometers • Must be cleaned after each use • The procedure will vary

Cleaning Thermometers • Must be cleaned after each use • The procedure will vary with different agencies and thermometers • Glass thermometers are cleaned with water and soaked in a disinfectant solution (70% alcohol) for a minimum of 30 minutes before using again • Electronic/digital thermometers use a probe or sheath that is discarded after each use © 2009 Delmar, Cengage Learning

14: 3 Measuring and Recording Pulse • Pressure of the blood pushing against the

14: 3 Measuring and Recording Pulse • Pressure of the blood pushing against the wall of an artery as the heart beats and rests • Major arterial or pulse sites • Pulse rate • Pulse rhythm • Pulse volume (continues) © 2009 Delmar, Cengage Learning

Measuring and Recording Pulse (continued) • Factors that change pulse rate • Basic principles

Measuring and Recording Pulse (continued) • Factors that change pulse rate • Basic principles for taking radial pulse • Recording information © 2009 Delmar, Cengage Learning

14: 4 Measuring and Recording Respirations • Measures the breathing of a patient •

14: 4 Measuring and Recording Respirations • Measures the breathing of a patient • Process of taking in oxygen and expelling carbon dioxide from the lungs and respiratory tract • One respiration: one inspiration (breathing in) and one expiration (breathing out) (continues) © 2009 Delmar, Cengage Learning

Measuring and Recording Respirations (continued) • • • Normal respiratory rate Character of respirations

Measuring and Recording Respirations (continued) • • • Normal respiratory rate Character of respirations Rhythm of respirations Abnormal respirations Voluntary control of respirations Record information © 2009 Delmar, Cengage Learning

14: 5 Graphing TPR • Graphic sheets are special records used for recording TPR

14: 5 Graphing TPR • Graphic sheets are special records used for recording TPR (temp. , pulse, resp. ) • Presents a visual diagram • Used most often in hospitals and long term care facilities • Factors affecting VS are often noted on the graph - - examples include surgery, medications that lower temperature such as aspirin and antibiotics (continues) © 2009 Delmar, Cengage Learning

Graphing TPR (continued) • Graphic charts are legal records – so it must be

Graphing TPR (continued) • Graphic charts are legal records – so it must be neat, legible, and accurate • To correct an error mark a single line through the error and initial beside it © 2009 Delmar, Cengage Learning

14: 6 Measuring and Recording Apical Pulse • Pulse count taken at the apex

14: 6 Measuring and Recording Apical Pulse • Pulse count taken at the apex of the heart with a stethoscope • Reasons for taking an apical pulse – pts with irregular heart beats, hardening of the arteries, weak or rapid radial pulses • Protect the patient’s privacy and avoid exposure • 2 heart sounds “lubb-dupp” = 1 heart beat (continues) • Abnormal sounds or beats should be reported immediately © 2009 Delmar, Cengage Learning

Measuring and Recording Apical Pulse (continued) • Pulse deficit – a condition that occurs

Measuring and Recording Apical Pulse (continued) • Pulse deficit – a condition that occurs with some heart conditions – when the apical pulse rate is higher than the pulse rate on other sites on the body • Use the stethoscope : diaphragm side • Placement of stethoscope : 2 -3 in. to the left of the breast bone • Measuring apical pulse : count for 1 full min. • Record all information © 2009 Delmar, Cengage Learning

14: 7 Measuring and Recording Blood Pressure • Measurement of the pressure the blood

14: 7 Measuring and Recording 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 on a sphygmomanometer • Measurements read at two points (continues) © 2009 Delmar, Cengage Learning

Measuring and Recording Blood Pressure (continued) • • • Systolic pressure Diastolic pressure Pulse

Measuring and Recording Blood Pressure (continued) • • • Systolic pressure Diastolic pressure Pulse pressure Hypertension—high blood pressure Hypotension—low blood pressure Factors influencing blood pressure readings (high or low) (continues) © 2009 Delmar, Cengage Learning

Measuring and Recording Blood Pressure (continued) • Individual factors can all influence blood pressure

Measuring and Recording Blood Pressure (continued) • Individual factors can all influence blood pressure readings • Types of sphygmomanometers – Mercury – Aneroid – Electronic (continues) © 2009 Delmar, Cengage Learning

Measuring and Recording Blood Pressure (continued) • Factors to follow for accurate readings •

Measuring and Recording Blood Pressure (continued) • Factors to follow for accurate readings • Record all required information • Do not discuss the reading with the patient; it’s the doctor’s responsibility © 2009 Delmar, Cengage Learning

Summary • Vital signs are major indicators of body function • Accuracy of measurement

Summary • Vital signs are major indicators of body function • Accuracy of measurement and recording of vital signs • The health care worker needs to be alert and report any abnormalities © 2009 Delmar, Cengage Learning