Vital signs (VS) are the most important measurements you will obtain when you evaluate a client's condition. Temperature, pulse, respirations, and blood pressure give information about how a client will adjust to changes within the body and in the environment.
When you care for a client who is ill or complains of illness, body temperature (T) is one of the first assessments done.
A normal adult temperature is considered to be 37°C. When you take a temperature, you will find that most people are within a range of 36.0°C to 38.0°C. This variation is the result of changes within the body or exposure to the environment, such as: * Time of day- temperatures are usually lower in the morning and higher in the evening * Allergic reaction * Illness * Stress * Exposure to heat or cold- temperature is higher when a person is outside in the sun and lower when a person is exposed to cold air
When a temperature is above 38.0°C, you will document that the client is febrile. If the temperature is within normal range you will document that the client is afebrile.
Oral: within the mouth or under the tongue
Axillary: in the armpit, also known as the axilla
Tympanic: in the ear canal
Rectal: through the anus, in the rectum
A pulse (P) is a wave of blood flow created by a contraction o the heart. Usually, you will check a pulse by using your first two fingers to palpate, or feel. Sometimes, you will listen for sounds, or auscultate, using a stethoscope. Measurement of the pulse provides a pulse rate plus information on the amount of blood being pumped from the left ventricle of the heart to the artery being assessed, as well as to the body tissues that the artery feeds.
Because arteries are located in many places in the body, there are many sites for assessing pulses. These sites are usually named according to the bones or other structures near where they are located. The most common pulses assessed with vital signs are the radial, brachial, and apical. * The radial pulse is best palpated on the inside of the wrist, near the thumb * In adults, the brachial pulse is found in the antecubital space of the arm (the bend of the elbow). The brachial pulse assessment is most often used in very young children, before the brachial muscle is developed * The apical pulse is auscultated with a stethoscope placed on the chest wall. The apical pulse is found at the apex of the heart, which is located to the left side of the sternum and under the fifth to sixth intercostal space. For adults, the apical pulse must be taken before certain drugs are administered that may slow the heart rate.
Characteristics of the Pulse
When you evaluate the pulse, you will assess the following characteristics: * Rate * Rhythm * Volume * Bilateral presence
Pulse rate is assessed as beats per minute, abbreviated to BPM or bpm. The pulse is counted for 15, 20, 30, or 60 seconds. The normal ranges for pulse rate vary according to age and gender. As the cardiovascular system matures with age, the pulse rate decreases. Women also tend to have faster pulse rates than men. Expected Pulse Rates by Age Group | Age | Range | Newborn | 120-160 | 1 month - 1 year | 80-140 | 1-6 years | 80-120 | 6 years- adolescence | 75-110 | Adulthood | 72-80 | Late adulthood | 60-80 |
Pulse rhythm is the pattern of heartbeats. A client whose heartbeats are irregular is said to have an "arrhythmia" or "dysrthymia."
The volume of the pulse is also referred as the strength of the pulse. It is a measurement of the pulse as it presses against the arterial wall and against your fingertips when you palpate the area. The volume of the pulse can be described with the following scale: 0 | Absent, unable to detect | 1 | Thready or weak, difficult to palpate and