chapter 18 vital signs copyright © the mcgraw-hill companies, inc

Chapter 18Vital Signs

Vital Signs

most important measurements you will obtain when you evaluate or assess a client’s condition.

Temperature

Body temperature (T) is one of the first assessments done.

Temperature Ranges– Normal adult temperature is 98.6ºF, or 37ºC.– Normal range can be from 96.8ºF to 100.4ºF,

or 36ºC to 38ºC.

Temperatures can vary due to:

Time of day.Allergic reaction. Illness.Stress.Exposure to heat or cold.

Temperature Sites

Oral – within the mouth or under the tongue.

Axillary – in the armpit. Tympanic – in the ear canal. Rectal – through the anus, in the

rectum. Other sites include on the skin or in

the blood.

A wave of blood flow created by a contraction of the heart.

Name these pulses.Click HERE to check answers.

Pulse Sites

A. Temporal

B. Femoral

C. Popliteal

D. Posterior tibial

E. Carotid

F. Brachial

G. Radial

H. Dorsalis pedis

Characteristics of the Pulse

Pulse Rate– Assessed as beats per minute, or BPM. – Counted for 30 seconds.– Tachycardia – a pulse rate faster than

normal.

– Bradycardia – a pulse rate slower than normal.

Pulse Rhythm – the pattern of the heartbeats.– Measure for one for minute if

irregular.– When documenting pulse

rhythm, record as regular or irregular. Click Pictures for Click Pictures for

SoundsSounds

RhythmRhythm

RegularRegular

IrregularIrregular

Respiration

Respiration (R) is the act of breathing. Respiratory Rate (RR)

– Observe the client’s chest movement upward and outward for a complete minute.

– Children under 7 years of age use abdominal breathing.

– Auscultation with a stethoscope may be necessary on clients who are aware that you are counting their respiratory rate.

Characteristics of Respiration

Rate of Respiration – the number of breaths per minute.– Normal range is 12 to 20 breaths per

minute for an adult.– Rate will vary with age and size of client.

An increased respiratory rate is called hyperventilation.

A decrease in respiratory rate and depth is called hypoventilation.

Rhythm of Respiration – should be regular.

Quality of Respiration– Can be shallow or deep.

Blood Pressure

Blood pressure (BP) is the pressure or tension exerted on the arterial walls as blood pulsates through them.

Systolic blood pressure (SBP) – pressure exerted on the arteries during the contraction phase of the heartbeat.

Diastolic blood pressure (DBP) – the resting pressure on the arteries as the heart relaxes between contractions.

Blood Pressure (cont.)

Expected Blood Pressure Values– Expected SBP – 100 to 140 mm Hg.– Expected DBP – 60 to 90 mm Hg.– Hypotension – when the blood pressure

drops below expected levels. – Hypertension – high blood pressure.– Prehypertension – classified by the

American Heart Association as SBP 120 to 139 mm Hg or DBP 80 to 89 mm Hg.

Apply Your Knowledge

Where would one measure tympanic temperature?

Answer:

Tympanic temperature is measured in the ear canal.

Vital Signs Procedures

Order of Performance

Perform the least invasive vital sign first.

Use this order if possible:– Respiratory rate.– Pulse.– Temperature.– Blood pressure.

Documenting and Reporting

Check for common abbreviations in chart. – VS (vital signs)– T P R BP (temperature, pulse, respiratory

rate, blood pressure) – RR (respiratory rate)

Record results properly. Report information to your supervisor.

– Vital signs outside the expected range.– Vital signs significantly different from

previous results.

Apply Your Knowledge

List the order for taking vital signs.

Answer:1. Respiratory rate.2. Pulse.3. Temperature.4. Blood pressure.

Patient Patient AssessmentAssessmentMeasuring Pulse & RespirationMeasuring Pulse & Respiration

ObjectivesObjectives

Students will:– Identify normal and abnormal V/S measurements.– Measure and record vital signs according to industry

standards.– Measure and record height and weight according to

industry standards.– Explain why urine, stool, and sputum specimens are

collected.– Explain the rules for collecting different specimens– Describe the seven warning signs of cancer

Vital SignsVital Signs

Are important indicators of health Detect changes in normal body function May signal life-threatening conditions Provide information about responses to

treatment

Temperature Pulse Respirations Blood Pressure

Vital Signs Are Measured:Vital Signs Are Measured:

– Upon admission – As often as required by the person’s condition– Before & after surgery and other procedures– After a fall or accident– When prescribed drugs that affect the respiratory or

circulatory system– When there are complaints of pain, dizziness,

shortness of breath, chest pain– As stated on the care plan

When Measuring Vital SignsWhen Measuring Vital Signs

Usually taken with the person sitting or lying The person is at rest Always report:

– A change from a previous measurement– Vital signs above or below the normal range– If you are unable to measure the vital signs

PulsePulse

The pressure of blood pushing against the wall of an artery as the heart beats and rests.

Measured for one minute while noting:– rate - beats per minute– rhythm - regular or irregular– volume - strength or intensity - described as

strong, weak, thready, bounding

Rhythm and Force of the pulse

Rhythm-time interval between each beat, Rhythm should be regular. Irregular pulse- beats are not everly spaced or when beats are skipped

Force-related to pulse strengh

Pulse SitesPulse SitesMost Commonly Used:

Carotid – during CPR Apical – use stethoscope Brachial – for Blood Pressure Radial - to count pulse Femoral – assessment and

procedures Popliteal – assessment Dorsalis Pedis – assessment

Normal RangesNormal Ranges

Age Pulse per Minute

Birth to 1 year 80-190

2 years 80-160

6 years 75-120

10 years 70-110

12 years & older 60-100

Bradycardia – Under 60 beats per minuteTachycardia – Over 100 beats per minute

Factors that Affect PulseFactors that Affect Pulse

Factors that pulse

Exercise Stimulant drugs Excitement Fever Shock Nervous tension

Factors that pulse

Sleep Depressant drugs Heart disease Coma

Taking a Pulse

The radial pulse is used for routine vital signs

It is felt by placing the first two or three fingers of one hand against the radial artery.

Count the pulse for one minute.

RespirationsRespirations

Process of breathing air into (inhalation) and out of (exhalation) the lungs.

(Respiration Rate) Oxygen enters the lungs during inhalation. Carbon dioxide leaves the lungs during exhalation. The chest rises during inhalation and falls during

exhalation.

Normal rate 12-20 breaths per minute

Assessing RespirationAssessing Respiration

Respirations is measured when the person is at rest.

Rate may change is patient is aware that it is being counted.

To prevent this, count respirations right after taking a pulse.

Keep your fingers or stethoscope over the pulse site.

To count respirations, watch the chest rise and fall.

Assessing RespirationAssessing Respiration Character and quality of respirations is also assessed:

– Deep (diaphragmatic breathing) – Shallow (hypopnea)– Labored or difficult ( dyspnea)– Noises – wheezing, stertorous (a heavy, snoring type of sound)– Moist or rattling sounds

Apnea – absence of respirations Cheyne-Stokes – periods of dyspnea followed by periods of apnea;

often noted in the dying patient Rales – bubbling or noisy sounds caused by fluids or mucus in

the air passages

Patient AssessmentPatient AssessmentMeasuring BP, Ht and WtMeasuring BP, Ht and Wt

ObjectivesObjectives

Students will:– Identify normal and abnormal V/S measurements.– Measure and record vital signs according to industry

standards.– Measure and record height and weight according to industry

standards.– Explain why urine, stool, and sputum specimens are collected.– Explain the rules for collecting different specimens– Describe the seven warning signs of cancer

Are important indicators of health Detect changes in normal body function May signal life-threatening conditions Provide information about responses to

treatment

Temperature Pulse Respirations Blood Pressure

Vital Signs Are Measured:Vital Signs Are Measured:

– Upon admission – As often as required by the person’s condition– Before & after surgery and other procedures– After a fall or accident– When prescribed drugs that affect the respiratory or

circulatory system– When there are complaints of pain, dizziness,

shortness of breath, chest pain– As stated on the care plan

When Measuring Vital SignsWhen Measuring Vital Signs

Usually taken with the person sitting or lying The person is at rest Always report:

– A change from a previous measurement– Vital signs above or below the normal range– If you are unable to measure the vital signs

Blood PressureBlood Pressure Measure of the pressure blood exerts on the walls

of arteries

Blood pressure is controlled by:– The force of heart contractions

weakened heart drop in BP– The amount of blood pumped with each heartbeat

loss of blood drop in BP– How easily the blood flows through the blood vessels

Narrowing of vessels increase in BP Dilatation of vessels decrease in BP

Factors that Affect Blood PressureFactors that Affect Blood Pressure

Factors that blood pressure

Excitement, anxiety, nervous tension

Stimulant drugs Exercise and eating

Factors that blood pressure

Rest or sleep Depressant drugs Shock Excessive loss of blood

Measuring BPMeasuring BP

A sphygmomanometer is used to measure BP– Aneroid – has a round dial and needle– Mercury – has a column of mercury– Electronic – automated device

BP is measured in millimeters (mm) of mercury (Hg).

The systolic pressure is recorded over the diastolic pressure.

Contraindications for Taking BPMeasurement of BP at the brachial artery is a generally

benign procedure. However, there are some circumstances in which obtaining readings from a particular arm my not be appropriate:

-Presence of an arterial-venous shunt-Recent axillary node dissection-Any deformity or surgical history that interferes with proper

access or blood blow to the upper arm.If these relative contraindications are present, BP should be

assessed in the opposite arm. There may also be pre-existing conditions that can interfere with the accuracy or interpretation of readings, such as aortic coarctation, arterial-venous malformation, occlusive arterial dz, or the presence of an antecubital bruit. If neither arm can be used, then measurement of blood pressure in a leg may be indicated.

Normal Range of Blood PressureNormal Range of Blood Pressure

Systolic: Pressure on the walls of arteries when the heart is contracting.

Normal range – less than 120 mm Hg Diastolic: Constant pressure when heart is at rest

Normal range – less than 80 mm Hg

Hypertension—BP that remains above a systolic

of 140 mm Hg or a diastolic of 90 mm Hg Hypotension—Systolic below 90 mm Hg and/or

a diastolic below60 mm Hg

Measuring Height and WeightMeasuring Height and Weight

Used to determine if patient is underweight or overweight

Height and weight charts are used as averages Weight greater or less than 20% considered normal

BMI or Body Mass Index a statistical measure of body weight based on a person's weight and height.

BMI from 18.5 to 24.9 is considered normal

Measuring Height and WeightMeasuring Height and WeightGeneral Guidelines:

Use the same scale every day Make sure the scale is balanced before use Weigh the patient at the same time each day Remove jacket, robe, and shoes before weighing OBSERVE SAFETY PRECAUTIONS! Prevent injury from falls and the protruding height lever. Some people are weight conscious. Make only positive comments when weighing patients

Types of Scales

Clinical scales contain a balance beam and measuring rod.

Bed scales or chair scales are used for patients unable to stand

Infant scales come in balanced, aneroid, or digital.– When weighing an…keep slightly over but not touching

the infant.– A tape measure is used to measure infant height.

Converting Weight to Metric Measurement

To convert multiply by:

Grams to ounces 0.0353

Grams to pounds 0.0022

Kilograms to pounds 2.2046

Ounces to grams 28.35

Pounds to grams 453.592

Pounds to Kilograms 0.4536

Converting Height

Converting inches to centimeters is simple…just take the number of inches and multiply it by 2.54. So for example, 8 inches would be 20.3 cm (8 x 2.54= 20.3)

20.3 / 2.54 = 7.99 1foot = 12 inches

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