MA

Vital Signs are measurements reflecting the patient’s

physical well-being and condition.

Often VS are the first indicator that something

adverse is going on with the patient.

Routinely measured Vital Signs :

BP-blood pressure

P-pulse

R-respirations

T-temperature

Sp02-Pulse oximetry (ox)

Sometimes Pain is included

When ARE

vital signs

taken?

At each MD visit

When MD orders

Change in pt condition

Pt fall/incident

Monitor pt’s response to

a new med

*Always Consider:

The VS results as well as patient’s clinical appearance and

history. **Recheck if results do not match appearance.

This means look at the patient NOT just the numbers!

Temperature

Terms to Know

Febrile: fever

Afebrile: absence of fever

Pyrexia: fever (>100.4 F)

Hyperpyrexia: abnormally high fever (Emergent >104 F)

Fever is the body’s natural defense against infection

The most common sign of inflammation or infection is fever.

The patient may also exhibit other S/S of infection such as

chills, anorexia, malaise/fatigue, body aches, tachycardia

FUO: fever of unknown origin (can be the pt’s dx)

Fever lasting >3 weeks in an adult; >1 week in children

Temperature

Normal body temperature is 98.6ºF or 37ºC

Our internal body temperature is regulated by a part of our

brain called the hypothalamus.

Are variations normal?

Variations are caused by:

Individual differences

Age- elderly/infants have harder time regulating body temp

Time of day-temp increases in late evening; weather

Hot/cold liquids, smoking, chewing gum

Menstrual cycle- can increase body temperature

Normal Adult Range

Abnormal Adult Range

Emergent

NHA

Temperature

Ranges

97.6° to 99.6° F

99.6° to 104.0° F

Dangerous: 104° to 105° F

Fatal: 106° F or higher

YES

Temperature

Locations

Oral: mouth

Ear: tympanic (aural)

Rectum: rectal

Armpit: axillary

Forehead: Temporal

Oral

Temperature

(O)

Measured in the mouth

Most common, comfortable and convenient

method

May be inaccurate if patient has had

anything to eat/drink, chewed gum, or

smoked

Wait 10-15 minutes

Place a probe cover on the thermometer

Then place the probe in the heat pocket

under tongue (to the side of the frenulum

lingua)

Normal Average Oral Temp 97.6-99.6 F

Measured in the mouth

Most common, comfortable and convenient

method

May be inaccurate if patient has had

anything to eat/drink, chewed gum, or

smoked

Wait 10-15 minutes

Place a probe cover on the thermometer

Then place the probe in the heat pocket

under tongue (to the side of the frenulum

lingua)

Normal Average Oral Temp 97.6-99.6 F

Axillary

Temperature

(A)

Temperature measured under the armpit

Least accurate reading because measures external

temperature

Record an A by the reading

Provide privacy

Center probe in armpit

Measure the temperature

Rectal

Temperature

(R)

Measured in the rectum

Most accurate because it is an internal temperature

Use red rectal thermometer

Record R by reading

Adult Procedure: Have pt lay on their side, lubricate

thermometer, insert thermometer no more than 1 inch

into the rectum

Children: insert probe no more than 5/8 inch

Infants: insert probe no more than ½ inch

Tympanic

(Aural)

Temperature

Temperature measured in the ear canal

May be inaccurate if the patient has impacted cerumen

(ear wax)

Contraindicated in patients with ear pain or ear

infection such as otitis externa

Adults-gently pull pinna (outside of ear) up and out

Children gently pull pinna down and back

Impacted

Cerumen

and

Tympanic

(Aural)

Temperature

Tympanic temperatures are obtained by measuring the

temperature of the ear drum (tympanic membrane)

Compare the above ear canals…can you see how a

tympanic temperature will be inaccurate if the ear canal is

occluded (covered) in cerumen (wax)

Temporal

Temperature

Temperature measured across the forehead

Obtains a measurement of temperature inside the

temporal artery

Preferred by pediatricians due to:

Inaccuracies in technique while obtaining tympanic

temperatures

*Pediatric Note:

Febrile seizures can occur in young children with

high fevers. Antipyretic drugs such as Tylenol

should be administered to prevent these dangerous

spikes in temperature.

Clinical

Situations-Te

mperature

At the bottom of your notes:

Answer the clinical situations in the boxes.

Review the “How to Read a Glass Thermometer” and

provide the correct reading on your notes

Large lines equal 1 degree

Represent a whole number- 96°, 97°, 98°, 99°, 100°, etc.

Small lines equal 0.2 degrees

Ex. 99.2°, 99.4°, 99.6°

For example, this reading would be recorded as 99.4 F

Rhythmic expansion and contraction of the heart causes a

palpable beating of the arteries throughout body

Normal Pulse

Rates

(per minute)

NHA Pulse Rates:

Before birth/birth

120-160/min

1-3 years old

80-150/min

3-6 years old 70-110/min

6-12 years

60-110/min

Over 12/Adults

60-100/min

**Follow your specific facility policies regarding normal ranges

When

taking a

pulse,

note

the…

Rate: # of pulse beats per minute (bpm)

Rhythm: regular or irregular (arrhythmia)

Strength/Force: volume of the pulse

3+ Bounding- very strong

2+ Normal pulse

1+Thready- weak, difficult to feel

Bradycardia: HR< 60/min

Tachycardia: HR> 100/min

**Always report a pulse under 60bpm or over 100 bpm

Pulse Points

Check

for adult

CPR

For injuries, check pulses distal to the injury for circulation.

A doppler unit (ultrasound) may need to be used to detect pulse.

Check for

infant CPR

and BP

technique

Most common

pulse for

adults

Common site

of temporal

temperature

Palpating

a Radial Pulse

Support pt’s arm

Use second and third finger of your dominant hand to

palpate (feel) the radial pulse

Your fingers are in a line with the patient’s thumb

Never use your own thumb*

Don’t press too hard- you will stop the flow of blood

and not feel the pulse

Count for a full minute

Look at the position of the second hand on your watch.

Start counting the pulse beats that you feel until the

second hand comes back to the same number on the

clock.

Record the rate, rhythm, and force.

Auscultating

an Apical

Pulse

Apical pulse is a measurement of the heartbeats at the

apex of the heart (just under the left breast)

Apical pulse commonly measured in:

Infants and children

Adults with irregular heartbeats

Uncover the patient’s chest

Auscultate (listen) with stethoscope for a full minute

Press down firmly with the stethoscope

Count the number of beats and note the rhythm

Compare these chest x-rays. Which one depicts dextrocardia?

Which pulse procedure technique will be affected?

How would you modify your technique to get an accurate pulse?

Clinical

Situations

Pulse

Answer the clinical situations in the boxes on your study

guide. Then write the correct answers on your

whiteboard.

Homework

Take a radial pulse on three “patients”. Write the

readings obtained on looseleaf and have the person sign

next to the reading.

If you do not have 3 different people at home, you may

take three separate readings on the same person at 3

different times. Have the “patient” sign.

Complete Fill-in-the-Blank Questions

Observing

Respirations

Respiration: involuntary process of inhaling and exhaling

The purpose of respiration:

To exchange oxygen and carbon dioxide between the

atmosphere, blood, and body cells

Medulla oblongata- location of respiratory center

In the brain between brainstem and top of spine

When blood CO2 levels increase, cells are starved for O2

The medulla oblongata responds by sending a stimulus to

respiratory muscle (diaphragm and intercostal muscles)

and breathing begins involuntarily

Respiration

Physiology

Counting

Respirations

Normal

Respiratory

Ranges

Counting respirations

Unintentional alterations can occur if patients realize you

are counting their breaths

Be subtle-act as though you are counting their pulse

Count the rise and fall of the chest in a minute

Note the rate, rhythm, and depth

Abnormalities could indicate respiratory distress

Adult Range

Children

Newborns

NHA

Respiratory

Ranges

12-20/min

20-40/min

30-50/min

*Ranges for pediatric vitals vary widely based on the child’s

age, use a validated reference guide when working pediatrics

Types of

Abnormal

Breathing

Tachypnea

Fast breathing

Bradypnea

Slow breathing

Hyperventilation

Fast and shallow

Pain, anxiety attacks

Hyperpnea

Excessively deep

Extreme pain, anxiety

Dyspnea

Difficult or painful

Asthma, COPD, Pneumonia

Orthopnea

Difficult breathing unless upright

COPD, Congestive heart failure

Apnea

Absence of breathing

Sleep apnea, death

Abnormal

Breath Sound

Recognition

The provider assesses breath sounds with a stethoscope

Abnormal breath sounds may be audible without a stethoscope and

can indicate severe respiratory disease

Wheezing

Whistling sound

Asthma

Rales

Small clicking, bubbling, or rattling sounds (crackles)

Pneumonia, fluid in air sacs (pulmonary edema)

Rhonchi

Large airway sounds (snoring or gurgling-mucous moving)

COPD, Chronic bronchitis, Pneumonia

*Be alert for the any of the following:

Cyanosis, vertigo, angina, numbness in fingers and toes

Pulse

Oximetry

(SpO2)

Using a sensor to measure the saturation of oxygen in the blood

Nail polish/artificial nails provide inaccurate results (remove prior)

Check capillary refill in fingers to select the best site

Alternate sites- earlobe, bridge of nose, toe

Normal SpO2: 95% or greater

A reading < 95 % indicates hypoxemia:

Low oxygen in the blood

Oxygen therapy may be ordered and initiated

*According to NHA, SpO2 readings <90% must be reported to the

provider—follow facility protocols for reporting!

Assessing and

Documenting

Pain

Pain is often assessed with vital signs and is subjective

Observe for grimacing, clutching areas of the body

Assessing and Documenting Pain

Assess pain scale 1-10 (10 is worst)

For children, use Wong-Baker Faces Scale

Ask about location, onset, duration, other characteristics

Also, any relieving or aggravating factors

Measuring

Blood Pressure

Blood

Pressure

Basics

The force of blood exerted on the inner walls of arteries, veins, &

heart chambers heart as blood flows through them

BP variations: age, internal conditions, external influences

Accurate BP impacts patient treatment

Normal adult range: Less than 120/80 mmHg

Equipment needed:

Stethoscope and aneroid sphygmomanometer

Or electronic sphygmomanometer

Measurements read at 2 points:

Systolic- pressure measured as heart contracts

Diastolic- pressure measured as heart relaxes

Recorded as a fraction

Blood

Pressure

Procedure

Special

Considerations

Wait 15 min. after strenuous activity

Anxiety/stress elevates BP- help pt relax

Do not take BP in same arm as:

An injury or implant

The same side as a mastectomy

An IV or AV shunt (dialysis fistula)

-Use proper size cuff

The bladder inside the cuff should encircle 80-100% of the arm

Legs uncrossed, feet on floor, arm positioned at heart level

- Apply cuff to upper arm just above brachial pulse point

-Use palpatory method to determine approximate BP

Palpate the radial pulse

Inflate cuff until you no longer feel radial pulse

Note the pressure at this point

Deflate cuff

Rest arm 30-60 seconds

-Determine auscultated blood pressure

Inflate cuff 30 mmHg above palpatory result (usually 150-180 mmHg)

Listen with stethoscope over brachial artery as you release air

Note the blood pressure reading (see next slide)

Recording the

Blood

Pressure

Korotkoff

Sounds

Korotkoff Sounds

Phase 1- first tapping sound (systolic)

Phase 2- softer, swishing sounds

Phase 3- tapping sounds resume

Phase 4- sounds become muffled

Phase 5- sounds disappear (diastolic)

**When you begin the procedure by inflating cuff, you

should hear NO SOUND initially. The first sound is your

top number & the last sound is the bottom number.

Common

Causes of

Errors and

Troubleshootin

Wrong size cuff (can increase systolic and diastolic by 6.9 mmHg)

Legs crossed (increases 2-8mm Hg)

Arm is positioned above heart level (artificial decrease)

Arm is dangling by side (artificial elevation)

The pressure in the cuff is released too rapidly

The patient is nervous or anxious

The patient drank coffee or smoked a cigarette within 30 min of BP

Cuff was applied improperly

The cuff bladder was not completely deflated before a reading

The bladder is not centered over the artery or bladder bulges out

Failure to wait for 1 to 2 minutes between measurements

The instrument is defective

Air leaks in valve or bladder

Aneroid needle not calibrated to zero

Blood

Pressure

Abnormalities

Hypotension

Low Blood Pressure

Persistent reading <90/60 mmHg

Can cause vertigo, syncope

May be present with:

Dehydration

Hemorrhage

Traumatic shock

Nervous system diseases

Medications

Orthostatic (postural)

hypotension occurs when a

patient changes position

Hypertension (HTN)

High Blood Pressure

Increases risk of heart attack,

stroke, heart and kidney failure

Caused by:

Increased blood volume

Peripheral resistance in vessels

Can weaken heart muscle (CHF)

Know procedure to obtain

Orthostatic Vitals

Orthostatic

(postural)

Hypotension

Orthostatic VS may be ordered if the patient has:

Low blood pressure w/ symptoms such as vertigo or syncope

Procedure:

Obtain BP & pulse readings while patient is lying, sitting, then

standing

Keep arm rested on a bedside table

Avoid dangling of arm by side

Wait 2-5 minutes between position changes

Monitor patient safety- dizzy/unsteady during procedure

Positive Orthostatic Results:

BP drops by 20 points and Pulse rises by 10 bpm

MA Role: Vital Signs

Obtain Vital Signs

Recognize Abnormal Readings

Troubleshoot

Report/Record

Review the patient

scenarios on the

following slides and

determine whether you

need to:

Record the normal

readings in the chart

Recheck the vital signs

Report immediately to

the provider

Record as

Normal

Recheck

Report

Immediately

Patient: Molly Meyers

DOB: 12/24/92

Chief Complaint: Sore throat

HPI: Patient states “throat hurts really bad with swallowing” and

white patches are visible in throat.

Any abnormalities?

Any other questions to ask?

Vital Signs

118/68

114

16/min

99.8 Ax

SpO2

98%

Pain

7/10

Record as

Normal

Recheck

Report

Immediately

Patient: Ernest Williamson

DOB: 1/18/53

Chief Complaint: Cough and Chest Tightness

HPI: Patient states he has a “terrible cough that began 4 days ago”,

chest tightness with deep breathing. Patient reports cough is

productive with yellow sputum.

Any abnormalities?

Any other questions to ask?

Vital Signs

138/84

22/min

98.0

SpO2

92%

Pain

2/10

Record as

Normal

Recheck

Report

Immediately

Patient: Cason Everest

DOB: 3/7/23

Chief Complaint: Nasal Congestion and Cough

HPI: Mother reports patient has had intermittent fever, cough and

nasal congestion for 2 weeks. States patient has been “pulling at

ears constantly”.

Any abnormalities?

Any other questions to ask?

Vital Signs

N/A

74/min

12/min

98.9

SpO2

96%

Pain

Record as

Normal

Recheck

Report

Immediately

Patient: Helena Miles

DOB: 6/27/93

Chief Complaint: Itching

HPI: Patient reports intense itching and rash after eating shrimp 30

minutes ago. Denies shrimp allergy but reports hx of anaphylactic

shock after wasp sting 10 years ago.

Any abnormalities?

Any other questions to ask?

Vital Signs

77/49

144/min

32/min

SpO2

92%

Pain

10/10

Record as

Normal

Recheck

Report

Immediately

Patient: Catherine Smith

DOB: 10/14/59

Chief Complaint: Headache

HPI: Pt states she has a “throbbing H/A in the front of my head”

that began 2 days ago. Pt reports taking Tylenol with no relief.

Any abnormalities?

Any other questions to ask?

Vital Signs

146/90

74 Irreg

18/min

98.7

SpO2

99%

Pain

9/10