Chapter 19 Vital Signs

Vital Signs Vital Signs are measurements reflecting the patient’s physical well-being and condition. Vital Signs include the following: Pulse Respiration Blood pressure Temperature

When do we take vital signs? Upon admission When ordered by MD or outlined in plan of care Any time there is a change in the patient’s condition or c/o pain Patient falls or incident occurs Monitoring the patient’s response to a new medication At check up or physical examination

What could affect vital signs? Caffeine Medications Emotions Exercise Age

Temperature Body temperature is the measurement of the amount of heat in the body Measured in Fahrenheit or Celsius Normal body temperature is 98.6ºF or 37ºC Variations in temperature are caused by individual differences, time of day, part of body

Four Ways to Take Temperature Glass thermometer Battery-operated electronic thermometer Other electronic thermometers (ear, forehead) Chemically treated plastic/paper thermometer

Oral Temperature (O) Measured in the mouth Most common, comfortable and convenient method May be inaccurate if the patient has had anything to eat or drink

Axillary Temperature (A) Temperature measured under the armpit Less accurate reading because measures external temperature Record an A by the reading

Rectal Temperature Measured in the rectum Most accurate because it is an internal temperature Use red rectal thermometer Record R by reading

Pulse Pulse is the rhythmic expansion and contraction of the arteries caused by the beating of the heart; the expansion and contraction show how fast, how regular, and with what force the heart is beating.

Normal Pulse Rates (per minute) Before birth/birth 120-160 4 weeks to 1 year 80-160 Childhood years 80-115 Adult years 60-100

Terms Rate: the number of pulse beats per minute Rhythm: used to describe the regularity of the pulse beats Force: strength or power; used to describe the beat of the pulse Bradycardia: heart rate below 60 Tachycardia: heart rate over 100

Pulse Points Carotid Apical Brachial Radial Femoral Popliteal Dorsalis pedis/posterior tibial

Radial Pulse Pulse at the wrist Patient’s arm should be well supported and resting comfortably. Find the pulse by placing the tips of your first three fingers on the palm side of the patient’s wrist in a line with the thumb, next to wrist bone. If you press too hard, you will stop the flow of blood and not feel the pulse. Never use your thumb Note the rhythm and force

Radial Pulse Look at the position of the second hand on your watch. Start counting the pulse beats that you feel until the second hand comes back to the same number on the clock.

Apical Pulse Apical pulse is a measurement of the heartbeats at the apex of the heart, located just under the left breast. Uncover the patient’s chest Place the diaphragm of the stethoscope under the left breast. Listen for the heart sounds. Count the heart sounds for a full minute.

finishing up Report to immediate supervisor the following: The pulse rate If the pulse was regular or not Report anything unusual.

Apical Pulse Deficit The difference between the apical and radial pulse The heart is contracting but the pulse is not reaching the extremities. (A-Fib) Best obtained by having 2 people count the radial and apical pulses at the same time.