Vital Signs

1. Vital Signs Health Science 2 Chapter 15 Tessa Roberts, RN, BSN

2. Vital Signs • Important indicators of the health condition of the body • Provide information about the basic body condition of the patient • Often the 1st sign of a disease or abnormality in the patient

3. 4 Main Vital Signs • Temperature (T) • Pulse (P) • Respirations (R) • Blood Pressure (BP) Example: VS = T 98.2, P 60, R 18, BP 120/80

4. Temperature • Measurement of the balance between heat lost and heat produced by the body • Heat is lost through perspiration, respiration, and excretion (urine, feces) • Heat is produced by the metabolism of food, and by muscle and gland activity • Body tries to maintain a balance of temperature regulation through homeostasis

5. Most temperatures are measured in degrees on a thermometer that has a Fahrenheit scale. • Some health care facilities are now measuring temperature in degrees on a Celsius (centigrade) scale • (see table 15-1 page 415 for comparison chart) (see pages 413 & 414 for instructions on how to convert scales). • The normal range for body temperature Fahrenheit is: 97 to 100 degrees

6. Hypothermia • Very low or very high body temperatures are indicative of abnormal conditions • Hypothermia is a low body temperature below 95 degrees F (measured rectally)

7. What is a fever? • A fever is an elevated body temperature, usually above 101 degrees F. • Fevers are usually caused by infection or injury • The term febrilemeans a fever is present • The term afebrile means no fever is present or the temp is within normal range.

8. Hyperthermia • Occurs when the body temperature exceeds 104 degrees F (measured rectally) • Immediate actions must be taken to lower body temperature • Temperatures above 106 degrees F can quickly lead to convulsions, brain damage, and death

9. How to measure temperature • Orally (mouth/PO) • Rectally (rectum/R) • Axillary (armpit/Ax) • Tympanic (ear/T) • Temporal artery (forehead/TA)

10. Oral Temperatures • Taken in the mouth under the tongue • Clinical thermometer is left in place for 3 to 5 minutes (glass) • For the electronic thermometer, the time under the tongue varies depending on the type (It will beep when it is done) • Eating, drinking hot or cold liquids, and/or smoking can alter the temperature in the mouth. • Wait 15 minutesbefore taking the patients temperature if they have done so, or take it another route.

11. Rectal Temperatures • Most accurate route for taking a temperature (internal/core temperature) • Always use lubricant when checking rectal temp • Use RED thermometer probe

12. Axillary Temperature • Done by placing thermometer into armpit of patient. • Clothing should not touch thermometer • Reading generally 2 degrees lower than rectal temp

13. Tympanic Temperature • Non-invasive way to measure patient’s temperature • Performed by placing tympanic thermometer into ear of patient • Not accurate measurement of core body temperature

14. Temporal Artery Temperature • Newest method for checking temperature • The forehead is the ideal part of the body from which to take a temperature • It is supplied by the temporal artery, which receives blood through the aorta and the carotid artery, guaranteeing a considerable flow of blood. • The temporal artery thermometer uses infrared technology to detect the heat naturally emitting from the skin surface.

15. Thermometers

16. Glass Thermometers • A clinical thermometer consists of a slender glass tube • The glass oral thermometer has a long slender bulb or a shorter round bulb and is usually marked by a blue tip • The glass rectal thermometer has a short, stubby, rounded bulb and is usually marked with a red tip. • Disposable plastic sheaths should be used to cover the thermometer along with cleaning them with alcohol before and after each patient use

17. Let’s Practice • Clean with isopropyl alcohol before using it, then dip the tip into some cool water, or wipe with a tissue, to remove the taste of the alcohol. (use probe cover) • Shake down the glass thermometer until the mercury line is below 96.6 degrees F. • Slide the tip of the thermometer under one side of the tongue, well into the back of the mouth. • Close your mouth around the thermometer using your lips - don't clench the glass thermometer with your teeth. Breathe through your nose, with your mouth closed. • Leave the thermometer under your tongue for 3 full minutes. • Remove the thermometer and hold it under a bright light, so you can see how high the mercury has risen. An arrow will point to the normal temperature, which is 98.6 degrees F.

18. Digital Thermometer • Easy to read • Affordable • Can be used orally, axillary or rectally

19. Electronic Thermometers • Used in many facilities and usually registers the temperature in easy-to-read numbers on a viewer • They can be used to take oral, rectal, and axillary temperatures • Most facilities have electronic thermometers with blue probes for oral use and red probes for axillary or rectal use

20. Temporal Artery Thermometer

21. You must clean the thermometer with an alcohol wipe before and after use, along with using the protective disposable plastic sheath • Reading a clinical thermometer refer to page 419 figure 15-9-- Handout for thermometer readings

22. Documenting Temperature & Norms • It is important to note what route is used by putting the proper abbreviation after the results.

23. Measuring and Recording Pulse

24. What is your pulse? • The pressure of the blood pushing against the wall of an artery as the heart beats and rests • It is the throbbing of the arteries that is caused by the contractions of the heart

25. How do I feel for a pulse? • The pulse is more easily felt in the arteries that lie fairly close to the skin and can be pressed against a bone by the fingers. • Do not use your thumb to check a pulse because the thumb contains a pulse of its own that can be confused with the patient’s pulse

26. Where can I feel for a pulse? • Major pulse sites: • Carotid—at the neck on either side of the trachea • Brachial—inner aspect of the forearm at the crease in the elbow • Radial—inner aspect of the wrist, thumb side

27. What are we assessing by checking a pulse? • Each time a pulse is measured we are assessing the rate, the rhythm, and the volume of the pulse

28. Rate • Measured as the number of beats per minute (bpm) • Pulse rates vary among individuals, depending on age, sex, and body size. • Normal pulse rate for an adult is 70-90 • Bradycardia: pulse rate < 60 bpm or low pulse rate • Tachycardia: pulse rate > 100 bpm or high pulse rate

29. What are some factors that will cause my pulse rate to decrease? • Sleep • Depressant drugs such as morphine • Heart disease • Coma • Physical Training

30. What are some factors that will cause my pulse rate to increase? • Exercise • Stimulant drugs such as caffeine • Excitement • Fever • Shock • Nervous Tension, anxiety

31. Rhythm • Refers to the spacing of the beats • Regular • Irregular • Arrhythmia • Irregular or abnormal rhythm • Usually caused by a defect in the electrical conduction pattern of the heart

32. Volume • Describes the strength or intensity of the beats • Strong • Weak • Thready • Bounding

33. Apical Pulse • Pulse count taken at the apex of the heart with a stethoscope • Actual heartbeat is heard and counted • 2 separate sounds are heard • Lubb-dubb • Each lubb-dubb counts as 1 heartbeat • Sound is caused by the closing of the heart vales as blood flows through the chambers of the heart

34. Documenting Pulse • Include rate, rhythm, and volume • Example: Date, Time, P 82 strong and regular, Your signature and title • 09/07/10 1000 P82 strong and regular, Tessa Roberts, RN • If documenting apical pulse, use abbreviation AP before pulse: AP 82 strong and regular

35. Measuring & Recording REspirations

36. Respiration • Measures the breathing of the patient • Process of taking in oxygen and expelling carbon dioxide from the lungs and respiratory tract • One respiration consists of breathing in and breathing out • 1 Resp = Inspiration + Expiration

37. Respiratory Rate • Each time respiration is measured, three different facts must be noted: rate, character and rhythm • Rate of respirations counts the number of breaths per minute • Normal rate for respirations in adults is 12-20 breaths per minute.

38. Character of Respirations • Character: depth and quality of respirations • deep, shallow, labored, moist • Abnormal sounds such as rales, rhonchi and wheezing also describes the character of respiration

39. Abnormal Breath Sounds • Rales: bubbling or noisy sounds caused by fluids or mucus in the air passages • Wheezing: difficult breathing with a high-pitched whistling or sighing sound • Caused by a narrowing of bronchioles (as seen in asthma) and/or an obstruction or mucus accumulation in the bronchi

40. Rhythm • Rhythm: the regularity, or equal spacing between breaths • Regular • Irregular

41. Abnormal Respirations • Dyspnea- difficult or labored breathing • Apnea- absence of respirations, usually a temporary period of no respirations. • Cheyne-Stokes: abnormal breathing pattern characterized by periods of dyspnea followed by periods of apnea • frequently noted in the dying patient

42. Tachypnea- rapid, shallow RR above 25 respirations per minute • Bradypnea- slow RR, usually below 10 respirations per minute RR = Respiratory Rate

43. Cyanosis: dusky, bluish discoloration of the skin, lips and/or nail bed • Result of decreased oxygen and increased carbon dioxide in the bloodstream

44. When measuring respirations… • Respirations are partially under voluntary control. • A pt may breathe faster or slower when they are aware respirations are being counted. • Important to keep pt unaware. (Do not tell them you are counting respirations.) • Keep your hand on the pulse site while checking respirations.

45. Measuring & Recording Blood Pressure

46. Blood Pressure (BP) • 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 (mmHg) • Instrument used to measure BP: sphyg-moma-no-meter

47. Two Types of BP Measurements • Systolic pressure – occurs when the heart is contracting (working) • Pushing blood into the arteries to be returned to the body as well as to the lungs • This is the top number. Normal range 100-140. • Diastolic pressure – constant pressure in the walls of the arteries (when the heart is at rest or in-between contractions) • This is the bottom number. Normal range 60-90.

48. Hypertension (HTN) • High blood pressure. When BP reading is greater than 140/90. • Common causes: stress, obesity, high salt intake, kidney disease, and vascular conditions (arteriosclerosis) • Often called “silent killer” • Most people do not have any s/sx of the disease • Left untreated can lead to stroke, kidney disease and/or heart disease

49. Hypotension • Low blood pressure • When BP reading is less than 100/60. • May occur with heart failure, dehydration, depression, severe burns, hemorrhage, and shock.

50. Orthostatic (postural) Hypotension • Occurs when there’s a sudden drop in BP • When moving from lying down to sitting position • Caused by inability of blood vessels to compensate quickly to the change in position. • When BP drops, pt may become dizzy, lightheaded, and may experience blurred vision. • They may fall and hurt themselves. • Sx last a few seconds until the blood vessels compensate and more blood is pushed to the brain.