Vital Signs Measuring Temperature Pulse Respirations and Blood

Vital Signs Measuring Temperature, Pulse, Respirations, and Blood Pressure

Standards and Goals Standards n 19: Understand principles of and successfully perform skills related to Medical Assisting Skills, incorporating rubrics from textbooks or clinical standards of practice for the following: n A. temperature, pulse, respiration and blood pressure assessment n B. screening for vision problems Goals (You will): n n n Demonstrate ability to assess (take) temperature, pulse, respiration and blood pressure Demonstrate ability to screen for vision problems Synthesize data obtained from assessments to evaluate overall health and wellness of the patient.

Essential Question n How does vital sign and vision screening data provide valuable information to a patient’s condition?

Four Main Vital Signs Pulse n Respirations n Temperature n Blood Pressure n

Additional Vital Signs: Pain Scale n Pulse Oximetry n

Measuring and Recording Vital Signs n n n Procedure for Measuring and Recording Vital Signs: Assemble Equipment. Wash hands. Introduce yourself. Identify the patient and explain the procedure Perform procedure (pulse, respirations, temperature, blood pressure) Document procedure details/information Check the patient before leaving the area. Observe all safety precautions. Replace all equipment Wash hands. Report any unusual observations to your supervisor if necessary.

Pulse n n n Pulse is defined as “the pressure of the blood pushing against the wall of the artery as the heart beats and rests”. Pulses can be palpated (felt) in arteries that lie close to the skin and can be pressed against a bone by the fingers. Pulse rate is measured as number of beats per minute. Normal range for an adult is 60 -90 beats per minute.

Major Pulse Sites n n n n Temporal Carotid Brachial Radial Femoral Popliteal Pedal

Pulse Variations n n n Bradycardia: slow heart rate, pulse of <60 beats per minute Tachycardia: fast heart rate, pulse of >100 beats per minute Arrhythmia: irregular or abnormal rhythm

Documentation n Rhythm should also be noted. It is described as regular or irregular. If beats are spaced evenly, a pulse is considered regular. n Volume should also be addressed. This is the strength of the pulse. It is described by words such as strong, weak, thready, bounding.

Respirations Respiration is “the process of taking in oxygen and expelling carbon dioxide from the lungs and respiratory tract”. n Normal adult respiratory rate is 14 -18 breaths per minute. n Respiratory rate should be counted for 3060 seconds just following pulse assessment. n

Documentation n Character or respirations should be noted. This refers to depth and quality. Deep, shallow, labored and difficult all refer to character. n Rhythm should also be addressed. This is regularity of respirations. Are they regular and even or irregular?

Temperature Defined as “the balance between heat lost and heat produced by the body”. n Normal range of body temperature is 97 to 100 degrees Fahrenheit. n Time of day affects temperature: temperature is lower in the am and higher in the pm. n

Body Sites For Assessing Temperature n n Oral Rectal Axillary Aural

Factors Affecting Temperature n n Increased temperature: illness, infection, exercise, environmental temperature Decreased temperature: starvation, sleep, decreased muscle activity, mouth breathing, exposure to cold

Temperature Terminology n Hypothermia- low body temperature, below 95 degrees rectally. Death occurs if temperature is less than 93 degrees for a period of time. n Hyperthermia- high body temperature, over 104 degrees. Fever is a temperature above 101 degrees. Pyrexia is another term for fever. Febrile means “with fever”. Afebrile means “without fever”

Documenting Temperature To record temperatures write 98 n If a temperature is oral, there is no reason to indicate this, it is understood. If it is a rectal temperature, write ® beside the reading. If the reading is axillary, write (Ax) beside it. n

Factors Affecting Temperature Readings n n n Eating Drinking Smoking n Do not take oral temperature if patient has eaten, drank or smoked within 15 minutes of assessing temperature.

Respiratory Terminology n n n Dyspnea: difficult/labored breathing Apnea: absence of respirations Orthopnea: severe dyspnea n n n Tachypnea: fast breathing, >25/min Bradypnea: slow breathing, <10/min Cyanosis: bluish coloring of skin, lips, nails due to decreased oxygen in the bloodstream.

Blood Pressure n Blood Pressure is “the measurement of the pressure that the blood exerts on the walls of the arteries during various stages of heart activity”.

n The "lub" is the first heart sound, commonly termed S 1, and is caused by turbulence caused by the closure of mitral and tricuspid valves at the start of systole. The second heart sound, "dub" or S 2, is caused by the closure of the aortic and pulmonic valves, marking the end of systole.

Systolic and Diastolic Blood Pressure n n Systolic: pressure that occurs in the walls of the arteries when the left ventricle is contracting and pushing blood into the arteries. Normal SBP is <120. n n Diastolic: constant pressure in the walls of the arteries when the left ventricle is at rest. Blood has moved to the capillaries and veins. Normal DBP is <80.

Influencing Factors n Factors that influence blood pressuren n Force of heartbeat Resistance of arterial system Elasticity of the arteries Volume of blood in the arteries

Blood Pressure Variations n Hypotension: low blood pressure, < 100/60 n Influencing factors: • • • Sleep Depressant drugs Shock Excessive blood loss Fasting n Hypertension: high blood pressure, > 140/90 n Influencing factors: • • • Anxiety Stimulant drugs Exercise Eating Smoking

Documentation n Blood pressure is recorded as a fraction. It is written systolic reading/diastolic reading.

Summary Vital signs are major indications of body function. n Healthcare workers must use precise methods to measure vital signs to produce the most accurate results. n Healthcare workers need to be alert for abnormal findings so that they may report them to the correct team member. n

Taking A Blood Pressure n Materials you will need: Blood Pressure Cuff n Stethoscope n Paper/Pen n

Taking A Blood Pressure § § § Make sure all equipment is clean. Wash hands. Identify patient Position arm so it is comfortable and close to level of the heart. Roll up patient sleeve, wrap cuff around upper arm.

Taking a Blood Pressure Find brachial artery with fingertips. Place stethoscope over artery. n Put earpieces in ears. n AUSCULTATION=LISTENING WITH STETHOSCOPE n

Taking a Blood Pressure n Stethoscope n Chest piece: end to patient • Diaphragm: flat side • Bell: curved side (not present on all types) n Earpieces: one in each ear of person taking blood pressure. • Should be pointed forward n Tubing: Should be free of kinks

Taking Blood Pressure Close valve on rubber bulb of cuff n Inflate cuff to 180 mm. Hg for an adult. n Open bulb valve SLOWLY so air escapes gradually. n

Taking a Blood Pressure n n n Note gauge reading when first sound is heard. This is SYSTOLIC pressure. Continue to release air slowly. DIASTOLIC pressure in adults= point where sound becomes very faint/stops. Rapidly release remaining air. **Practice You. Tube videos**

Taking a Blood Pressure n Documentation: Systolic / Diastolic n “Sky-over-dirt” n Should always document date, time, and include signature of who read it, and their title (RN, CNA, LPN, etc) n n Evaluation: Is this within normal range? Why or Why not?

It’s Your Turn… Complete Worksheet n Blood Pressure Arm n Patient 1 n Patient 2 n n One set of vital assessment (TPR, BP) n Document and Evaluate

Did you achieve you goals? Can you successfully take temperature, pulse, respirations and blood pressure? Can you evaluate these findings based on normal ranges and predict what these finding might tell you about your patient? Can you screen for vision problems and evaluate your data?