Vital Signs 4 Major

Temperature

Pulse

Respiration

Blood Pressure

Other Important Measurements

Pain Scale

Color of Skin

Pupil Size

Pupil Reactivity

Level of Consciousness

Response to Stimuli

Body TemperatureA measurement of the balance heat lost and heat produced by the body.

Can be measured in mouth (oral), the rectum (rectal), the armpit (axillary), and the ear (aural) Forehead (Temporal)

The loss and production of

HEAT!!!!!

Variations in TempNormal Range: 97-100 degrees Fahrenheit

Individual differences: bodily processes (slow/fast)

Time of the day: morning vs. eveningBody Sites:

OralRectalAxillaryAuralTemporal

Changes in Body Temperature

Increases

Decreases

Hypothermia: low body temp (below 95) death usually occurs at below 93

Hyperthermia: high body temp (above 104) convulsions, brain damage or death can occur above 106

(Pyrexia) Fever: elevated body temperature (101 degrees)

Febrile=fever

Afebrile=no fever

Temp. Continued Different readings can indicate disease

Most temperature is measured in degree

Fahrenheit vs. Celsius- Conversion may be necessary.

Normal Range: 97.8 F – 99 F equivalent to 36.5 C-37.2 C

PulseThe pressure of blood exerted against the wall of an artery as the heart contracts and relaxes.Rate= BPM (beats per minute)Rhythm= regularityVolume= strength

Apical Pulse: taken at the apex of the heart

Pulses: RangesNormal ( regular)

60-100 bpm

Should be regular

Measure for 30 secs and time by 2 for bpm.

Abnormal ( Irregular)

Below 60 Bradycardia

Above 100 Tachycardia

Abnormal rhythms etc.

A Fib

RespirationsBreathing rate of person

Rhythm/Rate= regularity

Character= type

Respiratory RatesNormal ( Eupnea)

12-20 respirations per minute

Type: Regular

Unlabored

Abnormal ( dyspnea, apnea)

Below 12 bradypnea

Above 20 Tachypnea

Blood PressureThe force exerted by the blood against the arterial walls when the heart contracts or relaxes.

Systolic/Diastolic Pressure

Systolic –measurement of max. force exerted on arterial walls when heart contracts. (gushing sound in stethoscope)

First sound you hear

Diastolic –measurement of force in arteries during relaxation of heart. (Lowest pressure) Also measures resistance in arteries.

Last sound you hear

Blood Pressure RangesNormal

Normal blood pressure

Systolic 100 to 119

Diastolic 60 to 79

Abnormal

Pre hypertension

Systolic 120 to 139

Diastolic 80 to 89

Hypertension

High Blood Pressure (Hypertension)

140/95 possible hypertension

(1 case) Arteriosclerosis “artery hardening”-decreased elasticity of arterial walls and narrowed lumens increase blood pressure.

As heart works overtime, the heart enlarges, muscle thickens and the heart becomes less efficient and damaged.

HYPERTENSIONSTAGE TWO

Systolic 160 or higher

Diastolic 100 or higher

STAGE ONE

Systolic140-159

Diastolic 90-99

HYPERTENSIVE CRISISSystolic 180 or above

Diastolic 110 or above

Cardiovascular disorders

Neurological conditions

Kidney and urological disorders

HYPOTENSIONSystolic less than 90

Diastolic less than 60

OXYGEN SATURATION

Oxygen SaturationOxygen Saturation provides important information about oxygen perfusion

Normal levels 90-100%

Make sure patient has no nail polish on

Make sure hand is flat on table

Capillary refill should be less than 3 seconds.