Measuring and recording vital signs

1. Measuring and recording vital signs Temperature- Pulse- Respiration and Blood pressure

2. Temperature • Temperature is a measurement of the balance between heat lost and heat produced in the body. • Temperature may be measured in the mouth (oral), rectum (rectal), armpit (Axillary), or ear (aural/tympanic) temporal (artery) • Normal temperature is 97 to 100 degrees Fahrenheit. • Above 101 F indicates fever

3. Oral • Mouth under tongue • Use to be the most common • Clean thermometer or dispose of sheath after each use

4. Rectal • Rectum • Internal measurement • Most accurate • Insert 1-11/2 inches • Have pt lie on left side with right knee bent up. Infants on their back • Avoid exposure • Lubricate thermometer

5. Axillary • Armpit/ close to body between skin folds • Groin between skin folds of inner thigh and lower abdomen. • Less accurate

6. Aural/ Tympanic • In the ear or auditory canal • Special thermometer measures the thermal infrared energy radiating from the blood vessels in the tympanic membrane or eardrum • Less than 2 seconds

7. Temporal Artery • Taken over the forehead and down the side of temporal area. • Measures the temperature in the temporal artery …..similar to rectal • Research shows more accurate

8. Fahrenheit and Celsius • Most temperatures are measured in Fahrenheit, however, it may be necessary to convert to Celsius. • To convert Fahrenheit to Celsius subtract 32 from the Fahrenheit temperature and then multiply the result by 0.5556. Example to convert 98.6 F to Celsius you subtract 32 from 98.6 which leaves 66.6 and multiply by 0.5556 which equals 37 degrees Celsius. • To convert Celsius to Fahrenheit you multiply the temperature by 9/5 or 1.8 and then add 32

9. Hypothermia • Low body temperature is called hypothermia • Temperature below 95 degrees F measured rectally • If below 93 rectally for extended period death may occur. • Caused by starvation, sleep, mouth breathing, exposure to cold

10. Hyperthermia • Elevated temperature above 104 degrees F rectally • Above 106 can lead to convulsions and brain damage.. • Causes : infection, exercise, excitement

11. Recording temperature • Different thermometers used • Record accurately with type of temp. • 98.6 ® or 98.6(Ax) or 98.6 (A) 98.6 (TA) • If taken orally no need to indicate/ understood • Eating /drinking/smoking can alter temp • Wait 15 minutes

12. Pulse • Pulse is the pressure of the blood felt against the wall of an artery as the heart contracts and relaxes. • The rate rhythm and volume are measured and recorded. • Rate refers to the number of beats per minute • Rhythm refers to the regularity of the beat • Volume refers to the strength of the beat

13. Pulse sites • Temporal- at the side of the forehead • Carotid- at the neck • Brachial- crease of the elbow/inner aspect of forearm • Radial- inner aspect of wrist, above thumb • Femoral- inner aspect of the upper thigh • Popliteal- behind the knee • Dorsalis pedis- at the top of the foot arch • ( pulse is usually taken over the radial artery)

14. Ranges • Adults- 60-100 • Children aged over 7 years: 70-100 • Children aged 1-7: 80-110 • Infants 100-160 • Bradycardia: under 60 • Tachycardia: over 100 except children

15. Arrythmia • Irregular or abnormal rhythm • Usually caused by a defect in the electrical conduction system of the heart • Strength observed also: strong, weak thready or bounding • Various factors affect pulse • Drugs, excitement, fever, exercise

16. Recording pulse • Palm turned down • Use tips of first two or three fingers • Locate pulse on the thumb side of wrist • Do not use your thumb • Locate pulse and exert slight pressure and begin counting for a full minute and record • Note rate, rhythm, volume, date and time when recording

17. Apical pulse • Taken with a stethoscope over the apex of the heart • Two sounds heard: lubb-dupp • One heart beat • Sounds caused by closing of the heart valves as the heart beats and blood flows thru the chambers of the heart • Pulse deficit is the difference between the apical rate and the radial rate • Caused by heart disease not enough blood being pumped thru the heart to produce a pulse • Place stethoscope 2-3 inches to the left of the breastbone below the nipple line

18. Respiration • Rate that a person breaths during process of taking oxygen into the lungs and expelling carbon dioxide • Count for one minute by observing rise and fall of the chest with each breath • Also check regularity and character. • Normal range is 12-20 • Children range is 16-30 • Infants 30-50 • Do not make pt aware that you are recording respiration.

19. Character of respirations • Deep, shallow, labored, moist and difficult • Abnormal respirations usually indicate lung problems • Dyspnea- difficult breathing • Apnea- absence of breathing • Tachyapnea- >25 breaths per minute • Bradyapnea- <10 breaths per minute • Orthopnea- difficult breathing in any position other than erect or standing • Cheyne –Stokes- periods of dyspnea followed by periods of apnea (frequently noted in the dying pt) • Rales- bubbly or noisy sounds caused by fluid or mucus in the air passages • Wheezing – high pitch sounds • Cyanosis -dusky bluish color of the skin and lips

20. Blood pressure • Measurement of the pressure that the blood exerts on the walls of the arteries during various stages of heart activity • Read in millimeters of mercury • Sphygmomanometer • Two types of blood pressure: systolic and diastolic.

21. Systolic blood pressure • Pressure occurs in the walls of the arteries when the heart is contracting and pushing blood into the arteries • Normal reading is 120 • Range: 100-120

22. Diastolic blood pressure • Pressure that is constant against the walls of the arteries when the heart is at rest and between contractions. • Blood volume in the arteries has decreased • Normal reading is 80 • Range is 60-80

23. B/P • Pulse pressure is the difference between the systolic and diastolic pressure • Normal range is 30-50 • Hypertension: high blood pressure >140/90. Causes; stress, anxiety, disease of kidney or thyroid, obesity • Hypotension: low blood pressure<100/60. causes; heart failure, dehydration, depression, severe burns, shock and bleeding . • Other factors influencing B/P are: disease, excitement, drugs, exercise, rest/sleep, positioning

24. Prehypertension • 120- 139/ 80-89 • Hypertension is called the silent killer • Factors that may influence B/P are: sleep, meds, exercise, force of the heart beat, elasticity of the arteries, hemorrhage, shock, dehydration • Orthostatic hypotension—sudden drop from sitting to standing—inability of blood vessels to compensate quick enough

25. Taking a blood pressure reading • Place pt in comfortable position • Place appropriate size cuff on patients arm between shoulder and 1-1.1/2inches above the elbow and over the brachial artery • Find the brachial artery and place the stethoscope over the artery • Inflate the cuff to approximately 160mm Hg or 30 mm Hg above the palpatory pulse. • Slowly release the air from the cuff and note the first sound on the manometer and this is your systolic pressure. • Note when the sound stops and this is your diastolic reading. At this point release the air quickly from the cuff.