Vital Signs Indicates the body’s states of health

Pulse: rate of heart beats  Radial  Pressure of the blood felt against the wall of an artery as heart beat  Count each pulse for 30 seconds, multiply x 2  Apical  Over apex of the heart, listen with stethoscope for 1 full minute, every other sound of the heart.  Normal range = per min.

Different Pulses: Radial pulse Carotid Pulse Apical pulse

Checking the radial pulse  Wash or sanitize hands  Identify and introduce self to patient  Explain what you are going to do  Locate radial artery and count pulse for 30 seconds, multiply results x 2  Document results on graphic sheet

The Stethoscope

Document Pulse  Rate, # beats/minute on graphic  In Nurses’ notes document:  Rate & Rhythm, regular or irregular  Volume,(thready-weak-strong- bounding)  Example: “ Pulse 68,regular, strong.” “ Pulse 68,regular, strong.”

Medical terms related to vital signs  Bradycardia….slow heart rate, below 60  Tachycardia…fast heart rate, above 100  Arrhythmia…irregular or abnormal rhythm  Hypotension…low blood pressure  Hypertension…high blood pressure  Dyspnea…difficult or labored breathing  Wheezing…difficult breathing with high- pitched whistle sound during expiration

Respirations  After apical pulse, leave stethoscope in place on chest & count the rise of the chest for 30 seconds, multiply x 2  Do not tell the patient what you are doing!  One Respiration = 1 inhalation,1 exhale  Range for teens/young adults

What is Blood Pressure?  Force exerted by blood against the arterial walls as heart contracts & relaxes  Systolic, greatest pressure, top number  first sound heard  Diastolic, least pressure, bottom number  Last sound heard  Diastolic pressure>90 is considered high  Normal Range: over mm  Abbreviated B/P, Example: 120/70

Blood Pressure Equipment: Cuff Scale Bulb Control valve Ear tips Tubing Diaphragm

Yes, Size Matters!  Using a cuff too small will result in an incorrect B/P reading  Using a cuff too large will result in an incorrect B/P reading

How B/P is Taken Gather your equipment Clean stethoscope Select correct size cuff for pt. Check you cuff for leaks Identify patient Introduce self to patient Explain what you are going to do Take radial pulse first Take apical pulse for accuracy Take respirations Document pulse and respiration Take blood pressure Check accuracy with automatic cuff

Factors that influence B/P  Force of heartbeat  Resistance of arterial system  Elasticity of arteries  Volume of blood in arteries  Lying down  Sitting position  Standing position

Factors that influence B/P  Increases B/P  Excitement, anxiety, nervous tension  Stimulant drugs  Exercise, eating  smoking  Decreases B/P  Rest or sleep  Depressant drugs  Shock  Excessive blood loss  fasting

Temperature  Measures balance between heat lost & heat produced by body  Can be measured:  Orally (mouth)  Rectally (R)  Axillary (armpit) (Ax)  Aural (ear) (A)  Temporal (forehead)

Facts about Temperature  Heat is lost through  Perspiration  Respiration  Excretion (urine,feces)  Heat is produced through  Metabolism of food  Muscle activity  Gland activity

Temperature variations  Oral: average 98.6°  range 97.6°- 99.6°  Rectal: average 99.6° ( R)  range 98.6°-100.6°  Axillary: average 97.6° (Ax)  range 96.6°-98.6°

Causes of increased Temperature  Illness  Infection  Exercise  Environmental heat

Causes of decreased Temperature  Starvation or fasting  Sleep  Decreased muscle activity  Mouth breathing  Cold external temperature  Certain diseases

Variation of Temperature  Usually lower in morning  Higher in evening  Higher after food intake  Higher after muscular activity

Teminology  Hypothermia,low body temperature (95 °)  Hyperthermia,high body temp (104°)  Fever: elevated body temperature  Pyrexia: fever  Febrile: elevated body temperature  Afebrile: lack of elevated body temperature

Documentation  Vital signs must be ACCURATE  M.D. decides if pt. should know his vitals  Level of pain done by 1-10 pain scale  Level of consciousness important  Color of skin ( jaundice, cyanosis,pale, erythema)  Dyspnea, Difficulty breathing

Steps in Taking Vital Signs  Use hand sanitizer  Gather equipment  Stethoscope  Alcohol prep  sphygmomanometer  Knock on room door  Introduce self, explain why you’re there  Identify correct patient, talk with patient to put at ease

Taking vital signs:  Check radial pulse  Check apical pulse(leave stethoscope in place)  Check respirations  Check blood pressure  Re-check any abnormal vital sign to verify  Notify supervisor of verified abnormality  Document results as soon as possible  Make sure pt. call light within reach, provide for pt. comfort, raise bed rail

Practice makes Perfect  Practice taking vital signs on fellow class mates  Practice documenting results, black ink  Verify your vital signs with automatic Blood Pressure equipment.  Document automatic results In pencil. In pencil.