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Vital Signs The most important measurements obtained when assessing a client’s condition. Temperature Pulse Respirations Blood Pressure.

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Presentation on theme: "Vital Signs The most important measurements obtained when assessing a client’s condition. Temperature Pulse Respirations Blood Pressure."— Presentation transcript:


2 Vital Signs The most important measurements obtained when assessing a client’s condition. Temperature Pulse Respirations Blood Pressure

3 Body Temperature - defined Measurement of the balance between heat lost and heat produced in the body

4 TEMPERATURE The first assessment taken Normal adult temp – 98.6°F (37°C) Normal range – 96.8°F to 100.4°F (36.0° ° C) Variations may be due to Time of day Allergic reaction Illness/Infection Stress Exposure to heat or cold

5 TEMPERATURE High Temps above 100.4°F (38.0°C) Documented as febrile (fever) Normal temperature range – afebrile Hyperthermia Temperatures above 104°F Death & Convulsions Hypothermia Temperatures below 95°F Death

6 TEMPERATURE SITES Oral Normal °F Range – 97.6 – 99.6°F Axillary Normal – 97.6°F Range – 96.6 – 98.6°F Tympanic Rectal (most accurate) Normal – 99.6°F Range – 98.6 – 100.6°F

7 THERMOMETER TYPES Two basic types – Electronic/Digital – measures temperature through a probe Glass – contain mercury in the bulb Rounded tip – rectal use Long tip – oral use Security tip – both oral & rectal assessments

8 PULSE A wave of blood flow created by contractions of the heart The amount of blood pumped from the left ventricle of the heart to the artery being assessed Pulse is checked by palpating - to feel OR Auscultation - listening for sounds

9 PULSE SITES (points) Named according to bones or other structures near where they are located Most Common Sites Radial – inside of wrist Brachial – Adults – antecubital space (bend of the elbow) Children – middle of the inside of upper arm Apical – auscultated with a stethoscope placed on the chest wall

10 Pulse Sites (points) Named according to bones or other structures near where they are located Other Sites Carotid – alongside the trachea toward the ear Temporal – front edge of ears Femoral – in the groin or crease between thigh & abdomen Popliteal – behind the knee, toward the midline Dorsalis pedis – dorsal side of the foot Posterior tibial – behind the medial malleolus

11 PULSE CHARACTERISTICS Pulse assessment characteristics include Rate – BPM Tachycardia – pulse rate faster than 100 bpm Bradycardia – pulse rate slower than 60 bpm Normal Rages Infants bpm Children – 1 to 7 yrs – bpm Children  7 yrs – bpm Adults bpm

12 Pulse Characteristics Pulse assessment characteristics include Rhythm – pattern of heartbeats (regularity) Regular or Irregular Arrhythmia or Dysrhythmia – irregular heartbeat Must be counted for a full minute Medications Heart dysfunction Lack of oxygen

13 Pulse Characteristics Pulse assessment characteristics include Volume – the strength of the pulse Measurement as it presses against the arterial wall and against your fingertips when palpating Rating Scale 0 – Absent, unable to detect 1 – Thready or weak, difficult to palpate, easily obliterated by light pressure from fingertips 2 – Strong or normal, easily found & obliterated by strong pressure from fingertips 3 – Bounding or full, difficult to obliterate with fingertips

14 Pulse Characteristics Pulse assessment characteristics include Bilateral Presence – found on both sides of the body; having the same rate, rhythm, and volume Unilateral – found on one side of the body

15 RESPIRATIONS The act of breathing; the exchange of oxygen and carbon dioxide from the air into the lungs Breathing in – inspiration & Breathing out – expiration Assessment Rate Rhythm Quality Respiratory Rate Observing the client’s chest movement for one minute

16 Respirations Respiratory Rate – the number of breaths per minute – counted for one full minute Suggested normal rates – 12 – 20 breaths/minute Ventilation – movement of air in & out of lungs Hyperventilation – increased respiratory rate Hypoventilation – decreased respiration rate

17 Respirations Respiratory Rhythm Should be regular Abnormal respiration – Cheyne-Stokes Periods of dyspnea followed by periods of apnea

18 Respirations Quality of respiration is seen in volume & effort Volume – the amount of air taken into the lungs and exhaled from the lungs Documented as shallow or deep Effort – the amount of work the client uses in order to breath Muscle use seen in the neck, chest & abdomen is an indication of labored or difficult breathing

19 Measuring Methods If using a mercury thermometer, measure the pulse and respiration while waiting for the temperature If using another method of measuring the temperature, complete the temperature - then measure the pulse and respiration Keep your fingers on the pulse while measuring the respiration

20 BLOOD PRESSURE Blood Pressure – the amount of pressure or tension exerted on the arterial walls as blood pulsates through them Systolic pressure – the pressure exerted on the arteries during the contraction phase of the heartbeat Diastolic pressure – the resting pressure on the arteries as the heart relaxes between contractions Measured in millimeters (mm) of mercury (Hg)

21 Blood Pressure Normal Systolic readings Between mm Hg Normal Diastolic readings Between mm Hg Prehypertension Readings Systolic – mm Hg Diastolic – mm Hg

22 Blood Pressure Readings American Heart Association recommendations Patient should sit quietly for at least 5 minutes before the B/P is taken Two separate readings should be taken and averaged Minimum wait of 30 seconds between readings

23 BLOOD PRESSURE SITES Blood pressure can be obtained from any artery. Need a pulse site Safest & most convenient sites Brachial – most common for routine VS for adults/children Radial – possible site for infants or clients with very large upper arms Popliteal/Femoral – behind the knee/thigh – used because of trauma, disease, medical treatments to the arm, or recent mastectomy Dorsalis pedis/Posterior Tibial – lower leg – common use for infants

24 BLOOD PRESSURE EQUIPMENT Sphygmomanometer – the instrument used to measure BP sphygmo – pulse mano – pressure meter – measure Commonly referred to as the BP cuff Types of Sphygmomanometers Mercury Aneroid Electronic (no stethoscope needed)

25 VITAL SIGNS PROCEDURES Perform the least invasive first Invasive – invading someone’s personal space or inserting a needle into the skin Noninvasive – actions that do not intrude – a simple observation Temperature Pulse Respiration Blood Pressure

26 Vital Sign Procedures Documentation & Reporting Check on the chart for VS or T P R BP Always record in this order 98.6 – 72 – 16 – 145/69 Always report information to the supervisor if it falls outside of the normal range for the client or if the VS is significantly different from the previous recorded result

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