Index

Lecture Notes

 

VITAL SIGNS Lecture Notes

 

Vitals Signs : Temperature, Pulse Respiration and Blood Pressure (TPR

& BP)

    Earliest indicators of change in the body

 

Temperature : balance between heat production and heat loss in the

body

    Disturbances either cause - hypothermia (low temp) or

    pyrexia (fever)

  

Body heat is created by - exercise

        food ingestion

        muscle tension

        hormones

        external factors such as clothing, blankets, etc.

  

Heat loss occurs by - sweating

          vaporization from the lungs

          dilation of blood vessels

  

Normal Temperature Ranges

Axillary (under the armpit)

Taken for 5-10 minutes

          96.6F - 98.6F

        

Oral Taken for 3 - 5 minutes

          97.6F - 99.6F

(fever is anything over 100.6F oral)

        

Rectal Taken 2-3 min . in the rectum after

inserting the thermometer 1 1/2 - 3 inches               Normal Range:  98.6 - 100.6F

 

Factors affecting Temperature :

  Time of day

  Age

  Environmental temperature

  Exercise

  Menstrual Cycle

 

Fevers/ Febrile (3 types)

    Constant

    Intermittent (comes and goes)

    Remittent (fever goes down in the day and rises at night)

     Symptoms of Infection:

      1. fever

      2. pus

      3. Warmth and reddness

      4. Malaise (feeling blah)

Treatment : ·   tempid baths, reduce room temperature and amount of bedding

      force fluids, high calorie diet

      Medication if necessary

  **Fluctuations 0f 2-3 degrees increases metabolic rate and pulse

rate (10 beats/degree)

 

Process for taking an oral temperature :

Ask the patient - “Have you had anything to eat, drink or smoke in the last 15 minutes?”

  (If they have, wait 5-10 minutes the take the temp

Rectal temps are not taken on

patients who have had any rectal surgery

    patient with inflamed hemorrhoids

    patients with bleeding from the rectum

 

Oral temps are not taken on

patients under the age of 5

patients who mouth breathe or have nasal congestion

patients with a nasogastric tube

  patients on Oxygen

patients who have had face/neck injuries or surgery

patients who are confused or unconscious

 

   Report all temperatures over 100.6F or 37.9C Immediately!!

 

 

Pulse - heart rate/minute

  

  ** Most often taken at the radial artery

-   usually taken for 30 seconds and multiplied by 2, unless the heart rate is irregular

-   if the heart rate is irregular, the pulse must be taken Apically (at

the apex of the heart in the chest) with a stethoscope for 1 Full

minute

 

   Normal Adult pulse: 60 - 100

  Slow pulse rate less than 60/ minute = bradycardia, and must immediately be reported

-   Rapid heart rate over 100/ minute = tachycardia, and must be reported

  

 

Respirations - number of breaths per minute

represented by 1 Inspiration + 1 Expiration

   Normal range for Adult Respirations: 12- 20   

**You must document the symmetry of the chest on inspiration, depth, rhythm and any abnormal sounds heard

  

-   Slow respirations less than 12/min = bradypnea

-   Rapid respirations over 28/min = tachypnea

   Abnormal sounds :

    1. rales - wet sounds

    2. rhonchi - noisy, harsh lung sounds

    3. stridor - ‘crowing' on inspiration (usually will see the chest

caving in with inspiration)

    4. wheezing - high pitch whistling sounds with SOB   

 

Types of Breathing :

   Eupnea - normal breathing   

   Dyspnea - difficulty breathing

   Orthopnea - difficulty breathing while lying down flat

   Apnea - no breathing

   Sterterous - noisy breathing that sounds like snoring

   Cheyne Stokes breathing - periods of deep breaths, followed by

very short or no breaths, and repeat in cycles (occurs shortly

before death)

   Kussmaul breathing : heavy labored breathing with a fruity odor

 

Blood Pressure: pressure exerted on the walls of arteries when the blood is pumped out of the heart ( Systolic BP ),

and the pressure left when the heart is at rest ( Diastolic BP ).

The top number is - systolic

The bottom number - diastolic   

**The difference between the two readings is called Pulse pressure

 

Factors affecting Blood Pressure:

  1. age

  2. stress

  3. disease

  4. race

  5. exercise

  6. pain

  

Sounds of blood pressure - Korotkoff Sounds

   Tapping

  Swishing

  knocking

  muffled

  silence

 

Principles related to Blood Pressure:

1. Patient should be resting for 5 minutes prior to taking the reading

2.   You must document the position the patient was in (sitting/lying)

* Do not take the BP standing unless ordered that way

  3. Use the correct size cuff

  4. Use the brachial artery

5. Palpate the brachial artery and inflate the cuff 30mm above where the pulse   

disappeared. Deflate the cuff slowly. Where you feel the pulse return, will be

approximately what the systolic BP will be.

6. Deflate completely before re-inflating the cuff. Wait 15 seconds

if you must recheck.

  7. Once the cuff is inflated, immediately start slowly deflating or

venous congestion will occur and the reading will be inaccurate

 

Hypotension - low blood pressure   

**only dangerous with symptoms of shock :

      1. Pale, cold clammy skin

2. rapid weak pulse

3. Sudden drop in blood pressure

    4. Thirst/ nausea

 

Hypertension - sustained elevated blood pressure

**Can cause a stroke ( Cerebral vascular accident / CVA )     

**High blood pressure also damages the kidneys, heart and retina of the

eyes

 

 

Oxygen Administration

Precautions:

  NO SMOKING!!

  Electrical equipment must be in good working condition and be

grounded

  Use of wool or nylon materials that can generate a spark or static

electricity should be avoided.   

 

 

Care for patients on Oxygen Therapy:

•    Maintain an open airway by positioning for comfort, and

•  suctioning as necessary

•    Oxygen is very drying, use humidification

•    Prevent infections by removing and cleaning nasal cannulas every

•  shift

•    Pad elastic around the ears to prevent decubitus ulcers (sores)

•    Give oral care every 2-4 hours because O2 causes tissue drying

•    Set the gauge correctly and do not adjust it yourself (any changes

must be ordered by the doctor)

** Watch for changes in the breathing pattern of the patient. Wet gurgling noises or increased

difficulties breathing must immediately be reported.