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Chapter 15

Chapter 15. Vital Signs. 15:1 Measuring and Recording Vital Signs (VS). Record information about the basic body conditions Abnormalities from homeostasis Main vital signs (VS) Temperature Pulse Respiration Blood pressure. Other Assessments.

Thomas
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Chapter 15

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  1. Chapter 15 Vital Signs

  2. 15:1 Measuring and RecordingVital Signs (VS) • Record information about the basic body conditions • Abnormalities from homeostasis • Main vital signs (VS) • Temperature • Pulse • Respiration • Blood pressure

  3. Other Assessments • Pain—patients asked to rate on scale of 1 to 10 (1 is minimal and 10 is severe)

  4. Other Assessments • Color of skin • Pallor • Cyanosis • Jaundice • Erythema • Ecchymosis

  5. Other Assessments • Size of pupils and reaction to light

  6. Other Assessments • Level of consciousness

  7. Other Assessments • Response to stimuli

  8. Vital Sign Readings • Accuracy is essential • Must know how to accomplish task with various equipment • Never guess or report false readings • Report abnormality or change • Severe abnormalities indicate life-threatening conditions • If unable to get reading, ask another person to check

  9. 15:2 Measuring and Recording Temperature • Temperature: Measures balance between heat lost and heat produced in the body • Thermal activity • Heat produced by metabolism of food and by muscle and gland activity • Heat lost through perspiration, respiration, and excretion

  10. 15:2 Measuring and Recording Temperature • Conversion between Fahrenheit and Celsius temperature F C: C = (F - 32) x (5/9 or 0.5556) C F: F = (C x 9/5 or 1.8) + 32 • Practice: • 102o F to C 212o F to C • 19o C to F 37o C to F

  11. Variations in Body Temperature • Normal range • 97-100o F, 36.1-37.8o C • Causes of variations • Size/shape of individual, time of day, part of body, metabolic activity

  12. Variations in Body Temperature • Temperature measurements — oral, rectal (often used on infants/children), axillaryor groin, aural, and temporal • Normal: • Oral: 98.6o F Axillary: 97.6o F • Rectal: 99.6o F Aural/Temporal: no normal range

  13. Variations in Body Temperature Abnormal conditions affecting temperature Increase: Illness and infection Exercise, excitement, fear High environmental temperatures Decrease: Starvation or fasting Sleep Sedation Mouth breathing Cold environmental temperatures

  14. Variations in Body Temperature • Abnormal conditions • Hypothermia: body temperature < 95o F • Fever: elevated above 101o F • Pyrexia, Febrile, Afebrile • Hyperthermia: body temperature > 104o F

  15. Thermometers • Clinical thermometers • Glass: contains mercury, analog • Electronic: digital reading, quicker results • Tympanic: use infrared energy • Temporal: measures temporal artery • Plastic or paper: disposable • Reading thermometers and recording results • Read in 1o increments, labeled by site • R, Ax,, A, 986 (continues)

  16. Thermometers(continued) • Avoid factors that could alter or change temperature • Examples??? • Cleaning glass clinical thermometers • Clean with alcohol wipe or soap/cool water • Paper/plastic sheath on glass thermometer • Used to prevent transmission of disease • Dispose of properly • Still wipe with alcohol pad

  17. 15:3 Measuring and Recording Pulse • Pulse: Pressure of the blood pushing against the wall of an artery as the heart beats and rests (continues)

  18. 15:3 Measuring and Recording Pulse • Major arterial or pulse sites • Temporal • Carotid • Brachial • Radial • Femoral • Popliteal • Dorsal Pedal (continues)

  19. 15:3 Measuring and Recording Pulse • Must note 3 different factors of the pulse: • Pulse rate (beats per min) • Pulse rhythm (regular or irregular) • Pulse volume (strong, weak, thready, bounding) (continues)

  20. 15:3 Measuring and Recording Pulse • Pulse rate – adult 60-100 bpm, varies • Bradycardia: slow pulse rate, < 60 bpm • Tachycardia: fast pulse rate, >100 bpm • Pulse rhythm – spacing between beats • Regular vs. irregular • Arrythmia: abnormal heart rhythm • Pulse volume – strength/intensity of the pulse • Strong vs. weak, thready, bounding (continues)

  21. Measuring and Recording Pulse Factors that change pulse rate Increase: Exercise Stimulant drugs Excitement Fear Fever Shock Nervous tension Decrease: Sleep Depressant drugs Heart disease Coma Physical training

  22. Measuring and Recording Pulse (continued) Basic principles for taking radial pulse: • Patient positioned comfortably, palm down • Use tip of index/middle fingers to locate pulse on thumb side of wrist • First beat counted starts with zero • 10 sec x 6 • 15 sec x 4 • 30 sec x 2 • 60 sec

  23. Measuring and Recording Pulse (continued) • Recording information: • Include rate, rhythm, volume Example: P 82 regular and strong (rate)(rhythm)(volume)

  24. 15:4 Measuring and Recording Respirations • Respiration: Measures the breathing of a patient • Process of taking in oxygen and expelling carbon dioxide from the lungs and respiratory tract (continues)

  25. 15:4 Measuring and Recording Respirations • One respiration: one inspiration (breathing in) and one expiration (breathing out) (continues)

  26. Measuring and Recording Respirations (continued) • Normal respiratory rate • Adults: 12-20 breaths per minute • Children: 16-30 per minute • Infants: 30-50 per minute

  27. Measuring and Recording Respirations • Must note 3 different factors: • Rate (breaths per minute) • Character (depth and quantity) • Rhythm (regularity)

  28. Measuring and Recording Respirations (continued) • Character of respirations – refers to depth and quality • Deep vs. shallow, labored, moist, difficult, noisy • Rhythm of respirations – refers to spacing between breaths • Regular (or even) vs. irregular

  29. Measuring and Recording Respirations (continued) • Abnormal respirations • Dyspnea: difficulty breathing • Apnea: absence of respirations • Tachypnea: rapid, shallow > 25/min • Bradypnea: slow <10/min

  30. Measuring and Recording Respirations (continued) • Abnormal respirations • Orthopnea: severe dyspnea in any position besides sitting or standing • Cheyne-Stokes: abnormal breathing pattern, periods of dyspnea and apnea • Rales: bubbling or noisy sounds caused by fluid

  31. Measuring and Recording Respirations (continued) • Voluntary control of respirations • Respiration can be controlled if consciously thought about • Important to keep the patient unaware breathing is being assessed • Do not tell the patient you are counting respirations

  32. Measuring and Recording Respirations (continued) • Record information • Rate, character, rhythm • Ex: A child with R 22, shallow, labored, and regular would suffer from? • Ex: An adult with R 8, deep, regular would suffer from?

  33. 15:5 Graphing Temperature (TPR) • Graphic sheets are special records used for recording TPR • Presents a visual diagram (easier to follow) • Uses – hospitals or long care facilities (continues)

  34. 15:5 Graphing TPR • Color codes • Temperature in blue • Pulse in red • Respirations in green • Factors affecting vital signs are often noted on the graph • Surgeries, medications, day & time, etc. (continues)

  35. Graphing TPR(continued) • Graphic charts are legal records • Must be legible and neat • Completed in ink • Use straightedge to connect lines • HIPAA act! • To correct an error: cross out in redink and correct, initial next to correction

  36. Graphing TPR(continued) • Basic principles for completing: • Fill in patient information accurately • Fill in dates, times (mm/dd/yyyy, __:__am/pm) • Adm = admission (first measurement) • Following days are numbered • PO = after surgery • PP = post partum (after delivery)

  37. 15:7 Measuring and RecordingBlood Pressure • Blood Pressure: Measurement of the pressure the blood exerts on the walls of the arteries during the various stages of heart activity • Measured in millimeters of mercury (mmHg) on a sphygmomanometer (continues)

  38. Measuring and Recording Blood Pressure(continued) • Systolic pressure: pressure when left ventricle contracts and pushes blood to arteries • Normal is <120 mmHg (range of 100-120 mmHg) • First sound heard during reading of sphygmomanometer

  39. Measuring and Recording Blood Pressure(continued) • Diastolic pressure: constant pressure when left ventricle is at rest, or between contractions • Normal is < 80 mmHg (range of 60-80 mmHg) • Last sound heard during reading of sphygmomanometer

  40. Measuring and Recording Blood Pressure(continued) • Blood pressure is read as a fraction • Systolic pressure / Diastolic pressure • Ex: (120/80 mmHg)

  41. Measuring and Recording Blood Pressure(continued) • Pulse pressure: difference between systolic & diastolic pressure • Important indicator of health and tone of arterial walls • Normal range is 30-50 mmHg • The pulse pressure should be approximately one third of the systolic reading (120 - 80 = 40)

  42. Measuring and Recording Blood Pressure(continued) • Hypertension—high blood pressure • Prehypertension (120-139 mmHg / 80-89 mmHg) • Systolic > 140 mmHg / Diastolic > 90 mmHg • Hypotension—low blood pressure • Systolic < 90 mmHg / Diastolic < 60 mmHg (continues)

  43. Measuring and Recording Blood Pressure(continued) • Factors influencing blood pressure readings (high or low) • Force of heartbeat • Resistance of arterial system • Elasticity of the arteries • Volume of blood in arteries • Position of the patient(standing vs sitting vs lying down) (continues)

  44. Measuring and Recording Blood Pressure(continued) Decrease BP Rest or sleep Depressant drugs Shock Dehydration Hemorrhage fasting Increased BP Excitement, anxiety, nervous tension Pain Obesity Stimulant drugs Exercise and eating Smoking

  45. Measuring and RecordingBlood Pressure(continued) • Types of sphygmomanometers • Mercury: uses a column of mercury in a tube to measure the pressure (discouraged by OSHA) • Aneroid: uses a round gauge to measure pressure • Each line on gauge = 2 mmHg • Measure at eye level, deflated cuff should read zero • Electronic: measures pressure automatically • Shows reading on a digital display (continues)

  46. Measuring and RecordingBlood Pressure(continued) • Factors to follow for accurate readings • Patient should sit quietly for at least five minutes before BP is taken • Two readings should be taken and averaged • Minimum wait of 30 seconds between readings • Arm should be rested on a flat surface & free of restrictions

  47. Measuring and RecordingBlood Pressure(continued) • How to measure blood pressure • Cuff should be placed above the crook of the elbow, with arrow pointing over brachial artery • Place the bell/diaphragm of stethoscope directly over brachial artery in the antecubital fossa • Hold as securely as possible with index/middle fingers • Inflate cuff to 150-180 mmHg • Deflate slowly and listen for heart sounds • First sound = Systolic Blood Pressure (Top #) • When sound disappears = Diastolic Blood Pressure (Bottom #)

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