Vital Signs
Pat Rutherford
HSTE
Hart County High School
2009
Temperature
Measurement of balance of heat loss and heat produced
Abbreviation T
Homeostasis
Constant state of fluid balance Body reacts to chemicals and influences
temperature
Sites to measure T
Rectal - rectum Mouth - oral Axillary - armpit Aural – ear Temporal – forehead
Factors that affect body temp
Individual people differ – metabolic rates Time of day Body Sites Activities
Causes of increase T
illness infection exercise excitement environment
Cause of decrease
starvation of fasting ↓muscle activity mouth breathing exposure to cold certain disease
Methods to Measure Temp
Oral Most comfortable and common Questions pt about eating, drinking or
smoking prior to temp Leave in place 3-5 minutes if using
merciless thermometerDigital – leave until beeps usually one
minuteElectronic – records within 2 – 4 seconds
Continued
Tympanic – record aural readings, placed in the ear canal uses inferred reading of the tympanic membrane. Must be used correctly for accuracy
Temporal – measure the temporal artery
Terminology related to temp
Hypothermia – low body temp ↓ 95° Hyperthermia – high body temp 104° F Fever – an elevated (↑) temp usually 101°F Pyrexia – another term for fever
How to read a glass thermometer
The long line represents a whole number ex 98°
The short line represents .2 ° (2 tenths) of a degree
Normal Ranges
Oral = 98.6° F (+ or - 1°) 37° C Rectal = 99.6° F (+ or - 1°) 37.6° C Axillary =97.6° F (+ or - 1°) 36.4° C
Guidelines for Obtaining a Oral Temperature
Standard Precautions – wipe with alcohol or facility guideline before and after use; cover tip/probe; check glass thermometer prior to use, make sure the line is below 96° careful when shaking down not to hit objects close by. Use cool water when rinsing to prevent from breaking glass and destroying contents inside of the thermometer
Record and Report
Supplies for Temperature
Oral thermometer Plastic sheath Holder of with disinfectant Tissues or dry cotton balls Watch with second hand Soapy cotton balls Gloves Paper and pen
Pulse
Pulse is defined as the pressure of the blood pushing against the wall of an artery as the heartbeats and rests
Feel throbbing of the arteries caused by contractions of the heart
More easily felt in arteries that lie close to the skin and can be pressed against a bone.
Major arterial or pulse sites in the body
Temporal: side of the forehead Carotid: side of the neck, used for CPR Brachial: inner aspect of forearm at the
antecubital space (crease of elbow), used for blood pressure
Radial: inner aspect of wrist, above thumb, most common site for measuring pulse
Femoral: inner aspect of upper thigh
Pulse sites continued
Popliteal: behind knee Dorsalis pedis: top of foot arch Apex of the heart – inferior tip of the heart. Not
a pulse site, but a location to hear the heart rate accurately using a stethoscope. This is called an apical pulse
Posterior tibialis – behind the ankle
TEMPORAL
Carotid
Apex
Brachial
Radial
4
5
Femoral
Popiiteal
Dorsalis pedis
Posterior tobialis
Three items to note when obtaining a pulse
Rate Rhythm Volume
Pulse rate
Noted as the number of beats per minute Vary with individuals depending on age, sex, and body
size Adults: wide range of 60 to 90 beats per minute Adult men: 60 to 70 beats per minute Adult women: 65 to 80 beats per minute Children over 7to 12: 70 to 90 beats per minute Children from 1 to 7: 80 to 110 beats per minute Infants: 100 to 160 beats per minute
Related Terms
Bradycardia: pulse rate under 60 beats per minute
Tachycardia: pulse rate over 100 beats per minute (except in children)
Pulse Rhythm
Should be noted along with rate Refers to the regularity of the pulse, or the
spacing of the beats Described as regular or irregular Arrhythmia
Irregular or abnormal rhythm Usually caused by a defect in the electrical
conduction pattern of the heart.
Pulse Volume
Refers to the strength of the force Noted along with rate and rhythm Described by words such as strong, weak,
thready, or bounding
Various factors will change the pulse rate
1. Increased or accelerated rates caused by fever, shock, nervous tension, exercise, stimulant drugs and other similar factors
2. Decreased or slow rates caused by sleep, depressant drugs, heart disease, coma, and physical training and other similar factors
Basic principles for taking radical pulse
Position patient’s arm supported comfortably with palm of hand turned down
Use tips of two or three fingers to locate pulse site on thumb side of wrist
Count pulse for one full minute Note rate, rhythm, and volume of pulse
Record all information
Include rate, rhythm, and volume Example: Date, Time, P 82 strong and regular,
your signature and title
Respiration
Measures the breathing of the patient Process of taking in oxygen and expelling
carbon dioxide from the lungs and respiratory tract
One respiration consists of one inspiration (breathing in) and one expiration (breathing out)
Normal Respiratory Rate
Adults: 14 to 18 breaths per minute Wider adult range: 12-20 breaths per minute Children: 16-25 minutes Infants: 30-50 per minute
Character of respirations
Should be noted along with rate Refers to the depth and quality of respirations Described by words such as deep, shallow,
labored, moist, difficult, stertorous (abnormal sounds like snoring), and moist
Rhythm of respirations
Should be noted along with rate and character Refers to the regularity or equal spacing
between breaths Described as regular (or even) or irregular
Abnormal respirations
Dyspnea: difficult or labored breathing Apnea: absence of respirations, usually temporary Tachypnea: respiratory rate above 25 respirations per minute. Bradypnea: slow respiratory rate, usually below 10 respirations per minute Orthopnea: severe dyspnea in which breathing is very difficult in any position
other than sitting erect or standing Cheyne-Strokes: periods of dyspnea followed by periods of apnea; frequently
noted in dying patient Rales: bubbling or noisy sounds caused by fluids or mucus in the air passages Wheezing
Difficult breathing with a high pitched whistling or sighing sound during expiration
Caused by narrowing of bronchioles (as seen in asthma) and/or an obstruction or mucus accumulation in the bronchi
Cyanosis Dusky, bluish discoloration of the skin, lips, and/or nail beds Result of decreased oxygen and increased carbon dioxide in the
bloodstream
Voluntary control of respirations
Respirations are partially under voluntary control Patients may breathe faster or slower when they are
aware respirations are being counted Important to keep patient unaware of this procedure
Do not tell a patient you are counting respirations Keep your hand on pulse site while measuring
respirations Patient will think you are still counting pulse Will not be as likely to alter respiration
Record all information
Include rate, character, and rhythm Example: Date, Time, R 18 deep and regular,
Your signature and title
Report any abnormalities immediately to your supervisor