Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Measuring Vital Signs.

Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Measuring Vital SignsMeasuring Vital Signs

Slide 2Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

The four vital signs of body function are:The four vital signs of body function are:• TemperatureTemperature

• PulsePulse

• RespirationsRespirations

• Blood pressureBlood pressure

Slide 3Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

MEASURING AND REPORTING VITAL MEASURING AND REPORTING VITAL SIGNSSIGNS Vital signs:Vital signs:

• Are measured to detect changes in normal body functionAre measured to detect changes in normal body function

• Tell about responses to treatmentTell about responses to treatment

• Often signal life-threatening eventsOften signal life-threatening events

• Are part of the assessment step in the nursing processAre part of the assessment step in the nursing process

Slide 4Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Vital signs are measured:Vital signs are measured:• During physical examsDuring physical exams• When the person is admitted to the nursing centerWhen the person is admitted to the nursing center• As often as required by the person’s conditionAs often as required by the person’s condition• Before and after surgeryBefore and after surgery• Before and after complex procedures or diagnostic testsBefore and after complex procedures or diagnostic tests• After some care measures, such as ambulationAfter some care measures, such as ambulation• After a fall or other injuryAfter a fall or other injury• When drugs affect the respiratory or circulatory systemWhen drugs affect the respiratory or circulatory system• When there are complaints of pain, dizziness, When there are complaints of pain, dizziness,

lightheadedness, shortness of breath, rapid heart rate, or lightheadedness, shortness of breath, rapid heart rate, or not feeling wellnot feeling well

• As stated on the care planAs stated on the care plan

Slide 5Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Accuracy is essential when you measure, record, Accuracy is essential when you measure, record, and report vital signs.and report vital signs.

Unless otherwise ordered:Unless otherwise ordered:• Take vital signs with the person lying or sitting.Take vital signs with the person lying or sitting.

• The person is at rest when vital signs are measured.The person is at rest when vital signs are measured.

Report the following at once:Report the following at once:• Any vital sign that is changed from a prior measurementAny vital sign that is changed from a prior measurement

• Vital signs above the normal rangeVital signs above the normal range

• Vital signs below the normal rangeVital signs below the normal range

If you cannot measure vital signs, tell the nurse If you cannot measure vital signs, tell the nurse right away.right away.

Slide 6Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

BODY TEMPERATURE IS THE AMOUNT BODY TEMPERATURE IS THE AMOUNT OF HEAT IN THE BODY.OF HEAT IN THE BODY. Thermometers are used to measure temperature.Thermometers are used to measure temperature.

• It is measured using the Fahrenheit (F) and centigrade or It is measured using the Fahrenheit (F) and centigrade or Celsius (C) scales.Celsius (C) scales.

Temperature sites are the mouth, rectum, axilla, Temperature sites are the mouth, rectum, axilla, tympanic membrane, and temporal artery.tympanic membrane, and temporal artery.

Fever means an elevated body temperature.Fever means an elevated body temperature. Always report temperatures that are above or Always report temperatures that are above or

below the normal range.below the normal range.

Slide 7Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

These types of thermometers are used:These types of thermometers are used:• Glass thermometersGlass thermometers

• Electronic thermometersElectronic thermometers Some have oral and rectal probesSome have oral and rectal probes Tympanic membrane thermometersTympanic membrane thermometers Temporal artery thermometersTemporal artery thermometers

• DigitalDigital

• Disposable oral thermometersDisposable oral thermometers

• Temperature-sensitive tapeTemperature-sensitive tape

Slide 8Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Slide 21Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

A PULSE IS FELT EVERY TIME THE A PULSE IS FELT EVERY TIME THE HEART BEATS.HEART BEATS. Pulse sitesPulse sites

• The temporal, carotid, brachial, radial, femoral, popliteal, The temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis (pedal) pulses are on posterior tibial, and dorsalis pedis (pedal) pulses are on each side of the body.each side of the body.

• The radial pulse is used most often.The radial pulse is used most often.

• The carotid pulse is taken during CPR and other The carotid pulse is taken during CPR and other emergencies.emergencies.

• The apical pulse is felt over the heart.The apical pulse is felt over the heart. This pulse is taken with a stethoscope.This pulse is taken with a stethoscope.

Slide 23Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

To use a stethoscope:To use a stethoscope:• Wipe the earpieces and diaphragm with antiseptic wipes Wipe the earpieces and diaphragm with antiseptic wipes

before and after use.before and after use.

• Place the earpiece tips in your ears.Place the earpiece tips in your ears.

• Place the diaphragm over the artery.Place the diaphragm over the artery.

• Prevent noise.Prevent noise.

The pulse rate is the number of heartbeats or The pulse rate is the number of heartbeats or pulses felt in 1 minute.pulses felt in 1 minute.• The rate varies for each age-group.The rate varies for each age-group.

• The adult pulse rate is between 60 and 100 beats per The adult pulse rate is between 60 and 100 beats per minute.minute.

• Report abnormal pulses to the nurse at once.Report abnormal pulses to the nurse at once. TachycardiaTachycardia BradycardiaBradycardia

Slide 25Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

The rhythm of the pulse should be regular.The rhythm of the pulse should be regular.• An irregular pulse occurs when the beats are not evenly An irregular pulse occurs when the beats are not evenly

spaced or beats are skipped.spaced or beats are skipped.

Force relates to pulse strength.Force relates to pulse strength.• A forceful pulse is described as strong, full, or bounding.A forceful pulse is described as strong, full, or bounding.

• Hard-to-feel pulses are described as weak, thready, or Hard-to-feel pulses are described as weak, thready, or feeble.feeble.

You must count pulses accurately.You must count pulses accurately. You must report and record the pulse rate You must report and record the pulse rate

accurately.accurately.

Slide 27Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

The apical pulse is on the left side of the chest The apical pulse is on the left side of the chest slightly below the nipple.slightly below the nipple.• It is taken with a stethoscope.It is taken with a stethoscope.

• Count the apical pulse for 1 minute.Count the apical pulse for 1 minute.

• Count each lub-dub as one beat.Count each lub-dub as one beat.

The apical and radial pulses should be equal.The apical and radial pulses should be equal.• To see if the apical and radial pulses are equal, two staff To see if the apical and radial pulses are equal, two staff

members are needed.members are needed.

• The pulse deficit is the difference between the apical and The pulse deficit is the difference between the apical and radial pulse rates.radial pulse rates.

Slide 29Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

RESPIRATIONSRESPIRATIONS Respiration means breathing air into (inhalation) Respiration means breathing air into (inhalation)

and out of (exhalation) the lungs.and out of (exhalation) the lungs.• Oxygen enters the lungs during inhalation.Oxygen enters the lungs during inhalation.

• Carbon dioxide leaves the lungs during exhalation.Carbon dioxide leaves the lungs during exhalation.

• The chest rises during inhalation and falls during The chest rises during inhalation and falls during exhalation.exhalation.

The healthy adult has 12 to 20 respirations per The healthy adult has 12 to 20 respirations per minute.minute.

Slide 30Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Respirations are normally quiet, effortless, and Respirations are normally quiet, effortless, and regular.regular.• Both sides of the chest rise and fall equally.Both sides of the chest rise and fall equally.

Count respirations when the person is at rest.Count respirations when the person is at rest. Count respirations right after taking a pulse.Count respirations right after taking a pulse.

• Keep your fingers or stethoscope over the pulse site.Keep your fingers or stethoscope over the pulse site.

To count respirations, watch the chest rise and To count respirations, watch the chest rise and fall.fall.

Slide 31Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

BLOOD PRESSUREBLOOD PRESSURE Blood pressure is controlled by:Blood pressure is controlled by:

• The force of heart contractionsThe force of heart contractions• The amount of blood pumped with each heartbeatThe amount of blood pumped with each heartbeat• How easily the blood flows through the blood vesselsHow easily the blood flows through the blood vessels

The period of heart muscle contraction is called The period of heart muscle contraction is called systole.systole.

The period of heart muscle relaxation is called The period of heart muscle relaxation is called diastole.diastole.

Blood pressure is measured in millimeters (mm) of Blood pressure is measured in millimeters (mm) of mercury (Hg).mercury (Hg).

The systolic pressure is recorded over the diastolic The systolic pressure is recorded over the diastolic pressure.pressure.

Slide 32Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Blood pressure has normal ranges:Blood pressure has normal ranges:• Systolic pressure—less than 120 mm Hg Systolic pressure—less than 120 mm Hg

• Diastolic pressure—less than 80 mm HgDiastolic pressure—less than 80 mm Hg

Hypertension—blood pressure measurements that Hypertension—blood pressure measurements that remain above a systolic pressure of 140 mm Hg or a remain above a systolic pressure of 140 mm Hg or a diastolic pressure of 90 mm Hgdiastolic pressure of 90 mm Hg

Hypotension—when the systolic blood pressure is below Hypotension—when the systolic blood pressure is below 90 mm Hg and the diastolic pressure is below 60 mm Hg90 mm Hg and the diastolic pressure is below 60 mm Hg

A stethoscope and a sphygmomanometer are used to A stethoscope and a sphygmomanometer are used to measure blood pressure.measure blood pressure.

Blood pressure is normally measured in the brachial Blood pressure is normally measured in the brachial artery.artery.

Slide 38Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

QUALITY OF LIFEQUALITY OF LIFE You must protect the right to privacy when You must protect the right to privacy when

measuring vital signs.measuring vital signs. Always keep resident information confidential.Always keep resident information confidential. The right to personal choice is important.The right to personal choice is important.