© 2009 delmar, cengage learning vital signs. © 2009 delmar, cengage learning 14:1 measuring and...

© 2009 Delmar, Cengage Learning

Vital Signs


14:1 Measuring and RecordingVital Signs (VS)

• Vital Signs are defined as various determinations that provide basic information about the basic conditions of the patient

• The 4 main vital signs (VS)– Temperature (T)

– Pulse (P)

– Respiration (R)

– Blood pressure (BP)


Other Assessments on Patients

• 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


VS Readings

• Accuracy is essential

• Report abnormality or change

• If unable to get reading, ask another person to check

• As a health care worker, it is your responsibility to measure and record the VS of your patients


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 balance in the body

• Conversion between Fahrenheit and Celsius temperature


Variations in Body Temperature

• Normal range 97- 100 degrees Fahrenheit

• Causes of variations –individual differences, time of day, body sites

• Temperature measurements—oral, rectal (often used on infants/children), axillary (arm pit) or groin, aural (ear), and temporal (forehead-is measuring the temp in the temporal artery)


Causes of Increased Body Temperature

• Illness

• Infection

• Exercise

• Excitement

• High temperatures in the environment


Causes of Decreased Body Temperature

• Starvation or fasting

• Sleep

• Decreased muscle activity

• Mouth breathing

• Exposure to cold temperatures in the environment

• Certain diseases


Thermometers

• Clinical thermometers – are used to record temperatures– Glass – consists of a slender glass tube containing mercury

or alcohol with red dye, which expands when exposed to heat

– Electronic – registers the temp on a viewer in a few seconds

– Tympanic – records aural temp in the ear

– Temporal – measures the temp in the temporal artery of the forehead

– Plastic or paper - contain special chemical dots/strips that change color when exposed to specific temps (continues)


Thermometers(continued)

• Reading thermometers and recording results:

* Electronic & tympanic thermometers are easily read because of digital displays

* Mercury thermometers should be held at eye level & rotated slowly to find the mercury

Examples of how to record a temperature:

98.6 is an oral reading

99.6 (R) is a rectal reading

97.9 (Ax) is an axillary reading

98.6 (A) is an aural reading


Cleaning Thermometers

• Must be cleaned after each use

• The procedure will vary with different agencies and thermometers

• Glass thermometers are cleaned with water and soaked in a disinfectant solution (70% alcohol) for a minimum of 30 minutes before using again

• Electronic/digital thermometers use a probe or sheath that is discarded after each use


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

• Pulse rate

• Pulse rhythm

• Pulse volume

(continues)


Measuring and Recording Pulse (continued)

• Factors that change pulse rate

• Basic principles for taking radial pulse

• Recording information


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)

(continues)


Measuring and Recording Respirations (continued)

• Normal respiratory rate

• Character of respirations

• Rhythm of respirations

• Abnormal respirations

• Voluntary control of respirations

• Record information


14:5 Graphing TPR

• Graphic sheets are special records used for recording TPR (temp., pulse, resp.)

• Presents a visual diagram

• Used most often in hospitals and long term care facilities

• Factors affecting VS are often noted on the graph - - examples include surgery, medications that lower temperature such as aspirin and antibiotics (continues)


Graphing TPR(continued)

• Graphic charts are legal records – so it must be neat, legible, and accurate

• To correct an error mark a single line through the error and initial beside it


14:6 Measuring and RecordingApical Pulse

• Pulse count taken at the apex of the heart with a stethoscope

• Reasons for taking an apical pulse – pts with irregular heart beats, hardening of the arteries, weak or rapid radial pulses

• Protect the patient’s privacy and avoid exposure

• 2 heart sounds “lubb-dupp” = 1 heart beat• Abnormal sounds or beats should be reported

immediately (continues)


Measuring and Recording Apical Pulse (continued)

• Pulse deficit – a condition that occurs with some heart conditions – when the apical pulse rate is higher than the pulse rate on other sites on the body

• Use the stethoscope : diaphragm side

• Placement of stethoscope : 2-3in. to the left of the breast bone

• Measuring apical pulse : count for 1 full min.

• Record all information


14:7 Measuring and RecordingBlood 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 a sphygmomanometer

• Measurements read at two points

(continues)


Measuring and Recording Blood Pressure

(continued)

• Systolic pressure

• Diastolic pressure

• Pulse pressure

• Hypertension—high blood pressure

• Hypotension—low blood pressure

• Factors influencing blood pressure readings (high or low) (continues)


Measuring and RecordingBlood Pressure

(continued)

• Individual factors can all influence blood pressure readings

• Types of sphygmomanometers– Mercury

– Aneroid

– Electronic

(continues)


Measuring and RecordingBlood Pressure

(continued)

• Factors to follow for accurate readings

• Record all required information

• Do not discuss the reading with the patient; it’s the doctor’s responsibility


Summary

• Vital signs are major indicators of body function

• Accuracy of measurement and recording of vital signs

• The health care worker needs to be alert and report any abnormalities

© 2009 delmar, cengage learning vital signs. © 2009 delmar, cengage learning 14:1 measuring and...

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