Vital Signs

4 Main vital signs T-P-R-BP

4 Main vital signs T-P-R-BP

• Temperature

• Pulse

• Respirations

• Blood Pressure

other vital signs--Pain

• considered the 5th vital sign. Can be acute or chronic. Pain is what the person says it is!

  • Scale - 0 to 10

    • Patients are asked to rate their level of pain on the 0 – 10 scale

  • If patient is a child or nonverbal, FACES pain scale is used

other vital signs--skin color

cyanosis

other vital signs-

• Size of the pupil & reaction to light (PERRLA)

• Pupils (are)

• Equal

• Round

• Reactive (to)

• Light (and)

• Accomodation

other vital signs--Level of consciousness (LOC)

• Awake, Alert and Oriented to (person, place, time) - AAOx3

other vital signs--

• Patients response to stimuli

• Pulse oximetry reading 95%+

other vital signs--

• Patients response to stimuli

• Pulse oximetry reading 95%+

• Accuracy is essential because they are:

• Used to detect problems

• Monitor the effectiveness of medication

• Make a diagnosis

• You should ALWAYS report abnormality or change

• If unable to get reading, ask another person to check

***Guidelines for “normals” will vary according to state laws and policies of health care agencies.

It is your legal responsibility to know and follow guidelines for your state and agency.

temperature: 96.6 to 100.6 F avg 98.6

• a measurement of the balance between heat lost and heat produced

• Heat is lost thru perspiration, respiration, & excretion (urine & feces)

• Heat is produced by the metabolism of food; and by muscle and gland activity

• A constant state of fluid balance, known as homeostasis, is the ideal health state in the human body.

  • The rates of chemical reactions in the body are regulated by body temp.

    • If body temp is too high or too low the body’s fluid balance is affected

oral

(PO) -Mouth; most common, convenient

-blue

-

• Factors that can alter temp in mouth

  • Eating, drinking (hot or cold)

  • Smoking

  • Wait at least 15 min before taking temp

rectal

• (R or pr)- Rectum; most accurate, invasive

• red

axillary

• (Ax) -Under the armpit; least accurate

• blue

temporal

• (T)- Side of head; easy to use, accurate

Tympanic

• (Tymp) or Aural - in the ear canal; accurate

  • Usually used for infants to 3 years

  • Measures infrared energy from blood

    vessels in tympanic membrane

factors that lead to ↑ body temp

Illness, infection, exercise, excitement, environmental temp

Factors that lead to ↓ body temp

Starvation/fasting, sleep, ↓ muscle activity, sleeping, mouth breathing, environmental temp, certain diseases

Fever/pyrexia

• elevated body temp >101oF rectally

febrile

• having or showing the symptoms of a fever.

afebrile

no fever is present, WNL (within normal limits)

hypothermia

• body temp <95oF rectally

  • Death usually occurs if temp <93oF rectally

hyperthermia

• body temp >104oF rectally

  • Prolonged exposure will cause brain damage or serious infection

  • 106oF will lead to convulsions, brain damage, or death

pulse(P or HR) 60-100

• The blood pushing against the wall of an artery as the heart contracts and relaxes. In other words- it is a throbbing of the arteries (that is FELT) caused by contractions of the heart.

  • Rate - # of beats per minute (bpm)

  • Rhythm – refers to regularity of beats

  • Volume – refers to strength

    • Bounding/Full:

    • Normal/Strong:

    • Weak:

    • Thready:

pulses

• Pulses that are PALPATED (felt)

on an artery

• Temporal – sides of the forehead

• Carotid – sides of the neck

• Brachial – inner aspect of forearm at the ante-

cubital space

• Radial – inner aspect of the wrist, above thumb

• Femoral – inner aspect of the upper thigh

• Popliteal – behind the knee

• Dorsalis pedis – top of the foot arch

• Posterior tibial- behind ankle on lateral side of

  the foot.

\n Apical Pulse is AUSCULTATED (Heard)

apical pulse

• Taken with a stethoscope at the apex of the heart

  • Use diaphragm (flat, flexible disk)

  • Actual heartbeat is heard (auscultated) & counted

• Pulse Deficit – take the apical then the radial pulse, then subtract the radial from the apical = difference is the pulse deficit

  • Occurs with pts with heart conditions

  • Heart is weak & does not pump enough blood to produce a pulse

bradycardia

pulse <60 bpm

tachycardia

• pulse >100 bpm

rhythm

• Rhythm refers to the regularity of the pulse (the spacing of the beats)

  • Regular

  • Irregular  - arrhythmia

    • Usually caused by a defect in the electrical conduction pattern of the heart

increasing pulse

fever, shock, exercise, stimulant drugs, excitement, nervous tension(stress)

decrease pulse

depressant drugs, physical training, sleep, heart disease, coma

respiration(R or RR) 12-20 breaths per min in adults

• Dyspnea – difficult or labored breathing

• Apnea – absence of respirations

• Tachypnea – RR >20 breaths per minute

• Bradypnea – RR <12 breaths per minute

• Orthopnea – severe dyspnea in which breathing is very difficult in any position other than sitting erect or standing

• Cyanosis – a dusky, bluish discoloration of the skin, lips, and/or nail beds as a result of ↓O2 and ↑CO2 in the bloodstream. In darker skinned patients, check mucus                                                membranes

cheyne-stokes respiration

frequently noted in dying patient

periods of dyspnea followed by periods of apnea that causes fluctuating carbon dioxide levels

rales or crackles

bubbling or noisy sounds

wheezing

high pitched whistling

rhonchi

rattling snoring sounds

blood pressure (BP)

pressure that the blood exerts on the walls of the arteries

• Systolic BP (top/first number)

  • Pressure occurs in the walls of the arteries when the left ventricle of the heart is contracting and pushing blood into the arteries

• Normal range 100 to 120

      mm Hg

• Diastolic BP (Bottom/second number)

  • The constant pressure in the walls of the arteries when the left ventricle of the heart is at rest, or between contractions.

Blood has moved forward into the capillaries and veins, so the volume of blood in the arteries has decreased.

• Normal range 60 – 80 mm Hg

causes of inaccurate BP

-Increased activity: the patient to sit quietly for at least 5 minutes before BP is taken.

You should wait 30 seconds between each reading if you are having to repeat the BP for any reason

-Size and placement of the cuff: It contains a rubber bladder that fills with air to apply pressure (squeeze) to the arteries.

-If its Too small = inaccurate high reading

**-**If its Too large = inaccurate low reading

-Patient positioning: Patient should be sitting with feet flat on the floor (do not cross legs)

pulse pressure

• The difference between Systolic BP and Diastolic BP

• Important indicator of the health and tone of the arterial walls

• Normal range 30 – 50 mm Hg

  • 120/80         120 – 80 = 40 pulse pressure

Helps to see trends in blood pressure and heart function.

A high pulse pressure can be caused by an increase in blood volume or heart rate, OR a decrease in the ability of the arteries to expand.

prehypertension

120-139 mmHg Systolic OR 80-89 mmHg Diastolic.

120-139/80-89 mmHg

• Condition can harden arteries, dislodge plaque, and block blood vessels that nourish the heart

• They don’t have “high blood pressure” but are at risk for developing hypertension (HTN) if lifestyle changes do not occur such as proper nutrition and exercise program.

hypertension(HTN)

higher than 140/90

silent killer

arteriosclerosis

leads to kidney failure, stroke, heart disease

hypotension

less than 90/60

• May occur with heart failure, dehydration, depression, severe burns, hemorrhage, and shock

orthostatic or postural hypotension

• Sudden drop in both SBP & DBP when a person changes positions

• Caused by the inability of blood vessels to compensate quickly to positional change

• Signs/Symptoms: lightheaded, dizziness, blurred vision

  -lying, sitting, standing