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Chapter 15

Chapter 15. Vital Signs. Measuring and Recording Vital Signs(VS). Record information about the basic body conditions Defined as various determinations that provide information about the basic body conditions of the patient Main vital signs (VS) Temperature Pulse Respiration Blood pressure.

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Chapter 15

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  1. Chapter 15 Vital Signs

  2. Measuring and Recording Vital Signs(VS) • Record information about the basic body conditions • Defined as various determinations that provide information about the basic body conditions of the patient • Main vital signs (VS) • Temperature • Pulse • Respiration • Blood pressure

  3. 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

  4. VS Readings • Accuracy is essential • Often is the first indication of a disease or abnormality in the patient • Report abnormality or change to the provider • If unable to get reading, ask another person to check

  5. Temperature (T) measure of body heat; balance between heat produced & heat lost.

  6. Measuring and Recording Temperature • Heat produced by metabolism of food and by muscle and gland activity • Homeostasis: constant state of balance in the body • The hypothalamus regulates body temperature • Conversion between Fahrenheit and Celsius temperature

  7. Shell & Core Temperature • Shell temperature - warmth at skin surface • Core temperature - inner body temp; higher than shell temp

  8. Variations in Body Temperature • Normal range (°F) • Oral - 986 • Rectal - 996 • Axillary - 976 • Tympanic - 996

  9. Variations in Body Temperature • Temperature measurements— • By mouth (oral) - leave in place 3-5 minutes • By rectum (rectal) - often used on infants/children – leave in place 3-5 minutes • By armpit (axillary) or groin – leave in place 10 minutes • By tympanic membrane in ear (aural) – usually reads in less than 2 seconds • By temporal artery in forehead (temporal) – usually instantaneous reading

  10. Abnormal conditions affecting temperature • Causes of increased temperatures • Illness • Infection • Exercise • Excitement • High temperatures in the environment • Cause of decreased temperatures • Starvation or fasting • Sleep • Decreased muscle activity • Mouth breathing • Exposure to cold temperatures in the environment • Certain diseases

  11. Definitions • Hypothermia • Low body temperatures below 95°F (35°C) measured rectally • Death usually occurs if body temperature drops below 93°F for a period of time • Fever • Elevated body temperature, usually above 101°F (38.3°C) measured rectally • Usually caused by infection or injury • Pyrexia is another name for fever • Febrile means a fever is present • Afebrile means no fever is present • Hyperthermia • Occurs when the body temperature exceeds above 104°F measured rectally • Actions must be taken to lower temp immediately – above 106°F can quickly lead to convulsions, brain damage, and death

  12. Thermometers • Clinical thermometers • Glass • Electronic • Tympanic • Temporal • Plastic or paper • Avoid factors that could alter or change temperature – drinking hot or cold liquids if taken orally • Clean thermometers thoroughly after use • Paper/plastic sheath is used on glass thermometers

  13. Thermometers • Reading thermometers and recording results • Many new models have digital readouts • Many older models have to be read by where the line of mercury or alcohol ends – to the nearest 2/10ths of a degree. • Record temperature of 100.2 as 1002 • If not taken orally, must record how temperature was taken • (R) for rectal • (Ax) for axillary • (A) for aural • (T) for temporal ????

  14. Reading a glass thermometer

  15. Tympanic Thermometer probe cover tympanic membrane external auditory meatus measures heat from tympanic membrane

  16. Temporal thermometer Infrared readings of temporal artery

  17. 15:3 Measuring and Recording Pulse • Pressure of the blood pushing against the wall of an artery as the heart beats and rests • Pulse rate – refers to the number of beats per minute • Normal adult range is 60-100 beats per minute • Men 60-70 • Women 65 – 80 • Children over 7 yr of age: 70-100 beats per minute • Children between 1-7 yrs: 80-110 beats per minute • Infants: 100-160 beats per minute • Pulse rhythm – refers to regularity, or spacing of the beats • Arrhythmia is an irregular rhythm • Pulse volume – refers to strength or intensity of the pulse • Described as strong, weak, thready, or bounding

  18. Measuring and Recording Pulse (cont.) • Pulse is more easily felt in arteries that lie close to the skin and can be pressed against a bone by the fingers. • Arterial or pulse sites • Temporal – on either side of the forehead • Carotid – at the neck on wither side of the trachea • Brachial – at the inner aspect of the wrist, above the thumb • Femoral – at the inner aspect of the upper thigh where the thigh joins with the truck of the body • Popliteal – behind the knee • Dorsalispedis– at the top of the foot arch

  19. Measuring and Recording Pulse • Factors that change pulse rate • Increased – caused by exercise, stimulant drugs, excitement, fever, shock, nervous tension, and other similar factors • Decreased – caused by sleep, depressant drugs, heart disease, coma, physical training, or other similar factors • Basic principles for taking radial pulse • Use 2 or 3 fingers and place on the thumb side of the wrist (do not use your thumb since it has its own pulse • Once pulse is felt, exert slight pressure and count for 1 full minute • Recording information • Record date, time, pulse rate, strength and rhythm

  20. How to chart pulse rate: P = 76 regular, strong P = 112 weak, thready Patient: Todd Smith P =

  21. Measuring and Recording Respirations • Measures the breathing of a patient • Process of taking in oxygen (O2) and expelling carbon dioxide (CO2) from the lungs and respiratory tract • One respiration = one inspiration (breathing in) and one expiration (breathing out) • When respirations are measured, 3 different facts must be noted: • Rate, Character and Rhythm

  22. Measuring and Recording Respirations (cont.) • Respiratory rate – number of breaths per minute • Normal adult rate is 12-20 breaths per minute • Normal child rate is 16-30 breaths per minute • Normal infant rate is 30-50 breaths per minute • Character of respirations –”type” refers to the depth and quality of respirations • Words to describe – deep, shallow, labored, difficult, stertorous (abnormal sound like snoring), and moist • Rhythm of respirations – refers to regularity, or equal spacing between breaths. Described as regular, or irregular.

  23. Abnormal Respirations • Dypsnea – difficult or labored breathing • Apnea – absence of respirations, usually a period of no respirations • Tachypnea – rapid, shallow respiratory rate above 25 respirations per minute • Bradypnea – slow respiratory rate, usually below 10 respirations per minute • Orthopnea – severe dyspnea where breathing is difficult in any position other than sitting erect or standing

  24. Abnormal Respirations (cont) • Cheyne-Stokes – abnormal breathing pattern characterized by periods of dypsnea followed by periods of apnea; frequently noted in the dying patient • Rales – bubbling or noisy sounds caused by fluids or mucus in the air passages • Wheezing – difficult breathing with a high-pitched whistling or sighing sound during expiration; caused by a narrowing of the bronchioles (as seen in asthma) and/or an obstruction or mucus accumulation in the bronchi

  25. Abnormal Respirations (cont) • Cyanosis: a dusky, bluish discoloration of the skin, lips, and/or nail beds due to reduced oxygen and increased carbon dioxide in the bloodstream. • Respirations must be counted in a way that the patient is unaware of the procedure • Respirations are partially under voluntary control • Count by leaving your hand on a pulse site while counting respirations

  26. 15:5 Graphing TPR • Graphic sheets are special records used for recording TPR • Presents a visual diagram of variations over time of a patient’s vital signs • Color codes are often used - makes it easier to view temp, pulse, resp or BP (for example – use red for temp, blue for BP, green for respirations, etc)

  27. Graphing TPR • Factors affecting VS are often noted on the graph • Examples include surgery, medications that lower temperature, or antibiotics • Graphic charts are legal records • It must be neat, legible, and accurate • To correct an error • It should be crossed out carefully with red ink and initialed

  28. Measuring and Recording Apical Pulse • Pulse count taken at the apex of the heart with a stethoscope • Reasons for taking an apical pulse • Frequently ordered for patients with irregular heartbeats, hardening of the arteries (arteriosclerosis), or weak or rapid pulses. • Protect the patient’s privacy and avoid exposure • Heart sounds • Sounds resemble a “lubb-dupp” • Sounds caused by closing of the heart valves as blood flows through the chambers of the heart • Abnormal sounds or beats should be reported immediately to the provider

  29. Measuring and Recording Apical Pulse • Pulse deficit • Condition that occurs with some heart conditions • Heart is weak and does not pump enough blood to produce a pulse • Heart beats too fast (tachycardia), not allowing enough time for heart to fill with blood, therefor the heart does not produce a pulse • In these cases, the apical pulse is higher than the pulse rate • Check the apical pulse while having the pulse counted. • Pulse deficit = apical pulse rate – pulse rate

  30. Measuring and Recording Apical Pulse • Use the stethoscope • Tips of stethoscope should be bent forward when they are placed in the ears • Earpieces should fit snugly but should not cause pain or discomfort. • Clean earpieces and bell/diaphragm (chest piece) after every use • Placement of stethoscope • Locate apex of the heart at the fifth intercostal space by the midclavicular line (midline of the collarbone) • Place bell or diaphragm over the apical region and listen for heart sounds • Record all information

  31. Bell and Diaphragm tubing Ear piece Bell Diaphragm

  32. Place stethoscope diaphragm 2 to 3” to left of sternum, just below nipple. Rt. Lf.

  33. 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 a sphygmomanometer • Measurements read at two points • Systolic pressure – the pressure exerted when the left ventricle of the heart is contracting and pushing blood into the arteries • Diastolic pressure – the constant pressure exerted on the walls of the arteries when the left ventricle of the heart is at rest, or between contractions • Hypertension—high blood pressure • Hypotension—low blood pressure

  34. Measuring and Recording Blood Pressure • Pulse pressure • Difference between the systolic and diastolic pressure • Important indicatory of the health and tone of the arterial walls • Normal range for adults is 30 to 50 mm Hg • If systolic pressure is 120 and diastolic is 80, the pulse pressure is 120-80 = 40 mm Hg • This pressure should be approximately one third the systolic pressure reading • A high pressure can indicate an increase in blood volume or heart rate, or a decrease in the ability of the arteries to expand

  35. Measuring and Recording Blood Pressure • Factors influencing blood pressure readings (high or low) • Force of the heartbeat • Resistance of the arterial system • Elasticity of the arteries • Volume of blood in the arteries • Position of the patient (lying sown, sitting, or standing) • Factor that may increase BP • Excitement, anxiety, nervous tension, exercise, eating, pain, obesity, smoking, and/or stimulant drugs • Factors that may decrease BP • Rest or sleep, depressant drugs, shock, dehydration, hemorrhage (excessive loss of blood), and fasting (not eating)

  36. Measuring and Recording Blood Pressure • Types of sphygmomanometers • Mercury • Aneroid • Electronic • Obtaining accurate blood pressure measurements • Patient sits quietly for at least 5 minutes before BP is taken • The AHA recommends 2 separate reading be taken and averaged, with a minimum wait of 30 seconds between readings • The BP cuff must fit properly • Too wide or too narrow will give an inaccurate reading • Too small will give an artificially high reading, • Too large will give an artificially low reading • Width of cuff should be 40% or the circumference of the patient’s arm, the length of the cuff should be 80% the circumference of the arm.

  37. Sphygmomanometer (aneroid)

  38. Digital Manometer Wall Manometer (Aneroid)

  39. Place cuff just above crease of arm with bladder over brachial artery. Arrow on cuff will indicate where brachial artery should line up.

  40. Supinate arm & support at level of heart

  41. Measuring and Recording Blood Pressure • Record all required information • Do not discuss the reading with the patient; it’s the doctor’s responsibility

  42. 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

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