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VITAL SIGNS. Vital Signs. Temperature Breathing +Pulse Oximeter Pulse Blood pressure Pain (5 th VS). TEMPERATURE. Skin temperature - taken by placing the back of your hand on the patient’s skin Equipment – thermometer for accurate temperature reading/measurement. Shell Temperature

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  2. Vital Signs • Temperature • Breathing +Pulse Oximeter • Pulse • Blood pressure • Pain (5th VS)

  3. TEMPERATURE • Skin temperature - taken by placing the back of your hand on the patient’s skin • Equipment – thermometer for accurate temperature reading/measurement

  4. Shell Temperature • Core Temperature

  5. Temperature • Normal: 98.6 ° F (37°C) • Hypothermia: 95°F (35°C) • Hyperthermia – excessively high core temp. > 105 = brain damage • Routes • Oral • Axillary • Rectal • Tympanic • Temporal, etc.

  6. Placement – rear sublingual pocket at base of tongue

  7. PULSE • Pressure wave that is felt as the heart contracts

  8. PULSE-Assess… • Rate - number of beats per minute • 60-100 bpm • Rate varies with age and other factors • Do not use your thumb • Tachycardia - > 100 bpm • Bradycardia - < 60 bpm

  9. The Pulse • Rhythm - The pattern of pulsations and pauses between them • Regular/Irregular • arrhythmia, sinus arrhythmia • Quality /Volume-Force of the contraction of the heart • Strong • Weak • Grading of pulse volume: 0-3+/4+

  10. Pulse Assessment Locations • Carotid • Brachial • Radial • Femoral • Popliteal • Dorsalis pedis • Posterior tibial

  11. PULSE • If peripheral pulse is not palpable, assess carotid pulse • Use caution. Avoid excess pressure on geriatrics • Never attempt to assess carotid pulse on both sides at one time

  12. Measuring Pulse Radial Palpate thumb side of wrist with two to three fingers, do not press too hard or it will obliterate. Count 30 seconds and multiply by 2. If irregular, count for one full minute. If unable to find, measure apical pulse.

  13. Radial site

  14. Apical pulse • Site: fifth intercostal space midclavicular line • The apical pulse is considered more accurate than the radial pulse • the sound of each heartbeat is obvious and distinct when listening to the apical pulse • Pulse deficit – difference between apical and radial rate

  15. Apical site: Left 5th ICS Midclavicular Line

  16. Apical Place stethoscope on chest under clothing Auscultate apex of the heart below left nipple Move around a little at a time until heart beat clearly heard If difficulty finding apical pulse, have patient lean forward while sitting, or turn to left side when lying down Lub-dub is one beat Always count for one full minute Counting Apical Pulse

  17. RESPIRATIONS(Breathing) • Assessed by observing the patients chest rise and fall • Rate - Count # of breaths for 1 minute • Ventilation – one inhalation and one expiration

  18. Determined while assessing the rate DEPTH Even Shallow Deep EFFORT Labored Unlabored QUALITY (and)

  19. Eupnea Tachypnea Bradypnea Hyperventilation Dyspnea Orthopnea Apnea Types of Respirations

  20. BLOOD PRESSURE • Pressure of circulating blood against the walls of arteries

  21. Systolic pressure - the pressure exerted against the walls of the arteries during the contraction of the heart Diastolic pressure - pressure that is constantly present within the arterial walls as the heart relaxes and fills with blood Pulse pressure - normal range of pulse pressure- 30 to 50. Blood pressure

  22. Blood Pressure • There are two methods of obtaining blood pressure • Auscultation - listen for the systolic and diastolic sounds • Palpation - In certain situations, the systolic blood pressure may be measured by feeling for return of pulse with deflation of the cuff

  23. Korotkoff Sounds • Korotkoff I- onset of faint but clear tapping sounds which gradually increase in pitch and intensity • Korotkoff II- murmur or swishing like sound • Korotkoff III- distinct, loud tapping sounds without the murmurs • Korotkoff IV- lower-pitched distinct, abrupt muffling sound with a soft, blowing quality • Korotkoff V- cessation /disappearance of sound

  24. Auscultatory gap • Orthostatic Hypotension

  25. Measuring BP


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