Vital Signs

Pat Rutherford

HSTE

Hart County High School

2009

Temperature

Measurement of balance of heat loss and heat produced

Abbreviation T

Homeostasis

Constant state of fluid balance Body reacts to chemicals and influences

temperature

Sites to measure T

Rectal - rectum Mouth - oral Axillary - armpit Aural – ear Temporal – forehead

Factors that affect body temp

Individual people differ – metabolic rates Time of day Body Sites Activities

Causes of increase T

illness infection exercise excitement environment

Cause of decrease

starvation of fasting ↓muscle activity mouth breathing exposure to cold certain disease

Methods to Measure Temp

Oral Most comfortable and common Questions pt about eating, drinking or

smoking prior to temp Leave in place 3-5 minutes if using

merciless thermometerDigital – leave until beeps usually one

minuteElectronic – records within 2 – 4 seconds

Continued

Tympanic – record aural readings, placed in the ear canal uses inferred reading of the tympanic membrane. Must be used correctly for accuracy

Temporal – measure the temporal artery

Terminology related to temp

Hypothermia – low body temp ↓ 95° Hyperthermia – high body temp 104° F Fever – an elevated (↑) temp usually 101°F Pyrexia – another term for fever

How to read a glass thermometer

The long line represents a whole number ex 98°

The short line represents .2 ° (2 tenths) of a degree

Normal Ranges

Oral = 98.6° F (+ or - 1°) 37° C Rectal = 99.6° F (+ or - 1°) 37.6° C Axillary =97.6° F (+ or - 1°) 36.4° C

Guidelines for Obtaining a Oral Temperature

Standard Precautions – wipe with alcohol or facility guideline before and after use; cover tip/probe; check glass thermometer prior to use, make sure the line is below 96° careful when shaking down not to hit objects close by. Use cool water when rinsing to prevent from breaking glass and destroying contents inside of the thermometer

Record and Report

Supplies for Temperature

Oral thermometer Plastic sheath Holder of with disinfectant Tissues or dry cotton balls Watch with second hand Soapy cotton balls Gloves Paper and pen

Pulse

Pulse is defined as the pressure of the blood pushing against the wall of an artery as the heartbeats and rests

Feel throbbing of the arteries caused by contractions of the heart

More easily felt in arteries that lie close to the skin and can be pressed against a bone.

Major arterial or pulse sites in the body

Temporal: side of the forehead Carotid: side of the neck, used for CPR Brachial: inner aspect of forearm at the

antecubital space (crease of elbow), used for blood pressure

Radial: inner aspect of wrist, above thumb, most common site for measuring pulse

Femoral: inner aspect of upper thigh

Pulse sites continued

Popliteal: behind knee Dorsalis pedis: top of foot arch Apex of the heart – inferior tip of the heart. Not

a pulse site, but a location to hear the heart rate accurately using a stethoscope. This is called an apical pulse

Posterior tibialis – behind the ankle

TEMPORAL

Carotid

Apex

Brachial

Radial

4

5

Femoral

Popiiteal

Dorsalis pedis

Posterior tobialis

Three items to note when obtaining a pulse

Rate Rhythm Volume

Pulse rate

Noted as the number of beats per minute Vary with individuals depending on age, sex, and body

size Adults: wide range of 60 to 90 beats per minute Adult men: 60 to 70 beats per minute Adult women: 65 to 80 beats per minute Children over 7to 12: 70 to 90 beats per minute Children from 1 to 7: 80 to 110 beats per minute Infants: 100 to 160 beats per minute

Related Terms

Bradycardia: pulse rate under 60 beats per minute

Tachycardia: pulse rate over 100 beats per minute (except in children)

Pulse Rhythm

Should be noted along with rate Refers to the regularity of the pulse, or the

spacing of the beats Described as regular or irregular Arrhythmia

Irregular or abnormal rhythm Usually caused by a defect in the electrical

conduction pattern of the heart.

Pulse Volume

Refers to the strength of the force Noted along with rate and rhythm Described by words such as strong, weak,

thready, or bounding

Various factors will change the pulse rate

1. Increased or accelerated rates caused by fever, shock, nervous tension, exercise, stimulant drugs and other similar factors

2. Decreased or slow rates caused by sleep, depressant drugs, heart disease, coma, and physical training and other similar factors

Basic principles for taking radical pulse

Position patient’s arm supported comfortably with palm of hand turned down

Use tips of two or three fingers to locate pulse site on thumb side of wrist

Count pulse for one full minute Note rate, rhythm, and volume of pulse

Record all information

Include rate, rhythm, and volume Example: Date, Time, P 82 strong and regular,

your signature and title

Respiration

Measures the breathing of the patient Process of taking in oxygen and expelling

carbon dioxide from the lungs and respiratory tract

One respiration consists of one inspiration (breathing in) and one expiration (breathing out)

Normal Respiratory Rate

Adults: 14 to 18 breaths per minute Wider adult range: 12-20 breaths per minute Children: 16-25 minutes Infants: 30-50 per minute

Character of respirations

Should be noted along with rate Refers to the depth and quality of respirations Described by words such as deep, shallow,

labored, moist, difficult, stertorous (abnormal sounds like snoring), and moist

Rhythm of respirations

Should be noted along with rate and character Refers to the regularity or equal spacing

between breaths Described as regular (or even) or irregular

Abnormal respirations

Dyspnea: difficult or labored breathing Apnea: absence of respirations, usually temporary Tachypnea: respiratory rate above 25 respirations per minute. Bradypnea: slow respiratory rate, usually below 10 respirations per minute Orthopnea: severe dyspnea in which breathing is very difficult in any position

other than sitting erect or standing Cheyne-Strokes: periods of dyspnea followed by periods of apnea; frequently

noted in dying patient Rales: bubbling or noisy sounds caused by fluids or mucus in the air passages Wheezing

Difficult breathing with a high pitched whistling or sighing sound during expiration

Caused by narrowing of bronchioles (as seen in asthma) and/or an obstruction or mucus accumulation in the bronchi

Cyanosis Dusky, bluish discoloration of the skin, lips, and/or nail beds Result of decreased oxygen and increased carbon dioxide in the

bloodstream

Voluntary control of respirations

Respirations are partially under voluntary control Patients may breathe faster or slower when they are

aware respirations are being counted Important to keep patient unaware of this procedure

Do not tell a patient you are counting respirations Keep your hand on pulse site while measuring

respirations Patient will think you are still counting pulse Will not be as likely to alter respiration

Record all information

Include rate, character, and rhythm Example: Date, Time, R 18 deep and regular,

Your signature and title

Report any abnormalities immediately to your supervisor