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Chapter 15

Chapter 15. Vital Signs. 15:1 Measuring and Recording Vital Signs (VS). Record information about the basic body conditions Main vital signs (VS) Temperature Pulse Respiration Blood pressure. Other Assessments.

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Chapter 15

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  1. Chapter 15 Vital Signs

  2. 15:1 Measuring and RecordingVital Signs (VS) • Record information about the basic body conditions • Main vital signs (VS) • Temperature • Pulse • Respiration • Blood pressure

  3. Other Assessments • 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

  4. VS Readings • Accuracy is essential • Report abnormality or change • If unable to get reading, ask another person to check

  5. 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

  6. Variations in Body Temperature • Normal range • Causes of variations • Temperature measurements—oral, rectal (often used on infants/children), axillary or groin, aural, and temporal • Abnormal conditions affecting temperature

  7. Thermometers • Clinical thermometers • Glass • Electronic • Tympanic • Temporal • Plastic or paper • Reading thermometers and recording results

  8. Thermometers • Avoid factors that could alter or change temperature • Cleaning thermometers • Paper/plastic sheath on glass thermometer

  9. Measuring and Recording Pulse • Pulse: Pressure of the blood pushing against the wall of an artery as the heart beats and rests • Major arterial or pulse sites: • Temporal, carotid, brachial, radial, femoral, popliteal & dorsalis pedis • Pulse rate • Adult men- 60-70 bpm • Adult women- 65-80 bpm • Children over 7yrs- 90 bpm • Children 1-7yrs- 80-110 bpm • Infants- 100-160 bpm • Pulse rhythm- regularity of beat • Pulse volume- strength or intensity of pulse

  10. Measuring and Recording Pulse • Arrhythmia- irregular or abnormal rhythm, usually caused by a defect in the electrical conduction pattern of the heart • Factors that change pulse rate: • exercise • Stimulant or depressant drugs • Excitement • Fever • Shock • Nervous tension • Sleep • Depression • Heart disease • Coma • Basic principles for taking radial pulse • Recording information

  11. Measuring and Recording Respirations • Measures the breathing of a patient • Respiration: 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)

  12. Measuring and Recording Respirations • Normal respiratory rate: • Adults: 14-18 breaths per minute • Children: 16-25 breaths per minute • Infants: 30-50 breaths per minute • Character of respirations- the depth and quality of respiration • Rhythm of respirations- regularity of respirations • Abnormal respirations: • Dyspnea- difficult or labored breathing • Apnea- absence or respirations, usually temporary • Tachypnea- respiratory rate above 25 respirations per minute • Bradypnea- slow rate, usually below 10 respirations per minute • Orthopnea- severe dyspnea in any position other than sitting erect • Cheyne-Stokes- periods of dyspnea followed by apnea (often in the dying) • Rales- bubbling or noisy sounds caused by fluids or mucus • Wheezing- difficult breathing with whistling • Cyanosis- dusky, bluish discoloration of the skin, lips and nail beds • Voluntary control of respirations • Record information

  13. Graphing TPR • Graphic sheets are special records used for recording TPR • Presents a visual diagram • Uses: most often in hospitals and long-term care facilities • Color codes: EX: temperature in blue ink, pulse in red ink and inspirations in green ink • Factors affecting VS are often noted on the graph: surgery, medications and antibiotics (continues)

  14. Graphing TPR • Graphic charts are legal records: must be legible, neat and accurate • To correct an error- cross out error with red ink and initialed

  15. Measuring and Recording Apical Pulse • Apical Pulse- count taken at the apex of the heart with a stethoscope • Reasons for taking an apical pulse: patients with irregular heartbeats, hardening of the arteries, or weak or rapid radial pulse • Protect the patient’s privacy and avoid exposure • Heart sounds: lubb-dubb; sounds of the heart valves opening and closing in the heart • Abnormal sounds or beats (continues)

  16. Measuring and Recording Apical Pulse • Pulse deficit: check the apical pulse while a second person checks the radial pulse; subtract the radial pulse from apical pulse for difference • Use the stethoscope • Placement of stethoscope: 2-3” to left of breastbone • Measuring apical pulse • Record all information

  17. Measuring and Recording Blood Pressure • 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 • 120/80 mm Hg • Measurements read at two points: • Systolic pressure- occurs in the walls of the arteries when the left ventricle of the heart is contracting and pushing blood in the arteries • Diastolic pressure- the constant pressure in the walls of the arteries when the left ventricle of the heart is at rest, or between contractions (continues)

  18. Measuring and Recording Blood Pressure • Pulse pressure: the difference between systolic and diastolic pressure • Hypertension—high blood pressure; >140/90 • Hypotension—low blood pressure; < 100/60 • Factors influencing blood pressure readings (high or low): • Force of the heartbeat • Resistance of the arterial system • Elasticity of the arteries • Volume of the blood in arteries • Excitement, anxiety, nervous tension, shock • Stimulant and depressant drugs • Exercise and eating or fasting • Rest or sleep • Lying down, standing up or sitting position

  19. Measuring and Recording Blood Pressure • Individual factors can all influence blood pressure readings • Types of sphygmomanometers • Mercury • Aneroid- no mercury but calibrated in mmHg • Electronic

  20. Measuring and Recording Blood Pressure • Factors to follow for accurate readings: size and placement of sphygmomanometer • Record all required information • Do not discuss the reading with the patient; it’s the doctor’s responsibility

  21. 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

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