Understanding Vital Signs

Vital Signs Overview

• Vital signs are the body's most basic functions, routinely monitored by medical professionals
• Main vital signs include temperature, pulse, respiration, blood pressure (BP), and oxygen saturation
• These measurements indicate a person's hemodynamic status

Temperature

• Temperature indicates the balance between heat produced and heat lost by the body
• Can be measured using a thermometer
• Normal oral temperature is considered to be 98.6°F (37°C)
• Acceptable range is between 97.6°F (36.4°C) to 99.6°F (37.5°C)
• A temperature over 100.4°F (38°C) indicates a fever caused by illness or injury
• Hypothermia (low temperature) occurs when the body temperature dips below 95 degrees F (35 degrees C)
• Digital thermometers are most commonly used
• Glass thermometers and forehead strips are not accurate or recommended

Equipment Needed for Temperature Measurement:

• Tray with thermometer
• Jar of cotton balls soaked in water and soap suds solution
• Jar with cut tissue paper and waste receptacle
• Wrist watch with second-hand
• Notebook and pen

Clinical Manifestations of Fever

• Onset (Cold or Chill Phase): increased heart rate, respiratory rate and depth, shivering, pallid skin, complaints of feeling cold and cessation of sweating
• Course (Plateau Phase): absence of chills, warm skin, photosensitivity, increased pulse and respiratory rates, thirst, possible dehydration, changes in mental status, herpetic lesions, loss of appetite, malaise and aching muscles
• Defervescence (Fever Abatement/Flush Phase): flushed and warm skin, sweating, decreased shivering, possible dehydration

Oral Temperature Method

• Contraindications: infants, unconscious/irrational patients, those with history of seizures, mouth breathers, patients with oral cavity disease or nose surgery, after consuming hot/cold food or fluids

Axillary Temperature Method

• Indications: oral inflammation, recovering from oral surgery and cannot breathe through their noses

Tympanic/Aural Temperature Method

• Contraindications: infants with significant ear pathology, a foreign body in the ear, or moisture/blood in the ear
• Advantages: more accurate reflection of core temperature, minimally invasive, easy-to-use and comfortable for children, more hygienic and safer than other forms of thermometry

Rectal Temperature Method

• Indication: to obtain the first temperature in newborns to check anal patency, also useful when oral or other routes cannot be used
• Contraindications: diarrhea, rectal disorder/injury, hemorrhoids, patients with heart disease/cardiovascular issues, recent rectal surgery, leukemia and is confused/agitated patients
• Disadvantage: slightly uncomfortable

Other Temperature Measurement Methods

• Strip-type thermometers are held against the forehead
• They are not an accurate way of taking a temperature, showing the temperature of the skin rather than the body

Celcius to Fahrenheit Conversion

• C = (Fahrenheit temperature -32) × 5/9

Fahrenheit to Celcius Conversion

• F = (Celsius temperature × 9/5) + 32

Action and Rationale for Taking Temperatures

• Explain the procedure to the patient to encourage participation and allay anxiety
• Gather necessary equipment
• Practice hand hygiene and apply gloves to prevent transmission of microorganisms
• Clean the thermometer from the bulb downward to reduce spread of microorganisms
• To measure temperature with an oral thermometer, encourage the patient to refrain from drinking, eating and smoking
• Instruct the patient to close mouth with the lips and not the teeth around the thermometer

Axillary Temperature Measurement

• To measure temperature with axillary thermometer, cleanse the patient's armpit and pat it dry with tissue
• Place the thermometer well into the patient's axilla and bring the arm down close to his body
• For children under 5 years old, hold the child on your knee and gently hold the forearm against their body

Tympanic Temperature Measurement

• For tympanic thermometer, gently pull the patient's ear
• Adults: up and back
• Children: down and back, only insert the tip of the probe and don't force the probe

Rectal Temperature Measurement

• With a rectal thermometer, close the door and position the patient in a lateral position
• Lubricate the thermometer and separate the buttocks to visualize the anus
• Insert the thermometer approximately 0.5 to 1 inch into the rectum
• Wait until the thermometer beeps and inform the patient of the result

Last Steps In The Temperature Taking Process

• Clean or sterilize the thermometer and discard all used cotton balls and tissue paper in the waste receptacle
• Remove gloves and wash hands, and record the temperature

Pulse

• Pulse is a rhythmical throbbing resulting from a wave of blood passing through an artery as the heart contracts
• Heart rate or pulse is the number of times a heart beats per minute (bpm)
• Purpose is to estimate the quality of the heart's action per minute

Assessing When Taking Pulse

• RATE: count the pulse rate for 1 full minute
• STRENGTH/TENSION: grade the strength of the pulse and check the pulse points bilaterally and compare them
• Normal: 2+
• RHYTHM or REGULARITY: is the pulse regular or irregular
• VOLUME
• Note that anxiety, injury, pain, fever and medications can affect heart rate

Pulse Sites

• Temporal
• Carotid
• Apical
• Brachial
• Radial
• Femoral
• Popliteal
• Dorsalis pedis
• Posterior Tibial

Normal Pulse Rate Range by Age

• Newborn (resting): 100-180 bpm
• Infant (resting): 80-150 bpm
• Child 2-6 years: 75-120 bpm
• Child 6-12 years: 70-110 bpm
• Adolescent-adult: 60-90 bpm

Equipment Needed To Take Pulse:

• Wrist watch with second-hand
• Jot down notebook and pen
• Stethoscope (for apical pulse)

Procedure for Taking Pulse

• Wash hands to stop cross-contamination
• Explain to the patient what is to be done
• Make sure the patient is relaxed and comfortable
• Ask whether the patient has walked, climbed stairs, or otherwise exerted himself in the last 20 minutes

Radial Pulse

• Position the patient's arm with the palm downward
• Lightly press the radial artery while counting the number of felt pulsations for one full minute

Cardiac Rate Or Apical Pulse

• Warm the diaphragm of the stethoscope and place it on the patients chest
• Diaphragm should be placed on the apex of the heart, located at the fifth intercostal space in line with the middle of the clavicle
• Note the rhythm and evaluate the intensity or loudness of the heart sounds

Steps to Take Carotid Pulse

• May be taken when radial pulse is not present or difficult to palpate
• Used during CPR on adults
• Tilt the head to the side and palpate below the jaw line between the trachea and sternomastoid muscle
• Wash hands and dry for each step
• Record pulse rate in notepad and describe strength and rhythm

Respiration

• Respiration is the exchange of oxygen and carbon dioxide between the atmosphere and the body
• Respiration rate is the number of breaths a person takes per minute
• The purpose is to estimate a respiratory status

Normal Respiration Rate By Age:

• Adults: 16-20 breaths per minute
• Infants: 30-40 breaths per minute
• Children: 20-25 breaths per minute

Equipment Needed for Measuring Respiratory Rate

• Wrist watch with second - hand
• Notebook and pen

Steps to Measure Respiratory Rate

• While the fingertips are still in place after counting the pulse rate, observe the patient's respiration
• Count the number of respirations for one full minute

Respiratory Rate Reminders

• Longer counting and palpations are necessary to identify the unusual characteristics of the pulse
• If respirations are abnormal, repeat to determine rate more accurately
• Record the respiratory rate abnormalities

Blood Pressure

• Blood pressure is the lateral force exerted by the blood on the arterial walls during contraction and relaxation of the heart
• The measurements taken are to aid in diagnosis, and to monitor changes in a patient's condition

Situations Where Blood Pressure Measurements Should Be Avoided

• Surgeries, Venous access, and injuries to the shoulder

Locations Blood Pressure Can Be Measured At

• Either arm, either leg, and dorsalis pedis

Factors that Cause Variation in Blood Pressure

• Emotional state
• Temperature/respiration
• Bladder overextension
• Pain
• Tobacco/Alcohol use
• The race/ethnicity of patient
• Diet

Equipment Needed for Blood Pressure

• Notebook and pen
• Sphygmomanometer and stethoscope (for manual reading) as well as BP apparatus

Classifications of Blood Pressure Levels

• Normal: less than 120/80 (systolic/diastolic)
• Prehypertension: 120-139/80-89
• Hypertension Stage 1: 140-159/90-99
• Hypertension Stage 2: Greater than 160/100

Steps for Measuring Blood Pressure

• For accurate reading, ask the patient if they have been walking
• Support their back as well as their legs if possible
• Use the correct size cuffs
• The cuff should be around the upper arm and should be about 3 cm above elbow area
• Face their palm upwards when extending their arm

Steps For Measuring Blood Pressure

• Properly place stethoscope while closing the valve to inflate cuff
• Open the valve and slowly release air
• Monitor rate on the manometer and deflate the cuff

Things to Avoid

• Don't wrap anything too loosely
• Let the patients have some time for rest before assessment
• Don't deflate at too quick of a pace
• Make sure nothing is above the arm, like pillows
• Avoid using any instruments or tools that may have contact with pain

Oxygen Saturation

• Measurement of oxygen in the blood carrying a percentage of the maximum, using a pulse oximeter or something smaller
• Used as a tool to assess patients, and assess how new lung medication is working
• Helps understand if someone needs help breathing

Precautions

• Patient's who have burns, require close probe maintenance
• Monitor conditions of the skin in the probes area

List of Equipment

• Pulse oximeter and notepad

Steps with Oxygen Saturation

• Clean the test area where the probe will go on pulse oximeter
• Let patient feel any pain coming to the finger while checking
• Check pulse and oxygen saturation
• Important Note:* Please remember that these notes are for studying purposes only and should not be used as a substitute for professional medical advice. Always consult with qualified healthcare professionals for accurate information and guidance.