Measuring and Recording Vital Signs

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Measuring and RecordingVital Signs
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Pulse

• Defined as the pressure of the blood pushing
  against the wall of an artery as the heart beats
  and rests
• Feel throbbing of the arteries caused by
  contractions of the heart
• More easily felt in arteries that lie close to
  the skin and can be pressed against a bone

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Major Arterial or Pulse Sites of the Body

• Temporal side of the forehead
• Carotid side of the neck (used for CPR)
• Brachial inner aspect of forearm at the
  antecubital space (used for BP)
• Radial inner aspect of wrist above thumb (most
  common place to measure pulse)
• Femoral inner aspect of upper thigh
• Popliteal behind knee
• Dorsalis pedis top of foot arch

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Pulse Rate

• The number of beats per minute
• Varies with each individual depending on age, sex
  and body size
• Adults 60 90 bpm
• Adult men 60 70 bpm
• Adult women 65 80 bpm
• Children over 7 70 90 bpm
• Children 1 to 7 80 110 bpm
• Infants (less than 1) 100 160 bpm

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Pulse Rate

• Bradycardia pulse rates under 60 bpm
• Tachycardia pulse rates over 100 bpm (except in
  children)
• Any variations or extremes in pulse rates should
  be reported immediately

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Pulse Rhythm

• Should be noted along with rate
• Refers to the regularity of the pulse or the
  spacing of the beats
• Described as regular or irregular
• Arrhythmia
• Irregular or abnormal rhythm
• Usually caused by a defect in the electrical
  conduction pattern of the heart

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Pulse Volume

• Should be noted along with rate and rhythm
• Describes the strength or intensity of the pulse
• Described by words such as strong, weak, thready
  or bounding

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Factors that Change Pulse Rate

• Increased rates can be caused by exercise,
  stimulant drugs, excitement, fever, shock or
  anxiety
• Decreased rates can be caused by sleep,
  depressant drugs, heart disease or coma

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Basic Principles for Taking Radial Pulse

• Position pts arm supported comfortably with palm
  of hand turned down
• Use tips of 2 or 3 fingers to locate pulse site
  on thumb side of wrist
• Count pulse for 1 full minute
• Note rate, rhythm and volume of pulse
• Record info as
• 9/15/06, 0830, P 82 strong and regular, Teresa
  Briggs, RN

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Respiration

• Measures the breathing of the patient
• Process of taking in oxygen and expelling carbon
  dioxide from the lungs and respiratory tract
• 1 respiration consists of 1 inspiration
  (breathing in) and 1 expiration (breathing out)

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Normal Respiratory Rate

• Adults 12 20 rpm
• Children 16 25 rpm
• Infants 30 50 rpm

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Character of Respirations

• Should be noted along with rate
• Refers to the depth and quality of respirations
• Described by words such as deep, shallow,
  labored, moist, difficult, stertorous (abnormal
  sounds like snoring)

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Rhythm of Respirations

• Should be noted along with rate and character
• Refers to the regularity or equal spacing between
  breaths
• Described as regular (or even) or irregular

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Abnormal Respirations

• Dyspnea difficult or labored breathing
• Apnea absence of respirations
• Tachypnea rapid respiratory rate above 25 rpm
• Bradypnea slow respiratory rate, usually below
  10 rpm
• Orthopnea severe dyspnea in which breathing is
  very difficult in any position other than sitting
  erect or standing

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Abnormal Respirations

• Cheyne-Stokes periods of dyspnea followed by
  periods of apnea, frequently noted in the dying
  patient
• Rales bubbling or noisy sounds caused by fluids
  of mucus in the air passages

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Basic Principles for Taking Respirations

• Respirations are partially under voluntary
  control
• Pts may breathe faster or slower when they are
  aware respirations are being counted
• Important to keep pt unaware of this procedure
• Do not tell pt you are counting respirations

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Basic Principles for Taking Respirations

• Keep your hand on pulse site while measuring
  respirations
• Pt will think you are still counting pulse
• Pt will not be as likely to alter respiratory
  rate
• Count respirations for 1 full minute
• Note rate, character and rhythm of resps
• Record info as
• 9/15/06, 0830, R 18 deep and regular, Teresa
  Briggs, RN

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Apical Pulse

• Pulse count taken at the apex of the heart with a
  stethoscope
• Actual heartbeat is heard and counted
• Reasons for taking apical pulse
• Physician orders for pts with irregular heart
  beats, hardening of the arteries or weak or rapid
  radial pulses
• Also taken on infants and kids due to their rapid
  pulses because they may be difficult to feel

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Measuring Apical Pulse

• Position stethoscope over apex of heart (2 3
  inches to the left of the breastbone below the
  left nipple)
• Count pulse for 1 full minute so arrhythmias can
  be detected
• Note rate, rhythm and volume
• Record info as
• 9/15/06, 0830, AP 84 strong and regular, Teresa
  Briggs, RN

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Heart Sounds

• 2 separate sounds are heard while listening to a
  heart beat
• Sounds resemble a lubb-dupp
• Each lubb-dupp counts as 1 heartbeat
• Sounds are caused by the closing of heart valves
  as blood flows through the chambers of the heart
• Abnormal sounds or beats should be reported to
  your supervisor immediately

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Pulse Deficit

• Heart is weak and does not pump enough blood to
  produce a pulse in some cases
• In other cases, heart is beating so fast the
  heart does not have enough time to fill with
  blood so the heart beat does not produce a pulse
  each time
• The apical pulse rate is higher than radial pulse
  rate

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How to Measure Pulse Deficit

• One person measures apical pulse with stethoscope
• Second person measures pulse at radial site at
  same time
• Measure both pulses for 1 full minute
• Subtract radial pulse from apical pulse rate
• Difference is pulse deficit

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Blood Pressure

• Measurement of the pressure that the blood exerts
  on the walls of the arteries as the heart
  contracts or relaxes
• Measured in millimeters of mercury on an
  instrument called a sphygmomanometer
• Measurements are read a 2 points
• Systolic
• Diastolic

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Blood Pressure

• Blood pressures are recorded as fractions
• Systolic is the top number (numerator)
• Diastolic is the bottom number (denominator)

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Systolic Pressure

• Pressure that occurs in the walls of the arteries
  when the heart is contracting and pushing blood
  into arteries
• Normal systolic reading is 120 mm of Hg
• Normal range is 100 140 mm of Hg
• Noted as the reading on the sphygmomanometer
  gauge when the first sound is heard

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Diastolic Pressure

• Constant pressure that is in the walls of the
  arteries when the heart is at rest or between
  contractions
• Blood has moved into the capillaries and veins,
  so the volume of blood in the arteries has
  decreased
• Normal diastolic reading is 80 mm of Hg
• Normal range is 60 90 mm of Hg

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Diastolic Pressure

• Adults Noted as the reading on the
  sphygmomanometer gauge when the sound stops or
  becomes very faint
• Children Noted as the reading on the
  sphygmomanometer gauge when the sound changes and
  becomes soft or muffled

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Pulse Pressure

• Difference between the systolic and diastolic
  pressure
• Important indicator of the health and tone of
  arterial walls
• Normal range for pulse pressure in adults is 30
  to 50 mm Hg
• Ex If the systolic pressure is 120 mm Hg and the
  diastolic pressure is 80 mm Hg, the pulse
  pressure is 40 mm Hg

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Hypertension

• High blood pressure
• Indicated when pressures are greater than 140 mm
  Hg systolic and 90 mm Hg diastolic
• Common caused include stress, anxiety, obesity,
  high salt intake, aging, kidney disease, thyroid
  deficiency and vascular conditions such as
  arteriosclerosis

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Hypotension

• Low blood pressure
• Indicated when pressures are less than 100 mm Hg
  systolic and 60 mm Hg diastolic
• Occurs with heart failure, dehydration,
  depressions, severe burns, hemorrhage and shock

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Factors Influencing Blood Pressure Readings

• Force of heartbeat
• Resistance of the arterial system
• Elasticity of the arteries
• Volume of blood in the arteries

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Factors That May IncreaseBlood Pressure

• Excitement, anxiety, nervous tension
• Stimulant drugs
• Exercise and eating

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Factors That May DecreaseBlood Pressure

• Rest or sleep
• Depressant drugs
• Shock
• Excessive blood loss

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Factors Causing MiscellaneousBlood Pressure
Readings

• Lying down (usually lower)
• Sitting position
• Standing position (usually highest)

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Types of Sphygmomanometers

• Mercury sphygmomanometer
• Contains a long column of mercury
• Each line on gauge represents 2mm of Hg
• Must be placed on a flat, level surface or
  mounted on a wall or stand
• Level of Hg should be at zero when viewed at eye
  level if manometer is calibrated correctly

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Types of Sphygmomanometers

• Aneroid sphygmomanometer
• Does not have a mercury column, just a round
  gauge
• Calibrated in mm of Hg
• Each line on gauge represents 2 mm of Hg
• Gauge should be positioned at eye level for
  correct readings

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Size and Placement of Sphygmomanometer Cuff

• Cuff contains a rubber bladder
• Bladder fills with air as cuff is inflated
• Applies pressure to arteries to stop blood flow
• Cuffs that are too narrow or too wide cause
  inaccurate readings
• Width of cuff should be approximately 20 wider
  that diameter of pts upper arm
• Small cuff can result in false high reading
• Large cuff can result is false low reading

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Size and Placement of Sphygmomanometer Cuff

• Pt should be seated or lying comfortably
• Forearm should be supported on a flat surface
• Area of the arm covered by the cuff should be at
  heart level
• Arm must be free of any constricting clothing and
  cuff should be applied to bare arm

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Size and Placement of Sphygmomanometer Cuff

• Deflated cuff should be placed on arm with the
  center of rubber bladder directly over the
  brachial artery
• Lower edge of cuff should be 1 to 1 ½ inches
  above the antecubital area

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Placement of Stethoscope

• Place bell/diaphragm of stethoscope directly over
  the brachial artery at the antecubital area
• Hold it securely but with as little pressure as
  possible
• Record info as
• 9/15/06, 0830, 122/76, Teresa Briggs, RN