Vital SignsChapter 15

Vital Signs

• Various factors that provide information about the basic body conditions of the patient

• 4 Main Vital Signs1. Temperature

2. Pulse

3. Respirations

4. Blood Pressure

Other Vital Signs

• Pain• Scale 0 to 10

• Patients are asked to rate their level of pain on the 0-10 scale (relative to the patient)

• Skin Color• Size of pupils and reaction to light• Level of consciousness• Patient’s response to stimuli• Pulse oximeter reading

Temperature

• A measurement of the balance between heat lost and heat produced

• Measured:• Oral (O)• Rectal (R)• Axillary (Ax)• Aural (ear) (T)

• aka tympanic• A low or high reading can indicate disease

Temperature

• Normal range 96.6 to 100.6 F depending on route used• Individuals have different body temperatures• Time of day

• Lower in am, after resting• Higher in the pm or after activity or food intake

• Parts of the body vary• O – 98.6• R – 99.6• Ax – 97.6

Temperature

• Hypothermia – body temp < 95 F rectally• Death usually occurs if temp < 93 F

rectally

• Hyperthermia – body temp > 104 F rectally• Prolonged exposure will cause brain

damage or serious infection• > 106 F will lead to convulsions, brain

damage, or death

Temperature

• Clinical thermometer• Red – rectal• Blue – oral or axillary

Pulse

• The pressure of the blood felt against the wall of an artery as the heart contracts and relaxes

• RATE - # of beats per minute• RHYTHM – refers to regularity• VOLUME – refers to strength

Pulse

• Usually taken on the radial or carotid artery• Pulse is taken on an artery

• Temporal – sides of forehead• Carotid – sides of the neck• Brachial – inner aspect of forearm• Radial – inner aspect of the wrist• Femoral – inner aspect of the upper thigh• Popliteal – behind the knee• Doralis Pedis – top of the foot arch

Pulse

• Bradycardia – pulse < 60 bpm• Tachycardia – pulse > 100 bpm

• (except in children)

• Normal Ranges:• Newborn baby - 120 to 160 bpm• Baby aged from 1 to 12 months - 80 to 140 bpm• Baby/toddler aged from 1 to 2 years - 80 to 130 bpm• Toddler/young child aged 2 to 6 years - 75 to 120 bpm• Child aged 7 to 12 years - 75 to 110 bpm• Adults – 60-100 bpm

Respirations

• Normal ranges:• Adults: 12-20 breaths per minute• Newborns up to 6 months old: 30-60 breaths per minute• Infants 6-12 months old: 24-30 breaths per minute• Toddlers and Children 1-5 years old: 20-30 breaths per

minute• Children 6-12 years old: 12-20 breaths per minute• Adults: 12-20 breaths per minute

Respirations

• 1 breath consists of 1 inspiration and 1 expiration

• Dyspnea – difficult or labored breathing• Apnea – absence of respirations• Tachypnea – RR > 20 bpm• Bradypnea – RR < 12 bpm• Orthopnea – severe dyspnea in which breathing is very

difficult in any position other than sitting erect or standing

• Respirations should be counted in a way that the patient is unaware of the procedure

Blood Pressure

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

• BP is read in mm of Hg• Medical name: Sphygmomanometer• SYSTOLIC:

• Top number in reading• Normal range 100 to 120 mm Hg

• DIASTOLIC:• Bottom number in reading• Normal range 60 to 80 mm Hg

Blood Pressure

Height and Weight

• They are important because they provide necessary information in performing and evaluating:• Lab tests• Calculating dosages of medication• Monitor patients who have cancer and are on

chemotherapy• Monitor patients who have edema (swelling) due to

heart, kidney, or other diseases

Height and Weight

• For those patients who require daily weights:• Use the same scale each day• Make sure the scale is balanced

before weighing a patient• Weigh the patient at the same time

each day• Make sure the patient is wearing

the same amount of clothing each day

Balance Beam Scale Bed Scale Chair Scale

Wheelchair Scale Infant Scale

Pulse Oximeter

• Normal is over 96% O2 saturation• Levels below 96% can indicated a respiratory or

cardiovascular abnormality (congenital heart disease, sickle cell anemia, asthma, etc)