Vital Signs

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Vital Signs
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V. S. Introduction

• Refers to an assessment of temperature, pulse,
  respiratory rate, and blood pressure
• Related to ones ability to maintain life and a
  state of homeostasis
• Used to determine -pt. response to
  therapy
• -knowledge of expected results of
  prescribed meds. and tx. -baseline
  determination of pt.s physical status

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Temperature

• Reflects the ability of the body to produce,
  retain, and eliminate heat
• Varies according to time of day (lowest in
  morning) and with age (infant and aged increase
  by 0.6 - 1 C)
• Oral Temp. by placing thermometer under tongue
  for 3-4 min. (glass)
• Rectal Temp. by pt. lying on side and inserting
  1-2 inches (adults) for 2 min.

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Temperature (contd)

• Axillary Temp. in axilla for 10 min.
• Tympanic Temp. by placing probe in ear and using
  infrared light to measure core body temp. (only
  takes 1 second)
• Normal Values - neonatal range 35.5 -
  37.5C - adult 33.7 - 37.8C (avg. 37C) -
  range consist. with life 24 - 45C
• Rectal 1F gt Oral 1F gt Axillary

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Pulse

• Is an indirect measure of cardiac dynamics and
  cardiac output
• Is a throbbing sensation caused by an artery as
  it is gently pressed against a bony prominence
• Assessed at 9 sites - radial - temporal -
  femoral - ulnar - brachial - popliteal -
  carotid - facial - dorasalis pedis

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Pulse (contd)

• To assess, place the index, middle, and fourth
  fingers gently on the skin at the site where the
  artery passes next to a bony prominence
• Count for 30 sec. if regular and 60 sec. in
  irregular
• Assess for - Rate of beats - Rhythm
  pattern, reg. or irregular - Intensity weak,
  thready, bounding

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Pulse (contd)

• Normal rate for adults 60 - 100 bpm, but
  fluctuations occur with exercise, injury,
  illness, and emotional reactions

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Respiratory Rate

• Assessment includes - Type of breathing,
  i.e., abdominal or thoracic - Pattern of
  breathing
• When counting use insp. or exp., not both
• Normal adult 12 - 20

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Respiratory Patterns

• Eupnea
• Hypopnea shallow resp., maybe incr. rate
• Hyperpnea deep resp. with incr. rate, even and
  regular
• Bradypnea slow rate
• Tachypnea rapid rate, normal depth
• Cheyne - Stokes waxing and waning with periods
  of apnea
• Kussmaul fast and deep

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Patterns (contd)

• Biots irreg. pattern with apnea between
• Paradoxic chest wall moves in with inhalation
  and out with exhalation
• Apneustic prolonged inspiration
• Apnea
• Orthopnea difficulty breathing in recumbent
  positions

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Blood Pressure

• Quickest way to evaluate the effectiveness of
  pt.s C-V system
• Measurement of the force exerted against the
  walls of vessels by the blood in response to
  contraction of the heart
• Dependant on cardiac output, peripheral
  resistance of the vessels, and velocity of the
  arterial blood

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Classification of B. P.

• Diastolic - Normal BP lt85 mmHg - High
  Normal 85-89 mmHg - Mild HTN 90-104
  mmHg - Mod. HTN 105-114 mmHg - Severe HTN
  115 mmHg
• Systolic, when diastolic is lt 90 mmHg - Normal
  BP lt140 - Borderline isolated syst.HTN
  140-159 - Isolated systolic HTN 160

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Procedure for B. P.

• Place cuff around upper arm 2 -3 cm above
  antecubital space
• Brachial artery is palpated and cuff in inflated
  12-20 mmHg per second to 30 mmHg gt the point at
  which the pulse disappears
• Place the stethoscope over the brachial artery
  and deflate cuff at rate of 2-3 mmHg per heart
  beat

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B. P. Procedure (contd)

• Pressure is read as systolic pressure where
  Korotkoffs sounds are first heard
• Diastolic pressure is noted at the disappearance
  of all sounds

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Korotkoffs Sounds

• 1st Korotkoff clear tapping rhthymical sound,
  systolic press.
• 2nd K. murmur or swishing sound as cuff is
  deflated
• 3rd K. sounds become crisper and more intense
• 4th K. sounds become muffled and low-pitched,
  diastolic press. in infants/peds.
• 5th K. disappearance of all sounds

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Errors in B. P.

• Cuff too wide - False low reading
• Cuff too narrow - False high reading
• Deflating cuff too slowly - False high diast.
• Deflating cuff to quickly - False low systolic
  and false high diastolic
• Cuff wraped too loosely - False high reading