1. Vital Signs

2. Most important measurements you will obtain from Pt
Temp, pulse, respirations, and blood pressure
These are all vital to life, thus vital signs
Variances indicate a possible underlying issue not seen with the naked eye

3. Temperature Body temp is a good indicator for Pt assessment
Normal temp is considered 98.6 or 37 C
There is a range for a normal temp from F or C
ºC * = F
So 32 F would be 0 C

4. Range in temp is related to 5 factors
Time of day- temp usually lower in the am and higher in the pm
Allergic reaction
Illness
Stress
Exposure to heat or cold

5. When temp gets above 100.4 F or 38 C you would document or chart this as the Pt being febrile
If temp is within norms you would document afebrile
When taking a temp, ensure that the pt hasn’t been drinking hot fluid, been wrapped up in blankets, or other means of giving a false high temp.

6. There are a few places on the body you can get an accurate temp
Orally- within the mouth or under the tongue
Axillary- in the armpit also known as axilla
Tympanic- within the ear canal
Rectal- through the rectum or anus

7. Contraindication of oral temperature:
• Infants and children.
• Unconscious patients.
• Inflammation or surgery of mouth.
• Persistent frequent coughing.
• Mouth breathing patients.

8. Contraindication of rectal temperature:
• Patients with surgical operation in the rectum or perineal region.
• Disease or inflammation of the rectum.
• Diarrhea
Hemorrhoids

9. Pulse A pulse is a wave of blood flow created by a contracting heart
You will check a pulse by palpating or feeling it on a Pt
Sometime we would listen or ausculate by using a stethoscope or vital sign machine

10. Pulse Locations Most common are radial, brachial, and apical
Radial is located on the inside of the Pt wrist, near the thumb
Note: your thumb can have a pulse or it’s own so don’t mistake your pulse for your Pt

11. The brachial is adults is found in the antecubital (AC)
The brachial in children it is found in the middle of the inside of the arm

12. The apical pulse is ausculated with a stethoscope on the chest
Note anatomically were the apex of the heart is
It is located on the Pt left side of sternum and under the fifth and sixth intercostal space
Apical-radial pulse occurs due to obstruction, trauma, abnormal heart rate, or disorder

14. Characteristics of pulse
Rate, Rhythm, Volume, Bilateral presence
Assessed in Beats per min or BPM
Counted for seconds
Rates vary for age, gender underlying medical condition, medication
As we age our pulse decreases
Women tend to have faster pulses

15. Pulse per Age group Newborn= 120-160 1-12 months= 80-140
1-6 year=
6-adolescence=
Adult= 72-80
Late adulthood= 60-80

16. Tachycardia
Fast HR
Physical or emotional stress, infection, pain, exercise etc…
Lack of oxygen or low bp

17. Bradycardia Slow HR Physically fit Certain medications
Severe lack of oxygen or bp
Symptomatic

18. Pulse Rhythm Pattern of heartbeats Should be regular
Irregular rates are referred to as an arrhythmia or dysrhythmia
When you document pulse rhythm you should record it as regular or irregular.

19. EKG Electrocardiogram Measures electric cardiac voltage
Doesn’t measure muscle contraction just the electrical activity
Known as a 12-lead

21. Normal Sinus Rhythm

22. Sinus Tachycardia

23. Sinus Bradycardia

25. Respiration Act of breathing Exchange of oxygen and carbon dioxide
Difference between respiration and ventilation
When counting resp. you will count one inhalation and one exhalation as one this is a complete breath

26. Respiration- is the actual gas exchange that takes place within the lungs
Ventilation- is the process of moving air in and out of the lungs
The air we breath has only 21% oxygen and when we exhale we breath out 14% oxygen
Thus in CPR when we do mouth to mouth our Pt is still receiving O2 during breaths

27. Most common way to assess resp. is to observe chest rise and fall
Children under 7 are known as belly breathers hence the healthcare worker will observe the child's belly to obtain resp. rate
Belly breathing in adults is an ominous sign or indicates resp. distress

29. Rate of resp. This is number of breaths a minute Counted for full min
Normal range is bpm
Ventilation again refers to movement of air in and out of the lungs
An increase in ventilation is documented as hyperventilation

30. Causes of hyperventilation
Physical/mental stress such as infection, exercise, anxiety
Increase in body temp.
Lack of oxygen and reduced or no blood pressure

31. Rhythm of resp. should be regular and a quiet process
Should hear no auditory indicators
Apnea is another word for not breathing

32. Blood pressure
Amount of pressure or tension exerted on the arterial walls
Systolic blood pressure(top #)- pressure exerted on the arteries during the contraction of the heart. This # is higher of the two because pressure should be higher during the heart beat
Diastolic (lower #)- is the resting pressure on the arteries as the heart relaxes between contractions

33. When you document bp it should look like 120/80
Bp is measured in mm of mercury
Expected systolic readings are between 100 and 140 mm Hg
Expected diastolic readings are between 60 and 90 mm Hg

34. A systolic reading of mm Hg and a diastolic reading of mm Hg is classified as prehypertension
When the bp drops below normal levels(hypotension) the body attempts to raise the pressure

35. Shock
When a traumatic injury occurs and there is substantial blood loss the body is classified as going into shock
Compensated shock
Non-compensated shock

36. Symptoms of shock
Change in LOC/AMS
Increase in HR and Resp.
Weak irregular thready pulse
Diaphoretic skin

37. Compensated Shock The bodies attempt to reverse the shock process
Elevated Bp, HR, Resp
As the body loses blood volume the harder it is on the body to maintain homeostatis
This stage however can be reversed with rapid transport or acute medical care, thermoregulation of Pt, and volume replacement

38. Decompensated Shock This stage is the failing of the body systems
The increase in body vitals seen with compensated are no longer present
Lowered bp, diminished HR and Resp. are all classic signs of impending death

39. Sites for bp Bp can be obtained from any artery
Brachial- taken from upper arm, most common site for routine vitals for adults and older children
Radial-taken on lower arm, possible site for infants or Pt who have large upper arms
Popliteal-taken on the thigh, alternate to arms due to trauma, disease, mastectomy

40. Orthostatic hypotension-occurs when the Pt with normal bp develops symptoms and low bp upon rising to an upright position

41. Pulse Ox Pulse ox measures oxygen saturation
Probe with LED and photo sensor
Probe requires highly vascular area to detect the degree of oxygenation
Earlobe, finger, toe, bridge of nose