Essential Guide to Measuring Vital Signs

1. Chapter 16 Vital Signs

2. 16:1 Measuring and Recording Vital Signs • Vital signs provide information about a patient’s basic body conditions - Temperature - Pulse - Respirations - Blood Pressure • Pain is often considered the fifth VS

3. Temperature: • Measure of balance between heat lost and produced by body • Usually measured on Fahrenheit scale (also Celsius) • Measured in: mouth (oral) rectum (rectal) armpit (axillary) ear (aural temporal artery in the forehead (temporal)

4. Pulse • Pressure of blood felt against wall of an artery as the heart contracts and relaxes, or beats • Rate: number of beats per minute • Rhythm: regularity • Volume: strength, force, or quality • Usually taken over the radial artery, although it may be felt over any superficial artery with a bone behind it • Apical pulse is taken with stethoscope at the apex of the heart

5. Respirations • Patient’s breathing rate • Includes rhythm & character of respirations Blood pressure • Force exerted by blood against arterial walls when the heart contracts or relaxes • Two readings (systolic & diastolic) are taken to show the greatest pressure and the least pressure

6. 16:2Measuring and RecordingTemperature

7. 16:2 Measuring & Recording Temperature • Temperature is defined as “the balance between heat lost and heat produced by the body” • Heat lost through perspiration, respiration, excretion • Heat produced by food metabolism, muscle and gland activity • Homeostasis (constant state of fluid balance) is the ideal health state in the human body - rates of chemical reactions are regulated by body temperature. Therefore, if the body temp is too high or too low, the body’s fluid balance is affected

8. Variations in Body Temperature • Normal range: 97 to 100 degrees F (36.1 – 37.8 C) • Causes of variations can include: - Individual differences some people have accelerated body processes (increased temp) or slower body processes (decreased temp) • Time of day body temp is lower in the morning after rest & higher in the evening after muscular activity & food intake - Body sites (refer to Table 16-1 in Text)

9. Variations in Body Temperature (continued) • Oral temperature - taken in the mouth - most common - Eating, drinking hot or cold liquids, and/or smoking can alter oral temp (patient should not smoke or have anything to eat/drink 15 min prior to taking temp)

10. Variations in Body Temperature (continued) • Rectal Temperature - taken in the rectum - internal measurement - most accurate of all methods - frequently taken on infants & small children and patients with hypothermia

11. Variations in Body Temperature (continued) • Axillary Temperature - taken in the armpit, under the upper arm - arm is held close to the body, & the thermometer is inserted between the two fold of skin - less accurate because it is an external temperature

12. Variations in Body Temperature (continued) • Aural temperature - taken with a tympanic thermometer - taken in auditory canal - measures thermal, infrared energy radiating from blood vessels in tympanic membrane (eardrum) - measures body core temp, similar to internal (rectal) temp - fast & convenient method (usually < 2 secs) - innacurate result if thermometer is inserted incorrectly or if ear has infection / excessive ear wax

13. Variations in Body Temperature (continued) • Temporal Temperature - taken with temporal scanning thermometer that is passed in a straight line across the forehead, midway between the eyebrows and upper hairline - measures temperature in the temporal artery to provide accurate measurement of blood temperature - Considered very accurate / similar to rectal temp, because it measures temperature inside the body or bloodstream

14. Variations in Body Temperature (continued) Body temperature can be above or below normal range for many reasons: • Hypothermia - Body temperature below 95°F - starvation/fasting, sleep, decreased muscle activity, mouth breathing, exposure to cold temps in environment, & certain diseases • Pyrexia (fever)- Body temperature above 101°F - infection or injury ** Febrile means fever is present; Afebrile means no fever is present • Hyperthermia - Rectal body temperature exceeding 104°F - illness, infection, exercise, excitement, & high temps in the environment

15. Types of Thermometers • Clinical thermometers • Slender glass tube containing mercury • Used by very few health care agencies due to danger of mercury contamination • Oral / rectal • Electronic thermometers • Used in most health care facilities • Measures temp within a seconds (usually < 60 secs) • Oral / rectal / axillary / groin • Disposable cover used over probe to prevent contamination

16. Types of Thermometers (continued) • Tympanic thermometers - electronic / record aural temp in ear - disposable plastic probe placed on ear probe - temp recorded within 1 to 2 seconds • Temporal scanning thermometers • Accurate and noninvasive for internal body temperature • Measures within 1 to 2 seconds • Plastic or disposable thermometers - chemical dots or colors that change color with temp change - used once and discarded

17. Reading and Recording Temperature • Electronic and tympanic thermometers are easy to read because they have digital displays • Glass cylinder thermometer readings can be difficult & must be practiced - Record temperature to the nearest two-tenths of a degree • Indicate how temperature was taken: (R) rectal, (Ax) axillary, (A) aural, (TA) temporal artery reading

18. Cleaning Thermometers • Clean thermometers thoroughly after each use • Use cool water on glass thermometers to prevent breakage • Disposable plastic sheath may be used • Use disposable probe covers whenever possible • Follow agency policies

19. 16:3Measuring and Recording Pulse

20. 16:3 Measuring and Recording Pulse • Pulse • Pressure of blood pushing against the wall of an artery as the heart beats and rests • The pulse can be felt and counted in arteries close to the skin and can be pressed against a bone by the fingers • Major arterial or pulse sites • Temporal, Carotid, Brachial, Radial, Femoral, Popliteal, Dorsalis pedis, Posterior tibial

22. 16:3 Measuring and Recording Pulse(continued) • Pulse rate • Number of beats per minute • Bradycardia: pulse rate under 60 beats/minute • Tachycardia: pulse rate over 100 beats/minute • Pulse rhythm • Regularity of pulse (spacing of the beats) • Arrhythmia is an irregular or abnormal rhythm, usually caused by a defect in the electrical conduction pattern of the heart

23. 16:3 Measuring and Recording Pulse(continued) • Pulse volume • Strength, force, quality, or intensity of pulse • Described as strong, weak, thready, bounding • Factors that change pulse rate - exercise, stimulants, excitement, fever, shock, nervous tension - sleep, depressants, heart disease, coma, physical training • Measuring and recording radial pulse - Procedure 16:3 / page 440

24. 16:4Measuring and RecordingRespirations

25. 16:4 Measuring and Recording Respirations • Respiration • Process of taking in oxygen and expelling carbon dioxide from lungs and respiratory tract • One respiration • One inspiration (breathing in) and one expiration (breathing out) **Each time respirations are measured, three different facts must be noted: Rate, Character, & Rhythm

26. 16:4 Measuring and Recording Respirations (continued) • Rate of respirations • Number of breaths per minute • Normal rate: adult 12-20, children 16-20, infant 30-50 • Character of respirations • Depth and quality of respirations • EX: deep, shallow, labored, difficult, stertorous (snoring), moist • Rhythm of respirations • Regularity of respirations/space between breaths • Regular or Irregular

27. 16:4 Measuring and Recording Respirations(continued) Abnormal respirations are described as: • Dyspnea – difficult or labored breathing • Tachypnea – rapid, shallow rate (above 25) • Bradypnea – slow rate (usually below 10) • Orthopnea – severe dyspnea in which breathing is very difficult in any position other than sitting erect or standing

28. 16:4 Measuring and Recording Respirations(continued) • Cheyne-Stokes – abnormal breathing pattern characterized by periods of dyspnea followed by periods of apnea; frequently noted in the dying patient • Rales – bubbling, crackling, or noisy sounds caused by fluids or mucus in air passages • Wheezing – difficult breathing with high-pitched whistling during expiration, caused by narrowing of the passages • Cyanosis – bluish discoloration of the skin, lips, and/or nail beds as a result of decreased oxygen

29. 16:4 Measuring and Recording Respirations(continued) • Respirations must be counted in such a way that the patient is unaware of the procedure - respirations are partially under voluntary control, patients may alter breathing pattern - leave hand on the pulse site while counting respirations

30. 16:5Graphing TPR

31. 16:5 Graphing TPR • Graphic sheets are used for recording temperature, pulse, and respirations (TPR) • Presents a visual diagram of variations in patient’s vital signs • May use color coding • Refer to Procedure 16:5 in Text

32. 16:5 Graphing TPR (continued) • Factors affecting vital signs are often noted • Computerized graphs may be printed or kept in the electronic health record (EHR) • Graphic charts are legal medical records • Neat, legible, accurate • Correct all errors

33. 16:6Measuring and RecordingApical Pulse

34. 16:6 Measuring and Recording Apical Pulse • Pulse count taken with stethoscope at apex of the heart • Usually ordered by physician • Reasons for taking an apical pulse - irregular heartbeats, hardening of the arteries, weak or rapid pulse - infants’ pulse frequently assessed this way • Protect patient’s privacy and avoid exposure

35. 16:6 Measuring and Recording Apical Pulse (continued) • Two separate heart sounds can be heard - Count as one heartbeat • Pulse deficit • Difference between apical and radial pulse • Refer to Procedure 16:6 in Text

36. 16:7 Measuring and Recording Blood Pressure • Measurement of the pressure blood exerts on walls of arteries during various stages of heart activity • Read in millimeters (mm) of mercury (Hg) on a sphygmomanometer (sfig-moh-ma-nam-eh-ter) • Measurements read at two points

37. 16:7 Measuring and Recording Blood Pressure (continued) • Systolic pressure • Pressure in walls of arteries when left ventricle contracts • Diastolic pressure • Constant pressure in walls of arteries when left ventricle is at rest • Written as: Systolic / Diastolic • Normal BP = 120 / 80 - Systolic should be between 90-120 - Diastolic should be less than 90

38. 16:7 Measuring and Recording Blood Pressure (continued) • Pulse pressure • Difference between systolic and diastolic pressure • Important indicator of health & tone of arterial walls • Hypertension (high blood pressure) • Greater than 140 mm Hg systolic, 90 mm Hg diastolic • Often called the “silent killer” because most people do not have any s/s of the disease • If not treated, can lead to: Stroke, Kidney disease, Heart disease

39. 16:7 Measuring and Recording Blood Pressure (continued) • Hypotension (low blood pressure) • Less than 90 mm Hg systolic, 60 mm Hg diastolic • May occur with heart failure, dehydration, depression, burns, hemorrhage, and shock • Orthostatic hypotension - occurs when there is a sudden drop in both systolic & diastolic pressure when a person moves from lying to sitting or standing position too quickly - patient experiences dizziness/ lightheadedness

40. 16:7 Measuring and Recording Blood Pressure (continued) • Individual factors can influence blood pressure readings Increased BP: excitement, anxiety, nervous tension, exercise, eating, pain, obesity, smoking, stimulants Decreased BP: rest/ sleep, depressants, shock, dehydration, hemorrhage, and fasting

41. 16:7 Measuring and Recording Blood Pressure (continued) • There are 3 main types of sphygmomanometers: - Mercury, Aneroid, and Electronic • Correct cuff size is essential for accuracy • AHA factors to observe for accurate readings • 5 minutes of quiet rest • Take two separate readings and average • Refer to Procedure 16:7 in Text