Chapter 16 Vital Signs Copyright 2014 Cengage Learning

16: 1 Measuring and Recording Vital Signs • Vital signs provide information about a

16: 1 Measuring and Recording Vital Signs (continued) • Pulse – Pressure of blood

16: 1 Measuring and Recording Vital Signs (continued) • Respirations – Patient’s breathing rate

16: 2 Measuring and Recording Temperature • Temperature measures balance between heat lost and

Variations in Body Temperature • Normal range: 97°to 100° Fahrenheit • Causes of variations

Variations in Body Temperature (continued) • • • Oral temperature Rectal temperature Axillary temperature

Variations in Body Temperature (continued) • Hypothermia – Body temperature below 95°F • Pyrexia

Types of Thermometers • Clinical thermometers – Slender glass tube containing mercury – Used

Types of Thermometers (continued) • Tympanic thermometers • Temporal scanning thermometers – Accurate and

Reading and Recording Temperature • Record temperature to the nearest two-tenths of a degree

Cleaning Thermometers • Clean thermometers thoroughly after each use • Use cool water on

16: 3 Measuring and Recording Pulse • Pulse – Pressure of blood pushing against

16: 3 Measuring and Recording Pulse (continued) • Pulse rate – Number of beats

16: 3 Measuring and Recording Pulse (continued) • Pulse volume – Strength, force, quality,

16: 4 Measuring and Recording Respirations • Respiration – Process of taking in oxygen

16: 4 Measuring and Recording Respirations (continued) • Rate of respirations – Number of

16: 4 Measuring and Recording Respirations (continued) • Abnormal respirations – Dyspnea – Apnea

16: 5 Graphing TPR • Graphic sheets are used for recording temperature, pulse, and

16: 5 Graphing TPR (continued) • Factors affecting vital signs are often noted •

16: 6 Measuring and Recording Apical Pulse • Pulse count taken with stethoscope at

16: 6 Measuring and Recording Apical Pulse (continued) • Two heart sounds • Pulse

16: 7 Measuring and Recording Blood Pressure • Measurement of pressure blood exerts on

16: 7 Measuring and Recording Blood Pressure (continued) • Systolic pressure – Pressure in

16: 7 Measuring and Recording Blood Pressure (continued) • Pulse pressure – Difference between

16: 7 Measuring and Recording Blood Pressure (continued) • Hypotension (low blood pressure) –

16: 7 Measuring and Recording Blood Pressure (continued) • Individual factors can influence blood

16: 7 Measuring and Recording Blood Pressure (continued) • AHA factors to observe for

Slides: 28

Download presentation

16: 1 Measuring and Recording Vital Signs • Vital signs provide information about a patient’s basic body conditions • Temperature – Measure of balance between heat lost and produced by body – Usually measured on Fahrenheit scale Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

16: 1 Measuring and Recording Vital Signs (continued) • Pulse – Pressure of blood felt against wall of an artery – Rate: number of beats per minute – Rhythm: regularity – Volume: strength, force, or quality Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

16: 1 Measuring and Recording Vital Signs (continued) • Respirations – Patient’s breathing rate • Blood pressure – Force exerted by blood against arterial walls • Apical pulse – Taken with stethoscope at apex of heart Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

16: 2 Measuring and Recording Temperature • Temperature measures balance between heat lost and heat produced in the body – Heat lost through perspiration, respiration, excretion – Heat produced by food metabolism, muscle and gland activity • Homeostasis – Constant state of fluid balance in the body Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

Variations in Body Temperature • Normal range: 97°to 100° Fahrenheit • Causes of variations – Individual differences – Time of day – Body sites (refer to Table 16 -1 in Text) Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

Variations in Body Temperature (continued) • • • Oral temperature Rectal temperature Axillary temperature Aural temperature Temporal temperature Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

Variations in Body Temperature (continued) • Hypothermia – Body temperature below 95°F • Pyrexia (fever) – Body temperature above 101°F • Hyperthermia – Rectal body temperature exceeding 104°F Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

Types of Thermometers • Clinical thermometers – Slender glass tube containing mercury – Used by few health care agencies – Danger of mercury contamination • Electronic thermometers – Used in most health care facilities Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

Types of Thermometers (continued) • Tympanic thermometers • Temporal scanning thermometers – Accurate and noninvasive for internal body temperature • Plastic or disposable thermometers Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

Reading and Recording Temperature • Record temperature to the nearest two-tenths of a degree • Refer to Figure 16 -9 in Text • Record to avoid error in reading Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

Cleaning Thermometers • Clean thermometers thoroughly after each use • Use cool water on glass thermometers to prevent breakage • Disposable plastic sheath may be used • Follow agency policies Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

16: 3 Measuring and Recording Pulse • Pulse – Pressure of blood pushing against the wall of an artery as the heart beats and rests • Major arterial or pulse sites – Refer to Figure 16 -18 in Text Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

16: 3 Measuring and Recording Pulse (continued) • Pulse rate – Number of beats per minute – Bradycardia: pulse rate under 60 beats/minute – Tachycardia: pulse rate over 100 beats/minute • Pulse rhythm – Regularity of pulse – Arrhythmia Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

16: 3 Measuring and Recording Pulse (continued) • Pulse volume – Strength, force, quality, or intensity of pulse – Strong, weak, thready, bounding • Factors that change pulse rate • Measuring and recording radial pulse – Refer to Procedure 16: 3 in Text Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

16: 4 Measuring and Recording Respirations • Respiration – Process of taking in oxygen and expelling carbon dioxide from lungs and respiratory tract • One respiration – One inspiration (breathing in) and one expiration (breathing out) Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

16: 4 Measuring and Recording Respirations (continued) • Rate of respirations – Number of breaths per minute • Character of respirations – Depth and quality of respirations • Rhythm of respirations – Regularity of respirations/space between breaths Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

16: 4 Measuring and Recording Respirations (continued) • Abnormal respirations – Dyspnea – Apnea – Tachypnea – Bradypnea – Orthopnea – Cheyne-Stokes – Rales – Wheezing – Cyanosis Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

16: 5 Graphing TPR • Graphic sheets are used for recording temperature, pulse, and respirations (TPR) • Presents a visual diagram of variations in patient’s vital signs • May use color coding • Refer to Procedure 16: 5 in Text Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

16: 5 Graphing TPR (continued) • Factors affecting vital signs are often noted • Computerized graphs may be printed or kept in the electronic health record (EHR) • Graphic charts are legal medical records – Neat, legible, accurate – Correct all errors Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

16: 6 Measuring and Recording Apical Pulse • Pulse count taken with stethoscope at apex of the heart • Usually ordered by physician • Reasons for taking an apical pulse • Protect patient’s privacy and avoid exposure Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

16: 6 Measuring and Recording Apical Pulse (continued) • Two heart sounds • Pulse deficit – Difference between apical and radial pulse • Refer to Procedure 16: 6 in Text Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

16: 7 Measuring and Recording Blood Pressure • Measurement of pressure blood exerts on walls of arteries during various stages of heart activity • Read in millimeters (mm) of mercury (Hg) on a sphygmomanometer • Measurements read at two points Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

16: 7 Measuring and Recording Blood Pressure (continued) • Systolic pressure – Pressure in walls of arteries when left ventricle contracts • Diastolic pressure – Constant pressure in walls of arteries when left ventricle is at rest Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

16: 7 Measuring and Recording Blood Pressure (continued) • Pulse pressure – Difference between systolic and diastolic pressure • Hypertension (high blood pressure) – Greater than 140 mm Hg systolic, 90 mm Hg diastolic Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

16: 7 Measuring and Recording Blood Pressure (continued) • Hypotension (low blood pressure) – Less than 90 mm Hg systolic, 60 mm Hg diastolic • Refer to Table 16 -2 in Text for adult blood pressure classifications Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

16: 7 Measuring and Recording Blood Pressure (continued) • Individual factors can influence blood pressure readings, increase or decrease blood pressure • Types of sphygmomanometers – Mercury – Aneroid – Electronic Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

16: 7 Measuring and Recording Blood Pressure (continued) • AHA factors to observe for accurate readings – 5 minutes of quiet rest – Take two separate readings and average • Correct cuff size is essential for accuracy • Refer to Procedure 16: 7 in Text Copyright © 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.