Understanding Vital Signs

• Vital signs reflect the status of body temperature regulation, heart function, and breathing.
• Vital signs abbreviations are Temperature (T), Pulse (P), Respirations (R), and Blood Pressure (BP); Vital signs are also referred to as TPR and BP combined.
• Measuring vital signs helps detect changes in normal body function and response to treatment.

Measurements

• Temperature measures body heat.
• Pulse measures heart rate.
• Respiration measures how often a resident inhales and exhales.
• Blood Pressure measures the pressure against the walls of arteries.
• Pain is also considered a vital sign and is based on the patient's description.

Temperature Measurement

• Body temperature is the balance between heat production and heat loss.
• Types of thermometers include plastic disposable, electronic (with probe covered), tympanic (ear probe), and infrared (forehead).
• Temperature can be taken orally, rectally, axillary (armpit), tympanically (ear canal), and with an infrared forehead scanner.
• The resident's condition determines the best measurement site.
• Normal oral temperature ranges from 36.5° to 37.5° C.
• Normal rectal temperature ranges from 37.0° to 38.1° C.
• Normal axillary temperature ranges from 36.0° to 37.0° C.
• Normal tympanic temperature ranges from 37.0° to 38.1° C.
• Normal infrared temperature ranges from 36.0° to 37.0° C.

Pulse Measurement

• Pulse is the pressure of blood pushing against artery walls as blood passes through when the heart beats.
• Pulse can be measured at the radial (base of thumb), temporal (side of forehead), carotid (side of neck), brachial (inner elbow), and femoral (inner upper thigh) arteries.
• Additional pulse measurement sites include the popliteal (behind the knee), dorsalis pedis (top of foot), and apical pulse (over the apex of the heart, taken with a stethoscope on the left chest).
• Normal pulse range is 60-100 beats per minute, with a regular rhythm.
• Documenting pulse rate involves noting the number of beats per minute, the rhythm (regular or irregular), and the volume (strong, weak, thready, bounding).

Respiration Measurement

• Respiration involves taking in oxygen and expelling carbon dioxide from lungs and the respiratory tract.
• Normal respirations: 12-20 respirations per minute, quiet, effortless, and regular.
• Documenting respiratory rate includes noting the number of inhalations and exhalations per minute (one inhalation and one exhalation equal one respiration), rhythm (regular or irregular), and character (shallow, deep, labored).

Blood Pressure Measurement

• Blood pressure is the force of blood pushing against the walls of arteries.
• Systolic pressure is the greatest force exerted when the heart contracts.
• Diastolic pressure is the least force exerted when the heart relaxes.
• A sphygmomanometer (manual) with cuffs of different sizes, a pressure control bulb, and a pressure gauge marked with numbers is required to manually measure blood pressure.
• The equipment to measure blood pressure also includes a stethoscope.
• Normal blood pressure ranges: Systolic (top number) 100-130, Diastolic (bottom number) 70-85, for example, 120/80.
• Blood pressure needs to be measured on the upper arm with the correct cuff size.
• Identify the brachial artery for correct stethoscope placement when measuring blood pressure.
• The first sound heard indicates the systolic pressure.
• The last sound heard or the point at which the sound changes indicates the diastolic pressure.
• Blood pressure should be recorded as systolic/diastolic.
• The resident should be in a relaxed position, sitting or lying down, when blood pressure is measured.
• Blood pressure is usually taken in the left arm.