VITAL SIGNS

Vital SignsVital signs are important

indicators of health states of the body

Vitals Signs Defined as: various determinations that provide basic body conditions of the patient

Four Main Vital Signs• Temperature

• Pulse

• Respirations

• Blood Pressure

Additional Vital Signs• Degree of Pain: scale 1 – 10

• Color of skin

• Size of pupils & reaction to light

• Level of consciousness

• Response to stimuli

They are usually the first sign of disease or abnormality in the patient.

Healthcare WorkersAs a healthcare worker it is your

responsibility to measure and record the vital sign of a patient.

However it is not your responsibility to reveal this information to the patient – Physician’s responsibility.

Temperature• Temperature is the

measurement of balance of heat lost and heat produced in the body

• Can be measured: • mouth (oral)

• Rectum (rectal)

• Armpit (axillary)

• Ear (aural)

• Too high or too low can be a sign of disease or infection

TemperatureMost temperatures are measured

in Fahrenheit Scale

However many healthcare facilities are now using Celsius Scale

Temperature ConversionFahrenheit to Celsius:Subtract 32 from F temp, than

multiply by 5/9 or 0.5556

IE: 212 Degrees F – 32 = 180 180 X 5/9 or 0.5556 = 100 C

Temperature ConversionCelsius to Fahrenheit:Multiply Celsius Temp by 9/5 or

1.8 and than add 32.

IE: 37 degrees Celsius X 9/5 or 1.8 = 66.6

66.6 + 32 = 98.6 F

TemperatureNormal ranges vary:

97 – 100 degrees F (98.6)

36.1 – 37.8 degrees C (37)

Temps vary during the day and where

you take them

TemperatureOral – taken in the mouth with

thermometer, 3 – 5 minutesRectal – taken in rectum, 3-5

minutesAxillary – taken under the armpit,

10 minutesAural – Special thermometer is

placed in the ear and measures thermal infrared energy from blood vessels in the ear.

Temperature IndicationsHypothermia – low temp, below

95 F

• Prolonged exposure to cold

• Death occurs below 93 F

Fever – above 101 F, infection or injury

Hyperthermia – above 104 F

• Gets above 106, convulsions/brain damage/death

PulsePulse is the pressure of the blood

felt against the artery wall as the heart contracts & relaxes (beats)

What gets recorded:

• Rate

• Rhythm

• Volume

Pulse• Rate – refers to the number of

beats per minute

• Rhythm – refers to regularity of the beats

• Volume – refers to the strengthPulse is usually taken over the radial artery

Pulse MeasurementThe pulse of a patient can be

measured at various sites.

• Radial – inner aspect of wrist above the thumb

• Brachial – Inner aspect of elbow

• Femoral – inner aspect of upper thigh

• Popliteal – behind the knee

• Dorsalis Pedis – top of arch of foot

Pulse RatesPulse rates vary by age, sex,

body size and physical condition.

Adults: 60- 90 Beats per minute-bpm

Adult men: 60- 70 bpmAdult Women: 65- 85 bpmInfants: 100 – 160 bpm

Bradycardia – pulse under 60 bpmTachycardia – pulse over 100 bpm

except infants

RespirationsRespirations reflect the breathing

rate of the patient

• Also note the regularity – rhythm

• Character – type (deep, shallow)

RespirationsNormal rate is 14 – 18 breaths per

minute (sometimes 12 – 20)

• Children slightly faster: 16 – 25

• Infants: 30 – 50

Words used to describe breathing are also used – labored, shallow, deep, difficulty

Breathing TerminologyDyspnea – difficult or laboredApnea – Absence of respiration Tachypnea – rate above 25Bradypnea – below 10Orthopnea – very, very difficult in

any other position other than sitting

Cheyne-Stokes – periods of dyspnea followed by Apnea

Breathing TerminologyRales – bubbling or noisy sounds

caused by mucus or fluid in lungs

Wheezing - difficulty in breathing along with high pitched whistling during expiration

Cyanosis – a dusky, bluish discoloration of the skin, lips and/or nail beds as a result of decreased oxygen and increase carbon dioxide in blood

Measuring Breathing• Best done with the patient

unaware that you are doing it.

• Count respirations after performing pulse check.

• Continue holding wrist and count each inspiration/expiration as one.

Blood PressureBlood pressure is the force

exerted by the blood against the artery walls when the heart contracts and relaxes.

• Two readings are recorded• Systolic - contraction

• Diastolic - relaxation

Measuring Blood PressureInstrument: sphygmomanometerNormal Systolic is 120 mm Hg

range from 100 – 140 mm Hg

Normal Diastolic is 80 mm Hgrange from 60 – 90 mm Hg

Hypertension – BP to highHypotension – BP to low

Measuring Blood Pressure• Roll up patient sleeve to 5”

above elbow

• Position arm palm up and supported

• Wrap deflated cuff 1 -1.5 “ above elbow (Center of bladder of cuff should be over brachial artery)

Measuring Blood PressureSystolic Pressure: tighten valve

pump up until pulse is no longer heard, slowly release pressure and record pressure when pulse is first heard.

Diastolic Pressure: Continue slowly releasing valve and note when pulse disappears or when there is a significant change in sound.

Additional Vital SignsApical Pulse – Taken by a

stethoscope at the apex of the heart.

• Actual heartbeat is heard and counted

• Used when radial pulse is weak as in diseased arteries or infants when pulse is to rapid to count