Chapter 16

Vital Signs

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 16:1 Measuring and Recording Vital
Signs
• Vital signs provide information about a
patient’s basic body conditions
• Temperature
– Measure of balance between heat lost and
produced by body
– Usually measured on Fahrenheit scale

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 16:1 Measuring and Recording Vital
Signs
• Pulse
– Pressure of blood felt against wall of an artery
– Rate: number of beats per minute
– Rhythm: regularity
– Volume: strength, force, or quality

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 16:1 Measuring and Recording Vital
Signs
• Respirations
– Patient’s breathing rate
• Blood pressure
– Force exerted by blood against arterial walls
• Apical pulse
– Taken with stethoscope at apex of heart

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 16:1 Measuring and Recording Vital
Signs
• Pain
– Acute or chronic
– Patient should describe the feeling
– Everyone tolerates pain differently
– Use of a 0 to 10 scale

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 16:2 Measuring and Recording
Temperature
• Temperature measures balance between heat
lost and heat produced in the body
– Heat lost through perspiration, respiration, excretion
– Heat produced by food metabolism, muscle, and
gland activity
• Homeostasis
– Constant state of fluid balance in the body
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 Variations in Body Temperature
• Normal range: 97°to 100° Fahrenheit
• Causes of variations
– Individual differences
– Time of day
– Body sites (refer to Table 16-1 in text)

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 Variations in Body Temperature
• Oral temperature
• Rectal temperature
• Axillary temperature
• Aural temperature
• Temporal temperature

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 Variations in Body Temperature
• Hypothermia
– Body temperature below 95°F
• Pyrexia (fever)
– Body temperature above 101°F
• Hyperthermia
– Rectal body temperature exceeding 104°F

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 Types of Thermometers
• Clinical thermometers
– Slender glass tube containing mercury
– Used by few health care agencies
– Danger of mercury contamination
• Electronic thermometers
– Used in most health care facilities

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 Types of Thermometers
• Tympanic thermometers
• Temporal scanning thermometers
– Accurate and noninvasive for internal body
temperature
• Plastic or disposable thermometers

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 Reading and Recording Temperature
• Record temperature to the nearest two-tenths
of a degree
• Refer to Figure 16-9 in text
• Record to avoid error in reading

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 Cleaning Thermometers
• Clean thermometers thoroughly after each
use
• Use cool water on glass thermometers to
prevent breakage
• Disposable plastic sheath may be used
• Follow agency policies

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 16:3 Measuring and Recording Pulse
• Pulse
– Pressure of blood pushing against the wall of an
artery as the heart beats and rests
• Major arterial or pulse sites
– Refer to Figure 16-18 in text

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 16:3 Measuring and Recording Pulse
• Pulse rate
– Number of beats per minute
– Bradycardia: pulse rate under 60 beats/minute
– Tachycardia: pulse rate over 100 beats/minute
• Pulse rhythm
– Regularity of pulse
– Arrhythmia
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 16:3 Measuring and Recording Pulse
• Pulse volume
– Strength, force, quality, or intensity of pulse
– Strong, weak, thready, bounding
• Factors that change pulse rate
• Measuring and recording radial pulse
– Refer to Procedure 16:3 in text

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 16:4 Measuring and Recording
Respirations
• Respiration
– Process of taking in oxygen and expelling carbon
dioxide from lungs and respiratory tract
• One respiration
– One inspiration (breathing in) and one expiration
(breathing out)

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 16:4 Measuring and Recording
Respirations
• Rate of respirations
– Number of breaths per minute
• Character of respirations
– Depth and quality of respirations
• Rhythm of respirations
– Regularity of respirations/space between breaths

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16:4 Measuring and Recording
Respirations

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 16:5 Graphing TPR
• Graphic sheets are used for recording
temperature, pulse, and respirations (TPR)
• Presents a visual diagram of variations in
patient’s vital signs
• May use color coding
• Refer to Procedure 16:5 in text

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 16:5 Graphing TPR
• Factors affecting vital signs are often noted
• Computerized graphs may be printed or kept
in the electronic health record (EHR)
• Graphic charts are legal medical records
– Neat, legible, accurate
– Correct all errors

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 16:6 Measuring and Recording Apical
Pulse
• Pulse count taken with stethoscope at apex of
the heart
• Usually ordered by physician
• Reasons for taking an apical pulse
• Protect patient’s privacy and avoid exposure

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 16:6 Measuring and Recording Apical
Pulse
• Two heart sounds
• Pulse deficit
– Difference between apical and radial pulse
• Refer to Procedure 16:6 in text

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 16:7 Measuring and Recording Blood
Pressure
• Measurement of pressure blood exerts on
walls of arteries during various stages of heart
activity
• Read in millimeters (mm) of mercury (Hg) on a
sphygmomanometer
• Measurements read at two points

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 16:7 Measuring and Recording Blood
Pressure
• Systolic pressure
– Pressure in walls of arteries when left ventricle
contracts
• Diastolic pressure
– Constant pressure in walls of arteries when left
ventricle is at rest

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 16:7 Measuring and Recording Blood
Pressure
• Pulse pressure
– Difference between systolic and diastolic pressure
• Hypertension (high blood pressure)
– Greater than 140 mm Hg systolic, 90 mm Hg
diastolic

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 16:7 Measuring and Recording Blood
Pressure
• Hypotension (low blood pressure)
– Less than 90 mm Hg systolic, 60 mm Hg diastolic
• Refer to Table 16-2 in text for adult blood
pressure classifications

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 16:7 Measuring and Recording Blood
Pressure
• Individual factors can influence blood pressure
readings, increase or decrease blood pressure
• Types of sphygmomanometers
– Mercury
– Aneroid
– Electronic

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 16:7 Measuring and Recording Blood
Pressure
• AHA factors to observe for accurate readings
– 5 minutes of quiet rest
– Take two separate readings and average
• Correct cuff size is essential for accuracy
• Refer to Procedure 16:7 in text

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