CHAPTER 26 MEASURING VITAL SIGNS Copyright 2012 by

VITAL SIGNS • Vital signs reflect the function of three body processes essential for life. • • The four vital signs of body function are: • • • Regulation of body temperature Breathing Heart function Temperature Pulse Respirations Blood pressure Some agencies consider “pain” to be a vital sign. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 2

MEASURING AND REPORTING VITAL SIGNS • • A person’s vital signs vary within certain limits. Vital signs: • • Are measured to detect changes in normal body function Tell about treatment response Often signal life-threatening events Are part of the assessment step in the nursing process Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 3

MEASURING AND REPORTING VITAL SIGNS (CONT’D) • Vital signs are measured: • • • During physical exams When the person is admitted to a health care agency As often as the person’s condition requires Before and after surgery, complex procedures, and diagnostic tests After some care measures, such as ambulation (walking) After a fall or other injury When drugs affect the respiratory or circulatory system When the person complains of pain, dizziness, lightheadedness, feeling faint, shortness of breath, a rapid heart rate, or not feeling well As stated on the care plan Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 4

MEASURING AND REPORTING VITAL SIGNS (CONT’D) • Vital signs show even minor changes in the person’s condition. • • • Accuracy is essential when you measure, record, and report vital signs. Take vital signs with the person at rest—lying or sitting, unless otherwise ordered. Report the following at once: • • • Any vital sign that is changed from a prior measurement Vital signs above the normal range Vital signs below the normal range Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 5

BODY TEMPERATURE • • Body temperature is a balance between amount of heat produced and amount lost by the body. Thermometers measure temperature. • • Temperature sites include: • • • Fahrenheit (F) and centigrade (C) scales are used. Mouth, rectum, axilla (underarm), tympanic membrane (ear), and temporal artery (forehead) Each site has a normal range. Always report temperatures that are above or below the normal range. • Fever means an elevated body temperature. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 6

BODY TEMPERATURE (CONT’D) • Types of thermometers used: • • Glass thermometers Standard electronic thermometers • • Tympanic membrane thermometers Temporal artery thermometers Digital thermometers Disposable oral thermometers Temperature-sensitive tape Pacifier thermometers Taking Temperatures • The nurse and care plan tell you when to take the person’s temperature, what site to use, and what thermometer to use. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 7

BODY TEMPERATURE (CONT’D) • Electronic thermometers are commonly used. • • • Some have batteries. Others are kept in battery chargers when not in use. Standard electronic thermometers • • • Tympanic membrane thermometers • • • Measures temperature in a few seconds They have oral (blue) and rectal (red) probes. Measures temperature in 1 to 3 seconds Risk of spreading infection is reduced. Temporal artery thermometers • • Measures temperature in 3 to 4 seconds Measures the temperature of the blood in the temporal artery, which is the same temperature of the blood coming from the heart Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 8

BODY TEMPERATURE (CONT’D) • Glass thermometers are color coded. • • • Blue—oral and axillary Red—rectal Glass thermometers are reusable. However, the following are problems: • • • They take a long time to register. They break easily. The person may bite down and break an oral thermometer. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 9

PULSE • • • A pulse is felt every time the heart beats. The pulse is the beat of the heart felt at an artery as a wave of blood passes through the artery. Pulse sites: • • Temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis (pedal) pulses are on each side of the body. Radial pulse is used most often. Carotid pulse is taken during CPR and other emergencies. The apical pulse is felt over the heart. • This pulse is taken with a stethoscope. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 10

PULSE (CONT’D) • A stethoscope is an instrument used to listen to the sounds produced by the heart, lungs, and other body organs. • • • It is used to take apical pulses and blood pressures. The device makes sounds louder for easy hearing. To use a stethoscope: • • • Wipe the earpieces and diaphragm with antiseptic wipes before and after use. Place the earpiece tips in your ears. Tap the diaphragm gently. Place the diaphragm over the pulse site. Prevent noise. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 11

PULSE (CONT’D) • The pulse rate is the number of heart beats or pulses felt in 1 minute. • • The rate varies for each age-group. The adult pulse rate is between 60 and 100 beats per minute. Report abnormal pulses to the nurse at once. • • Tachycardia is a heart rate of more than 100 beats per minute. Bradycardia is a heart rate of less than 60 beats per minute. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 12

PULSE (CONT’D) • Rhythm and force of the pulse • Pulse rhythm should be regular (felt in a pattern with the same interval between beats). • • Force relates to pulse strength. • • • An irregular pulse occurs when the beats are not evenly spaced or beats are skipped. A forceful pulse is described as strong, full, or bounding. Hard-to-feel pulses are described as weak, thready, or feeble. Electronic blood pressure equipment can also count pulses. • • Some show if the pulse is regular or irregular. You need to feel the pulse to determine its force. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 13

PULSE (CONT’D) • You will take radial, apical, and apical-radial pulses. • You must accurately: • • • Count. Report and record. The radial pulse is used for routine vital signs. • • Count the pulse for 30 seconds and then multiply the number by 2. If the pulse is irregular, count it for 1 minute. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 14

PULSE (CONT’D) • The apical pulse is on the left side of the chest slightly below the nipple. • • It is taken with a stethoscope. Count the apical pulse for 1 minute. Count each lub-dub as one beat. Apical pulses are taken on persons who: • • • Have heart disease. Have irregular heart rhythms. Are taking drugs that affect the heart. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 15

PULSE (CONT’D) • Taking an apical-radial pulse • • The apical and radial pulse rates should be the same. To see if the apical and radial pulses are equal, two staff members are needed. • • One takes the radial pulse. The other takes the apical pulse. Doing this at the same time is called the apical-radial pulse. The pulse deficit is the difference between the apical and radial pulse rates. • To obtain the pulse deficit, subtract the radial rate from the apical rate. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 16

PULSE (CONT’D) • Checking pedal pulses • • Pedal (dorsalis pedis) pulse is used to check circulation in the foot. Doppler ultrasound stethoscope (DUS) is used when the pedal pulse cannot be felt. • Your role may include using a DUS. Make sure you: Ø Ø Ø Have received the necessary training. Follow the nurse’s directions. Follow the manufacturer’s instructions. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 17

RESPIRATIONS • Respiration means breathing air into (inhalation) and out of (exhalation) the lungs. • • • Each respiration involves one inhalation and one exhalation. • • Oxygen enters the lungs during inhalation. Carbon dioxide leaves the lungs during exhalation. The chest rises during inhalation. The chest falls during exhalation. The healthy adult has 12 to 20 respirations/min. Respirations are normally quiet, effortless, and regular. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 18

RESPIRATIONS (CONT’D) • • • Count respirations when the person is at rest. Position the person so you can see the chest rise and fall. The person should not know that you are counting respirations. • 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. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 19

BLOOD PRESSURE • Blood pressure (BP) is the amount of force exerted against the walls of an artery by the blood. • Blood pressure is controlled by: • • • The force of heart contractions The amount of blood pumped with each heartbeat How easily the blood flows through the blood vessels • Systole is the period of heart muscle contraction. • Diastole is the period of heart muscle relaxation. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 20

BLOOD PRESSURE (CONT’D) • • • Systolic pressure—the pressure in the arteries when the heart contracts Diastolic pressure—the pressure in the arteries when the heart is at rest Blood pressure is measured in millimeters (mm) of mercury (Hg). • • The systolic pressure is recorded over the diastolic pressure. Blood pressure has normal ranges. • • Systolic pressure— 90 mm Hg or higher but lower than 120 mm Hg Diastolic pressure— 60 mm Hg or higher but lower than 80 mm Hg Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 21

BLOOD PRESSURE (CONT’D) • Treatment is indicated for: • Hypertension—When the systolic blood pressure is 140 mm Hg or higher (hyper), or the diastolic blood pressure is 90 mm Hg or higher • • • Report any systolic measurement at or above 120 mm Hg. Report any diastolic pressure at or above 80 mm Hg. Hypotension—Systolic blood pressure is below (hypo) 90 mm Hg, or the diastolic blood pressure is below 60 mm Hg • • Report a systolic pressure below 90 mm Hg. Report a diastolic pressure below 60 mm Hg. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 22

BLOOD PRESSURE (CONT’D) • A stethoscope and a sphygmomanometer are used to measure blood pressure. • • The sphygmomanometer has a cuff and a measuring device. These types of sphygmomanometers are used (follow the manufacturer’s instructions): • • • Aneroid type Mercury type Electronic type Wrist monitor Blood pressure is normally measured in the brachial artery. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 23

PAIN • Pain is a warning sign from the body. • • Pain can signal tissue damage. Many agencies consider pain to be a vital sign. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 24