Chapter 29 Measuring Vital Signs Copyright 2017 Elsevier

Chapter 29 Measuring Vital Signs Copyright © 2017, Elsevier, Inc. All rights reserved.

Vital Signs Vital signs reflect the function of three body processes essential for life. Regulation of body temperature Ø Breathing Ø Heart function Ø The four vital signs of body function are: Temperature Ø Pulse Ø Respirations Ø Blood pressure Ø Some agencies consider “pain” to be a vital sign. Copyright © 2017, Elsevier, Inc. All rights reserved. 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 Ø Tell about treatment response Ø Often signal life-threatening events Ø Are part of the assessment step in the nursing process Ø Copyright © 2017, Elsevier, Inc. All rights reserved. 3

Measuring and Reporting Vital Signs (Cont. ) Vital signs are measured: Ø Ø Ø Ø Ø 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 © 2017, Elsevier, Inc. All rights reserved. 4

Measuring and Reporting Vital Signs (Cont. ) Vital signs show even minor changes in the person’s condition. Ø 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 Ø Vital signs above the normal range Ø Vital signs below the normal range Ø Copyright © 2017, Elsevier, Inc. All rights reserved. 5

Body Temperature Body temperature is a balance between amount of heat produced and amount lost by the body. Thermometers measure temperature. Ø Fahrenheit (F) and centigrade (C) scales are used. Temperature sites include: Mouth, rectum, axilla (underarm), tympanic membrane (ear), and temporal artery (forehead) Ø Each site has a normal range. Ø Always report temperatures that are above or below the normal range. Ø Fever means an elevated body temperature. Copyright © 2017, Elsevier, Inc. All rights reserved. 6

Body Temperature (Cont. ) Types of thermometers used: Glass thermometers Ø Standard electronic thermometers Ø • Tympanic membrane thermometers • Temporal artery thermometers Digital thermometers Ø Disposable oral thermometers Ø Temperature-sensitive tape Ø Pacifier thermometers Ø Taking temperatures Ø The nurse and care plan tell you when to take the person’s temperature, what site to use, and what thermometer to use. Copyright © 2017, Elsevier, Inc. All rights reserved. 7

Body Temperature (Cont. ) Electronic thermometers are commonly used. Some have batteries. Ø Others are kept in battery chargers when not in use. Ø Standard electronic thermometers Ø • Measure temperature in a few seconds • They have oral (blue) and rectal (red) probes. Ø Tympanic membrane thermometers • Measure temperature in 1 to 3 seconds • Risk of spreading infection is reduced. Ø Temporal artery thermometers • Measure temperature in 3 to 4 seconds • Measure the temperature of the blood in the temporal artery, which is the same temperature of the blood coming from the heart Copyright © 2017, Elsevier, Inc. All rights reserved. 8

Body Temperature (Cont. ) Glass thermometers are color coded. Blue—oral and axillary Ø Red—rectal Ø Glass thermometers are reusable. However, the following are problems: They take a long time to register. Ø They break easily. Ø The person may bite down and break an oral thermometer. Ø Copyright © 2017, Elsevier, Inc. All rights reserved. 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. Ø Radial pulse is used most often. Ø Carotid pulse is taken during CPR and other emergencies. Ø The apical pulse is felt over the heart. Ø • This pulse is taken with a stethoscope. Copyright © 2017, Elsevier, Inc. All rights reserved. 10

Pulse (Cont. ) 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. Ø The device makes sounds louder for easy hearing. Ø To use a stethoscope: Ø Ø Ø 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 © 2017, Elsevier, Inc. All rights reserved. 11

Pulse (Cont. ) The pulse rate is the number of heartbeats or pulses felt in 1 minute. Ø 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. Ø Bradycardia is a heart rate of less than 60 beats per minute. Ø Copyright © 2017, Elsevier, Inc. All rights reserved. 12

Pulse (Cont. ) Rhythm and force of the pulse Ø Pulse rhythm should be regular (felt in a pattern with the same interval between beats). • An irregular pulse occurs when the beats are not evenly spaced or beats are skipped. Ø Force relates to pulse strength. • A forceful pulse is described as strong, full, or bounding. • Hard-to-feel pulses are described as weak, thready, or feeble. Ø 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 © 2017, Elsevier, Inc. All rights reserved. 13

Pulse (Cont. ) You will take radial, apical, and apical-radial pulses. You must accurately: • Count. • Report and record. Ø The radial pulse is used for routine vital signs. • Count the pulse for 30 seconds and then multiply the Ø number by 2. • If the pulse is irregular, count it for 1 minute. Copyright © 2017, Elsevier, Inc. All rights reserved. 14

Pulse (Cont. ) The apical pulse is on the left side of the chest slightly below the nipple. It is taken with a stethoscope. Ø Count the apical pulse for 1 minute. Ø Count each lub-dub as one beat. Ø Apical pulses are taken on persons who: • Have heart disease. • Have irregular heart rhythms. • Are taking drugs that affect the heart. Ø Copyright © 2017, Elsevier, Inc. All rights reserved. 15

Pulse (Cont. ) Taking an apical-radial pulse The apical and radial pulse rates should be the same. Ø 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 Ø pulse. Ø 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 © 2017, Elsevier, Inc. All rights reserved. 16

Pulse (Cont. ) Checking pedal pulses Pedal (dorsalis pedis) pulse is used to check circulation in the foot. Ø A Doppler ultrasound stethoscope (DUS) is used when the pedal pulse cannot be felt. • Your role may include using a DUS. Make sure you: Ø Have received the necessary training. Follow the nurse’s directions. Follow the manufacturer’s instructions. Copyright © 2017, Elsevier, Inc. All rights reserved. 17

Respirations Respiration means breathing air into (inhalation) and out of (exhalation) the lungs. Oxygen enters the lungs during inhalation. Ø Carbon dioxide leaves the lungs during exhalation. Ø Each respiration involves one inhalation and one exhalation. The chest rises during inhalation. Ø The chest falls during exhalation. Ø The healthy adult has 12 to 20 respirations/min. Respirations are normally quiet, effortless, and regular. Copyright © 2017, Elsevier, Inc. All rights reserved. 18

Respirations (Cont. ) 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. Ø 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 © 2017, Elsevier, Inc. All rights reserved. 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 Ø The amount of blood pumped with each heartbeat Ø How easily the blood flows through the blood vessels Ø Systole is the period of heart muscle contraction. Diastole is the period of heart muscle relaxation. Copyright © 2017, Elsevier, Inc. All rights reserved. 20

Blood Pressure (Cont. ) 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. Ø Blood pressure has normal ranges. Ø • 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 © 2017, Elsevier, Inc. All rights reserved. 21

Blood Pressure (Cont. ) Treatment is indicated for: Ø 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. Ø Hypotension—when 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 © 2017, Elsevier, Inc. All rights reserved. 22

Blood Pressure (Cont. ) A stethoscope and a sphygmomanometer are used to measure blood pressure. The sphygmomanometer has a cuff and a measuring device. Ø These types of sphygmomanometers are used (follow the manufacturer’s instructions): • Aneroid type • Mercury type • Electronic type • Wrist monitor Ø Blood pressure is normally measured in the brachial artery. Copyright © 2017, Elsevier, Inc. All rights reserved. 23

Pain is a warning sign from the body. Pain can signal tissue damage. Ø Many agencies consider pain to be a vital sign. Ø Copyright © 2017, Elsevier, Inc. All rights reserved. 24