Vital Signs
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Description and Tags
Measure various factors that provide information about the basic body conditions of the patient.
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40 Terms
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4 Main vital signs T-P-R-BP
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* Temperature
* Pulse
* Respirations
* Blood Pressure
* Temperature
* Pulse
* Respirations
* Blood Pressure
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other vital signs--Pain
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* 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
* 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
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other vital signs--skin color
cyanosis
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other vital signs-
* Size of the pupil & reaction to light (PERRLA)
* Size of the pupil & reaction to light (PERRLA)
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* Pupils (are)
* Equal
* Round
* Reactive (to)
* Light (and)
* Accomodation
* Pupils (are)
* Equal
* Round
* Reactive (to)
* Light (and)
* Accomodation
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other vital signs--Level of consciousness (LOC)
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* Awake, Alert and Oriented to (person, place, time) - AAOx3
* Awake, Alert and Oriented to (person, place, time) - AAOx3
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other vital signs--
* Patients response to stimuli
* Pulse oximetry reading 95%+
* Patients response to stimuli
* Pulse oximetry reading 95%+
other vital signs--
* Patients response to stimuli
* Pulse oximetry reading 95%+
* Patients response to stimuli
* Pulse oximetry reading 95%+
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* Accuracy is essential because they are:
* 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.
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* 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.
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temperature: 96.6 to 100.6 F avg 98.6
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* **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.
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* 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
* **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.
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* 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
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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**
\-blue
\-
* **Factors that can alter temp in mouth**
* **Eating, drinking (hot or cold)**
* **Smoking**
* **Wait at least 15 min before taking temp**
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rectal
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* (R or pr)- Rectum; **most accurate**, invasive
* red
* (R or pr)- Rectum; **most accurate**, invasive
* red
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axillary
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* (Ax) -Under the armpit; **least accurate**
* blue
* (Ax) -Under the armpit; **least accurate**
* blue
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temporal
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* (T)- Side of head; easy to use, accurate
* (T)- Side of head; easy to use, accurate
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Tympanic
* (Tymp) __**or**__ Aural - in the ear canal; accurate
* *Usually used for infants to 3 years*
* Measures infrared energy from blood
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vessels in tympanic membrane
* *Usually used for infants to 3 years*
* Measures infrared energy from blood
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vessels in tympanic membrane
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factors that lead to ↑ **body temp**
Illness, infection, exercise, excitement, environmental temp
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Factors that lead to ↓ body temp
Starvation/fasting, sleep, ↓ muscle activity, sleeping, mouth breathing, environmental temp, certain diseases
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Fever/pyrexia
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* elevated body temp >101oF rectally
* elevated body temp >101oF rectally
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febrile
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* having or showing the symptoms of a fever.
* having or showing the symptoms of a fever.
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afebrile
no fever is present, WNL (within normal limits)
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hypothermia
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* body temp
* body temp
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hyperthermia
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* body temp >104oF rectally
* Prolonged exposure will cause brain damage or serious infection
* >106oF will lead to convulsions, brain damage, or death
* body temp >104oF rectally
* Prolonged exposure will cause brain damage or serious infection
* >106oF will lead to convulsions, brain damage, or death
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pulse(P or HR) 60-100
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* 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:
* 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:
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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)
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)
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apical pulse
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* 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
* 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
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bradycardia
pulse
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tachycardia
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* pulse >100 bpm
* pulse >100 bpm
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rhythm
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* 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
* 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
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increasing pulse
fever, shock, exercise, stimulant drugs, excitement, nervous tension(stress)
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decrease pulse
depressant drugs, physical training, sleep, heart disease, coma
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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
* **Apnea** – absence of respirations
* **Tachypnea** – RR >20 breaths per minute
* **Bradypnea** – RR
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cheyne-stokes respiration
frequently noted in dying patient
periods of dyspnea followed by periods of apnea that causes fluctuating carbon dioxide levels
periods of dyspnea followed by periods of apnea that causes fluctuating carbon dioxide levels
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rales or crackles
bubbling or noisy sounds
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wheezing
high pitched whistling
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rhonchi
rattling snoring sounds
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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**__
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* **Normal range 100 to 120**
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**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.
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* **Normal range 60 – 80 mm Hg**
* __**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**__
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* **Normal range 100 to 120**
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**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.
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* **Normal range 60 – 80 mm Hg**
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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**
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**-**__Patient positioning__: Patient should be sitting with feet flat on the floor (do not cross legs)
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**
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**-**__Patient positioning__: Patient should be sitting with feet flat on the floor (do not cross legs)
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pulse pressure
* The __difference__ between Systolic BP and Diastolic BP
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* Important indicator of the health and tone of the arterial walls
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* **Normal range 30 – 50 mm Hg**
* **120/80 120 – 80 = 40 pulse pressure**
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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.**
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* Important indicator of the health and tone of the arterial walls
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* **Normal range 30 – 50 mm Hg**
* **120/80 120 – 80 = 40 pulse pressure**
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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.**
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prehypertension
120-139 mmHg Systolic OR 80-89 mmHg Diastolic.
120-139/80-89 mmHg
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* Condition can harden arteries, dislodge plaque, and block blood vessels that nourish the heart
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* 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.
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120-139/80-89 mmHg
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* Condition can harden arteries, dislodge plaque, and block blood vessels that nourish the heart
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* 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.
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hypertension(HTN)
higher than 140/90
silent killer
arteriosclerosis
leads to kidney failure, stroke, heart disease
silent killer
arteriosclerosis
leads to kidney failure, stroke, heart disease
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hypotension
less than 90/60
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* May occur with heart failure, dehydration, depression, severe burns, hemorrhage, and shock
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* May occur with heart failure, dehydration, depression, severe burns, hemorrhage, and shock
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orthostatic or postural hypotension
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* **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
* **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