vitals and measurements (part one)

vital signs

• temperature, pulse, respirations, blood pressure, pain assessment

• taken at each visit

• understand the standard range of values

• also completed as a baseline

body measurements

• height

• weight

• head circumference

what are vital signs and body measurements used for?

used to evaluate health problems

temperature

• determined the relationship of heat production and heat loss

• most common reason for fever is infection

• measurements are taken in:

  • degrees fahrenheit (ºF)

  • degrees celsius/centigrade (ºC)

normal adult oral temperature

• 98.6 ºF

• 37.0 ºC

febrile

• fever (greater than 100.5)

• sign of inflammation or infection

afebrile

normal temperature (98.6 - 99.1 ºF)

pyrexia

fever

hyperpyrexia

extremely high temperature

oral temperature

• electronic or digital

• normal is 98.6

• place under tongue in one pocket just of-center in lower jaw

• insure patient does not talk

• wait at least 15 minutes after eating, drinking, or smoking

aural (ear) temperature

• tympanic

• normal is 99.6

• proper technique is essential

• fit in ear must be snug

• adult → pull ear up and back

• child → pull eat down and back

temporal temperature

• temporal scanner

• normal is 99.6

• stroke scanner across forehead, crossing over the temporal artery

• infrared thermometers (thermal) - direct laser in middle of forehead

axially (under the arm) temperature

• least accurate

• electronic or digital

• normal is 97.6 (1 degre lower)

• place tip in middle of axilla

• probe must touch skin on all sides

rectal temperature

• most accurate

• electronic or digital

• normal is 99.6 (1 degree higher)

• use standard precautions

• slowly and gently insert tip

• use lubrication

• hold thermometer in place

why and how are pulse and respirations related?

• circulatory is pulse, respiratory is respirations

• they are related because the heart and lungs work together

• normally an increase or decrease in one causes the same effect on the other

pulse

• palpate artery against a bone

• measure at the radial artery (most common)

• count for 1 minute

• may be counted for 30 seconds and multiplied by 2

• if the pulse is irregular, count for 1 full minute

normal pulse

60-100 bpm

tachycardia

• pulse greater than 100 bpm

• fast

bradycardia

• pulse less than 60 bpm

• slow

what rhythms can a pulse be?

regular or irregular

what volumes can a pulse be?

weak, strong, bounding

what are the reasons for an elevated pulse rate?

• fever

• pain

• dehydration

• anxiety

• infection

• poor physical conditioning

what are other locations to obtain pulse besides the radial artery?

• carotid

• temporal

• brachial

• femoral

• popliteal

• posterior tibial

• dorsalis pedis

• apex of the heart (use stethescope to listen)

apical pulse

• using a stethescope

• method for obtaining pulse in an infant

• the apex is located in the fifth intercostal space between the ribs on the left side of the sternum of the chest

respiratory rate

• indication of how well the body provides oxygen to the tissues

• check by watching chest rise and fall, listening, or feeling movement

• may use stethoscope

• count for one full minute and note rate and rhythm

one respiration

one inhalation and one exhalation

normal respiration rate

12-20 / minute in adults

why and how do you count respirations subtly?

• once the patient is aware that respiration is being measured, they may unintentionally alter breathing

• count the respirations while you have your hand on the pulse site

• if using a stethoscope, tell the patient that you want to listen to their lungs

what can the quality of effort be for respiratory rate?

normal, shallow, or deep

what are the abnormal sounds found when using a stethoscope to measure respiratory rate?

• wheezing

• rales

• rhonchi

what are the irregularities that can be found when measuring respiratory rate?

• hyperventilation

• dyspnea - difficult of painful breathing

• tachypnea - rapid breathing

• bradypnea - slow breathing

• hyperpnea - abnormally rapid or labored breathing

rales

• clicking or crackling sounds

• fluid in the lungs

• pneumonia, collapse of part or all of a lung, pulmonary edema (excess fluid in the lungs)

rhonchi

• deep rattling sounds

• partial obstruction of airway

• asthma, acute bronchitis

apnea

• period of breathing cessation

• sleep apnea

• periods of increasing and decreasing depth of respiration between periods of apnea

  • strokes, head injuries, brain tumors, congestive heart failure

blood pressure

• the force at which blood is pumped against the walls of the arteries

• standard unit of measurement is millimeters of mercury (mmHg)

systolic pressure

• measure of pressure when left ventricle contracts

• top number

• first sound heard during a blood pressure reading

diastolic pressure

• measure of pressure when heart relaxes

• minimum pressure exerted against the artery walls at all times

• bottom number

• last sound heard during a blood pressure reading

normal blood pressure

less than 120/80

prehypertension

• 120-139 mmHg systolic

• 80-89 mmHg diastolic

hypertension

• 140/90 mmHg or more

• if blood pressure reading is elevated after 2 or more visits to the physican

essential hypertension

• no identifiable cause

• 95% of all hypertension

secondary hypertension

as a result of some other condition like kidney or heart disease

hypotension

• low blood pressure

• not generally a chronic health problem

• slightly low blood pressure may be normal and does not usually require treatment

sphygmomanometer

• blood pressure cuff and dial

• inflatable cuff

• pressure bulb or automatic device for inflating cuff

• manometer to read the pressure

• aneroid and electronic

aneroid sphygmomanometers

• circular gauge for registering pressure

• each line 2 mmHg

• requires use of a stethescope

• must be calibrated to maintain accuracy

electronic sphygmomanometers

• digital readout

• easy to use

• costly

• less accurate

stethoscope

• amplifies body sounds

• earpieces

• chest piece

  • diaphragm - high-pitched sounds

  • bell - low-pitched sounds

measuring blood pressure

• place cuff on the upper arm

• measured in the brachial artery

• palpatory method - to determine the palpatory pressure that represents the target peak inflation

  • palpate the radial pulse

  • inflate the cuff until you can no longer feel the radial pulse

  • note the pressure at that point

• allow the arm to rest for 1 minute or remove the cuff and replace

• inflate the cuff to 30 mmHg above the palpatory result (approximately 180-200 mmHg)

• place the stethoscope over the brachial pulse point

• release the air in cuff and listen for sounds (the first sound is the systolic BP and the last sound is the diastolic BP)

korotkoff sounds

• the five phases of sound that are heard during a blood pressure reading

• phase 1: tapping sounds (systolic pressure)

• phase 2: change to softer swishing sound

• phase 3: resumption of a crisp tapping sound

• phase 4: sound becomes muffled

• phase 5: sound disappears (diastolic pressure)

what are special considerations for measuring blood pressure in adults?

• allow patients to relax if the initial reading is elevated

• especially for patients who are:

  • post exercise

  • ambulatory disabilities

  • obese

  • known blood pressure problems

  • anxiety or stress

when do you avoid measuring blood pressure in an arm?

• on the same side as a mastectomy (causes lymphoedema)

• with an injury or blocked artery

• with an implanted device under the skin

what happens to the blood pressure if the cuff is too small?

artificially elevated

what happens to the blood pressure if the cuff is too large?

artificially low

orthostatic or postural hypotension

• blood pressure drops and pulse increases as patient stands up

• assess for by checking BP and pulse in three positions: lying down, sitting up, and standing

palpation

the act of touching

auscultation

listening with a stethoscope

which method gives the most accurate temperature?

• temporal

• oral

• rectal

• tympanic

rectal

how should the MA manipulate the ear to obtain a tympanic temperature on a child?

• pull ear down and back

• pull ear up and back

• pull ear outward

• pull ear up and out

pull ear down and back

when measuring an abnormal pulse or rhythm, how long should the MA count the beats?

• 30 seconds

• 1 minute

• 3 minutes

• 15 seconds

1 minute

which is the most common pulse point?

• dorsalis pedis

• femoral

• radial

• brachial

radial

why should the MA avoid telling the patient that they are counting respirations?

• to prevent the patient from refusing the procedure

• to avoid scaring the patient

• to keep the patient from unconsciously changing their breathing rate

• to help the MA count the pulse rate more accurately

to keep the patient from unconsciously changing their breathing rate

which of the following statements is true regarding a patient’s respiratory rate?

• high pulse means that respiration rate is likely to be low

• one breath equals one inhalation and one exhalation

• the respiration rate is the number of complete breaths counted in 30 seconds

• the respiration rate in females is generally faster than in males

one breath equals one inhalation and one exhalation

what do you actually measure when you take blood pressure?

• the minimum amount of pressure the veins can withstand

• the force with which the heart beats

• the force with which blood is pumped against the arterial walls

• the amount of pressure the chest exerts on the heart

the force with which blood is pumped against the arterial walls

what is the maximum expected systolic blood pressure in a healthy adult?

• less than 80 mmHg

• less than 120 mmHg

• less than 140 mmHg

• less than 100 mmHg

less than 120 mmHg

where should the cuff of the stethoscope be wrapped?

• above the brachial pulse point

• below the brachial pulse point

• above the radial pulse point

• below the radial pulse point

above the brachial pulse point

you asked your patient to roll up her sleeve so that you can check her blood pressure. however the sleeves of her blouse are too tight to roll up without the risk of cutting off circulation to the arm. what should you do?

• ask the patient to change into a gown and check her blood pressure

• leave the sleeve in place and check her blood pressure

• roll up the sleeve anyway and check her blood pressure

• explain that you cannot check her blood pressure today

ask the patient to change into a gown and check her blood pressure