Vital Signs

Vital Signs

* Commonly refer to the taking of temperature, pulse, respirations and blood pressure of a client. (we don’t require HHA’s to take blood pressure)

* Indicated how the body is functioning or how the client is responding to treatment.

* Can also be an indicator that the client’s condition is changing.

* Service plan should detail the frequency vital signs should be performed.

* Always document vitals in your charting if it is required during your visit. If it’s not required mark N/A

* Report any temperatures above 101.0 to the nurse

Four types of Temperature Measurement

* Oral

* Rectal (you will not do this route)

* Axillary

* Tympanic

* Different situations cause need for different measurement sites.

Temperature

* Your body temperature is set by your hypothalamus, an area at the base of your brain that acts as a thermostat for your whole system.

* Your temperature is the balance of the heat produced by your body tissues, particularly your liver and muscles, and the heat your body loses.

* When you’re ill, your normal temperature may be set a few points higher as your body directs the blood away from your skin to decrease heat loss.

* When a fever starts, and your body tries to elevate its temperature, you feel chilly and may shiver to generate heat until the blood around your hypothalamus reaches the new set point.

* When your temperature begins to return to normal, you may sweat profusely to get rid of the excess heat.

* If you’re very old, very young or alcoholic, your body’s ability to produce a fever may be lessened.

* Your normal body temperature varies throughout the day according to circadian rhythm ---- it’s lower in the morning and higher in the late afternoon and evening. In fact, your normal temperature can range from about 97 F (36.1 C) to 99 F (37.2 C). Although most people consider 98.6 F (37 C) normal, your temperature may vary by a degree or more. Other factors, such as your menstrual cycle or heavy exercise, can affect your temperature.

A high fever can mean:

* The body is responding to a viral or bacterial infection.

* Heat exhaustion

* Extreme sunburn

* Certain inflammatory conditions such as rheumatoid arthritis

* Malignant tumor or some forms of kidney cancer

* Some medications, such as antibiotics and drugs used to treat high blood pressure or seizures

* Some immunizations, such as the diphtheria, tetanus and acellular (DTaP) or pneumococcal vaccines (in infants and children)

Complications

* A rapid rise or fall in temperature may cause a fever-induced seizure (febrile seizure) in a small number of children ages 6 months to 5 years. Although alarming for parents, most of febrile seizures cause no lasting effects.

* Febrile seizures usually involve loss of consciousness and shaking of limbs on both sides of the body. Less commonly, a child may become rigid and twitch only part of his or her body. If a seizure occurs, lay your child on his or her side or stomach on the floor or ground. Remove and sharp objects that are near your child, loosen tight clothing and hold your child to prevent injury. Don’t place anything in your child’s mouth or try to stop the seizure. Although most seizures stop on their own, call for emergency medical assistance if a seizure lasts longer than 10 minutes.

How to take an oral temperature

* Place the tip of either digital or oral thermometer beneath the tongue on either side, the tip pointing to the rear facing the tonsil area. It is important to place the tip in the correct place to get an accurate reading. Once the thermometer is correctly placed under the tongue wait three minutes for the thermometer reading.

* Most oral thermometers are now filled with a dyed alcohol, rather than mercury. If you find that your client has a mercury filled thermometer, contact your supervisor.

To read a non-mercury thermometer

* To read an oral thermometer, hold at eye height and gently rotate until you can see the dye level mark.

Digital thermometer

* A digital thermometer will give you a reading

Do not use oral temperature measurement if the client is:

* Mentally confused

* Uncooperative

* Combative

* Coughing excessively

* Unconscious

* Using oxygen via a mask

* Has an NG tube

* On seizure precautions

* Unable to keep his mouth shut around thermometer

* A small child or infant

* Recently drank fluids within the last 15 minutes

Axillary Temperature

* Arm pit must be dry

* For traditional thermometer, must remain under arm for a full ten minutes

* This method is the least reliable temperature measurement

* Place a clean thermometer under the arm and place the arm back down on top of it snugly. If you are using a digital thermometer, it should beep when it is finished measuring Be careful the client stays still when using a glass thermometer so that it does not break

* Average axillary temperature is 96.9-98.6

Pulse

* The pulse rate is a measurement of the heart rate, or the number of times the heart beats per minute. As the heart pushes blood through the arteries, the arteries expand and contract with the flow of the blood. Taking a pulse not only measures the heart rate, but also can indicate the following:

* Heart rhythm

* Strength of the pulse

* Normal pulse is 60-100 beats/minute

* Children 6-15 have a rate of 70-100

* Infants pulse is 130-160. With infants, use your stethoscope to measure the apical pulse.

To measure pulse

* Using the first and second fingertips, press firmly but gently on the arteries until you feel a pulse

* Begin counting the pulse when the clock’s second hand is on the 12

* Count your pulse for 60 seconds (or for 15 seconds and then multiply by four to calculate beats per minute

Pulse rate changes may indicate

Increased Pulse Rate:

Fever

Infections

Heat Failure

Agitation, anxiety

Lower Pulse Rate:

Dehydration

Shock

Blood loss

Sleep

Respirations

Average respiratory rates, by age:

* Newborns: Average 44 breaths per minute

* Infants: 20-40 breaths per minute

* Preschool children: 20-30 breaths per minute

* Older children: 16-25 breaths per minute

* Adults: 12 to 20 breaths per minute

* Client’s may breathe more quickly when they know they are being observed. It is usually best to count respirations following taking a client pulse. Keep your fingers on the client’s wrist while counting respirations.

* Also observe the client to determine if they have difficulty breathing, shallow, rapid, or irregular breathing

* Count the times a client takes a breath for 15 seconds and multiply x 4

Blood Pressure

* Blood pressure is measured with a blood pressure cuff and a stethoscope

* Blood pressure reading measure the force of the blood pushing against the artery walls, each time the heart beats, it pumps blood into the arteries, resulting in the highest blood pressure as the heart contracts

* RN’s/LPN’s will monitor blood pressure



Quiz Vital Signs

1. Which vitals signs can you take?

A. Temperature

B. Pulse

C. Respirations

D. All the above

2. An example of why a person might have a fever.

A. Infection

B. Sunburn

C. Recent immunization

D. All the above

3. You arrive at patient home and they are drinking coffee. Should you check temperature?

A. Yes – it shouldn’t matter

B. Wait 15 min after finished drink and check

C. Do rectal temperature

D. Don’t check temperature that day

4. The normal range of a pulse for an adult is:

A. 60-100 b/min

B. 70-100 b/min

C. 130-160 b/min

5. The normal range of respirations for an adult is:

A. 12-20 breaths/minute

B. 20-30 breaths/minute

C. 44 breaths/minute

D. 20-40 breaths/minute

6. When should you chart vitals.

A. Only if abnormal

B. Every shift

C. Never

D. When indicated on care plan

Answer Key: Vital Signs

1. D

2. D

3. B

4. A

5. A

6. D