Unit 14 Vital Signs

Janet. J. Nelson RN, CMA

14:1 Measuring and Recording Vital Signs (VS)

2

Main vital signs (VS) Temperature Oral Rectal Axillary Temporal Tympanic Pulse
Rate Rhythm Volume

oRespiration
Rate Rhythm Character

oBlood pressure
Systolic diastolic

Other Assessments
3

Pain patients asked to rate on scale of 1 to 10 (1 is

minimal and 10 is severe) Pulse oximetry Color of skin Size of pupils and reaction to light Level of consciousness Response to stimuli

VS Readings
4

Accuracy is essential Report abnormality or change immediately If unable to get reading, ask another person to check

14:2 Measuring and Recording Temperature 5

Measures balance between heat lost and heat

produced in the body

Heat produced by metabolism of food and by

muscle and gland activity

Homeostasis: constant state of fluid balance Conversion between Fahrenheit and Celsius
Where

do you find the formulas???

Variations in Body Temperature

6

Normal range What can causes of variations? Increase/decrease Temperature measurements oral, rectal, axillary or

groin, tympanic and temporal

NORMAL TEMPERATURES
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ORAL 98.6 degrees =/- 1 degree RECTAL 99.6 =/- 1 degree AXILLARY 97.6 =/- 1 degree TYMPANIC core temperature but thermometer can be set to read

as oral, rectal

TEMPORAL SCAN core temp (same as rectal)

ABNORMAL CONDITIONS
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Hypothermia Fever Intermittent Remittent Relapsing Constant Hyperthermia

Thermometers
Clinical thermometers Glass Electronic Tympanic Temporal Scan Plastic or paper
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Reading thermometers and recording results Date Time in military time (no colons) T & Temperature. Fly the fraction Indicate if it is R, Ax, T, or TA

Thermometers

(continued)
10

Avoid factors that could alter or change temperature

Wait 15 minutes for oral temp

THINGS TO REMEMBER WITH TEMPS

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ORAL- Check eating, drinking, smoking. It is understood

the temp is oral unless otherwise indicated.

RECTAL-Insert electronic thermometer -3/4 inch for

peds and 1 inch for adult. Pt to lie on left side (Sims) Never with bradycardia. Record with a R. What are some contraindications for rectal temp?
AXILLARY-Dry axillary area. Record with AX

When would you use axillary temp?

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TYMPANIC (Aural) TEMPERATURES

12

Ear canal is not straight. You need to straighten the

ear canal in an adult by pulling up & back on the ear.

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Infant Tympanic Temps.

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An infants ear needs to be pulled straight back REMEMBER that earwax (cerumen) can obstruct

the infrared rays coming from the tympanic membrane

Hearing aides need to be removed and wait 20 min.
If bathing or swimming wait 20 min

Copyright 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.

TEMPORAL ARTERY TEMPERATURES

14

High-resolution

infrared image of a persons temporal artery being scanned with the TAT-5000 Temporal Artery Thermometer. The measurement is obtained by swiping the thermometer probe across the forehead and behind the ear.
Copyright 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.

14:3 Measuring and Recording Pulse

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Pressure of the blood

pushing against the wall of an artery as the heart beats and rests. Major arterial or pulse sites Pulse rate Adults 60-90 Child (>7yr) 72-90 Child 1-7yr 80-120 Infant 90-140

Measuring and Recording Pulse (continued)

Pulse volumeWhat does this mean? Bounding Thready Factors that change pulse rateLike what? Basic principles for taking radial pulse
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Recording information: Date, time (military), P

rate, any abnormalities, your first initial, last name & title. Pulse Tachycardia

Bradycardia

14:4 Measuring and Recording Respirations

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Measures the inspiration and expiration= one breath Normal respiratory rate. What cause this to vary? Adults 14-18 (20) Rhythm : o Dyspnea Apnea Cheynes Stokes Tachypnea Bradypnea
Copyright 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.

Measuring and Recording Respirations

(continued)
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Character of respirations Rales Hyperventilation Hypoventilation Orthopnea Wheezing RESPIRATIONS ARE UNDER VOLUNTARY

CONTROL.So what does that mean? Record information; date, time (military), R rate, any abnormalities, your first initial, last name and title.

14:5 Graphing TPR

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Graphic sheets are special records used for recording

TPR Presents a visual diagram Uses Color codes Factors affecting VS are often noted on the graph

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Graphing TPR

(continued)
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Graphic charts are legal records To correct an error Basic principles for completing

14:6 Measuring and Recording Apical Pulse

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Pulse count taken at the apex of the heart Reasons for taking an apical pulse Protect the patients privacy and

avoid exposure Heart sounds Abnormal sounds or beats

Measuring and Recording Apical Pulse

(continued)
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Pulse deficit Use the stethoscope Placement of stethoscope

Measuring apical pulse

Record all information

14:7 Measuring and Recording Blood Pressure

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Measurement of the pressure the blood exerts on the

walls of the arteries during the various stages of heart activity Measured in millimeters of mercury on an instrument called a sphygmomanometer Measurements read at two points
http://www.pennmedicine.org/encyclopedia/em_DisplayAnimation.as

px?gcid=000013&ptid=17

Measuring and Recording Blood Pressure (continued)

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Systolic pressure Diastolic pressure Pulse pressure

Hypertension high blood pressure

Hypotension low blood pressure Factors influencing

blood pressure readings

NEW RECOMMENDATIONS FROM AHA

SYSTOLIC LESS THAN 120 DIASTOLIC LESS THAN 80

Measuring and Recording Blood Pressure (continued)

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Individual factors can all influence blood pressure

readings Blood pressure is recorded as fractions Types of sphygmomanometers

Mercury Aneroid Electronic

Manometers

Measuring and Recording Blood Pressure (continued)

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Factors to follow for accurate readings Pt sit quietly with arm at heart level Width of cuff about same diameter as arm Support forearm on surface Do NOT use thumb on stethoscope Place stethoscope medial antecubital space Cuff on bare skin Determine plapatory systolic pressurewait 30-60sec and blow up to +30 mm/Hg Record all required information. Write BP in fraction.

Do not reveal the reading to the patient

How many errors can you find in this picture?

Procedure for BP
ID patient and explain procedure

Obtain palpatory systolic pressure

Wait 30+ sec Inflate cuff 30 mm/Hg over palpatory systolic

pressure. Listen and remember the first number you hear and last number you hear. In case of a child the diastolic is the where the sound changes. Finish with patient and record date, time, BP systolic/diastolic, name and title.