Observing & Measuring Vital SignsNATCEP Day Twenty-Five through Twenty-Seven

Why measure Vital Signs

• Means of getting information about the body’s condition

• Vital signs include– Temperature– Pulse– Respirations– Blood Pressure

Objectives: Temperature

• Identify– Cause of body temperature– “Normal” range or average body temperature

• List situations that may cause the thermometer reading to vary from “normal or average”

• Identify types of thermometers and situations in which they are used

• Demonstrate how to care for thermometers• Describe each method of checking temperature

Temperature is. . . . .

• A measurement of the amount of heat in the body, a balance between heat created and lost

• Created as the body changes food to energy

• Lost from the body to the environment by contact, perspiration, breathing and other means

Normal Ranges (Fahrenheit)

• Oral: 97.5 – 99.5• Rectal: 98.5 – 100.5• Axillary: 96.6 – 98.6• Tympanic: 96.4 – 100• Temporal: 99.6• Baseline: range varies from person to

person• Peak: 6pm; Low: 6am• Normal decreases with age

Variations High & Low: Causes

• Higher than normal– Eating warm food– Time of day– Infection– Disease

• Lower than normal– Eating cold food– Time of day– Dry mouth– Disease processes

Types of Thermometers

• Electronic • Digital• Chemically treated paper• Tympanic: eardrum/ear• Temporal: temporal artery/forehead

Care of Thermometers

• Probe Covers• Follow Manufacturer’s Instructions

– Electronic or Digital– Tympanic– Temporal

Taking an Oral Temperature

• Most common temperature• Under tongue• Mouth and lips closed• Beeping indicates done• Electronic/Digital

Taking an Axillary Temperature

• Least accurate– Safety prohibits other sites

• Under the arm• Tip placed in center of underarm• Arm should hold in place• Beeping indicates done• Electronic/Digital

Taking an Tympanic Temperature

• Open ear canal by gently lifting the ear up and back

• Gently insert tip inside ear canal• Beeping indicates done

Taking an Temporal Temperature

• Follow manufacturer’s instructions – Typical moved from center of forehead to

temporal artery site• Beeping indicates done

Taking a Rectal Temperature

• Infants • Children & Adults

– Used when other methods unavailable or inaccurate

• Lubricate and insert about 1 inch with resident on their side – hold in place

• Beeping indicates done• Electronic/Digital

Recording Temperature

• Use “ax” to indicate axillary• Use “r” to indicate rectal• Notify nurse

– Above or below normal range– Difficulty obtaining temperature

Practice

• Follow my instructions to practice on your peers

Objectives: Pulse

• State the “normal” or average pulse rate

• Identify variations from the “normal” pulse that should be reported

• Demonstrate the accurate taking of a radial pulse

• Discuss how to record and report pulse measurements

Pulse

• A measurement of the number of times the heart beats per minute

• Normal/average– 60-100 minute (adult)– Regular in rate, rhythm, strength/force

Variations in Pulse: Force

• Abnormal force can be distinguished by– Bounding pulse

• Cannot be occluded (blocked) by mild pressure

– Feeble, weak and thready• Occluded (blocked) by slight pressure• Thready: usually fast

Variations in Pulse: Rate

• Abnormal rate distinguished by– Rate under 60 per minute: Bradycardia– Rate over 100 per minute: Tachycardia

• Can be caused by– Exercise/activity– Fever

Variations in Pulse: Rhythm

• Abnormal rhythm distinguished by– Irregularity of beats– Feeling that beats are “skipped” when

pulse counted for one full minute

Sites for Checking Pulse

• Apical

• Radial

Report

• Pulse varies from “normals”• Difficulty obtaining pulse

Practice

• Follow my instructions to practice on your peers– Apical pulse– Radial pulse

Objectives: Respirations

• State the average respiratory rate• Describe how to measure respiratory

rate• Describe variations of respirations• Discuss how to record and report the

respiratory rate measurement

Respirations

• Inspiration and expiration of air • Average rate is 12-20 per minute (adult)

How to Count Respirations

• Look at chest or abdomen • Count for one full minute

Variations

• Rate– Increased by

• Exercise/activity• Fever• Lung Disease• Heart Disease

– Report fewer than 12 or more than 20 breaths per minute

Variations

• Character– Labored

• Difficulty breathing

– Noisy• Sounds of obstruction or wheezing

– Shallow• Small amounts of air exchange

– Irregular

Report

• Record in the appropriate area of the worksheet per facility policy

• Variations from “normals” immediately

Practice

• Follow my instructions to practice on your peers

Objectives: Blood Pressure

• Describe blood pressure (BP)• State the “normal” or average BP• Describe variations in BP • Identify instruments to check BP • Demonstrate correct procedure for

obtaining a BP• Identify how to record and report BP

measurements

Blood Pressure

• Force of blood against artery walls• Amount of pressure depends on

– Rate & strength of heart beat– Ease with which blood flows through the

blood vessels– Amount of blood within the system

Terms

• Systolic Pressure– Force when the heart is contracted– Top number of the BP– First sound when measuring

• Diastolic Pressure– Force when the heart is relaxed– Lower number of the BP– Level at which pulse sound change or

cease

Normal

• Adult is less than 120/80– Less than 120 systolic– Less than 80 diastolic

Variations

• May slightly increase with age• Hypertension: Higher than normal• Hypotension: Lower than normal• Postural Hypotension (Orthostatic)

– Elderly person’s body & blood pressure unable to rapidly adjust when changing positions = dizziness or feeling faint

Tools/Instruments

• Sphygmomanometer– Cuff and gauge

• Cuff– Correct size for the resident’s arm– Placed correctly over the brachial artery– Applied correctly

• Gauge: can be Aneroid: Dial or

Electronic: Digital

• Column of mercury• Stethoscope

Tools/Instruments

• Stethoscope

Factors that Influence Reading

• Proper clothing• Avoid smoking• Empty bladder• Allow time to rest & relax• Position body correctly

Body Position

• Arm supported at heart level• Back supported• Feet flat on floor• No talking or movement

Cautions

• DO NOT TAKE in arm with:– IV– Cast– Dialysis Shunt– Breast surgery on that side

Report

• Higher or lower than his/her usual range

• Difficulty obtaining

Blood Pressure – An OverviewCAUSE SYSTOLIC BP CORRECTIVE ACTION

Sit without back support + 6 to 10 Support back (sit in chair)

Full bladder + 15 Empty bladder before BP taken

Tobacco/caffeine use + 6 to 11 Don’t use before clinic appointment

BP taken when arm is:Parallel to bodyUnsupportedElbow too highElbow too low

+ 9 to 13 + 1 to 7 + 5 False low

While seated in chair, patient’s arm must be straight out and supported, with elbow at heart level

“White coat” reaction + 11 to 28 Have someone else take the BP

Talking or hand gestures + 7 No talking or use of hands during BP

Cuff too narrow/small + 8 to 10Right-sized cuff properly placed over bare upper armCuff too wide/large False low

Cuff not centered + 4

Cuff over clothing + 5 to 50(Pickering et al., 2005; Perry & Potter, 2006)

Practice

• Follow my instructions to practice on your peers