Measuring Vital Signs & Patient Assessment

1. Measuring Vital Signs&Patient Assessment

2. Objectives • Students will: • Identify normal and abnormal V/S measurements. • Measure and record vital signs according to industry standards. • Measure and record height and weight according to industry standards. • Explain why urine, stool, and sputum specimens are collected. • Explain the rules for collecting different specimens • Describe the seven warning signs of cancer

3. Vital Signs • Are important indicators of health • Detect changes in normal body function • May signal life-threatening conditions • Provide information about responses to treatment

4. Vital Signs • Temperature • Pulse • Respirations • Blood Pressure

5. Vital Signs Are Measured: • Upon admission • As often as required by the person’s condition • Before & after surgery and other procedures • After a fall or accident • When prescribed drugs that affect the respiratory or circulatory system • When there are complaints of pain, dizziness, shortness of breath, chest pain • As stated on the care plan

6. When Measuring Vital Signs • Usually taken with the person sitting or lying • The person is at rest • Always report: • A change from a previous measurement • Vital signs above or below the normal range • If you are unable to measure the vital signs

7. Temperature • Measurement of balance between heat lost and produced by the body. • Heat is produced by: • Metabolism of food • Muscle and gland activity • Heat may be lost through: • Perspiration, Respiration, Excretion • Measured with the Fahrenheit (F) or Celsius or Centigrade (C) scales

8. Body Temperature • Factors that  body temperature • Starvation or fasting • Sleep • Decreased muscle activity • Exposure to cold in the environment • Factors that  body temperature • Illness • Infection • Exercise • Excitement • High temperatures in the environment • Temperature is usually higher in the evening

9. Temperature Sites • Oral - by mouth – most common method • May be affected by hot or cold food, smoking, oxygen, chewing gum • Wait 15 minutes or use alternate site • Rectal - in the rectum -most accurate site • Do not use if patient has rectal surgery or bleeding • Axillary - under arm – less reliable site • Used when other sites are inaccessible • Do not use immediately after bathing

10. Temperature Sites • Tympanic or aural- in the ear • Measures in 1 to 3 seconds • Temporal Artery – temporal artery on the forehead • Record route temperature was taken • O - Oral • R- Rectal • T – Tympanic • A – Axillary

11. Normal Body Temperature Oral 98.6 ( 97.6 - 99.6) Rectal 99.6 (98.6 - 100.6) Axillary 97.6 (96.6 - 98.6)  Typmanic 98.6 (98.6 - 100.6) Temporal 99.6 (98.6 - 100.6) Hypothermia – temperature below normal Hyperthermia – temperature above normal

12. Types of Thermometers • Clinical (glass) thermometerno longer contain mercury. • Come in oral and rectal. • Disposable covers are usually used. • Electronic can be used for oral, rectal, or axillary and use disposable probe covers. • Tympanic placed in auditory canal and uses disposable cover. • Strips that contain special chemicals or dots that change colors can also be used.

13. Pulse • The pressure of blood pushing against the wall of an artery as the heart beats and rests. • Measured for one minute while noting: • rate - beats per minute • rhythm - regular or irregular • volume - strength or intensity - described as strong, weak, thready, bounding

14. Pulse Sites Most Commonly Used: • Carotid – during CPR • Apical – use stethoscope • Brachial – for Blood Pressure • Radial - to count pulse • Femoral – assessment and procedures • Popliteal – assessment • DorsalisPedis – assessment

15. Normal Ranges Bradycardia – Under 60 beats per minute Tachycardia – Over 100 beats per minute

16. Factors that Affect Pulse • Factors that  pulse • Exercise • Stimulant drugs • Excitement • Fever • Shock • Nervous tension • Factors that  pulse • Sleep • Depressant drugs • Heart disease • Coma

17. Respirations • Process of breathing air into (inhalation) and out of (exhalation) the lungs. • Oxygen enters the lungs during inhalation. • Carbon dioxide leaves the lungs during exhalation. • The chest rises during inhalation and falls during exhalation. • Normal rate 12-20 breaths per minute

18. Assessing Respiration • Respirations is measured when the person is at rest. • Rate may change is patient is aware that it is being counted. • To prevent this, count respirations right after taking a pulse. • Keep your fingers or stethoscope over the pulse site. • To count respirations, watch the chest rise and fall.

19. Assessing Respiration • Character and quality of respirations is also assessed: • Deep • Shallow • Labored or difficult • Noises – wheezing, stertorous (a heavy, snoring type of sound) • Moist or rattling sounds • Dyspnea – difficult or labored breathing • Apnea – absence of respirations • Cheyne-Stokes– periods of dyspnea followed by periods of apnea; often noted in the dying patient • Rales– bubbling or noisy sounds caused by fluids or mucus in the air passages

20. Blood Pressure • Measure of the pressure blood exerts on the walls of arteries • Blood pressure is controlled by: • The force of heart contractions • weakened heart  drop in BP • The amount of blood pumped with each heartbeat • loss of blood  drop in BP • How easily the blood flows through the blood vessels • Narrowing of vessels  increase in BP • Dilatation of vessels  decrease in BP

21. Factors that Affect Blood Pressure Factors that  blood pressure • Excitement, anxiety, nervous tension • Stimulant drugs • Exercise and eating Factors that  blood pressure • Rest or sleep • Depressant drugs • Shock • Excessive loss of blood

22. Measuring BP • A sphygmomanometer is used to measure BP • Aneroid – has a round dial and needle • Mercury – has a column of mercury • Electronic – automated device • BP is measured in millimeters (mm) of mercury (Hg). • The systolic pressure is recorded over the diastolic pressure.

23. Normal Range of Blood Pressure • Systolic: Pressure on the walls of arteries when the heart is contracting. Normal range – less than 120 mm Hg • Diastolic: Constant pressure when heart is at rest Normal range – less than 80 mm Hg • Hypertension—BP that remains above a systolic of 140 mm Hg or a diastolic of 90 mm Hg • Hypotension—Systolic below 90 mm Hg and/or a diastolic below60 mm Hg

24. Measuring Height and Weight • Used to determine if patient is underweight or overweight • Height and weight charts are used as averages • Weight greater or less than 20% considered normal • BMI or Body Mass Index a statistical measure of body weight based on a person's weight and height. • BMI from 18.5 to 24.9 is considered normal

25. Measuring Height and Weight General Guidelines: • Use the same scale every day • Make sure the scale is balanced before use • Weigh the patient at the same time each day • Remove jacket, robe, and shoes before weighing • OBSERVE SAFETY PRECAUTIONS! • Prevent injury from falls and the protruding height lever. • Some people are weight conscious. • Make only positive comments when weighing patients

26. Types of Scales • Clinical scales contain a balance beam and measuring rod • Bed scales or Chair scales are used for patients unable to stand • Infant scales come in balanced, aneroid, or digital • When weighing an infant…keep one hand slightly over but not touching the infant • A tape measure is used to measure infant height.

27. Urine Specimens • Can provide valuable information about the patients state of health • Urine is commonly tested for: • Bacteria, pus, or blood as found in bladder and kidney infection • Sugar and acetone as found in diabetes • Hormones as found in pregnancy • Drugs

28. Common Types of Specimens • Random urine specimen • Collected for a routine urinalysis. • No special measures are needed. • Midstream specimen (clean-voided or clean-catch) • The perineal area is cleaned before collecting the specimen. • Sterile gloves and container are needed. • Double voided • Patient voids and the specimen is discarded • After 30 minutes, patient voids again and specimen is collected for testing

29. Testing Urine • Urine pH measures if urine is acidic or alkaline. • Normal pH is 4.6 to 8.0. • Testing for glucose and ketones • These tests are usually done 30 minutes before each meal and at bedtime. • Information used to make drug and diet decisions. • Double-voided specimens are best for these tests. • Testing for blood • Sometimes blood is seen in the urine. • At other times it is unseen (occult). • A routine urine specimen is needed.

30. Testing Urine • Using reagent strips • Universal Precautions must be used at all times • Dip the strip into urine. • Compare the strip with the color chart on the bottle at the required time interval. • Record and report results

31. Stool Specimen • Stool, or feces, may be tested for: • Blood • Fat • Microbes • Worms • Other abnormal contents • The stool specimen must not be contaminated with urine.

32. Sputum Specimen • Sputum specimens may be tested for blood, microbes, and abnormal cells. • The person coughs up sputum from the bronchi and trachea. • It is easier to collect a specimen in the morning.

33. Other Types of Specimens • Specimens may be obtained from other body tissue and fluid. • A biopsy is done by removing a small piece of tissue for further examination. • A culture and sensitivity is done by swabbing a body surface and testing for the presence of microbes

34. Observations by Body Systems Using sight, touch, hearing, and smell

35. ABC’s of Observation • Appearance • Behavior – actions, conduct, pain • Communication

36. Signs and Symptoms • Signs Objective data are seen, heard, felt, smelled. You can see urine, hear a cough, feel a pulse and smell a foul odor. • Symptoms Subjective data are thing a person tells you about that you cannot observe through your senses. Examples include nausea, pain and dizziness.

37. Integumentary System Color – flushed, pale, ashen, icteric, cyanotic, (don’t forget nails) Temperature – warm, hot cool Moisture – dry, moist, perspiring Abnormalities – rashes, bruises, wounds

38. Posture – stooped, fetal position, straight Mobility – in bed, balance, ambulation Range of Motion – performance of ADL’s Musculoskeletal System

39. Pulse – strength, regularity, rate Blood Pressure Skin color Extremities – edema Circulatory System

40. Respirations – rate, regularity, depth, dyspnea, SOB (exertion, at rest), stertorous Cough – frequency, dry, productive Sputum – color, consistency Respiratory System

41. Mental state – orientation Ability to communicate Senses Eyes – pupils equal, reddened, drainage Ears – drainage, hearing Nose – drainage, bleeding Nervous System

42. Frequency, amount, color, dysuria Clarity, blood or sediment, incontinent Pain or burning upon urination Urinary System

43. Appetite – amount of solids/liquids consumed, belching, burping, intolerance to foods Eating – difficulty chewing or swallowing Nausea/Vomiting Bowel elimination – frequency, amount, consistency, color, diarrhea, constipation, flatus Digestive System

44. Female Breasts – drainage from nipples, discoloration, lumps Vagina – discharge, amount, color, character Male Testes – lumps Penis – drainage, amount and character Reproductive System