ASSESSMENT OF VITAL SIGNS

CONTENTS

 Consciousness

 Body temperature

 Respiration

 Blood pressure

 Pulse
1. CONSCIOUSNESS
Human ability to be aware of own thoughts,
emotions, surroundings → adequate responses

GLASGOW COMA SCALE (GCS)

Patient’s response to:

- verbal stimulation
- painful stimulation
- movement

Scale 3 – 15
 CONSCIOUSNESS

Changes in consciousness

QUALITATIVE QUANTITATIVE

anxiety somnolent
depression sopor
delirium coma (shallow/deep)
2. BODY TEMPERATURE
Balance between heat produced and heat lost by the body

Heat regulating centre – hypothalamus

Heat production caused by increasing cell metabolism

Heat losses (cool off process):

- perspiration
- respiration
- radiation

Types of thermometers:
- mercury-in-glass
- electronic
- chemical
 BODY TEMPERATURE

BODY TEMPERATURE SYMPTOMS

Hypothermia Skin paleness
↓ 36 °C Tiredness
Normal Lowest 5 – 6am
36 – 36,9 °C Highest 4 – 6pm
Pyrexia / slight fever Perspiration
37,0 – 37,9 °C Skin redness
Headache
Fever General weakness
38 °C Tachycardia / hyperpnea
Skin paleness/redness
Presence of infection → body defence Shivers
Perspiration
BODY TEMPERATURE
ROUTES FOR MEASURING THE BODY TEMPERATURE
- ORAL

best site for measuring in the clinical settings

triangle shaped thermometer
axillo – oral difference 0,3 °C
- AXILLARY

more likely to be affected by the environmental temperature,

used in children/adults

- RECTAL

fast thermometer, used in infants/confused patients/receiving O2 th.

axillo – rectal difference 0,5 °C

- VAGINAL
used in gynecology
3. RESPIRATION

NORMAL RESPIRATIONS RESPIRATORY RATE

 Effortless  Normal 12 – 20 / min
 Regular  Bradypnea ↓ 10 / min
 Smooth  Tachypnea 25 / min
 Apnea

AVERAGE RESPIRATIONS RESPIRATORY RHYTHM

 Infant to 2 years 24–34/min  Normal
 To puberty 20-26/min  Dyspnea (exertion/rest)
 Adults 12-18/min  Cheynes-Stokes respiration
(irregular deep/slow/shallow )
 Kussmaul’s breathing (deep)
4. BLOOD PRESSURE (BP)

The pressure of blood in the arterial wall

Factors affecting BP:

- blood volume
- strength of contraction
- elasticity of artery wall
Assessment:
- Normal 120-140/60-80 mmHg
- Hypertension 150/90 mmHg
- Hypotension ↓100 mmHg

Measurements stated in terms of millimetres of mercury (mmHg)

BLOOD PRESSURE (BP)

BP reading:
- systolic pressure (ventricle contraction)
- diastolic pressure (ventricle at rest)

BP readings record: BP 120/80

Equipment:
- sphygmomanometer
- stethoscope
BLOOD PRESSURE (BP)

Places for measuring:

- upper arm (brachial artery)
- calf / thigh (popliteal artery)

Measuring techniques:
- auscultation
(sphygmomanometer+stethoscope)
- palpation
(sphygmomanometer)
- invasive methods (CVP)
5. PULSE

Expansion of an artery with each hart beat

Measuring techniques / places of assessing:

- PALPATION
a. carotis
a. brachialis, radialis
a. femoralis, poplitea etc.

- AUSCULTATION
stethoscope
 PULSE

PULSE RATE PULSE RHYTHM

 Normal 60 – 90 / min  Regular
 Bradycardia ↓ 50 / min  Irregular – arrythmia
 Tachycardia 100 / min
 Asystolia PULSE QUALITY
 Strong (fever)
 Weak (shock/heart failure)
REPETITION

1. What do you evaluate in Glasgow Coma Scale?

2. What is the normal body temperature?
3. Name 3 symptoms of fever.
4. What is the most commonly used route for measuring the
body temperature in infant?
5. Could you define the term for the high respiratory rate?
6. What is the limit for hypertension?
7. Name 2 methods of BP measurement?
8. Name 2 arteries where the pulse is most commonly felt?
9. Could you specify the normal pulse rate?
10. What is the point at which the beat stops during the BP
measurement called?
THANK YOU !