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VITAL SIGNS

VITAL SIGNS. Module C. What are Vital Signs?. Temperature Pulse Respirations Blood Pressure Pain (considered the 5 th vital sign). When to measure vital signs?. On admission to health care facility In a hospital on regular hosp schedule or as MD ordered (q8hours, q4 hours, etc)

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VITAL SIGNS

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  1. VITAL SIGNS Module C

  2. What are Vital Signs? • Temperature • Pulse • Respirations • Blood Pressure • Pain (considered the 5th vital sign)

  3. When to measure vital signs? • On admission to health care facility • In a hospital on regular hosp schedule or as MD ordered (q8hours, q4 hours, etc) • Before and after procedures (surgery, invasive diagnostic procedures) • Before, during, and after blood transfusions • When patient’s general condition changes (nursing judgment)

  4. GUIDELINES FOR ASSESSMENT • Taken by nurse giving care • Equipment should be in good condition • Know baseline VS and normal range for pt and age group • Know pt’s medical history • Minimize environmental factors

  5. GUIDELINES CONTINUED • Be organized in approach • Increase frequency of VS as condition worsens • Compare VS readings with the whole picture • Record accurately • Describe any abnormal VS

  6. VS MUST BE ACCURATE • Both measuring and recording • VS vary according to pt’s illness/condition • Compare results with pt’s normal • Results are used to determine treatments, medications, diagnostic work, etc

  7. REPORTING ABNORMAL VS • WHEN—grossly abnormal, return to normal, noted change for that pt • WHY—indicates change in metabolism or physiological function within the body • WHO—student reports to instructor, then TL, RN, Dr (follow chain of command) • HOW—orally to appropriate person, then document on chart

  8. Body Temperature • Difference between heat produced by body processes and the heat lost to the external environment • Range 96.8 – 100.4 F (36 – 38 degree C) • Average for healthy young adults 98.6F or 37degrees C • No single temp is normal for all people

  9. HEAT IS PRODUCED BY: • Metabolism • Increased muscle activity • Vasoconstriction • External sources

  10. HEAT IS LOST BY: • Vasodilation • Convection • Radiation • Conduction • Evaporization

  11. TEMP or FEVER? • TEMPERATURE—the measurement of heat in the body • FEVER—the measurement of heat in the body that is above normal for the individual

  12. TYPES OF THERMOMETERS

  13. READING A THERMOMETER

  14. Adults- 96.8- 100.4 degree F Adult Avg 98.6 F Oral Adult Avg 99.5 F Rectal Adult Avg 97.7 F Ax Newborn range – 95.9- 99.5F Infants and children – same as adults Elderly – Avg 96.8F Normal Range Throughout Life Cycle

  15. Frequently used terms: • Pyrexia or fever • Febrile • Hyperthermia • Hypothermia • Afebrile

  16. FEVER—A DEFENSE MECHANISM • Indicator of disease in body • Pathogens release toxins • Toxins affect hypothalamus • Temperature is increased • Rest decreases metabolism and heat production by the body

  17. PATTERNS OF FEVER • SUSTAINED- remains above normal with little change • RELAPSING – periods of febrile episodes interspersed with acceptable temp values • INTERMITTENT—varies from normal to above normal to below normal (may have a fairly predictable pattern) • REMITTENT—fever spikes and falls w/o a return to normal temp values

  18. Age ( newborn- temp control mechanism immature, elderly- sensitive to temp changes) Exercise Hormonal level Circadian rhythm (temp normally changes 0.9 to 1.8 degree F /24hr Lowest 1-4AM Max-6PM ) Stress Environment Factors Affecting Body Temp

  19. ORAL TEMPERATURE • Accessible • Dependable • Accurate • Convenient

  20. RECTAL TEMPERATURE • Most reliable • MUST hold thermometer in place

  21. AXILLARY TEMPERATURE • Safe • Non-invasive • Least accurate

  22. TYMPANIC TEMPERATURE • Non-invasive • Safe • Accurate • Disadvantages • Excessive cerumen • Improper technique

  23. AXILLARY TEMPERATUREIMPORTANT POINTS • AXILLA MUST HAVE ADEQUATE TISSUE & BE FREE OF PERSPIRATION • Not good method for persons with elevated temp • Used when cannot get oral or tympanic • Leave in place 10 minutes

  24. ORAL TEMPERATURES • Wait 15-30 minutes after eating, drinking, chewing gum or smoking • If mouth breather-do not take orally • Leave in place 2 – 4 minutes with glass thermometer

  25. TYMPANIC TEMPERATURES • Oral & tympanic readings will be same/ similar • Must direct probe toward TM (eardrum) • Follow instructions • Keep plugged in and on charger when not in use • Usually preferred method • Adults –pull pinna of ear up & back • Children under 3y/o-pull pinna of ear down & back

  26. RECTAL TEMPERATURES • MOST accurate • MUST hold thermometer in place • Very high temp • Unconscious • Do not take rectal temp on clients with heart conditions • Leave in place 2-3 min with glass thermometer • Lubricate thermometer • DO Not take hand from thermometer while rectal in progress

  27. NURSING DIAGNOSIS Hyperthermia> 100.4F Hypothermia <96.8F Risk for altered body temperature Ineffective Thermoregulation

  28. Temperature Conversion • Temperature can be measured in Fahrenheit (F) or centigrade or Celsius (c) • To convert F to c, subtract 32 from F reading and multiply times 5/9. Ex. (104 F – 32) x 5/9 = 40 degree c • To convert c to F, multiply the c reading by 9/5 and add 32 to the product. Example (40 x 9/5) + 32 =104 F

  29. Pulse • Pulse- is the palpable bounding of the blood noted at various points on the body. It is an indicator of circulatory status.

  30. TERMS RELATED TO PULSE • Pulse—Rate, Rhythm, Quality • Pulse Deficit • Auscultate • Palpate • Tachycardia, Bradycardia

  31. Temporal Carotid Apical Brachial Dorsalsis Pedis (Pedal) Radial and Apical are most common pulse sites used! Radial Ulnar Femoral Popliteal Posterior Tibial Pulse Sites

  32. PULSE RANGES

  33. TECHNIQUE • Feel over BONY area • DO NOT use thumb • Use 2-3 fingers • DO NOT squeeze • Count 30 seconds if regular x 2 • Note Rate, Rhythm, Quality • If irregular, count for 1 full minute or take apical pulse for 1 minute.

  34. APICAL-RADIAL PULSE • Requires 2 nurses • 1 nurse counts apical heart rate • 1 nurse counts radial pulse • BOTH count during the same 60 seconds • 1 nurse acts as timekeeper for both nurses

  35. PULSE DEFICIT • Count apical-radial pulse • The difference is the PULSE DEFICIT • Apical pulse will always be the same or higher than the radial pulse if both are counted correctly • If the radial pulse is higher, one or both nurses counted incorrectly

  36. Factors Affecting Pulse Rates • Exercise • Temperature • Emotions • Drugs • Hemorrhage • Postural Changes • Pulmonary Conditions

  37. Variations of Pulse Rates • Tachycardia – Abnormally elevated pulse rate. (above 100 beats/ min) • Bradycardia – Abnormally slow pulse rate (less than 60 beats / min)

  38. Pulse Rhythm • Regular – A regular interval of time occurs between each heartbeat or pulse felt. • Irregular – Interval interrupted by early, late, or missed beat.

  39. Strength and Quality of Pulse • Pulse strength may be described as weak, strong, bounding, or thready. • PULSE GRADING (0-4 rating scale) • 0 – absent, not palpable • 1+ - diminished, barely palpable • 2+- easily palpable, normal pulse • 3+ - full, increased strength • 4+ - bounding, cannot be obliterated

  40. Respirations • Mechanism the body uses to exchange gases between the atmosphere, blood, and the cells. Involves three processes: • Ventilation • Diffusion • Perfusion

  41. PROCESS OF RESPIRATION • EXTERNAL RESPIRATION • Inhaled air enters lungs, at alveoli O2 crosses over to bloodstream • CO2 and other wastes cross over from bloodstream to alveoli and are exhaled • INTERNAL RESPIRATION • O2 carried in bloodstream crosses over to body cells • CO2 and other wastes from body cells cross over to the bloodstream

  42. RESPIRATION • Chest Cavity—airtight vacuum with negative pressure • INSPIRATION—diaphragm contracts and pulls down, ribs move up, lungs fill with air • EXPIRATION—diaphragm relaxes and moves up, ribs move down, lungs expel air

  43. NORMAL RESPIRATION RANGE

  44. COUNTING RESPIRATIONS • Count pulse first, then count respirations while holding wrist • Note rate, rhythm, quality, and character • Observe a full inspiration and expiration • Respiratory rates below 12 or greater than 20 require further assessment.

  45. Counting Respirations cont. • If respirations regular, count respirations for 30 seconds and multiply times 2. • If irregular, less than 12 or greater than 20, count for 1 full minute. • Quality of respirations- assess movement of chest or abdominal wall- deep, normal, shallow • Deep- full expansion of lungs • Normal- normal • Shallow- limited expansion of lungs

  46. Exercise Acute Pain Anxiety Smoking Body position Medications Neurological injury Age Environmental Temp Hemoglobin Function Factors Influencing Characteristics of Respirations

  47. Blood Pressure • Force exerted on the walls of the artery. Created by the pulsing blood under pressure of the heart. • Systolic- Peak and maximum pressure of ejection of blood from the heart into the aorta. This is the top number. • Diastolic- The minimal pressure remaining the heart when the heart relaxes. This is the bottom number. • Recorded as a ratio Ex. 120/80 • Pulse pressure- Difference between the systolic and diastolic. ( 120/80 – Pulse pressure 40)

  48. EQUIPMENT FOR BP

  49. “DOPPLER” OR ELECTRONIC BP READINGS

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