Vital Signs The most important measurements obtained when assessing a client’s condition. Temperature Pulse Respirations Blood Pressure.

VITAL SIGNS

Vital Signs

The most important measurements obtained when assessing a client’s condition.TemperaturePulseRespirationsBlood Pressure

Body Temperature - defined

Measurement of the balance between heat lost and heat produced in the body

TEMPERATUREThe first assessment taken

Normal adult temp – 98.6°F (37°C) Normal range – 96.8°F to 100.4°F (36.0° - 38.0° C)

Variations may be due to Time of day Allergic reaction Illness/Infection Stress Exposure to heat or cold

TEMPERATUREHigh Temps above 100.4°F (38.0°C)

Documented as febrile (fever)Normal temperature range – afebrile

HyperthermiaTemperatures above 104°F

Death & Convulsions

HypothermiaTemperatures below 95°F

Death

TEMPERATURE SITES

Oral Normal - 98.6°F Range – 97.6 –

99.6°F

AxillaryNormal – 97.6°FRange – 96.6 –

98.6°F

Tympanic

Rectal (most accurate)Normal – 99.6°FRange – 98.6 –

100.6°F

THERMOMETER TYPES

Two basic types –Electronic/Digital – measures temperature

through a probe

Glass – contain mercury in the bulb Rounded tip – rectal use Long tip – oral use Security tip – both oral & rectal assessments

PULSEA wave of blood flow created by contractions

of the heartThe amount of blood pumped from the left

ventricle of the heart to the artery being assessed

Pulse is checked by palpating - to feelOR

Auscultation - listening for sounds

PULSE SITES (points)Named according to bones or other structures

near where they are locatedMost Common Sites

Radial – inside of wrist Brachial –

Adults – antecubital space (bend of the elbow) Children – middle of the inside of upper arm

Apical – auscultated with a stethoscope placed on the chest wall

Pulse Sites (points)Named according to bones or other structures

near where they are locatedOther Sites

Carotid – alongside the trachea toward the ear Temporal – front edge of ears Femoral – in the groin or crease between thigh & abdomen Popliteal – behind the knee, toward the midline Dorsalis pedis – dorsal side of the foot Posterior tibial – behind the medial malleolus

PULSE CHARACTERISTICSPulse assessment characteristics include

Rate – BPM Tachycardia – pulse rate faster than 100 bpm Bradycardia – pulse rate slower than 60 bpm

Normal RagesInfants - 100-160 bpmChildren – 1 to 7 yrs – 80- 110 bpmChildren 7 yrs – 70-90 bpmAdults 60-90 bpm

Pulse CharacteristicsPulse assessment characteristics include

Rhythm – pattern of heartbeats (regularity)Regular or Irregular

Arrhythmia or Dysrhythmia – irregular heartbeat Must be counted for a full minute

Medications Heart dysfunction Lack of oxygen

Pulse CharacteristicsPulse assessment characteristics include

Volume – the strength of the pulse Measurement as it presses against the arterial wall and

against your fingertips when palpating

Rating Scale 0 – Absent, unable to detect 1 – Thready or weak, difficult to palpate, easily

obliterated by light pressure from fingertips 2 – Strong or normal, easily found & obliterated by

strong pressure from fingertips 3 – Bounding or full, difficult to obliterate with fingertips

Pulse CharacteristicsPulse assessment characteristics include

Bilateral Presence – found on both sides of the body; having the same rate, rhythm, and volume

Unilateral – found on one side of the body

RESPIRATIONSThe act of breathing; the exchange of oxygen

and carbon dioxide from the air into the lungsBreathing in – inspiration & Breathing out – expirationAssessment

Rate Rhythm Quality

Respiratory RateObserving the client’s chest movement for one

minute

RespirationsRespiratory Rate – the number of breaths per

minute – counted for one full minuteSuggested normal rates – 12 – 20

breaths/minute

Ventilation – movement of air in & out of lungsHyperventilation – increased respiratory rate

Hypoventilation – decreased respiration rate

RespirationsRespiratory Rhythm

Should be regular

Abnormal respiration – Cheyne-StokesPeriods of dyspnea followed by periods of

apnea

RespirationsQuality of respiration is seen in volume &

effortVolume – the amount of air taken into the lungs

and exhaled from the lungs Documented as shallow or deep

Effort – the amount of work the client uses in order to breath

Muscle use seen in the neck, chest & abdomen is an indication of labored or difficult breathing

Measuring MethodsIf using a mercury thermometer,

measure the pulse and respiration while waiting for the temperature

If using another method of measuring the temperature, complete the temperature - then measure the pulse and respiration

Keep your fingers on the pulse while measuring the respiration

BLOOD PRESSUREBlood Pressure – the amount of pressure or

tension exerted on the arterial walls as blood pulsates through themSystolic pressure – the pressure exerted on the

arteries during the contraction phase of the heartbeat

Diastolic pressure – the resting pressure on the arteries as the heart relaxes between contractions

Measured in millimeters (mm) of mercury (Hg)

Blood PressureNormal Systolic readings

Between 100-140 mm Hg

Normal Diastolic readingsBetween 60-90 mm Hg

Prehypertension ReadingsSystolic – 120-139 mm HgDiastolic – 80-89 mm Hg

Blood Pressure ReadingsAmerican Heart Association recommendations

Patient should sit quietly for at least 5 minutes before the B/P is taken

Two separate readings should be taken and averaged

Minimum wait of 30 seconds between readings

BLOOD PRESSURE SITESBlood pressure can be obtained from any

artery. Need a pulse site

Safest & most convenient sitesBrachial – most common for routine VS for

adults/childrenRadial – possible site for infants or clients with

very large upper armsPopliteal/Femoral – behind the knee/thigh –

used because of trauma, disease, medical treatments to the arm, or recent mastectomy

Dorsalis pedis/Posterior Tibial – lower leg – common use for infants

BLOOD PRESSURE EQUIPMENTSphygmomanometer – the instrument used to

measure BP sphygmo – pulse mano – pressure meter – measure

Commonly referred to as the BP cuff

Types of SphygmomanometersMercuryAneroidElectronic (no stethoscope needed)

VITAL SIGNS PROCEDURESPerform the least invasive first

Invasive – invading someone’s personal space or inserting a needle into the skin

Noninvasive – actions that do not intrude – a simple observation

TemperaturePulseRespirationBlood Pressure

Vital Sign ProceduresDocumentation & Reporting

Check on the chart for VS or T P R BPAlways record in this order

98.6 – 72 – 16 – 145/69Always report information to the supervisor if it

falls outside of the normal range for the client or if the VS is significantly different from the previous recorded result