copyright ©2012 delmar, cengage learning. all rights reserved. chapter 38 vital signs and...
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Copyright ©2012 Delmar, Cengage Learning. All rights reserved.
Chapter 38
Vital Signs and Measurements
Copyright ©2012 Delmar, Cengage Learning. All rights reserved.
Height and Weight
• Mensurations: the process of measuring• Purpose
– The baseline for all measurements to follow– Can provide information about treatment
• Obtained at the beginning of the visit– May not be taken at all visits
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Height and Weight
• Additional infant measurements taken to ensure proper growth and development– Length of extremities– Circumference of head– Circumference of abdomen or chest
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Body Mass Index
• Numerical correlation between height and weight
• May be documented in patient’s chart• There are a number of ways to determine BMI
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Vital Signs
• Measure body functions essential to life• Four vital indicators, TPR and B/P
– Temperature: body’s ability to control heat– Pulse: rate, volume, and rhythm of the heart– Respirations: rate and quality of breathing– Blood pressure: force of the heart and condition of
the blood vessels
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Temperature
• The balance between heat production and heat loss– Heat is produced when food is changed to energy– Heat is lost through perspiration, breathing, and
elimination of waste
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Temperature
• Factors affecting temperature– Metabolic rate– Time of date– Amount of activity
• Normal temperature may vary– Temperature above normal: febrile– Temperature below normal: afebrile
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Thermometers
• Disposable• Electronic (battery operated)• Digital• Tympanic infrared• Temporal artery
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Oral Temperature
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Oral Temperature
• Contraindications– Infants and young children– Certain respiratory conditions – Confused, disoriented, or unstable patients– Oral injuries or dental problems– Recent oral surgery– Facial paralysis– Nasal obstruction, sinus congestion, or colds
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Rectal Temperature
• Very accurate method for measurement• Indicated for babies and young children• When documenting, record (R) following
reading• Normal rectal temperature is one degree
above normal oral temperature
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Axillary Temperature
• Least accurate method for measurement• Indicated when oral and rectal temperatures
are undesirable• When documenting, record (Ax) following
reading• Normal axillary temperature is one degree
below normal oral temperature
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Tympanic (Aural) Temperature
• Thermometers are easy, safe, and fast• When documenting, record (Tym) following
reading
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Temporal Artery Temperature
• Very accurate method for measurement• Appropriate for all ages, infant through older
adult• When documenting, record (TA) following
reading• Normal TA temperature is one degree above
normal oral temperature
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Temperature Conversions
• Fahrenheit to Celsius
• Celsius to Fahrenheit
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Pulse
• Palpated in arteries close to body surface and lie over bone or firm structures
• Can be felt in several locations on the body
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Pulse Sites
• Radial – Most frequently used when measuring pulse rate
• Apical• Brachial
– Used to palpate and auscultate blood pressure• Carotid
– Palpated during CPR
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Pulse Sites
• Femoral• Dorsal pedalis• Popliteal
– These three sites are palpated to evaluate circulation in the lower extremities
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Pulse
• Pulse rates– Normal range is 60-100 beats per minute– Influenced by
• Exercise• Age• Gender• Size• Physical condition of body
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Pulse
• Pulse characteristics– Volume
• Normal, full or bounding, weak, thready
– Quality• Arrythmia, pulse lacks a specific rhythm• Intermittent
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Measuring Radial Pulse
• Patient should be sitting or laying down– The arm should be well-supported
• Use the tips of your fingers– Do not use the thumb
• Typically count for 30 seconds, multiply by 2– Count for 60 seconds if pulse is irregular– Measure respirations at the same time
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Measuring Apical Pules
• Indicated for – Instances when radial pulse is not appropriate– Infants and small children– Patients with heart conditions
• Listen to heart at its apex with a stethoscope – Palpate at fifth intercostal space
• Count for 60 seconds• Document using [Ap] to indicate apical site
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Pulse Oximetry
• Small device used to measure pulse and arterial oxygen saturation in blood
• Clip attached to patient’s finger
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Respirations
• Combination of inspiration (inhale) and expiration (exhale)
• Normal respiration rate is 16-20 per minute• Observe rate and quality of respirations
– Should be quiet, effortless, and regularly spaced– Breathing should be through the nose– Depth of respiration: normal, shallow, or deep
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Respirations
• Abnormal respirations– Hyperventilation– Dyspnea– Rales (noisy breathing)– Apnea, absence of breathing– Cheyne-Stokes
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Blood Pressure
• Measured in the brachial artery of the arm in the antecubital space– Uses stethoscope and sphygmomanometer to
measure• Blood pressure phases
– Systole, contraction phase– Diastole, relaxation phase
• Expressed as a fraction, systolic/diastolic
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Normal Blood Pressure
• Systolic pressure– 100-120 mm Hg
• Diastolic pressure– 60-80 mm Hg
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Abnormal Blood Pressure
• Hypertension– Consistent readings above 140/90– Idiopathic (essential hyptertension)– Primary, secondary, malignant
• Hypotension– Consistent readings below 90/60
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