By: Cindy Quisenberry

VITAL SIGNS

VITAL SIGNS• Vital signs usually include:–Temperature–Pulse (heart rate)–Respirations–Blood pressure (BP)–Some agencies consider “pain” to be a

vital sign (the “5th vital sign”)

VITAL SIGNS• Vital signs reflect three body processes regulation of body

temperature, breathing, and heart function.• A person’s vital signs vary within certain limits. Affected by:

– Sleep– Activity– Eating– Weather– Noise– Exercise– Drugs – Anger– Fear– Anxiety– Pain– Illness

VITAL SIGNS

• Vital signs show even minor changes in the person’s condition.

• Vital signs tell about responses to treatment.

• Vital signs often signal life-threatening events.

VITAL SIGNS• Accuracy is ESSENTIAL when you

measure, record, and report vital signs.– If unsure of your measurements, promptly ask

your instructor, supervisor, etc. to take them again.

• Report at once to your supervisor immediately:– Any vital sign that is changed from a prior

measurement.– Vitals above or below the normal range.

TEMPERATURE

• The amount of heat in the body. It is a balance between the amount of heat produced and the amount lost by the body.– Produced as cells use food for energy– Lost through the skin, breathing, urine, and feces

• Temperature is lower in the morning and higher in the afternoon and evening.

• Measured using the Fahrenheit (F) and Centigrade or Celsius (C).

TEMPERATURE

• Temperature sites are:–Mouth–Rectum–Axilla (armpit)–Tympanic membrane (ear)–Temporal artery (forehead)

TEMPERATURE• Temperature sites are:

– Mouth– Rectum– Axilla (armpit)– Tympanic membrane

(ear)– Temporal artery

(forehead)

• Baseline – 98.6° F– 99.6° F– 97.6° F– 98.6° F

– 99.6° F

• Normal range:– 97.6-99.6° F– 98.6-100.6° F– 96.6-98.6° F– 98.6° F

– 99.6° F

Note:* Older persons have lower body temperatures than younger persons. An oral temperature of 98.6° F may signal fever in an older person.

TEMPERATURE• Types of Thermometers:–Glass – a hollow glass tube with a bulb (tip)

at the end. Device is filled with a substance, when heated the substance expands and rises in the tube.– Electronic – battery powered; temperature

is shown on the front of the device• Oral or rectal probes• Tympanic membrane• Temporal artery

PULSE• The beat of the heart felt at an artery as a

wave of blood passes through the artery. A pulse is felt every time the heart beats.– Temporal– Carotid– Brachial– Radial– Femoral– Popliteal– Posterior tibial– Dorsalis pedis

ADULT PULSE RATE(HEART RATE)

• Heart rate (pulse rate) – the number of heart beats or pulses felt in 1 minute.

• Normal adult heart rate is 60-100 beats per minute.

• A rate of less than 60 or more than 100 is considered abnormal.

• Report abnormal heart rates.

CHILDREN’S HEART RATE• Children > 7 years of age: 70-100

beats/minute• Children 1-7: range of 80-100

beats/minute• Infants: 100-160 beats/minute

HEART RATE• What is Bradycardia?

• What is Tachycardia?

PULSE• Rhythm and Force:–Rhythm should be regular (pulse are felt in a

pattern)• The same time interval occurs between beats.• An irregular pulse occurs when the beats are

not evenly spaced or beats are skipped.– Force relates to pulse strength• A forceful pulse is easy to feel. It is described as

strong, full, or bounding.• Hard to feel pulses are described as weak,

thready, or feeble.

APICAL PULSE

• The apex of the heart is at the tip of the heart, just below the left nipple; felt over the heart.

• This pulse is taken with a stethoscope.• Taken for persons who:– Have heart disease– Have irregular rhythms– Take drugs that affect the heart.

RESPIRATIONS

• Respirations means breathing air into (inhalation) and out of (exhalation) the lungs.

• Each respiration involves 1 inhalation (inspiration) and 1 exhalation (expiration).

• Respirations are normally quiet, effortless, and regular.

• Both sides of the chest should rise and fall equally.

ADULT RESPIRATIONS

• The healthy adult has 12-20 breaths per minute.

• If the rate is above 24 or less than 12, it should be reported.

• Respirations are usually counted right after taking the pulse. (Keep your fingers or stethoscope over the pulse site while counting the respiratory rate.)

CHILDREN’S RESPIRATIONS

• Children’s respiratory rates are slightly faster than those of adults and average 16-30 breaths/minute.

• Infants: 30-50 breaths/minute

RESPIRATIONS

• Check the rate, the character and rhythm of respirations.

• Character refers to the depth and quality of respirations.– Deep– Shallow– Labored– Difficult

RESPIRATIONS• What is Dyspnea?• What is Apnea?• What is Tachypnea?• What is Bradypnea?• What is Orthopnea?• Cheyne-Stokes – abnormal breathing pattern

characterized by periods of dyspnea followed by periods of apnea

• Rales – bubbling, crackling, or noisy sounds caused by fluids or mucus in the air passages

RESPIRATIONS

• Wheezing – difficulty breathing with a high-pitched whistling or sighing sound during expiration; caused by a narrowing of bronchioles (as seen in asthma) and/or obstruction or mucus accumulation in the bronchi

• What is Cyanosis?

BLOOD PRESSURE

• The amount of force exerted against the walls of an artery by the blood.

• The period of heart muscle contraction is called systole.

• The period of heart muscle relaxation is called diastole.

BLOOD PRESSURE

• Systolic pressure is the pressure in the arteries when the heart contracts. It is the higher pressure.

• Diastolic pressure is the pressure in the arteries when the heart is at rest. It is the lower pressure.

BLOOD PRESSURE

• Normal blood pressure – systolic < 120; diastolic < 80• Normal Range – systolic 100-120; diastolic 60-80• Prehypertensive – systolic 120-139; diastolic 80-89• Hypertension Stage 1 – systolic 140-159; diastolic 90-

99• Hypertension Stage 2 – systolic 160 or higher;

diastolic 100 or higher• Hypertensive Crisis – systolic > 180; diastolic > 110

BLOOD PRESSURE

• Prior to taking BP you need the following information:–When to measure BP (VS’s qid?)–What arm to use– The person’s normal BP range–Position of the patient when taking the BP–What size cuff to use

PAIN

• Means to ache, hurt, or be sore. • Pain is a warning from the body. • It differs for each person. What one

person calls sore, another may call aching.

PAIN

• Types of pain–Acute – is felt suddenly from injury, disease,

trauma, or surgery.–Chronic (persistent) – lasts for a long time or

occurs off and on–Radiating – felt at the site of tissue damage

and in nearby areas (ie: myocardial infarction)–Phantom – felt in a body part that is no longer

there

PAIN• Assessment– Location– Onset and duration– Intensity (rate on a scale from 0-10)– Description (ie: stabbing, etc.)– Factors that cause pain – precipitating factors– Factors affecting pain – What makes it better, what

makes it worse?– Vital signs– Other signs and symptoms (ie: dizzy, nauseated,

vomiting, etc.)

PAIN

• Wong-Baker Scale