Unit 14 Vital Signs 14 1 Measuring and

Unit 14 Vital Signs

14: 1 Measuring and Recording Vital Signs (VS) § Vital signs are important indicators of health states of the body – They provide information about the basic body condition of the patient • They are often the first sign of a disease or abnormality in the patient. § 4 Main vital signs – Temperature – Blood pressure -Respiration -Pulse Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 2

Other Assessments § 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 Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 3

VS Readings § Accuracy is essential § Report abnormality or change immediately § If unable to get reading, ask another person to check Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 4

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 fluid balance § *Conversion : Fahrenheit to Celsius F-32 X 5/9 » : Celsius to Fahrenheit CX 9/5 +32 » Formulas given to you on the test Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 5

Variations in Body Temperature § Normal range 97 -100◦F or 36. 1 -37. 8◦C § *Natural causes of variations: time of day (- in am), part of body (low in axial readings), + exercise, +excitement, - sleeping, § *Temperature measurements – oral, rectal, axillary or groin, and aural § *Abnormal conditions affecting temperature +illness, +infection, - starvation, diseases+ Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 6

Thermometers § Clinical thermometers – Glass – Electronic – Tympanic – Plastic or paper § Reading thermometers & recording results: *Most accurate *Oral = 986 *Aural =986 (T) Rectal = 996(R) Axillary = 976 (Ax) Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 7

Thermometers (continued) § *Avoid factors that could alter or change temperature: eating, drinking, smoking for *15 minutes prior § Cleaning thermometers: cool water and soap, then soak in disinfectant (70% alcohol) for *30 min § Paper/plastic sheath on glass thermometer: dispose after each use Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 8

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: temporal, carotid, brachial, radial, femoral, popliteal, dorsalis pedis (know where on the body) § Pulse *rate: *Adults=60 -90/minute, children over 7=70 -90, Babies; 100 -160 § *High rate = tachycardia *Low rate = bradycardia § Pulse *rhythm: * spacing of the beats = regular or irregular (arrhythmia) Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 9

Measuring and Recording Pulse (continued) § Pulse *volume (strong/weak/thready/bounding) § Factors that change pulse rate: +exercise, +/drugs, fever, +shock, - sleep, -heart disease, -coma, etc. § Basic principles for taking radial pulse: 2 -3 finger tips over thumb side of wrist, use second hand to count for one minutes. § *Recording information: rate, volume, rhythm ex) P 82 strong, regular date/time/signature, Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 10

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) § Normal respiratory rate: *Adult= 14 -18 breaths/min. Children= 16 -25 Infants=30 -50 Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 11

§ *Character of respirations: depth & quality – (deep, shallow, labored, difficult, moist) § *Rhythm of respirations: regularities -(regular or irregular) § *Abnormal resp: dyspnea (difficult/labored, ) apnea (absence of resp), wheezing, rales, cyanosis etc (p. 366) *Cheyne-Stokes § *Voluntary control of respirations: If patient knows they may change rate so don’t let them know you are taking it! § Record information: rate, character, rhythm, R 16 deep and regular date, time, signature Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 12

14: 5 Graphing TPR § *Graphic sheets are special records used for recording TPR to follow the progress of a patient. § *Presents a visual diagram § Color codes: temp in blue, pulse in red , respirations in green. § Factors affecting VS are often noted on the graph: surgery, medications, antibiotics Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 13

Graphing TPR (continued) § Graphic charts are legal records § *To correct errors : cross out in red ink & initial § Basic principles for completing: neat, legible, and accurate Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 14

14: 6 Measuring and Recording Apical Pulse § Pulse count taken at the apex of the heart § *Reasons for taking an apical pulse: patients with irregular heartbeats, hardening of the arteries, or weak or rapid radial pulses § Protect the patient’s privacy and avoid exposure § *Heart sounds: one beat = lubb-dupp, caused by the closing of the valves § Abnormal sounds or beats: report Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 15

Measuring and Recording Apical Pulse (continued) § *Pulse deficit: the heart beats too fast/slow or too weak to produce a pulse. – *Apical pulse-radial pulse= deficit (calculate on test) § Use the stethoscope= tips faced forward § Placement of stethoscope: 5 th intercostal space, 2 -3 inches to the left of breastbone (sternum) § Measuring apical pulse: count one minute § Record all information: AP 86 strong, regular, date, time, signature Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 16

14: 7 Measuring and Recording Blood 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 an instrument called a *sphygmomanometer § Measurements read at two points: – Systolic and Diastolic Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 17

Measuring and Recording Blood Pressure (continued) § *Systolic pressure: left ventricle contracts pushing blood into arteries Normal=100 -140 mm. Hg § *Diastolic pressure: left ventricle at rest or between contractions Normal= 60 -80 mm. Hg § *Pulse pressure: indicator of the health and tone of arterial walls Normal systolic-diastolic = 30 -50 mm. Hg Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 18

§ *Hypertension – high blood pressure >*140/>90 What can it lead to? – Caused by stress, anxiety, obesity, high salt intake, aging, kidney or thyroid disease or arteriosclerosis. (list 3) § *Hypotension – low blood pressure *<100/<60 – Heart failure, dehydration, depression, severe burns, hemorrhage and shock (list 3) § Factors influencing blood pressure readings: – Elasticity or arteries, blood volume, force of heartbeat, stumulant drugs, excitement, anxiety, exercise, eating, smoking, blood loss, sitting, lying down, standing position Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 19

Measuring and Recording Blood Pressure (continued) § *Blood pressure is recorded as fractions – Systolic/diastolic ex. 120/80 § Types of sphygmomanometers – Mercury – Aneroid – Electronic Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 20

Measuring and Recording Blood Pressure (continued) § *Factors to follow for accurate readings – Sit quietly for at least *5 mins, take 2 separate readings 30 seconds apart. Average readings – *If cuff too tight = high readings – *If cuff too loose = low readings § Record all required information: – B. P. 126/74 date, time, signature – Report abnormal readings § Do not reveal the reading to the patient – Let doctor do that Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 21