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Vital Signs

Vital Signs

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Vital Signs

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  1. Vital Signs

  2. 14:1 Measuring and RecordingVital Signs (VS) • Vital Signs are defined as various determinations that provide basic information about the basic conditions of the patient • The 4 main vital signs (VS) • Temperature (T) • Pulse (P) • Respiration (R) • Blood pressure (BP)

  3. Other Assessments on Patients • Pain—patients asked to rate on scale of 1 to 10 (1 is minimal and 10 is severe) • Color of skin • Size of pupils and reaction to light • Level of consciousness • Response to stimuli

  4. VS Readings • Accuracy is essential • Report abnormality or change • If unable to get reading, ask another person to check • As a health care worker, it is your responsibility to measure and record the VS of your patients

  5. 14:2 Measuring and Recording Temperature • Measures balance between heat lost and heat produced in the body • Heat produced by metabolism of food and by muscle and gland activity • Homeostasis: constant state of balance in the body • Conversion between Fahrenheit and Celsius temperature

  6. Variations in Body Temperature • Normal range 97- 100 degrees Fahrenheit • Causes of variations –individual differences, time of day, body sites • Temperature measurements—oral, rectal (often used on infants/children), axillary (arm pit) or groin, aural (ear), and temporal (forehead-is measuring the temp in the temporal artery)

  7. Causes of Increased Body Temperature • Illness • Infection • Exercise • Excitement • High temperatures in the environment

  8. Causes of Decreased Body Temperature • Starvation or fasting • Sleep • Decreased muscle activity • Mouth breathing • Exposure to cold temperatures in the environment • Certain diseases

  9. Thermometers • Clinical thermometers – are used to record temperatures • Glass – consists of a slender glass tube containing mercury or alcohol with red dye, which expands when exposed to heat • Electronic – registers the temp on a viewer in a few seconds • Tympanic – records aural temp in the ear • Temporal – measures the temp in the temporal artery of the forehead • Plastic or paper - contain special chemical dots/strips that change color when exposed to specific temps (continues)

  10. Thermometers(continued) • Reading thermometers and recording results: * Electronic & tympanic thermometers are easily read because of digital displays * Mercury thermometers should be held at eye level & rotated slowly to find the mercury Examples of how to record a temperature: 98.6 is an oral reading 99.6 (R) is a rectal reading 97.9 (Ax) is an axillary reading 98.6 (A) is an aural reading

  11. Cleaning Thermometers • Must be cleaned after each use • The procedure will vary with different agencies and thermometers • Glass thermometers are cleaned with water and soaked in a disinfectant solution (70% alcohol) for a minimum of 30 minutes before using again • Electronic/digital thermometers use a probe or sheath that is discarded after each use

  12. 14:3 Measuring and Recording Pulse • Pressure of the blood pushing against the wall of an artery as the heart beats and rests • Major arterial or pulse sites • Pulse rate • Pulse rhythm • Pulse volume (continues)

  13. Measuring and Recording Pulse (continued) • Factors that change pulse rate • Basic principles for taking radial pulse • Recording information

  14. 14:4 Measuring and Recording Respirations • Measures the breathing of a patient • Process of taking in oxygen and expelling carbon dioxide from the lungs and respiratory tract • One respiration: one inspiration (breathing in) and one expiration (breathing out) (continues)

  15. Measuring and Recording Respirations (continued) • Normal respiratory rate • Character of respirations • Rhythm of respirations • Abnormal respirations • Voluntary control of respirations • Record information

  16. 14:5 Graphing TPR • Graphic sheets are special records used for recording TPR (temp., pulse, resp.) • Presents a visual diagram • Used most often in hospitals and long term care facilities • Factors affecting VS are often noted on the graph - - examples include surgery, medications that lower temperature such as aspirin and antibiotics (continues)

  17. Graphing TPR(continued) • Graphic charts are legal records – so it must be neat, legible, and accurate • To correct an error mark a single line through the error and initial beside it

  18. 14:6 Measuring and RecordingApical Pulse • Pulse count taken at the apex of the heart with a stethoscope • Reasons for taking an apical pulse – pts with irregular heart beats, hardening of the arteries, weak or rapid radial pulses • Protect the patient’s privacy and avoid exposure • 2 heart sounds “lubb-dupp” = 1 heart beat • Abnormal sounds or beats should be reported immediately (continues)

  19. Measuring and Recording Apical Pulse (continued) • Pulse deficit – a condition that occurs with some heart conditions – when the apical pulse rate is higher than the pulse rate on other sites on the body • Use the stethoscope : diaphragm side • Placement of stethoscope : 2-3in. to the left of the breast bone • Measuring apical pulse : count for 1 full min. • Record all information

  20. 14:7 Measuring and RecordingBlood 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 on a sphygmomanometer • Measurements read at two points (continues)

  21. Measuring and Recording Blood Pressure(continued) • Systolic pressure • Diastolic pressure • Pulse pressure • Hypertension—high blood pressure • Hypotension—low blood pressure • Factors influencing blood pressure readings (high or low) (continues)

  22. Measuring and RecordingBlood Pressure(continued) • Individual factors can all influence blood pressure readings • Types of sphygmomanometers • Mercury • Aneroid • Electronic (continues)

  23. Measuring and RecordingBlood Pressure(continued) • Factors to follow for accurate readings • Record all required information • Do not discuss the reading with the patient; it’s the doctor’s responsibility

  24. Summary • Vital signs are major indicators of body function • Accuracy of measurement and recording of vital signs • The health care worker needs to be alert and report any abnormalities