Name the four main vital signs

temperature

pulserespirationsblood pressure

Unit 14 Vital Signs

Measuring and Recording Vital SignsWhy is it essential that vital signs are

measured accurately? They are important indicators of the health

state of the body.Main vital signs (VS)

TemperaturePulseRespirationBlood pressure

http://www.youtube.com/watch?v=f9OreW1n0qU

Other AssessmentsPain – patients asked to rate on scale of 1

to 10 (1 is minimal and 10 is severe)Color of skinSize of pupils and reaction to lightLevel of consciousnessResponse to stimuli

Measuring Temperature Measures balance between heat lost and

heat produced in the body. A high or low reading can indicate disease

Normal temperature is 97.0 – 100.0FFive sites in the body where temperature

can be measured are:Axillary (armpit)OralAural (ear)RectalTemporal

Measuring PulsePulse is the pressure of the blood felt

against the wall of an artery as the heart contracts and relaxes, or beats. Pulse is usually taken over the radial artery. Any abnormality can indicate disease.

The rate, rhythm, and volume are recordedRate – number of beats per minuteRhythm – the regularityVolume – refers to the strength

Measuring PulsePulse can be taken on several places

Temporal – side of foreheadCarotid – at the neckBrachial–inner aspect of the forearm at the

crease of the elbowRadial- at the inner aspect of the wrist,

above the thumbFemoral-inner aspect of the upper thighPopliteal-behind the kneeDorsalis pedis-at the top of the foot arch

Measuring Pulse – RateAdults have a range of 60 – 90 beats per

minuteChildren over 7 - a range of 70 – 90 beats

per minuteChildren age 1 – 7 have a range of 80 – 110 Infants 100 – 160 beats per minute

Any variation or extremes in pulse rate should be reported immediately

Bradycardia is a pulse rate under 60 beats per minute

Tachycardia is a pulse rate over 100 beats per minute (except in children)

Measuring Pulse – Rhythm and VolumeRhythm refers to the regularity of the

pulse or spacing of the beats.An arrhythmia is an irregular or abnormal

rhythm, usually caused by a defect in the electrical conduction pattern of the heart. (prefix a- means without)

Volume is the strength or intensity of the pulse. It is described as strong, weak, thready, or bounding

Factors that can change pulse ratePulse will be

increased by:ExerciseStimulant drugs

ExcitementFeverShockNervous tension

Pulse will be decreased by:

SleepDepressant drugs

Heart diseaseComaPhysical training

Apical PulseThe apical pulse is taken with a

stethoscope at the apex of the heart. The actual heartbeat is heard and counted.

An apical pulse is taken because of illness, hardening of the arteries, a weak and rapid pulse, or the patient is on heart medication.

Because infants and small children have a rapid pulse, an apical pulse is always done.

Apical PulseAn apical pulse is

the heartbeat at the apex of the heart and is heard with a stethoscope.

Apical PulseWhen listening to the heart two sounds will

be heard: lubb – dupp. Each lubb – dupp counts as one

heart beat. The sound is caused by the closing of the

heart valves as blood flows through the chambers of heart.

If an abnormal sound is heard contact the provider.

Measuring RespirationsRespiration is the process of taking in

oxygen and expelling carbon dioxide. Abnormal respirations indicate a health problem or disease.

Three factors that are noted about respirations are the count, rhythm, and character.Count – the number of breathsRhythm – the regularity of breathsCharacter – type of respirations

Respirations - RateThe normal rate for respirations in adults is

14 - 18 breaths per minuteIn children, respirations are a little faster

than adults, 16 -25 breaths per minuteInfants the rate is between 30 – 50 breaths

per minute

Respirations – Character and Rhythm

Character is the depth and quality of respirations. Character of respirations are described asDeepShallowLaboredDifficultStertorous (abnormal, like snoring)Moist

Rhythm is the regularity of the respirations. Rhythm is described asRegularirregular

Respirations – Abnormal Dyspnea – difficult or labored breathing Apnea – absence of respirations Tachypnea – respirations over the normal range Bradypnea – respirations below the normal range Orthopnea – severe dyspnea in which breathing is very

difficult in any position other that standing or sitting erect Cheyne - Stokes – periods of dyspnea followed by periods of

apnea. Seen in dying patients Rales – bubbling or noisy sound caused by fluids or mucus in

the air passages. Wheezing – Difficult breathing with high-pitched whistling or

sighing sounds during expiration. Seen in persons with asthma Cyanosis – a dusky, bluish discoloration of the skin, lips, and

nailbeds

Measuring Blood Pressure Blood pressure is the force exerted by the

blood against the arterial walls when the heart contracts and relaxes.

Two readings noted on a blood pressure are systolic and diastolic

Measuring Blood PressureSystolic pressure is noted when the pressure

is at its highest. Systolic pressure occurs in the walls of the arteries when the left ventricle of the heart is contracting and pushing blood through the arteries. Normal reading is 120mmhg. (range is 100 – 140 mmHg)

Diastolic pressure is the noted when the pressure is at its lowest. Diastolic pressure is the constant pressure in the walls of the arteries when the left ventricle of the heart is at rest, or between contractions. A normal reading is 80mmHg (range of 60 – 90 mmHg)

Blood PressureBlood pressure is read using an

stethoscope and a sphygmomanometer. Stethoscope is placed in ears and on the

forearm in the antecubital space. The sphygmomanometer is placed one to one and one half inches above the elbow. Cuff is inflated to about 160mmHg.

Listen for heart tones. First heart tone heard is the systolic pressure. The diastolic pressure is when the heart tone can no longer be heard.

Abnormal Blood Pressure readings

Hypertension – is high blood pressure (greater than 140 systolic and 90 diastolic) and can be caused by stress, anxiety, obesity, high salt intake, aging, kidney disease, thyroid deficiency, and vascular conditions such as arteriosclerosis.Hypotension –low blood pressure, can be caused by heart failure, depression, severe burns, hemorrhage, and shock. Orthostatic hypotension, occurs when there is a sudden drop in both systolic and diastolic pressures when a person moves from lying or sitting to a standing position.

Factors that influence blood pressureFactors that may increase BP are:

ExcitementAnxietyNervous tensionStimulant drugsExerciseEatingSmoking

Factors that can influence BPFactors that may decrease blood pressure

areRest or sleepDepressant drugsShockExcessive blood lossFastingChanges in body position