SPM 100 Skills Lab 2 Vital Signs Notes (Updated 5-2004)

Vital Signs:
Five Components of Vital Signs: 1. e!pe"at#"e$ No"!al %anges (&'o &(o)) 2. P#lse$ '0-100*!in &. %espi"ations$ 12-20*!in 4. +lood P"ess#"e$ 120*(0 !!,g 5. Pain -ssess!ent$ N#!e"i.al/ 0es."ipti1e 2 Vis#al Body Temperature: 3"al %e.tal -5illa 6!pani. &4o ) &4.5o) &'.5o) &4o)

,ealt76 indi1id#al bod6 te!pe"at#"e de1iates 8"o! &'-&(o ). )ells/ tiss#es and o"gans 8#n.tion best at t7ese te!pe"at#"es. No"!al bod6 te!pe"at#"e is &4o ). 7e bodies te!pe"at#"e is "eg#lated b6 t7e anterior hypothalamus (p"ote.ting 8"o! 76pe"t7e"!ia) and posterior hypothalamus (p"ote.ting 8"o! 76pot7e"!ia). Factors Influencing Body Temperature: ,6pot7e"!ia$ de."ease !etaboli. "ate/ inade9#ate .lot7ing/ .old en1i"on!ent/ d"#g * al.o7ol .ons#!ption/ ina.ti1it6/ aging. ,6pe"t7e"!ia$ in."ease !etaboli. "ate/ inapp"op"iate .lot7ing/ 7ot en1i"on!ent/ inabilit6 to pe"spi"e/ !edi.ations/ in8e.tio#s p"o.ess/ e5e".ise. :n."eased bod6 !etabolis! and !etaboli. a.ti1it6 a..o!pan6 ele1ations in bod6 te!pe"at#"e and !a6 be as 7ig7 as 10 1& pe".ent 8o" ea.7 1o). :n."eased !etaboli. de!and "es#lts in a in."ease in o56gen .ons#!ption. P#lse and "espi"ations$ in."ease in p#lse 10-15 beats*!in. ;it7 ea.7 1o). %espi"ato"6 "ate is in."eased d#e to t7e in."ease in o56gen de!and. Pulse: :n8ant oddle" -d#lt To calculate Maximum Heart Rate: 120-1'0*!in <0-140*!in '0-100*!in 220 age = _______ (=5$ 220 2' > 1<4)

Pulse sites$ e!po"al/ )a"otid/ +"a.7ial/ %adial/ 8e!o"al and -pi.al (8o" in8ants). Pulse rate$ .o#nt 8o" 15 se.onds and !#ltipl6 b6 4. 7e 9#alit6 o8 a"te"ial p#lsation indi.ates .a"dia. ;o"kload and .a"dia. e88i.ien.6. (-ssess!ent o8 Pe"ip7e"al Vas.#la" %esistan.e)

SPM 100 Skills Lab 2 Vital Signs Notes (Updated 5-2004)

Factors Influencing Pulse Rate: =5e".ise e!pe"at#"e =!otions 0"#gs ,e!o""7age Increase s7o"t-te"! 8e1e" 2 7eat pain/ an5iet6 ? .7"onot"opi. (epi) loss o8 blood Decrease t"ained at7letes 76pot7e"!ia se1e"e pain - .7"onot"opi. (digitalis)

@#alit6 o8 t7e p#lse is assessed and !a6 be noted on a point s.ale$ &? - bo#nding in."ease st"oke 1ol#!e 2? - no"!al 1? - ;eak t7"ead6 de."ease st"oke 1ol#!e 3 absen.es Respirations: Ne; +o"n )7ild -d#lt Factors Influencing Respiratory Rate: =5e".ise -.#te pain -n5iet6 S!oking Na".oti. Increase "ate 2 dept7 "ate 2 dept7 "ate 2 dept7 "ate Decrease &5-40*!in 20-&0*!in 12-20*!in

"ate 2 dept7

a.76pnea in."eased "espi"ato"6 "ate. A 24*!in. +"ad6pnea - B 10*!in. (dep"ession o8 "espi"ato"6 .ente" d"#gs/ b"ain inC#"6) -pnea total .essation o8 b"eat7ing 06spnea di88i.#lt/ labo"ed/ o" pain8#l b"eat7ing (ai" 7#ng"6)/ "apid/ s7allo; b"eat7ing -pain/ S3+/ ,6po5e!ia Blood Pressure: -"te"ial blood p"ess#"e is an i!po"tant pa"a!ete" o8 t7e .a"dio1as.#la" s6ste! and t7e stat#s o8 8l#id balan.e. +lood p"ess#"e 7as t;o .o!ponents$ s6stoli. and diastoli.. ystolic pressure$ t7e !a5 p"ess#"e e5e"ted on t7e a"te"ies ;it7 t7e le8t 1ent"i.#la" s6stole. !iastolic pressure$ t7e elasti. "e.oil p"ess#"e .onstantl6 p"esent on t7e a"te"ial ;alls. Pulse pressure$ t7e di88e"en.e bet;een t7e s6stoli. and diastoli. p"ess#"e. "ean Blood Pressure > 0iastoli. ? 1*& (P#lse P"ess#"e)

SPM 100 Skills Lab 2 Vital Signs Notes (Updated 5-2004)

&

+lood p"ess#"e is a p"od#.t o8 t7e .a"dia. o#tp#t (St"oke Vol#!e 5 ,ea"t %ate) ti!es t7e i!pedan.e to blood 8lo; t7"o#g7 t7e 1essels/ o" pe"ip7e"al 1as.#la" "esistan.e. Da.to"s t7at in."ease eit7e" t7e .a"dia. o#tp#t o" t7e 1as.#la" "esistan.e ;ill in."ease p"ess#"e. Normal BP: ge Ne; +o"n 1 6ea" ' 6ea" 14-14 6"s -d#lt Peds: Mini!#! S6stoli. +lood P"ess#"e (S+P) > 40 !!,g ? (2 5 age in 6ea"s) Classification of BP: No"!al P"e76pe"tension ,6pe"tension/ Stage 1 ,6pe"tension/ Stage 2 Systolic (!!,g) B120 120 -1&< 140 - 15< A 1'0 Diastolic (!!,g) B(0 (0 - (< <0 - << A 100 Blood Pressure (!!,g) 40 (!ean) <5*'5 105*'5 120*45 120*(0

#th $eport of the %oint &ational 'ommittee on Pre(ention) !etection) *(aluation) and Treatment of high Blood Pressure+ ,"ay 200-.

3"t7ostati. ,6potension$ 8all in s6stoli. +P 25 !!,g and 10 !!,g a..o!panied b6 sign and s6!pto!s. Factors Influencing Blood Pressure: Pain Sepsis -n5iet6 S!oking Na".oti.s +lood Loss Increase E E E E E .. Sa!e side o8 "adi.al !aste.to!6 d. -"! 7as a s7#nt * 8ist#la 8o" "enal dial6sis Decrease E

'ontraindications: a. :8 t7e a"! 7as int"a1eno#s 8l#id in8#sing. b. -"! inC#"ed o" diseased

*rrors in BP "easurements: !ig" %eadings$ #o$ %eadings$ 1 - :napp"op"iate .#88 siFe. 1 - -"! abo1e le1el o8 7ea"t. 2 - G"apping .#88 too loosel6 2 - Dail#"e to noti.e an a#s.#lato"6 gap. & - -8te" !eals/ s!oking/ bladde" distended. & :nabilit6 to 7ea" so#nds. 4 - 0e8lating t7e .#88 to slo;l6.

SPM 100 Skills Lab 2 Vital Signs Notes (Updated 5-2004)

Pain Scale: % Types Pain is s#bCe.t to an indi1id#alHs inte"p"etation. Pain s.ale assess!ent allo;s t7e !edi.al tea! to .o!8o"t and !eet t7e needs o8 t7e indi1id#al. 7e indi1id#al "eads t7e s.ale and .7ooses a ;o"d to des."ibe t7e intensit6 o8 t7ei" pain. -8te" identi86ing t7e le1el o8 pain "ating t7at is .o!8o"table 8o" t7e indi1id#al/ t7e !edi.al tea! ;ill ens#"e t7e pain !anage!ent is e88e.ti1e. ;o ;a6s to !anage pain$ 0"#g t7e"ap6 and Non-d"#g te.7ni9#es (Slo; %76t7!i. +"eat7ing). /+ &umerical IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII 0 1 2 & 4 5 ' 4 ( < 10 No Pain Se1e"e Pain 2+ !escripti(e IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII No Pain Mild Mode"ate Se1e"e Unbea"able Pain Pain Pain Pain -+ 0isual (Non1e"bal and )7ild"en)

%e8e"en.e$ Potte" Pe""6$ D#nda!entals o8 N#"sing/ )7apte" &2$ 0ital ignsJ Do#"t7 edition/ Mosb6 1<<4.