Document 1755657

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Outward signs of what is occurring inside the
body
Also give valuable information about the
patient’s condition
They are taken on every patient you assess.
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Pulse
Blood pressure (BP)
Respirations
Skin Condition
Pupillary Respons
Capillary refill (for children < 6yo)
 Initial
set of vial signs are
called baseline vital signs
 Must be repeated
periodically
◦Observe trends!
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The “waves” felt as blood is pumped by the
heart
Measures the heart rate and quality
Feel for the pulse and an artery near the
skin surface
Most often measured at the radial artery.
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Normal pulse rate
◦ 60-100 beats per minute (bpm) at rest
◦ >100 bpm – tachycardia
◦ <60 bpm – bradycardia
Regular Pulse
Measure over 15 seconds x 4 or 30 seconds x 2
Irregular pulse
Measure for a full minute
 Tachycardia
◦ Temporary tachycardia
 Fear
 Activity
 Some medication
 Sudafed is a common culprit!
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Bradycardia
◦ Seasoned athletes may normally have pulses from
40-50 bpm
◦ Some medications may depress pulse rate
 Beta blockers
A pulse consistently under 50 or
greater than 120 is a problem!
 Normal/full
 Weak/thready
 Strong/bounding
 Regular
vs irregular
 Regularly irregular vs.
irregularly irregular
A
complete pulse measurement
must include: Rate, strength,
regularity
 For example:
◦ Pulse rate of 120, thready and
regulary irregular
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Often overlooked, yet it’s an early and EASY
tipoff that the respiratory system is impaired.
Normal respiratory rate in an adult
◦ 12-20 breaths per minute
◦ One respiration cycle is one inhalation and one
exhalation
◦ Can measure for 30 seconds X 2
◦ Best to measure for a full minute
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Bradypnea: < 12 breaths per minute
Tachypnea: > 20 breaths per minute
Apnea: absence of breathing
Hyperpnea: Very deep respiration
Hyperventilation: Hyperpnea and tachypnea
Cheyne-Stokes: alternating between apnea
and tachypnea
Hypoxia: Inadequate oxygenation
 Deep
 Shallow
 Labored
 Normal
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Blood pressure is the
force of blood against the
arterial walls.
Responsible for the flow
of blood.
Blood pressure is the
result of:
- The pumping action of
the
heart.
- Resistance of the
blood vessels.
- Volume of blood.
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Distance from the heart.
Would B/P in the legs be lower or higher than
in the arm?
 Systolic
Phase-
Systole
 Ventricles
Contract
 Blood flows to
the body
 Diastolic
Phase
– Diastole
 Heart
relaxes
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Sex and age of the
patient.
Exercise, eating,
emotions
Stimulants
Obesity
Arteriosclerosis
Diabetes
Pain
Heredity factors
Some drugs
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Fasting
Rest
Depressants
Weight loss
Loss of blood or shock
Diuretics
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Recorded as an improper fraction. 120/80
Numerator equals systolic pressure, the first
sound you will hear.
Denominator equals diastolic pressure, the
last sound you will hear.
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Auscultated through a stethoscope
Sounds are correlated with the readings on a
sphygmomanometer.
Blood pressure is recorded in millimeters of
mercury. (mm Hg)
Determine baseline
- From medical record
- From systolic palpated pressure
 Hypertension – High blood pressure
 Hypotension – Low blood pressure
 Orthostatic hypotension – decrease
in B/P with position change from
supine to erect.
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Equipment
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Use the proper size cuff
Undersized cuff artificially raises blood
pressure
Oversized cuff artificially lowers blood
pressure
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The "ideal" cuff should have a bladder length
that is 80% and a width that is at least 40% of
arm circumference (a length-to-width ratio of
2:1).
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Ideally have the
patient seated and
their arm at heart
level. Make sure
that they do not
have any tight
clothing which may
constrict their arm.
Palpate in the
antecubital fossa
for the point of
maximal
pulsation of the
brachial artery.
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Cuff applied directly
over skin (not
through clothes)
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Clothes artificially
raises blood pressure
Center inflatable
bladder over brachial
artery
Position lower cuff
border 1 inch above
antecubital space
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The examiner should
assess the estimated
systolic pressure. To do
this, palpate the patient’s
radial pulse. Now inflate
the cuff until you feel the
exact point when the
pulse disappears. The
point on the manometer
at this moment
represents the estimated
systolic pressure.
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Place your
stethoscope over
the brachial artery
area. Now inflatean
extra 30mmHg
worth of pressure
above the estimate
systolic pressure
(e.g. if the estimate
systolic pressure
was 120mmHg –
inflate the cuff to
150mmHg).
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Now slowly release the pressure in the cuff by
using the valve.
 The pressure should be reduced at a rate of
2-3mmHg per second. The point where
consecutive tapping noises (i.e. Korotkoff
phase 1) occur you should read off the
pressure on the manometer – i.e. the systolic
pressure.
 When
the consecutive heart
beat sounds finally
disappear (i.e. Korotkoff
phase 5), read off the
measurement on the
manometer. This
represents the diastolic
pressure.
 False
high reading
- Cuff too small
- Cuff too loose
- Slow cuff release
- Column or dial not at eye level
- Anxiety or recent exercise
 False
low reading
- Incorrect position of arm…be
sure
to position at the level of the
heart
- Failure to notice
auscultatory gap:
Sounds fade out for 10 to 15
mm Hg then return
– Inaudibility of low volume
sounds
– Column or dial not at eye level
Blood pressure values
• Systolic normal range 90 –
140 mm Hg
 Diastolic normal range 60 –
90 mm Hg
 Pulse pressure: difference
between
systolic & diastolic pressure,
approximately 40 mm Hg
Blood pressure
readings…
 Use same arm for
readings
• Do not take B/P on
arm with:
 – An IV
 – Paralysis
 – Injury
 – A – V shunt
 – Edema
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Body temperature (T) is one of the first
assessments done.
Temperature Ranges
◦ Normal adult temperature is 98.6ºF, or 37ºC.
◦ Normal range can be from 96.8ºF to 100.4ºF,
or 36ºC to 38ºC.
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Temperature Ranges (cont.)
◦ Temperatures can vary due to:
 Time of day.
 Allergic reaction.
 Illness.
 Stress.
 Exposure to heat or cold.
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Temperature Sites
◦ Oral – within the mouth or under the
tongue.
◦ Axillary – in the armpit.
◦ Tympanic – in the ear canal.
◦ Rectal – through the anus, in the rectum.
◦ Other sites include on the skin or in the
blood.
 Types of Thermometers
◦ Electronic Thermometers
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Measure temperature
through a probe at the end
of the device.
Hold as close as possible to
the area where you wish to
measure the temperature.
 Types of Thermometers (cont.)
◦ Glass Thermometers
Mercury rises in a glass tube until its level matches
the temperature.
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Bulb shapes
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Long tip – for oral use.
Security tip – for oral
and rectal use.
Rounded tip – for rectal.