OA 11.1

1. OA 11.1 • Define: vital signs. What are they used for?

2. Chapter 15 Vital Signs

3. 15:1 Measuring and RecordingVital Signs (VS) • Record information about the basic body conditions • Abnormalities from homeostasis • Main vital signs (VS) • Temperature • Pulse • Respiration • Blood pressure

4. Other Assessments • Pain—patients asked to rate on scale of 1 to 10 (1 is minimal and 10 is severe)

5. Other Assessments • Color of skin • Pallor • Cyanosis • Jaundice • Erythema • Ecchymosis

6. Other Assessments • Size of pupils and reaction to light

7. Other Assessments • Level of consciousness

8. Other Assessments • Response to stimuli

9. VS Readings • Accuracy is essential • Must know how to accomplish task with various equipment • Never guess or report false readings • Report abnormality or change • Severe abnormalities indicate life-threatening conditions • If unable to get reading, ask another person to check

10. OA 11.4 • What information can be gathered from measuring vital signs?

11. 15:2 Measuring and Recording Temperature • Measures balance between heat lost and heat produced in the body • Thermal activity • Heat produced by metabolism of food and by muscle and gland activity • Heat lost through perspiration, respiration, and excretion

12. 15:2 Measuring and Recording Temperature • Conversion between Fahrenheit and Celsius temperature F  C: C = (F-32) x 0.5556 C  F: F = (C x 9/5) + 32 • Practice: • 102o F to C 212o F to C • 19o C to F 37o C to F

13. Variations in Body Temperature • Normal range • 97-100o F, 36.1-37.8o C • Causes of variations • Size/shape of individual, time of day, part of body, metabolic activity

14. Variations in Body Temperature • Temperature measurements — oral, rectal (often used on infants/children), axillaryor groin, aural, and temporal • Normal: • Oral: 98.6o F Axillary: 97.6o F • Rectal: 99.6o F Aural/Temporal: no normal range

15. Variations in Body Temperature Abnormal conditions affecting temperature Increase: • Illness and infection • Exercise, excitement, fear • High environmental temperatures Decrease: • Starvation or fasting • Sleep • Sedation • Mouth breathing • Cold environmental temperatures

16. Variations in Body Temperature • Abnormal conditions • Hypothermia: body temperature < 95o F • Fever: elevated above 101o F • Pyrexia, Febrile, Afebrile • Hyperthermia: body temperature > 104o F

17. Thermometers • Clinical thermometers • Glass: contains mercury, analog • Electronic: digital reading, quicker results • Tympanic: use infrared energy • Temporal: measures temporal artery • Plastic or paper: disposable • Reading thermometers and recording results • Read in 1o increments, labeled by site • R, Ax, Gr, A (continues)

19. Thermometers(continued) • Avoid factors that could alter or change temperature • Examples??? • Cleaning thermometers • Clean with alcohol wipe or soap/water • Paper/plastic sheath on glass thermometer • Used to prevent transmission of disease • Dispose of properly

20. OA 11.5 • List 3 factors that would affect your body temperature right now.

21. 15:3 Measuring and Recording Pulse • Pressure of the blood pushing against the wall of an artery as the heart beats and rests (continues)

22. 15:3 Measuring and Recording Pulse • Major arterial or pulse sites • Temporal • Carotid • Brachial • Radial • Femoral • Popliteal • Dorsal Pedal (continues)

23. 15:3 Measuring and Recording Pulse • Must note 3 different factors of the pulse: • Pulse rate • Pulse rhythm • Pulse volume (continues)

24. 15:3 Measuring and Recording Pulse • Pulse rate – adult 60-80 bpm, varies • Bradycardia: slow pulse rate, < 60 bpm • Tachycardia: fast pulse rate, >100 bpm • Pulse rhythm – spacing between beats • Regular vs. irregular • Arrythmia: abnormal heart rhythm • Pulse volume – strength/intensity of the pulse • Strong vs. weak, thready, bounding (continues)

25. Measuring and Recording Pulse Factors that change pulse rate Increased: • Exercise • Stimulant drugs • Excitement • Fear • Fever • Shock • Nervous tension Decreased: • Sleep • Depressant drugs • Heart disease • Coma • Physical training

26. Measuring and Recording Pulse (continued) Basic principles for taking radial pulse: • Patient positioned comfortably, palm down • Use tip of index/middle fingers to locate pulse on thumb side of wrist • First beat counted starts with zero • 10 sec x 6 • 15 sec x 4 • 30 sec x 2 • 60 sec

27. Measuring and Recording Pulse (continued) • Recording information: • Include rate, rhythm, volume

28. 15:4 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 (continues)

29. 15:4 Measuring and Recording Respirations • One respiration: one inspiration (breathing in) and one expiration (breathing out) (continues)

30. Measuring and Recording Respirations (continued) • Normal respiratory rate • Adults: 12-20 breaths per minute • Children: 16-25 per minute • Infants: 30-50 per minute

31. Measuring and Recording Respirations (continued) • Character of respirations – refers to depth and quality • Deep vs. shallow, labored, moist, difficult, noisy • Rhythm of respirations – refers to spacing between breaths • Regular (or even) vs. irregular

32. Measuring and Recording Respirations (continued) • Abnormal respirations • Dyspnea: difficulty breathing • Apnea: absence of respirations • Tachypnea: rapid, shallow > 25/min • Bradypnea: slow <10/min

33. Measuring and Recording Respirations (continued) • Abnormal respirations • Orthopnea: severe dyspnea in any position besides sitting or standing • Cheyne-Stokes: abnormal breathing pattern, periods of dyspnea and apnea • Rales: bubbling or noisy sounds caused by fluid

34. Measuring and Recording Respirations (continued) • Voluntary control of respirations • Respiration can be controlled if consciously thought about • Important to keep the patient unaware breathing is being assessed • Do not tell the patient you are counting respirations

35. Measuring and Recording Respirations (continued) • Record information • Rate, character, rhythm • Ex: A child with R 22, shallow, labored, and regular would suffer from? • Ex: An adult with R 8, deep, regular would suffer from?

36. 15:5 Graphing TPR • Graphic sheets are special records used for recording TPR • Presents a visual diagram (easier to follow) • Uses – hospitals or long care facilities (continues)

37. 15:5 Graphing TPR • Color codes • Temperature in blue • Pulse in red • Respirations in green • Factors affecting VS are often noted on the graph • Surgeries, medications, day & time, etc. (continues)

38. Graphing TPR(continued) • Graphic charts are legal records • Must be legible and neat • Completed in ink • Use straightedge to connect lines • HIPAA act! • To correct an error: cross out in redink and correct, initial next to correction

39. Graphing TPR(continued) • Basic principles for completing: • Fill in patient information accurately • Fill in dates, times (mm/dd/yyyy, __:__am/pm) • Adm = admission (first measurement) • Following days are numbered • PO/PP = after surgery • PP = post partum (after delivery)

41. OA 11.12 • What is blood pressure?

42. 15:7 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 (mmHg) on a sphygmomanometer (continues)

43. Measuring and Recording Blood Pressure(continued) • Systolic pressure: pressure when left ventricle contracts • Normal is <120 mmHg (range of 100-120 mmHg) • First sound heard during reading of sphygmomanometer

44. Measuring and Recording Blood Pressure(continued) • Diastolic pressure: constant pressure when left ventricle relaxes • Normal is < 80 mmHg (range of 60-80 mmHg) • Last sound heard during reading of sphygmomanometer

45. Measuring and Recording Blood Pressure(continued) • Blood pressure is read as a fraction • Systolic pressure / Diastolic pressure • Ex: (120/80 mmHg)

46. Measuring and Recording Blood Pressure(continued) • Pulse pressure: difference between systolic & diastolic pressure • Important indicator of health and tone of arterial walls • Normal range is 30-50 mmHg

47. Measuring and Recording Blood Pressure(continued) • Hypertension—high blood pressure • Prehypertension (120-139 mmHg / 80-89 mmHg) • Systolic >140 mmHg / Diastolic >90 mmHg • Hypotension—low blood pressure • Systolic <90 mmHg / Diastolic <60 mmHg (continues)

48. Measuring and Recording Blood Pressure(continued) • Factors influencing blood pressure readings (high or low) • Force of heartbeat • Resistance of arterial system • Elasticity of the arteries • Volume of blood in arteries • Position of the patient(standing vs sitting vs lying down) (continues)

49. Measuring and Recording Blood Pressure(continued) Increased BP Decrease BP Rest or sleep Depressant drugs Shock Dehydration Hemorrhage fasting • Excitement, anxiety, nervous tension • Pain • Obesity • Stimulant drugs • Exercise and eating • Smoking

50. Measuring and RecordingBlood Pressure(continued) • Types of sphygmomanometers • Mercury: uses a column of mercury in a tube to measure the pressure (discouraged by OSHA) • Aneroid: uses a round gauge to measure pressure • Each line on gauge = 2 mmHg • Measure at eye level, deflated cuff should read zero • Electronic: measures pressure automatically • Shows reading on a digital display (continues)