ch 15 vital signs. vital signs indicators of health states of the body 4 main vital signs –...

Ch 15 Vital Signs

Vital Signs

• Indicators of health states of the body• 4 main vital signs– Temperature, pulse, respirations and blood

pressureOther vital signs

pain on a scale of 1-10color of skin, size of pupils, level of

consciousness and response to stimuli

Temperature

• Balance of heat lost and produced• Heat is lost through perspiration, respiration

and excretion• Heat is produced by the metabolism of food

and by muscle and gland activity• Chemical reactions in the body are regulated

by body temperature

• Normal range- 97-100• People with faster body processes have higher

temperatures• Temp is lower in the morning• Different parts of the body have different

readings

• Oral temp-in the mouth, thermometer is placed 3-5 min, nothing in the mouth 15 min prior to temp

• Rectal-in the rectum, thermometer is left in place for 3-5 min, most accurate, most frequently used on infants and small children

• Axillary temp- in the armpit, less accruate, left for 10 min

• Aural temp-must use a special tympanic thermometer that is placed in the ear canal, measures heat from eardrum, provides a measure of core body temp and must be set to determine the core equivalent

• Less than 2 seconds• Inaccurate results if ear infection, wax buildup

or not placed in ear canal correctly

Temporal temperatures

• Scanning thermometer is passed in a straight line across the forehead, measures the temp of the temporal artery

Normal Temp Ranges

• Oral 97.6-98.6• Rectal and Temporal 98.6-100.6• Axillary 96.6-98.6

Causes of change in body temp

• Pyrexia- above 101 usually due to illness, infection other factors-excercise, excitement and increase temp in the environmentHyperthermia-above 104 measured rectally, 106-convulsions, brain damage and death• Hypothermia-below 95,exposure to cold temp,

death below 93 – Other factors-starvation or fasting, sleep, decreased

muscle activity, mouth breathing, and certain diseases

15.3 Pulse

• Measure of the pressure of the blood pushing of the wall of an artery as the heart beats and rests

• Temporal-on either side of the forehead• Carotid-at the neck on either side of the trachaea• Brachial- inner aspect of the forearm and the antecubital

space• Radial-at the inner space of the wrist above the thumb• Femoral-where the thigh joins the trunk of the body• Popliteal-behind the knee• Dorsalis pedis-at the top of the foot arch

• Rate-beats per minute• Rhythm and volume are recorded

• Adults-60-100 beats per minute• Children over 7yrs-70-100 beats/min• Children from 1-7 yrs 80-110 beats/min

• Bradycardia-under 60 beats/min• Tachycardia-over 100beats/min

• Rhythm-regularity of the pulse, regular or irregular

• Volume- strength or intensity,• strong or bounding (usually w/ tachycardia)• weak or thready (usually w/ low BP)

• Apical pulse-taken in infants, patients with hardening of the arteries or irregular heartbeats, weak radial pulses

Some factors that change pulse rate:

• Increase: exercise, stimulant drugs, fever, excitement, shock, nervous tension

• Decrease: sleep, depressant drugs, heart disease, coma, physical training

• Stethoscope

Respiration

• Taking in oxygen and expelling carbon dioxide• Note the rate, the character and the rhythm

• Rate-number of breaths/min• Adult-12-20• Children- 16-30• Infants-30-50

• http://www.easyauscultation.com/cases?coursecaseorder=6&courseid=201

• http://www.wilkes.med.ucla.edu/lungintro.htm

Abnormal Respirations

• Dyspnea-difficult or labored breathing• Apnea-absence of breathing• Tachypnea-rapid, shallow rate, above 25

respirations/min• Bradypnea-slow respiratory rate, below 10• Orthopnea-severe dyspnea in any position

other than standing or sitting erect

• Cheyne-Stokes-pattern of dyspnea followed by apnea, frequent in dying patient

• Rales, bubbling or noisy sounds caused by fluids or mucus in air passages

• Wheezing-breathing with a high-pitched whistling or sighing during expiration, caused by narrowing of bronchioles, seen in asthma

Blood Pressure

• Sphygmomanometer-used to measure BP• Measure of the pressure the blood exerts on

the walls of the arteries• Systolic-left ventricle is contracting• Diastolic- left ventricle is at rest• Normal- 120/80• Hypertension- 140/90• Hypotension- 90/60

Taking blood pressure

• Sit quietly for 5 min• Width of the cuff should be 40% of the width of the

circumference of the upper arm• Length of the bladder should be 80% of the upper

arm• The patient should be seated or lying comfortably and

the arm on a flat surface• The area of the arm covered by the cuff should be at

heart level• The arm should be free of constrictive clothing

• http://www.mayoclinic.org/diseases-conditions/high-blood-pressure/multimedia/how-to-measure-blood-pressure/vid-20084748

Factors influencing BP

• Changes in readings-force of heartbeat, elasticity of arteries, volume of blood, position of the patient

• Factors that may increase BP-anxiety, excitement, nervous tension, pain, obesity, smoking, stimulant drugs

• Factors that may decrease BP-rest or sleep, shock, depressant drugs, dehydration, fasting, hemorrhage