Vital Signs 4 Major
Temperature
Pulse
Respiration
Blood Pressure
Other Important Measurements
Pain Scale
Color of Skin
Pupil Size
Pupil Reactivity
Level of Consciousness
Response to Stimuli
Body TemperatureA measurement of the balance heat lost and heat produced by the body.
Can be measured in mouth (oral), the rectum (rectal), the armpit (axillary), and the ear (aural) Forehead (Temporal)
The loss and production of
HEAT!!!!!
Variations in TempNormal Range: 97-100 degrees Fahrenheit
Individual differences: bodily processes (slow/fast)
Time of the day: morning vs. eveningBody Sites:
OralRectalAxillaryAuralTemporal
Changes in Body Temperature
Increases
Decreases
Hypothermia: low body temp (below 95) death usually occurs at below 93
Hyperthermia: high body temp (above 104) convulsions, brain damage or death can occur above 106
(Pyrexia) Fever: elevated body temperature (101 degrees)
Febrile=fever
Afebrile=no fever
Temp. Continued Different readings can indicate disease
Most temperature is measured in degree
Fahrenheit vs. Celsius- Conversion may be necessary.
Normal Range: 97.8 F – 99 F equivalent to 36.5 C-37.2 C
PulseThe pressure of blood exerted against the wall of an artery as the heart contracts and relaxes.Rate= BPM (beats per minute)Rhythm= regularityVolume= strength
Apical Pulse: taken at the apex of the heart
Pulses: RangesNormal ( regular)
60-100 bpm
Should be regular
Measure for 30 secs and time by 2 for bpm.
Abnormal ( Irregular)
Below 60 Bradycardia
Above 100 Tachycardia
Abnormal rhythms etc.
A Fib
RespirationsBreathing rate of person
Rhythm/Rate= regularity
Character= type
Respiratory RatesNormal ( Eupnea)
12-20 respirations per minute
Type: Regular
Unlabored
Abnormal ( dyspnea, apnea)
Below 12 bradypnea
Above 20 Tachypnea
Blood PressureThe force exerted by the blood against the arterial walls when the heart contracts or relaxes.
Systolic/Diastolic Pressure
Systolic –measurement of max. force exerted on arterial walls when heart contracts. (gushing sound in stethoscope)
First sound you hear
Diastolic –measurement of force in arteries during relaxation of heart. (Lowest pressure) Also measures resistance in arteries.
Last sound you hear
Blood Pressure RangesNormal
Normal blood pressure
Systolic 100 to 119
Diastolic 60 to 79
Abnormal
Pre hypertension
Systolic 120 to 139
Diastolic 80 to 89
Hypertension
High Blood Pressure (Hypertension)
140/95 possible hypertension
(1 case) Arteriosclerosis “artery hardening”-decreased elasticity of arterial walls and narrowed lumens increase blood pressure.
As heart works overtime, the heart enlarges, muscle thickens and the heart becomes less efficient and damaged.
HYPERTENSIONSTAGE TWO
Systolic 160 or higher
Diastolic 100 or higher
STAGE ONE
Systolic140-159
Diastolic 90-99
HYPERTENSIVE CRISISSystolic 180 or above
Diastolic 110 or above
Cardiovascular disorders
Neurological conditions
Kidney and urological disorders
HYPOTENSIONSystolic less than 90
Diastolic less than 60
OXYGEN SATURATION
Oxygen SaturationOxygen Saturation provides important information about oxygen perfusion
Normal levels 90-100%
Make sure patient has no nail polish on
Make sure hand is flat on table
Capillary refill should be less than 3 seconds.