1. Patient Assessment

2. Objectives Students will:
Identify normal and abnormal V/S measurements.
Measure and record vital signs according to industry standards.
Measure and record height and weight according to industry standards.
Describe factors that would lead to error in V/S measurement
Describe health factors that would affect vital signs
Determine which methods to use when measuring vitals for patients in various scenarios.

3. Vital Signs Are important indicators of health
Detect changes in normal body function
May signal life-threatening conditions
Provide information about responses to treatment

4. Vital Signs Temperature (T) Pulse (P) –same as HR Respirations (R)
Blood Pressure (BP)
Weight (Wt)
Height (Ht)
Additional Measures – SpO2, CRT

5. When Are Vital Signs Measured:
Upon admission
Before & after surgery and other procedures
After a fall or accident
When prescribed drugs that affect the respiratory or circulatory system
When there are complaints of pain, dizziness, shortness of breath, chest pain
As stated on the care plan (min 8hrs at hosp)

6. When Measuring Vital Signs
Usually taken with the person sitting or lying
The person is at rest
Always report (immediately):
A change from a previous measurement
Vital signs above or below the normal range
If you are unable to measure the vital signs

7. Temperature
Measurement of balance between heat lost and produced by the body.
Heat is produced by:
Muscle and gland activity
Metabolism of food
Heat may be lost through:
Perspiration, Respiration, Excretion
Measured with the Fahrenheit (F)
or Celsius (C) scales

8. Body Temperature Factors that  body temperature
Illness
Infection
Exercise
Excitement, Stress
High temperatures in the environment
Temperature is usually higher in the evening
Factors that  body temperature
Starvation or fasting
Sleep
Decreased muscle activity
Exposure to cold in the environment
Body temperature is usually the lowest:
a. in the evening
b. n the afternoon
c. in the morning
d. at bedtime
Age- Younger=hotter
Time- T varies up to 2 degrees during the day

9. Temperature Sites Oral - by mouth – most common method
May be affected by hot or cold food, smoking, oxygen, chewing gum
Wait 15 minutes or use alternate site
Also avoid if patient is under 5, on oxygen, sedated, had oral surgery or otherwise cannot control their bite.
Rectal - in the rectum –highly accurate but uncomfortable
Do not use if patient has rectal surgery or bleeding
Axillary - under arm – less reliable site
Used when other sites are inaccessible, takes 10 min
Do not use immediately after bathing

10. Temperature Sites Tympanic or aural - in the ear
Measures in 1 to 3 seconds
Temporal Artery (TA/TEMP) – temporal artery on the forehead-highly accurate
Record route temperature was taken
Ax – Axillary
T - Oral
R- Rectal
A – Tympanic /Aural)
TA- Temporal

11. Normal Body Temperature
Oral ( )
Rectal ( )
 Axillary ( )
 Typmanic ( )
Temporal ( )
Hypothermia – temperature below normal (<95)
Hyperthermia – overheating, temperature above normal (heat stroke?)
(febrile-T(O)=1004°F and up for adults, hyperthermia= °F)
Afebrile- no fever
Hyperpryexia- High fever above 106.7F

12. Types of Thermometers
Clinical (glass) thermometer no longer contain mercury.
Oral or rectal. (rectal are thicker/longer & labeled)
Disposable covers are usually used.
Electronic can be used for oral, rectal, or axillary and use disposable probe covers.
Tympanic placed in auditory canal and uses disposable cover.
Strips that contain special chemicals or dots that change colors can also be used.

13. Pulse (HR/ P)
The pressure of blood pushing against the wall of an artery as the heart beats and rests.
Measured for one minute while noting:
rate - beats per minute
rhythm - regular or irregular
volume - strength or intensity - described as strong, weak, thready, bounding

14. Clicker question
You are taking Mr. James' pulse. The beats are not spaced evenly. How would you describe his pulse when reporting to the doctor or nurse?
A. thready and bounding
B. weak and feeble
C. strong and full
D. irregular

15. Pulse Sites Most Commonly Used: Carotid – during CPR
Apical – use stethoscope
Brachial – for Blood Pressure
Radial - to count pulse
Femoral – assessment and procedures
Popliteal – assessment
Dorsalis Pedis – assessment

16. Review Question Which is the most common site for taking the pulse?
A. radial
B. brachial
C. apical
D. carotid

17. Normal Ranges Age Pulse per Minute Birth to 1 year 80-190 2 years
80-160
6 years
75-120
10 years
70-110
12 years & older
60-100
Bradycardia – Under 60 beats per minute
Tachycardia – Over 100 beats per minute

18. Factors that Affect Pulse
Factors that  pulse
Exercise
Stimulant drugs, caffeine
Excitement, stress
Fever/Illness
Shock
Factors that  pulse
Sleep
Depressant drugs (digoxin- cardiac medication), diuretics (decrease volume)
Heart disease
Coma
Blood loss
Position
For an adult, which pulse rate is immediately reported to the doctor or nurse?
a. 80 beats per minute
b. 62 beats per minute
c. 48 beats per minute
d. 74 beats per minute

19. Pulse deficit Any observed difference between Apical and radial pulse.
Caused by cardiac arrhythmia
If the heart is rapidly or irregularly beating (like in A-fib) the flutter will create a rapid apical pulse but insufficient perfusion and pressure to have a solid peripheral pulse (radial).

20. Review question To take an apical pulse rate, you must:
A. count for only 15 seconds
B. feel for the artery on the side of the neck
C. have the patient sit or lie down
D. use a stethoscope

21. Capillary Refill Time (CRT)
For adults hold hand above heart level. Press on unpolished fingernail w/moderate pressure for 5 sec.
On infants-test on sternum
Observe time to reflush with color
Normal CRT is LESS than 2 sec
Slow CRT may indicate dehydration, hypoxia, or sepsis

22. Respirations
Process of breathing air into (inhalation) and out of (exhalation) the lungs.
Oxygen enters the lungs during inhalation.
Carbon dioxide leaves the lungs during exhalation.
The chest rises during inhalation and falls during exhalation.
Normal rate breaths per minute

23. Assessing Respiration
Respirations is measured when the person is at rest.
Rate may change is patient is aware that it is being counted.
To prevent this, count respirations right after taking a pulse.
Keep your fingers or stethoscope over the pulse site.
To count respirations, watch the chest rise and fall.

24. Assessing Respiration
Character and quality of respirations is also assessed:
Deep
Shallow
Labored or difficult
Noises – wheezing, stertorous (a heavy, snoring type of sound)
Moist or rattling sounds
 Dyspnea – difficult or labored breathing
Apnea – absence of respirations
Cheyne-Stokes – periods of dyspnea followed by periods of apnea;
often noted in the dying patient
Rales – bubbling or noisy sounds caused by fluids or mucus in
the air passages

25. Blood Pressure
Measure of the pressure blood exerts on the walls of arteries
Blood pressure is controlled by:
The force of heart contractions
weakened heart  drop in BP
The amount of blood pumped with each heartbeat
loss of blood  drop in BP
How easily the blood flows through the
blood vessels (resistance)
Narrowing of vessels  increase in BP
Dilatation of vessels  decrease in BP

26. Factors that Affect Blood Pressure
Factors that  blood pressure
Excitement, anxiety, nervous tension
Stimulant drugs
Exercise and eating
Factors that  blood pressure
Rest or sleep
Depressant drugs
Shock
Excessive loss of blood

27. Measuring BP A sphygmomanometer is used to measure BP
Aneroid – has a round dial and needle
Mercury – has a column of mercury
Electronic – automated device
BP is measured in millimeters (mm) of mercury (Hg).
The systolic pressure is recorded over the diastolic pressure.

28. Normal Range of Blood Pressure
Systolic: Pressure on the walls of arteries when the heart is contracting.
Normal adult range – mm Hg
Diastolic: Constant pressure when heart is at rest
Normal range – mm Hg
Hypertension—BP that remains above a systolic
of 140 mm Hg or a diastolic of 90 mm Hg
Hypertensive crisis- BP >180 systolic or 110 diastolic (emergency care needed)
Hypotension—Systolic below 90 mm Hg and/or a diastolic below60 mm Hg

29. Clicker response question
A persistent systolic pressure above 140 mmHg or a diastolic pressure above 90 mmHg is called:
A. hypertension
B. hypotension
C. bradycardia
D. tachycardia

30. Measuring Height and Weight
Used to estimate if a patient population is underweight or overweight
BMI or Body Mass Index a statistical measure of body weight based on a person's weight and height.
Wt in lbs/ (Height”x Height” x703)
BMI from 18.5 to 24.9 is considered normal
Used to estimate pop health and resource allocation, not great for indiv. Assessment
Does not account for differences in weight of body tissues
Circumference is more accurate for body fat

31. Measuring Height and Weight
General Guidelines:
Use the same scale every day
Make sure the scale is balanced before use
Weigh the patient at the same time each day
Remove jacket, robe, and shoes before weighing
OBSERVE SAFETY PRECAUTIONS!
Prevent injury from falls and the protruding height lever.
Some people are weight conscious.
Make only positive comments when weighing patients

32. Types of Scales
Clinical scales contain a balance beam and measuring rod
Bed scales or Chair scales are used for patients unable to stand
Infant scales come in balanced, aneroid, or digital
When weighing an infant…keep one hand slightly over but not touching the infant
A tape measure is used to measure infant height.