Hanik rachmawati

15.14201.31.31
Vital Signs
Temperature
Pulse
Respiration
Blood pressure
Pain
Vital Signs

Indicators of body function

Assess body systems
Signify changes taking place in body
Temperature
Balance of heat gained & heat lost
Hypothalamus is temp regulation center
Heat produced by
Cellular activity
Food metabolism
Muscle activity
Hormones
External factors heat, hot drinks, warm clothing
Internal factors - dehydration
Temperature

Heat lost from body by

Skin
Sweating
Lungs
Increased resp rate
Elimination
Urine or feces
Temperature Normally

36-37C
Temperature procedure

Wear gloves
Shake mercury down below 96
If smoked or had something to drink,
wait 10 min
Insert thermometer, wait.
Oral under tongue, 5 minutes
Axillary in armpit, 10 minutes
Rectal in rectum, 3 minutes
Pulse

Force against the arterial walls that

cause them to expand with each
heartbeat
Count for one minute
Norm adult pulse is 60 100 beats/min
< 60 beats/min = bradycardia
> 100 beats/min = tachycardia
Factors that increase pulse

Exercise
Strong emotions fear, anger, laughter,
excitement
Fever
Pain
Shock
Hemorrhage
Factors that decrease pulse

Sleep/rest
Depression
Drugs digitalis, morphine
Athletes in good physical condition may
have a lower pulse, probably <60
beats/min. This is normal
Respiration
Exchange of oxygen & carbon dioxide in
lungs
1 respiration = 1 inhalation + 1 exhalation
Regulated by the medulla
Normal adult rate is 16 20 breaths/min
Normal breathing is quiet, effortless, &
regular in rhythm
Qualities to observe for Resp
Rate
Rhythm
Depth shallow, norm, deep
Effort involved to breathe
Discomfort it causes
Position resident adopts
Sounds that accompany it
Color of skin, mucous membranes, nailbeds
check for cyanosis
Abnormal breathing
Labored struggles to breathe
Orthopnea- can breathe only when sitting or standing
Stertorous snoring sounds when breathing (partial airway
obstruction)
Abdominal uses abd muscles
Shallow uses only upper part of lungs
Dyspnea painful or difficult breathing
Tachypnea resp rate > 24 per min
Bradypnea resp rate < 10 per min
Apnea absence of breathing
Cheyne-Stokes resp gradually increase in rate & depth &
then become shallow & slow
Process of taking TPR

Take temperature first

Pulse second
Respirations last
When taking resp, keep fingers on
pulse so that resident does not know
you are counting resp
Document all together
Blood pressure
Pressure exerted against walls of blood vessels
Systolic highest reading
Pressure when heart contracting
Diastolic lower reading
Pressure when heart is at rest
Hear thumping sounds as blood flows through
arteries
Sounds correspond to numbers representing mm Hg
on sphygmomanometer
First sound heard is systolic
Last sound heard is diastolic
Blood pressure

Normal adult reading 120/80

Normal systolic = 100 140
Normal diastolic = 60 90
Abnormal readings
Hypertension BP > 140/90
Hypotension BP < 90/60
Factors increasing BP
Strong emotion
Exercise
Sitting or standing
Excitement
Pain
Decrease of vessel size
Digestion
Improperly placed or sized cuff
Factors decreasing BP

Rest/sleep
Lyingdown
Depression
Shock
Hemorrhage
Improperly sized cuff
Equipment for BP
Sphygmomanometer
Cuff
Stethescope
Cuff too narrow gives false high
Cuff below heart level will give false high
Cuff too large or improperly placed can
give false low
Procedure for BP
Guidelines
Measure BP at brachial artery
Do not use injured arm, arm with IV, or casted
Resident should be at rest
Position arm level with heart
Apply cuff to bare arm NOT over clothing
Use appropriate size cuff
Position sphygmomanometer at eye level
Pain

Ask resident if they have pain

Observe facial expression, movement,
respiration
Ask level of pain using facility method
(Usually number 0 10)
Report c/o pain to licensed nurse
Charting VS
Report norm & abn to licensed nurse
Record on flow sheets, graphic records, & NA
notes according to facility
Record in TPR order
Chart rectal temps with R
Chart axillary temps with Ax
Pulse readings other than radial are noted
If BP in a place other than arm,note location
Write BP on chart as a fraction
THANK YOU