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8/12/2019 vitalsigns-110724201642-phpapp02

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Vital SignsProvide Support to Meet Personal Care

Needs

Updated by Jo Lewis BHS

Fiona OToole & Josie Ashmore


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PERSONAL CARE WORKERS

ROLE Record

According to workplaceprotocol

Report

Supervisor

GP


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VITAL SIGNS

Most frequent measurements taken byhealth care professionals

Temperature, Pulse, Blood Pressure andRespirations

Indicators of health status - measure theeffectiveness of circulatory, respiratory,neural and endocrine body functions

Alteration in vital signs may signal the needfor further intervention


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TEMPERATURE

Oral Via Mouth, rarely used

Axilla Per Axilla (underarm)

Used infrequently

Tympanic Most common

Temple Recent introduction


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Oral

Oral:

No longer used in Residential Care,may still be used in homesetting

3 minutes

Under tongue, lips closed

No hot or cold drinks beforehand


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Per Axilla

ArmpitPreviously most common in aged care

Used now if tympanic/temple notavailable

3 minutes

Skin surfaces to touch bulb Record as p/a


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THE PULSE

The bounding of blood flow we can feel atvarious points around our body

Indicator of effective circulation For our cells to function normally we need

continuous blood flow and volume

Blood flows around the body in a continuouscircuit, pumped by the heart


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Cardiac output= volume of blood pumpedby the heart in one minute

Changes in heart rate alter how well theheart pumps - leads to changes in BP

As heart rate increases less time for heartto fill -less volume reduces BP

As heart rate decreases filling timeincreases - normalises BP


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Assessing the Pulse

Any artery can be used to assess pulserate

Radial and carotid easiest Carotid best in emergency situation - heart

will pump blood to brain for as long aspossible

When cardiac output drastically reducesperipheral pulses difficult to feel


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Carotid pulse


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Personal Care Workers

Use only the radial pulse point
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Pulse points in the bodyRadial and apical locations most commonly used


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Equipment needed:

Watch with second hand

Pen

Documentation as per organisation

protocol


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Factors which might affect

pulse rate Age

Exercise Position changes

Medications

Temperature

Emotional distress/anxiety/fear


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The steps for taking a radial

pulse Collect equipment Explain to client

Wash hands Provide privacy if required Place clients forearm alongside or

across lower chest or abdomen (lying) Bend clients forearm at 90 deg angle

and support lower arm on chair Make sure palm is facing downward


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Steps for taking a radial

pulse Place the tips of your first two fingers

over the groove along the thumb side

(radial side) of the clients wrist Do not use your thumb!!!!

Lightly compress against the radius to feela pumping sensation

Determine the strength of the pulse -

Is it strong, thready, bounding or weak ?


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Work out the rate

After pulse can be felt regularly, lookat watchs second hand and begin to

count rate If pulse is regular count for 30

seconds and multiply by 2 (x2)

If pulse is irregular, countrate for 60 seconds


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Things to consider

Rate

Rhythm - regular, regularly irregular,

irregularly irregular Strength


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Factors influencing pulse

rates Exercise

Temperature - fever and heat

Drugs

Loss of blood (haemorrhage)

Postural changes - sitting or standing Lung conditions - poor oxygenation


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Normal ranges

INFANT - 120-160 bpm

TODDLER - 90-140 bpm

SCHOOLAGE - 75-100 bpm

ADOLESCENT - 60-90 bpm

ADULT - 60-100 bpm


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Respiration Our survival depends on the ability of

O2and CO2to be removed from thecells

Respiration exchanges gases betweenthe atmosphere and the blood andcells

Ventilation= the movement of gasesin and out of the lungs

Regulated by the respiratory

centre in our brain


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Normal breathing Chest wall gently rises and falls Abdominal cavity rises and falls due

to diaphragmatic movement

No use of accessory muscles-intercostal, muscles in neck andshoulders

Accurate measurement necessary asbreathing tied to numerous bodysystems

Look at rate and depth


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Normal rates

Newborn - 30-60

Infant - 30-50

Toddler - 25-35

Child - 20-30

Adolescent - 16-20 Adult - 12-20


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How to assess respiration Equipment: watch, Obs chart, pen

Explain to client ????

Make sure chest is visible-place client arm

over abdomen/ or your arm Observe complete cycle (insp and exp)

Begin to count rate

If regularcount for 30 seconds andmultiply by 2 (x2)

If irregular, less than 12 or more than 20count for full minute


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Note depth of respirations, skin colorand effort

Replace linen Wash hands

Record on obs chart

Report abnormal findings


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Other terms you might hear Bradypnea - slow breathing Tachypnea - fast breathing

Apnoea - no breathing for severalseconds

Hyperventilation - fast rate anddepth

Hypoventilation - slow rate and depth

Cheyne-stokes respiration- irregular-apnoea - hyperventilation - shallower- a noea


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Blood pressure

The force applied to the inside of ourartery by the blood pulsing from our

heart


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Blood pressure

Can be affected by:

Effectiveness of heart pumping

Resistance in extremities

Blood volume

Thickness of the blood Elasticity of arteries and bloodvessels


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Systolic vs Diastolic BP

Systolic pressure= peak maximumpressure when heart contraction

forces blood into aorta (major bloodvessel to body)

Diastolic pressure= the amount of

blood left in the ventricles of theheart when they relax betweencontractions


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Factors influencing BP

Age

Stress

Race

Medications

Time of day

Gender


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Common conditions of BP

Hypertension high BP

Hypotension low BP

Postural hypotension droppingof BP when rising to an

upright position


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Normal values

Category Systolic Diastolic

Optimal < 120 mm hg 90

110 mmhg

Severe

Hypertension

> 180 mm hg > 110 mm hg


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Equipment needed

Sphygmomanometer and cuff

Stethoscope

Obs chart and pen


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Getting started

Gather equipment

Explain to client - rest 5 min if

anxious Select appropriate cuff size - S - XL

Client can lie or sit or stand

Wash hands

Expose extremity by removingconstricting clothes


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Palpate the brachial pulse (arm)

Place cuff about 2.5 cm above pulse

site Making sure cuff is fully

deflated wrap evenly and

snugly around extremity

(use arrow to centre on cuff)


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Position the manometer < 1m away

from you so you can see it Place stethoscope pieces in ears and

ensure sounds are clear and not

muffled ? Estimate systolic pressure (30

mmHg >)

Relocate pulse and place bell of thestethoscope over it (dont cover itwith clothing/cuff


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Steps cont.

Close valve of pressure bulb clockwiseuntil tight

Rapidly inflate cuff to 30 mmHg thanpalpated/previous BP

SLOWLY release bulb pressure valve

allow mercury to fall at a rate of 2-3mmHg per second


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Listen carefully...

Listen for the first thumping soundand note the measurement on the

manometer (systolic reading) Sound increases in intensity

Continue to deflate cuff and sound

will become muffled/dampened andnote the measurement again (diastolicreading)


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Continue to deflate cuff gradually -listen for 10-20 mmHg after the lastsound - let the rest of the air escapequickly

Remove cuff

Assist client to comfortable position,wash hands

Document reading on obs chart

Notify of abnormalities


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What if the BP is abnormal ?

Repeat the process

Check on other arm Ask client how they feel

Compare old readings Get someone else to check reading


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