UNDERSTANDING VITAL SIGNS

LEQ: WHY ARE VITAL SIGNS SO IMPORTANT? Vital Signs give Medical Professionals an idea of how well or how sick a patient may be. It also tells us how a treatment or change in medication is working. Vital Signs are an easy way to help diagnose the patient.

TEMPERATURE There are several ways to take a patients temperature: Oral (Normal is 98.6) Rectal (Normal is 99.6) Axillary (Normal is 97.6) Tympanic (Normal is 98.6)

Oral Temperature When taking a patients oral temperature, there are some things to remember: 1. You must position the thermometer directly under the tongue and have the patient close their lips tightly around the thermometer. 2. Never allow a patient to bite the thermometer 3. Make sure the patient has not had anything to eat, drink, or have smoked in the last 15 minutes before taking an oral temperature 4. Don’t use an oral thermometer on an unconscious, confused, or seizure-prone patient. 5. Don’t use an oral thermometer on a young child or infant.

IF YOU GET AN ABNORMAL TEMPERATURE Stop what you are doing REPORT IT!!

RECTAL Temperature Make sure the thermometer is a Rectal Thermometer and is clearly labeled Make sure there is enough lubricant on the thermometer before inserting it Keep the Patient covered for privacy Never let go of the thermometer HOW DEEP? Infants ½ inch Children 1 inch Adults 1 & ½ inch

Special Considerations for Rectal Temperatures Avoid taking Rectal Temps on patients with diarrhea, recent rectal surgery, prostate surgery, or injured or inflamed conditions of the rectal area Avoid taking a rectal temperature on a patient that has an irregular heart beat or had a recent heart attack

AXILLARY Temperature Remember to clean under the arm before taking an axillary temperature Once the area is clean, place the tip of the thermometer in the center of the under arm and have the patient lower their arm down to the side. If necessary, hold the arm and thermometer in place for patients that may not be able to perform this request.

TYMPANIC Temperature Keep in mind not everyone is shaped the same way and the ear canal is no different Make sure the patient does not have inflammation or infection in the ear Check the ear for excessive wax, this may give you the wrong temperature Make sure the tip is snuggly in place before mashing the button

PULSE Every time our heart beats, it creates enough force to be felt at various areas of the body There are several areas of the body to check for a pulse: Radial- (Most Common Site) On the wrist just below the thumb Carotid- Starting at the mid-point of the throat and sliding your fingers to the either side of the neck ( this is the site to check during CPR) Brachial- Located on the upper inner arm between the bicep and tricep

PULSES cont’d Femoral- At the crease of the groin area Popliteal- Behind the Knee-Cap Dorsalis Pedis- On the top of the foot Apical- Over the Apex of the Heart Normal Adult Pulse = Infants and Children under 3 years Old –Listen directly above the heart to hear the beat with a stethoscope and count for one minute

Things to Consider when taking a Pulse When you are taking a pulse you are: –Determining the rate ( number of beats per minute) –Determining the rhythm ( pattern of regularity of beats) –Volume (amount of blood pumped with each beat) –Counting for 30 seconds and multiplying by 2 –If the pulse is not regular, then you count for one minute and let someone know that the pulse is irregular –If the pulse is weak then a Doppler may be used

RADIAL PULSE Have the patient sitting or lying down with their arm across their chest (this will help later when you take the respirations) Gently press the radial artery on the patients wrist with your index and middle finger Because your thumb has a strong pulse, Do Not take the pulse with your thumb you may be counting your own After locating the pulse, count the beats you feel for 30 seconds and multiply by 2. If the beats are not regular, then count for one minute

APICAL PULSE Warm the stethescope before touching the patient with it Place the bell of the stethescope on the Apex of the heart and count for one minute The Apex of the heart should be at the fifth intercostal space left of the midclavicular line An Apical Pulse is needed when the patient is on certain medications and during other situtuations

BLOOD PRESSURE Blood Pressure is the force of blood on the arterial walls. Systolic is the maximum pressure on the artery walls and the top number Diastolic is the minimum pressure on the artery wall when the heart is at rest

Most Common Locations for BP Brachial Artery Popliteal Artery

Normal Ranges Neonate Systolic Diastolic Yr Old Systolic Diastolic Yr Old Systolic Diastolic Yr Old Systolic Diastolic Adult Systolic Diastolic Older Adult Systolic Diastolic ** Always Look at the Previous Blood Pressure Reading and Report any Sudden Changes in Pressure even if it appears normal!!

Hypotension-Low Blood Pressure Dizziness Clammy Skin Cool Skin Nausea Light-Headed Feeling Faint Black-Out

Hypertension-High Blood Pressure Headache Ringing in the Ears Nosebleed Blurred Vision Seeing Spots

Things to Remember Never place your thumb on the Bell of the stethescope Remember to pump the cuff 30 mmHG above the established Systolic Remember to place the cuff 1 inch above the break of the arm Notify someone as soon as possible if you get an abnormal Blood Pressure Notify someone as soon as possible if there is a sudden increase or decrease in BP

RESPIRATIONS The rise and fall of the chest wall indicates 1 respiration You can count respirations for 30 seconds and multiply times 2 or if the patient is breathing abnormally, count them for one full minute The best time to take respirations is immediately following taking the pulse rate. ** Don’t let the patient know that you are taking their respirations

Normal Respirations Newborns Toddlers Year Olds Adults ** Report Respirations in Adults below 8 and above 28 Immediately to the Nurse

Pulse Oximeter Used when checking for Oxygen Saturation in the blood Does not read through acrylic nails or polish If patient is already cyanotic, it will not register Range % Range for Chronics % O2 must be ordered not assumed

PAIN Scale from = No Pain 10 = Unbearable Must be documented BEFORE and AFTER pain medication is given

Immediate Attention Items (ABCS) 1. Change in ABCS –A. Airway = Is there something blocking the patients Airway? –B. Breathing = Has there been a change in the breathing pattern of the patient? –C. Cardiac and Circulation = Is the patient complaining of Chest Pain? Have the patients pulses decreased or changed? –S. Signs = Have their been any changes in Vital Signs? *If you see any of these changes, stop what you are doing and notify the nurse immediately!

Nip it in the Bud! (PLUM) Other times to notify the Nurse: Pain = Has there been a significant increase in the patients pain? Look at the Patient = Does the patient look different? Do they look sicker? Urinary = Has the patient put out less than 30cc’s an hour? Has the character of the urine changed? Mental = Has the patients mental state changed?