Vitals

Vital Signs include• Temperature• Pulse• Respiration• Blood Pressure• Skin Color• Level of Consciousness• Pupil Size, Reactivity &

Trackability

Vital signs are interdependent of each other because a change in one will affect another. Like a rise in temperature will increase respiration rate.

Temperature

Temperature is one way we can determine the body’s level of homeostasis & refers to temperature inside the body or core body heat.

TemperatureFour of the most commonly used routes measured are:

1. Oral2. Rectal3. Axillary4. Tympanic

Temperature

Several types of thermometers

1. Electronic/Digital2. Glass /Mercury3. Clinical

Normal Temperature Ranges

1. Oral 97.6 degrees F. – 99.6oF.• Most common site to measure tempt.

2. Axillary 96.6 degrees F. – 98.6oF.• Least accurate site measured3. Rectal 98.6 degrees F. – 100.6oF.• Most accurate site to measure tempt.

Reading Glass Thermometer

1. By degree and tenth of a degree

2. Place thermometer at eye level and look for silver line of mercury

3. Never place fingers on bulb of thermometer as this might change the value.

4. The short lines = .2oF5. The long lines = 1oF

Color Coding Thermometers

1. Probes for electronic and mercury-free ends are color coded for route.

2. Red = rectal; Blue = oral/axillary3. If no color present, the route will be written on the thermometer

Using a Thermometer

1. Use protective cover on each type of thermometer

2. Tympanic probe placed in ear canal.

3. Rectal thermometer or probe placed in rectum one inch with lubrication applied before insertion.

4. Oral thermometer placed in mouth under the tongue

Oral Thermometer Use5. Do not take oral temperatures on• a. preschool children• b. patients with oxygen• c. delirious, confused, disoriented patients• d. comatose patients• e. patients with nasogastric tubes in place• f. patients who have had oral surgery• g. patients who are vomiting or are

nauseated

Rectal Thermometer Use

6. Do not take rectal temperatures on• a. infants or children unless a core temperature is needed• b. patients who have had rectal surgery• c. combative patients

Duration of Taking Temperature

1. Tympanic – a couple of seconds – long

2. Oral and rectal (glass thermometer) – three minutes.

3. Axillary glass thermometer) – 10 minutes

4. Electronic temperatures – when beep sounds, temperature is obtained

Abnormal temperatures

1. Fever (febrile), hyperthermia all indicate someone has an elevated temperature (greater than 100oFahrenheit).

2. High fever would include anything over 103o Fahrenheit.

3. Moderate fever would include anything 100 – 103oFahrenheit.

4. Hypothermia is subnormal temperature. This can be equally problematic for a person. Anything under 96oFahrenheit would indicate hypothermia.

PulseA. Pressure against the arterial walls when

heart is contracting or relaxing.B. Can feel at points where the artery is

between finger tips and a bony area.C. These areas are called pulse points and

include:1. Temporal 2. Carotid3. Apical 4. Brachial5. Radial 6. Femoral7. Popliteal 8. Dorsal Pedalis9. Mandibular 10. Posterior Tibial

Pulse•D. Measured by index & middle, or middle & ring fingers over pulse point.• E. Do not take with the thumb, since it has a pulse of its own.• F. Count for 30 seconds and multiply by 2, or count for 60 seconds

Pulse

•G. Normal range is 60 – 100 beats per minute. The pulse should not constantly remain @ 90-100 bpm.•H. > than 100 = tachycardia• I. < than 60 = bradycardia

Quality of pulse is determined as well as

rate1. Rhythm – regular or irregular

2. Strength – Bounding or thready

Circumstances affecting pulse rate

1. Body temperature 2. Emotions

3. Activity level 4. Health of heart

5. Age 6. Sex7. Medications 8. Illness9. Shock 10. Bleeding11. Sleep

How to take a pulse

• How to take a pulse

Perfusion

L. Perfusion is the flow of blood throughout the body. Someone with sufficient perfusion has a strong enough heart beat to adequately oxygenate the body.

Respiration

• A. Each breath includes inspiration and expiration.• B. Measure by observing chest

rise and fall.• C. Measured in breaths per

minute.• D. Normal Adult range = 12-20

breaths per minute.

Respiration

E. > than 24 = tachypnea – if breathing in great depth then called hyperpnea

F. < than 12 = bradypneaG. Difficulty in breathing is called dyspneaH. Quality of breathing is determined as well as

the rate of breathing:1. Depth 2. Clarity of breath sounds3. Pain with breathing4. Difficulty breathing – use of accessory

muscles – sternocleidomastoid, intercostals or trapezius.

Croup

• http://www.youtube.com/watch?v=nmJzDicuPc4

• Http://www.youtube.com/watch?NR=1&v=jJTYLxS662w

Pertusis

http://www.youtube.com/watch?v=3akJVesMdvs&feature=related

Clinical presentation of Whooping Cough – YouTube

Stridor

• http://www.youtube.com/watch?v=1Enq2BvX9aw

• http://www.youtube.com/watch?v=obR9Y3Srplg&feature=related

Cheyene-Stokes

• http://www.youtube.com/watch?v=CrKfmfuP9l4

• ED Sing-a-Long: Cheyne-Stoking - YouTube

Rales, Rhonci & Wheezing

• http://www.youtube.com/watch?v=0Q6J0ybSuNo

• Adventitious Breath Sounds – YouTube

How to take respiration rate

• http://www.ehow.co.uk/video_4961828_measure-record-respiratory-rate.html

Procedure for taking TPRs

A. If using glass thermometer, insert the thermometer. If axillary or rectal-hold the thermometer throughout the time. If oral, insert the thermometer and proceed to take the pulse and respiration.

B. If using electronic – take the temperature first, then proceed to the pulse and respiration

Procedure for taking TPRs

C. When taking the pulse and respiration, do not drop the wrist until both the pulse and respiration are taken. This way the person does not know when

his/her respirations are being measured – insuring a more accurate measurement.

D. When measuring axillary temperature, remove any clothing that could impede the accuracy of the temperature. Also clean the axilla if there is excessive deodorant or perspiration present.

Procedure for taking TPRs

E. When measuring the rectal temperatures, always lubricate the thermometer with water-soluble gel before inserting into the rectum.

F. Never touch the bulb end of the thermometer with the fingers.

Charting TPR

Do not write T =, P =, etc., simply 98.6 – 84 – 22.

Instruct on the correct reading of a glass thermometer

A. Read between the markings and numbers.

B. Large lines indicate full degrees.

C. Small lines are two-tenths of a degree.

Complete Graphing TPR activity

Blood Pressure

BP = The measurement of the force of blood against artery walls.

1. Force comes from the pumping of the heart.

2. If arteries are hardened or narrowed, this force might be increased to pump the blood throughout the body.

Blood Pressure Measurement

Measurement is done by listening for two sounds with a

stethoscope - the first sound and the change in sound/or in some instances the last sound

1. The first sound is called the systolic blood pressure - it

measures the pressure in an artery when the heart iscontracting2. The change in sound/or last sound heard is the

diastolic blood pressure - it measure the pressure in an artery when the heart relaxes between contractions

Blood Pressure Measurements

BP is measured in units of millimeters of mercury (mmHg).

1. the top number/systolic is charted first, then the diastolic as in systolic/diastolic

2. 120/80 is an example of a normal blood pressure and this would be in millimeters of mercury or mm Hg

Blood pressure values

A. Normal range of B/P = 90/60 - 140/90

B. B/P < 90/60 is said to be hypotensive.

1. Hypotension symptoms include: dizziness, light-headedness, & might faint.

2. No presence of signs and symptoms

Blood pressure values

3. Contributing factors includea. Medications b.

Exercise/fitness levelc. Illness d. injurye.Pain f. Body positiong.Shock h. Hemmorhagei. Family Hx. j. diet

a B/P greater than 140/90 mmHg is said to be hypertensive

1. Hypertension is called the silent killer because there are often no symptoms. Some people might experience headache, pressure in the head, ringing in ears, general feeling of malaise.

2. Continued elevation over time may result in a Cerebral Vascular Accident (stroke).

Blood Pressure

Blood Pressure

Normal

Pre-hypertension

Hypertension

Systolic (top #)

120 mmHg or less

121-139 mmHg

140 mmHg or higher

Diastolic (bottom #)

80mmHg or less

80-89mmHg

90mmHg or higher

High blood pressure directly increases the risk of coronary heart disease (which leads to heart attack) and stroke, especially along with other risk factors.

High blood pressure can occur in children or adults. It's particularly prevalent in African Americans, middle-aged and elderly people, obese people and

heavy drinkers. People with diabetes mellitus, gout or kidney disease have hypertension more often.

High blood pressure usually has no symptoms. It's truly a "silent killer." But a simple, quick, painless test can detect it.

BP monitoring video

How to take blood pressure

• What bp sounds like: Taking Blood Pressure with Sound's of HeartBeat :) – YouTube

• Self bp w/manual operations: Video: How to measure blood pressure using a manual monitor - MayoClinic.com

• BP Sounds: Korotkoff Blood Pressure Sights and Sounds on Vimeo

Instruments need to take blood pressure

A. Blood pressure cuff/sphygmomanometer

1. This must fit the arm properly. The width of the cuff should approximately equal the width of the upper arm.

2. The gauge should be calibrated and the needle should be on 0

B. Stethoscope

BP Procedure

A. Person should be comfortably seated or lying down

B. Should have rested for 10-15 minutes prior to the reading

C. Arms that are paralyzed, injured, have an IV or shunt should not be used

BP Procedure

D. Infant blood pressures can be taken on the leg, but adults must use the arm

E. Electronic blood pressure equipment can be used - the type used most often in the hospital setting is the Dyna-map

F. Excess air should be squeezed out of the cuff

Taking BP

F. Excess air should be squeezed out of the cuffG. Cuff should be placed snugly on upper arm.H. Gauge should be easily visualizedI. Valve should be closed, but easily able to be openedJ. Two techniques for obtaining the pressure1. Find radial pulse. Pump cuff till pulse no longerpalpated. Then pump another 30 mm Hg higher. Placediaphragm of stethoscope on brachial artery about ½ - 1inch above the elbow. Release the valve and listen forthe two measurements - slowly deflating the cuff.

Taking BP

2. Find brachial artery and put diaphragm over the site. Pump cuff to 120 mm Hg and listen for the heart beat. If it is heard, pump another 30 mm Hg and listen again. When the pulse is no longer heard, then pump another 30 mm Hg and slowly deflate, listening for the two measurements.

Taking BP

K. If reading is uncertain, wait 30 seconds to 1 minute before remeasuring

L. Record the reading and report any abnormalities. If the B/P

reading is outside of the normal limits, retake it before reporting

How to Take Vitals

Vital Signs (Nursing Procedures) - Pluto – YouTube• Children’s vitals:

http://www.youtube.com/watch?v=fmPaXxw5gj8

• UCC Nursing Students Vital Signs Get'em RIght! – YouTube

• EMT vital skills: http://www.youtube.com/watch?v=D0kRS0wxIjg

• http://www.youtube.com/watch?v=Xk1ggKNj7T0

Reference

• http://www.texashste.com/documents/curriculum/health_science/Blood_Pressure_Assessment.pdf

• http://www.texashste.com/documents/curriculum/health_science/vital_signs.pdf