Measuring and recording vital signs

Temperature- Pulse- Respiration and Blood pressure

Temperature

• Temperature is a measurement of the balance between heat lost and heat produced in the body.

• Temperature may be measured in the mouth (oral), rectum (rectal), armpit (Axillary), or ear (aural/tympanic) temporal (artery)

• Normal temperature is 97 to 100 degrees Fahrenheit.

• Above 101 F indicates fever

Oral

• Mouth under tongue• Use to be the most common• Clean thermometer or dispose of sheath

after each use

Rectal • Rectum• Internal measurement • Most accurate• Insert 1-11/2 inches • Have pt lie on left side with right knee bent up.

Infants on their back• Avoid exposure• Lubricate thermometer

Axillary

• Armpit/ close to body between skin folds• Groin between skin folds of inner thigh and

lower abdomen. • Less accurate

Aural/ Tympanic

• In the ear or auditory canal• Special thermometer measures the

thermal infrared energy radiating from the blood vessels in the tympanic membrane or eardrum

• Less than 2 seconds

Temporal Artery

• Taken over the forehead and down the side of temporal area.

• Measures the temperature in the temporal artery …..similar to rectal

• Research shows more accurate

Fahrenheit and Celsius

• Most temperatures are measured in Fahrenheit, however, it may be necessary to convert to Celsius.

• To convert Fahrenheit to Celsius subtract 32 from the Fahrenheit temperature and then multiply the result by 0.5556. Example to convert 98.6 F to Celsius you subtract 32 from 98.6 which leaves 66.6 and multiply by 0.5556 which equals 37 degrees Celsius.

• To convert Celsius to Fahrenheit you multiply the temperature by 9/5 or 1.8 and then add 32

Hypothermia

• Low body temperature is called hypothermia

• Temperature below 95 degrees F measured rectally

• If below 93 rectally for extended period death may occur.

• Caused by starvation, sleep, mouth breathing, exposure to cold

Hyperthermia

• Elevated temperature above 104 degrees F rectally

• Above 106 can lead to convulsions and brain damage..

• Causes : infection, exercise, excitement

Recording temperature

• Different thermometers used• Record accurately with type of temp.• 98.6 ® or 98.6(Ax) or 98.6 (A) 98.6 (TA)• If taken orally no need to indicate/

understood• Eating /drinking/smoking can alter temp• Wait 15 minutes

Pulse

• Pulse is the pressure of the blood felt against the wall of an artery as the heart contracts and relaxes.

• The rate rhythm and volume are measured and recorded.

• Rate refers to the number of beats per minute

• Rhythm refers to the regularity of the beat• Volume refers to the strength of the beat

Pulse sites

• Temporal- at the side of the forehead• Carotid- at the neck• Brachial- crease of the elbow/inner aspect of

forearm• Radial- inner aspect of wrist, above thumb• Femoral- inner aspect of the upper thigh• Popliteal- behind the knee• Dorsalis pedis- at the top of the foot arch • ( pulse is usually taken over the radial artery)

Ranges

• Adults- 60-100• Children aged over 7 years: 70-100• Children aged 1-7: 80-110 • Infants 100-160• Bradycardia: under 60• Tachycardia: over 100 except children

Arrythmia

• Irregular or abnormal rhythm • Usually caused by a defect in the electrical

conduction system of the heart• Strength observed also: strong, weak

thready or bounding• Various factors affect pulse• Drugs, excitement, fever, exercise

Recording pulse

• Palm turned down• Use tips of first two or three fingers• Locate pulse on the thumb side of wrist• Do not use your thumb• Locate pulse and exert slight pressure and

begin counting for a full minute and record• Note rate, rhythm, volume, date and time

when recording

Apical pulse

• Taken with a stethoscope over the apex of the heart• Two sounds heard: lubb-dupp• One heart beat• Sounds caused by closing of the heart valves as the

heart beats and blood flows thru the chambers of the heart

• Pulse deficit is the difference between the apical rate and the radial rate

• Caused by heart disease not enough blood being pumped thru the heart to produce a pulse

• Place stethoscope 2-3 inches to the left of the breastbone below the nipple line

Respiration

• Rate that a person breaths during process of taking oxygen into the lungs and expelling carbon dioxide

• Count for one minute by observing rise and fall of the chest with each breath

• Also check regularity and character.• Normal range is 12-20• Children range is 16-30• Infants 30-50• Do not make pt aware that you are recording

respiration.

Character of respirations• Deep, shallow, labored, moist and difficult• Abnormal respirations usually indicate lung problems• Dyspnea- difficult breathing• Apnea- absence of breathing• Tachyapnea- >25 breaths per minute• Bradyapnea- <10 breaths per minute • Orthopnea- difficult breathing in any position other than

erect or standing• Cheyne –Stokes- periods of dyspnea followed by periods

of apnea (frequently noted in the dying pt)• Rales- bubbly or noisy sounds caused by fluid or mucus

in the air passages• Wheezing – high pitch sounds• Cyanosis -dusky bluish color of the skin and lips

Blood pressure

• Measurement of the pressure that the blood exerts on the walls of the arteries during various stages of heart activity

• Read in millimeters of mercury• Sphygmomanometer • Two types of blood pressure: systolic and

diastolic.

Systolic blood pressure

• Pressure occurs in the walls of the arteries when the heart is contracting and pushing blood into the arteries

• Normal reading is 120• Range: 100-120

Diastolic blood pressure

• Pressure that is constant against the walls of the arteries when the heart is at rest and between contractions.

• Blood volume in the arteries has decreased

• Normal reading is 80• Range is 60-80

B/P

• Pulse pressure is the difference between the systolic and diastolic pressure

• Normal range is 30-50• Hypertension: high blood pressure >140/90. Causes;

stress, anxiety, disease of kidney or thyroid, obesity • Hypotension: low blood pressure<100/60. causes; heart

failure, dehydration, depression, severe burns, shock and bleeding .

• Other factors influencing B/P are: disease, excitement, drugs, exercise, rest/sleep, positioning

Prehypertension

• 120- 139/ 80-89• Hypertension is called the silent killer • Factors that may influence B/P are: sleep,

meds, exercise, force of the heart beat, elasticity of the arteries, hemorrhage, shock, dehydration

• Orthostatic hypotension—sudden drop from sitting to standing—inability of blood vessels to compensate quick enough

Taking a blood pressure reading• Place pt in comfortable position• Place appropriate size cuff on patients arm between

shoulder and 1-1.1/2inches above the elbow and over the brachial artery

• Find the brachial artery and place the stethoscope over the artery

• Inflate the cuff to approximately 160mm Hg or 30 mm Hg above the palpatory pulse.

• Slowly release the air from the cuff and note the first sound on the manometer and this is your systolic pressure.

• Note when the sound stops and this is your diastolic reading. At this point release the air quickly from the cuff.