VITALS SIGNS AND MONITORING

BASIC PATIENT CARE

 LECTURE OUTLINE
• Components of vital signs
– Breathing rate
– Pulse rate.
– Skin color and temperature
– Blood pressure
• Pupillary assessment
• Reporting and recording the baseline vital
signs.
 LECTURE OBJECTIVES
• Identify the components of vital signs
• Methods to assess the pupils
• Methods of recording and reporting vital signs
• Additional medical identification
 PATIENT ASSESSMENT
GENERAL CONDITION
• Appearance is more valuable than vital sign
numbers.
– Respiratory distress, or unresponsive
• Level of consciousness
– Alert, verbal, pain or unresponsive
• Comfort or distress
– Sweating, pale and clutching the chest
– Wince or grimacing in pain
– Anxious
 VITAL SIGNS
BREATHING
• Method of assessment
– Observing the patient's chest rise and fall
• Component of assessment
– Breath rate
– Quality of breathing
 BREATHING
BREATH RATE
• Just look at patient and quietly count
– Avoid influencing the patient
• How to determine?
– Count the number of breaths in a 30-second
period and multiplying by 2.
 BREATHING
BREATH QUALITY
• Simultaneous while assessing the rate.
• 4 categories:
1. Normal – normal chest wall motion without use
of accessory muscles.
2. Shallow – minimal expansion of chest or
abdominal wall motion.
3. Labored – increased effort of breathing
4. Noisy – increase audible sound of breathing
 BREATH QUALITY
LABORED
• An increase in the effort of breathing
• Use of accessory muscles
– Nasal flaring, supraclavicular and intercostal
retractions in infants and children
• Occasionally presence of
– Noisy breathing such as grunting and stridor
– Gasping
 BREATH QUALITY
NOISY
• Increase in the audible sound of breathing.
– Snoring, wheezing, gurgling, crowing.
 VITAL SIGNS
PULSE
• Method of assessment
– Radial pulse in patients one year and older
– Brachial pulse in less than one year
• Other sites of pulse check
– Carotid
– Femoral
– Tibialis
• Component of assessment
– Pulse rate
– Quality
PALPATION OF RADIAL PULSE
 PULSE
PULSE RATE
• Number of beats felt in 30 seconds multiplied
by 2.
 PULSE
QUALITY
• Quality of the pulse can be characterized as:
– Strong
– Weak
– Regular
– Irregular
 VITAL SIGNS
SKIN
• Site of assessment
– Nail beds, oral Mucosa, and conjunctiva
– Palms of hands and soles of feet
• Component of assessment
– Color
– Temperature
– Condition
– Capillary refill
 SKIN
COLOR
• Usually assessed at nail beds, oral mucosa, and
conjunctiva.
– In infants and children – palms of hands and soles of feet.
• Normal skin – pink
• Abnormal skin colors
– Pale - indicating poor perfusion (impaired blood flow)
– Cyanotic (blue-gray) - indicating inadequate oxygenation
or poor perfusion
– Flushed (red) - indicating exposure to heat or carbon
monoxide poisoning.
– Jaundice (yellow) - indicating liver abnormalities
 SKIN
TEMPERATURE
• Assessed by placing the back of hand on the
patient's skin.
• Normal - warm
• Abnormal skin temperatures
– Hot - indicating fever or an exposure to heat.
– Cool - indicating poor perfusion or exposure to
cold.
– Cold - indicates extreme exposure to cold.
 SKIN
CONDITION
• Normal - dry
• Abnormal - skin is wet, moist, or dry.
 SKIN
CAPILLARY REFILL
• Indicated in infants and children less than six
years of age.
• Assessed by pressing on the patient's skin or nail
beds and determining time for return to initial
color.
• Normal capillary refill in infants and children is <
2 seconds.
• Abnormal capillary refill in infants and children is
> 2 seconds.
– Indicates poor perfusion
 VITAL SIGNS
BLOOD PRESSURE
• Measured in all patients older than 3 years of
age.
• Site of assessment
– Arms of patient
• Other sites
– Femoral blood pressure
– Tibial blood pressure
• Component of assessment
– Systolic blood pressure
– Diastolic blood pressure
ANATOMY OF BLOOD PRESSURE CUFF

B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N AND H I S T O R Y T A K I N G
 BLOOD PRESSURE
SELECTION OF CUFF
• Width of the inflatable bladder of the cuff
should be about 40% of upper arm
circumference
• Length of inflatable bladder should be about
80% of upper arm circumference
• Narrow or short cuff – false high reading
 OBSERVATION
PUPILLARY ASSESSMENT
• Assessed by briefly shining a light into the
patient's eyes
– Look at size and reactivity.
• Reactivity is whether or not the pupils change in
response to light shine
– Reactive - change when exposed to light
– Non-reactive - do not change when exposed to light
• Findings:
– Dilated (very big), normal, or constricted (small).
– Reactivity
– Equal or unequal reactivity to light
 VITAL SIGN
CONTINUED MONITORING
• Single vital sign does not represent condition
of patient which is dynamic
• Must be repeated
– To ensure stability or deterioration
– Determine success of intervention
• Guideline to interval of monitoring
– Every 15 minutes in a stable patient.
– Every 5 minutes in unstable patient.
– Assessed following all medical interventions.
 CONTINUED MONITORING
WHAT TO MONITOR
• Mental status.
• Airway patency
• Breathing for rate and quality.
• Pulse for rate and quality.
• Skin color and temperature.
• Assure management of bleeding.
 CONCLUSION
• General condition of patient is more
important that numeric values of vital signs
• Components of vital signs are respiratory rate,
pulse rate, skin color and temperature, blood
pressure and pupillary assessment
• Repeated assessment is important to detect
deterioration and determine success of
intervention