Understanding Vital Signs

• Vital signs reflect the body's temperature regulation, heart function, and breathing.
• Vital signs are essential for life.

Abbreviations

• Temperature is abbreviated as T.
• Pulse is abbreviated as P.
• Respirations are abbreviated as R.
• Blood Pressure is abbreviated as BP.
• Vital signs are abbreviated as TPR and BP.

Purpose of Measuring Vital Signs

• Vital signs are measured to detect changes in normal body function.
• Vital signs are used to determine response to treatment.

Measurement

• Measurements for vital signs should be taken at rest.
• Temperature measures body heat.
• Pulse measures heart rate.
• Respiration measures how often a resident inhales and exhales.
• Blood Pressure measures pressure against walls of arteries.
• Pain reports are based on the patient's description.

Temperature Measurement

• Body temperature is a balance between heat production and heat loss.

Thermometer Types

• Plastic thermometers are disposable.
• Electronic thermometers have a probe covered with a disposable shield.
• Tympanic thermometers use an electronic probe in the ear.
• Infrared thermometers are used on the forehead.

Sites for Taking Temperature

• Oral
• Rectal
• Axillary
• Tympanic (ear canal)
• Infrared (forehead)
• The resident's condition determines the best site for temperature measurement.

Normal Temperature Range for Adults

• Oral: 36.5° - 37.5° C
• Rectal: 37.0° - 38.1° C
• Axillary: 36.0° - 37.0° C
• Tympanic: 37.0° - 38.1° C
• Infrared: 36.0° - 37.0° C

Pulse Measurement

• Pulse is the pressure of blood pushing against the artery wall as blood passes when the heart beats.

Sites for Taking Pulse

• Radial (base of thumb)
• Temporal (side of forehead)
• Carotid (side of neck)
• Brachial (inner aspect of elbow)
• Femoral (inner aspect of upper thigh)
• Popliteal (behind knee)
• Dorsalis pedis (top of foot)
• Apical pulse (over apex of heart)
• Apical pulses are taken with a stethoscope on the left side of the chest.

Pulse Characteristics

• Normal pulse range is 60-100 beats per minute and regular.
• Document pulse rate as the number of beats per minute.
• Document whether the rhythm is regular or irregular.
• Volume can by strong, weak, thready or bounding.

Respiration

• Respiration is the process of taking in oxygen and expelling carbon dioxide from the lungs and the respiratory tract.

Normal Respirations

• Normal respirations range from 12-20 respirations per minute.
• Breathing should be quiet, effortless, and regular.

Respiratory Rate Documentation

• Document the number of inhalations and exhalations per minute (one inhalation and one exhalation equals on respiration).
• Document whether the rhythm is regular or irregular.
• Note the character; shallow, deep, or labored.
• Note if the patient is "working" to breathe.

Blood Pressure

• Blood pressure is the force of blood pushing against the walls of arteries.
• Systolic pressure: greatest force exerted when the heart is contracting.
• Diastolic pressure: least force exerted as the heart relaxes.

Equipment for Measuring Blood Pressure

• Sphygmomanometer (manual) includes:
  • Cuff (different sizes)
  • Pressure control bulb
  • Pressure gauge (marked with numbers)
• Stethoscope

Normal Blood Pressure

• Normal blood pressure range:
  • Systolic (top number): 100-130
  • Diastolic (bottom number): 70-85
  • Example: 120/80

Guidelines for Blood Pressure Measurements

• Measure blood pressure on the upper arm.
• Use the correct size cuff.
• Identify the brachial artery for correct placement of stethoscope.
• The first sound heard is the systolic pressure.
• The last sound heard or change in sound is the diastolic pressure.
• Record systolic/diastolic.
• The resident should be in a relaxed position, sitting or lying down.
• Typically, blood pressure is usually taken in the left arm.