Standards to verify signs of life:

• Indicate how the body is functioning

• A change in one vital sign may indicate a change in general health

• Should be checked every visit

TPR: Temperature, Pulse, Respiration

BP: Blood Pressure

5th Vital Sign: Degree of Pain (Scale of 1 to 10, where 1 is minimal and 10 is severe)

Temperature

Measure of balance between heat lost and heat produced by the body

Heat is produced in the body by muscles and glands and by metabolism of food

Heat is lost from the body by respiration, perspiration, and excretion

Factors that Influence Temperature

• Increase Temperature

  • Exercise

  • Digestion of food

  • Increased environmental temperature

  • Illness

  • Infection

  • Excitement

  • Anxiety

• Decrease Temperature

  • Sleep

  • Fasting

  • Exposure to cold

  • Certain illnesses

  • Decreased muscle activity

  • Mouth breathing

  • Depression

Elevated Temperature:

• Hyperthermia: 104

• Fever: > 100.4

• Febrile: fever present

• Afebrile: no fever

• Pyrexia: fever

Below Normal Temperature:

• Hypothermia: < 95

Variations:

• Normal range: 97-100

• Hyperthermia: 104

• Convulsions and death 106 or above

• Hypothermia <95

Temperature Sites:

• Oral: mouth, most common site

• Axillary: armpit (Ax)

• Aural/Tympanic: ear (T, Tym)

• Rectal: rectum (R)

• Temporal Artery: Forehead (TA)

Average Temperature Values (Fahrenheit Scale)

• Oral: 98.6

• Rectal: 99.6

• Axillary: 97.6

• Tympanic 98.6

• Temporal: 99.6

May also be reported in Celsius C using a different scale. 98.6 F = 37 C

Types of Thermometers

• Clinical: glass, non-mercury (oral, axillary, rectal)

  • Rectal: red

  • Oral/axillary: blue or green

• Digital: (oral, axillary, rectal)

• Probe (oral, axillary, rectal)

  • Rectal: red

  • Oral/axillary: blue or green

• Tympanic: measure the temperature of the eardrum

  • Adults: pull up and back

  • Children: pull straight back

• Temporal: forehead

Pulse

The number of times the heart beats in 1 minute. Pressure of the blood against the artery as heart contracts and relaxes.

Radial pulse: Most frequently used. Thumb side of wrist, 1 inch above base of thumb

Brachial pulse: Inner elbow, heard during blood pressure measurement

Apical: Heartbeat at the apex of the heart, heard with a stethoscope. 2-3 inches to left of the sternum, just below nipple on chest

Carotid: Front and side of the neck. Most frequently used in emergencies and CPR

Femoral pulse: femoral artery passes through the groin, Need to press deeply

Popliteal pulse: back of the knee, in a recumbent position, with knee slightly flexed

Dorsalis pedis pulse (pedal pulse): Top of the foot, lateral to midline. Indication of normal lower limb circulation

Posterior tibial pulse: inside ankle posterior or behind joint

What would you use the pulse sites of the lower limbs for?

• check circulation

• injury

Pulse rate: number of beats per minute

• Count number of beats felt for 1 minnute

• Assess rate, rhythm, and force

Average Pulse Rates

• At birth: 100-160

• Children 1-7 years: 80-110

• Children over 7 years: 70-100

• Adult women: 65-80

• Adult men: 60-70

• Adults: 60-100

Tachycardia: fast heart rate; above 100

Bradycardia: slow heart rate; below 60

Factors that Affect Pulse Rate

• Increase Pulse Rate (Tachycardia)

  • Exercise

  • Illness

  • Anxiety

  • Medication

  • Shock

  • Hemorrhage

• Decrease Pulse Rate (Bradycardia)

  • High level of aerobic fitness

  • Depression

  • Medication

Pulse Oximetry (spO2): measure the amount of oxygen in the hemoglobin of the arterial blood. 90% or above.

Respiration Rate

Respiration: Process of taking in O2 and expelling CO2

Inhalation: breathing in during respiration

Exhalation: Forcing air out during respiration

Each inhalation and exhalation is counted as one respiration

Average respiration per minute

• Adults: 12-20 breaths per minute

• Children: 16-30 breaths per minute

• Infants: 30-50 breaths per minute

Factors:

• Increase:

  • Exercise

  • Anxiety

  • Respiratory disease

  • Medication

  • Pain heart disease

• Decrease:

  • Relaxation

  • Depression

  • Head injury

  • Medication

Character of Respiration

• Deep

• Shallow

• Labored

• Difficult

• Moist

Rhythm of Respiration

• Regular

• Irregular

Dyspnea: Difficult or labored breathing

Apnea: Absence of respiration, usually temporary

Tachypnea: Rapid, shallow respiratory rate above 25 breaths per minute

Bradypnea: Slow respiratory rate, below 10 breaths per minute

Orthopnea: Severe dyspnea in which breathing is difficult in any position other than sitting

Cheyne-Stoke: Periods of dyspnea (difficult breathing) following periods of apnea (absence); frequently occur in dying patient

Rales: Bubbling or noisy sounds caused by fluid in air passages

Cyanosis: Bluish, dusky color of skin, lips and nail beds due to decreased O2

Blood Pressure

Blood Pressure: measurement of the pressure the blood exerts on the walls of the arteries during the various stages of heart activity

Systolic: pressure during contraction of left ventricle → Hearts pumps the blood out

Diastolic: pressure during relaxation of the left ventricle or between contractions → Heart is filled with blood

• Recorded as a fraction: systolic/diastolic or 120/80

Normal blood pressure: less than 120/80

• Range - Systolic is between 90-120 millimeters mercury

• Range - Diastolic is between 60-80 millimeters mercury

Pulse pressure

• Difference between systolic and diastolic pressure

• Subtract smaller number from larger

• Normal 30mm-50mm

• 110/70

• Pulse pressure is 40

• High pulse pressure indicates a stiff Aorta

• Low < 40 heart isn’t pumping enough blood

American Heart Associations changed guidelines in 2017.

Hypertension: (>140/90)

• Blood pressure above normal range

• Elevated BP: systolic between 120-129 and Diastolic less than 80

  • Stage 1 hypertension: systolic of 130-139 or diastolic of 80-89

  • Stage 2 hypertension: systolic at least 140 or diastolic at least 90

    • Silent killer

    • Asymptomatic (no symptoms observed or felt)

    • Discovered when BP taken

    • Heredity plays a major role

    • Stroke, kidney problems, retinal changes, heart disease

  • Hypertensive crisis: 180/120

• Factors that increase BP

  • Loss of elasticity of vessels

  • Excitement, anxiety

  • Exercise, eating

  • Smoking

  • Stimulant medications

Hypotension: (<90/60), abbreviated as HTN

• Below normal range

• May feel faint

• Dehydration

• Hemorrhage

• Orthostatic Hypotension: sudden drop in BP due to change in position from lying to sitting, or standing

  • Lightheaded, dizzy, blurred vision

  • Vessels compensate and push blood to brain

• Factors that decrease BP

  • Sleep

  • Depressants

  • Shock/hemorrhage

  • Fasting

  • Age

Sphygmomanometer: instrument used to measure blood pressure

• Sphygmo: refers to pulse or blood

• Mano: refers to pressure

• Meter: refers to measure

• Read in millimeters (mm of mercury - Hg)

Stethoscope: to hear pulse sounds at brachial artery (Korotkoff sound)

Korotkoff sounds: Audible sounds heard when taking blood pressure listening to brachial artery

BP cuff: Cloth-covered rubber bladder that fills with air as the bulb is squeezed, When cuff is inflated it stops flow of blood

• BP cuff too small: too high BP

• BP cuff too big: too low BP

Thumbscrew-valve: opens and closes to allow inflation and release of cuff

How to take BP? - Have a patient lying down or sitting down, feet flat on the floor. Sleeve rolled up above the elbow. Determine brachial pulse, inflate, and slowly release the valve (2-3mmHg per second). Listen for when sound is heard.

How to chart BP? - Date, time, result, signature