Vital Signs Notes - Denton ISD



Vital Signs Notes

Vital Signs: Various determinations that provide information about the basic body

Conditions of the patient.

Four main vital signs: blood pressure, pulse, temperature, and respiration.

Temperature: a measurement of the balance between heat lost and heat produced.

Oral (mouth): leave under tongue for 3-5 minutes or as long as it takes the

thermometer to read

Normal temp: 98.6

Normal range: 97.6 – 99.6

Use for adults and children over 3 years.

Rectal (rectum): leave in place for 3-5 minutes.

• most accurate method!

Normal temp: 99.6

Normal range: 98.6 – 100.6

Used for infants and children up to 3 years.

Axillary (under the upper armpit) and groin ( inner part of thigh)

Leave in place 5 to 10 minutes

Not as accurate.

Normal temp: 97.6

Normal range 96.6 – 98.6

Use for newborns

Aural (ear): measures the thermal, infrared energy radiating from the tympanic membrane, or eardrum.

For babies under 1 year pull the (ear) pinna straight back.

For everyone else pull pinna up and back

Variations in body temperature (you are not sick, these are normal variations)

a. normal range

b. individual differences

c. time of day

d. site temperature is measured

Abnormal body temperature conditions:

Hypothermia: below normal temperature - below 95, measured rectally

Death usually occurs if temperature falls below 93 for a period

What causes body temperature to decrease: starvation or fasting, sleep, decreased muscle activity, exposure to cold.

Hyperthermia: when body temperature exceeds 104 rectally.

Temp over 106 can for a period of time can lead to convulsions and death.

Temp over 101 = fever

What caused body temps to rise? Infection, injury, muscle and gland activity, food metabolism

Pyrexia or Febrile: Fever is present

Afebrile: No fever present

Homeostasis: a constant state of fluid balance. If a body temperature is too high or too low, the body’s fluid balance is affected.

How is heat lost? Perspiration, respiration, excretion (urine, feces)

If a patient has been eating, drinking or smoking, this will alter the oral temp. Wait 15 minutes before rechecking a temperature.

Pulse: The pressure of the blood felt against the wall of an artery as the heart beats.

How do you describe the pulse?

Rate – number of beats per minute

Rhythm – is it regular or irregular

Volume – is it strong, weak, thready or bounding

Normal range for pulse:

Adults: 60 – 100 bpm (beats per minute)

Children over 7 years: 65-80 bpm

Children 1 – 7 years: 80 – 110 bpm

Infants: 100 – 160 bpm

A rate under 60 bpm is bradycardia. This can be caused by sleep, depressant drugs, cold, heart disease, and coma

A rate over 100 bpm is Tachycardia. This can be caused by exercise, drugs, fever, heat, obesity, emotional state (nervousness, fear, anxiety)

When measuring a pulse, DO NOT use your thumb! The thumb contains a pulse that you may confuse with the patient’s pulse.

Apical Pulse: a pulse taken with a stethoscope placed at the apex of the heart.

Who do take an apical pulse on?

People with heart disease, infants, children, initial assessment

Respirations: The process of taking in oxygen and expelling carbon dioxide

Normal ranges:

Adults: 12 – 24

Children: 16 – 30

Infants: 30 – 50

1 inspiration + 1 expiration = respiration

How do you describe respirations?

Rate – number of times a person breathes per minute

Character – refers to the depth and quality of respirations

Ex. Deep, shallow, labored, difficult, striderous, and moist

Rhythm – refers to the regularity or respirations.

EX. Regular or irregular

Why should the patient not be aware when you are counting respirations?

If the patient is aware, they can alter their respiration.

Abnormal respirations

Dyspnea: difficult or labored breathing

Apnea: absence of respirations

Cheyne-stokes – periods of dyspnea followed by periods of apena

Rales: bubbling or noisy sounds caused by fluid in the lungs

Tachypnea – abnormal respiratory rate >24

Bradypnea – below normal respiratory rate ................
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