Other Assessments 3Pain – patients asked to rate on scale of 1 to 10 (1 is minimal and 10 is severe)Pulse oximetryColor of skinSize of pupils and reaction to lightLevel of consciousnessResponse to stimuli
VS Readings 4Accuracy is essentialReport abnormality or change immediatelyIf unable to get reading, ask another person to check.
14:2 Measuring and Recording Temperature 5Measures balance between heat lost and heat produced in the bodyHeat produced by metabolism of food and by muscle and gland activityHomeostasis: constant state of fluid balanceConversion between Fahrenheit and Celsius Where do you find the formulas???
Variations in Body Temperature 6Normal rangeWhat can causes of variations? Increase/decreaseTemperature measurements – oral, rectal, axillary or groin, tympanic and temporal
NORMAL TEMPERATURES 7 ORAL 98.6 degrees =/- 1 degree RECTAL 99.6 =/- 1 degree AXILLARY 97.6 =/- 1 degree TYMPANIC core temperature but thermometer can be set to read as oral, rectal TEMPORAL SCAN core temp (same as rectal)
Thermometers 9Clinical thermometers Glass Electronic Tympanic Temporal Scan Plastic or paperReading thermometers and recording results Date Time in military time (no colons) T & Temperature. Fly the fraction Indicate if it is R, Ax, T, or TA
Thermometers (continued) 10Avoid factors that could alter or change temperatureWait 15 minutes for oral temp
14:3 Measuring and Recording Pulse 15Pressure of the blood pushing against the wall of an artery as the heart beats and rests.Major arterial or pulse sitesPulse rate Adults 60-90 Child (>7yr) 72-90 Child 1-7yr 80-120 Infant 90-140
Measuring and Recording Pulse (continued) 16Pulse volume…What does this mean? Bounding ThreadyFactors that change pulse rate…Like what?Basic principles for taking radial pulseRecording information: Date, time (military), P rate, any abnormalities, your first initial, last name & title.PulseTachycardia Bradycardia
Measuring and Recording Respirations (continued) 18Character of respirations Rales Hyperventilation Hypoventilation Orthopnea WheezingRESPIRATIONS ARE UNDER VOLUNTARY CONTROL….So what does that mean?Record information; date, time (military), R rate, any abnormalities, your first initial, last name and title.
Graphing TPR (continued) 20Graphic charts are legal recordsTo correct an errorBasic principles for completing
14:6 Measuring and Recording Apical Pulse 24Pulse count taken at the apex of the heartReasons for taking an apical pulseProtect the patient’s privacy and avoid exposureHeart soundsAbnormal sounds or beats
Measuring and Recording Apical Pulse (continued) 25Pulse deficitUse the stethoscopePlacement of stethoscopeMeasuring apical pulseRecord all information
14:7 Measuring and Recording Blood Pressure 26Measurement of the pressure the blood exerts on the walls of the arteries during the various stages of heart activityMeasured in millimeters of mercury on an instrument called a sphygmomanometerMeasurements read at two points http://www.pennmedicine.org/encyclopedia/em_DisplayAnimation.aspx?g
NEW RECOMMENDATIONS FROM AHASYSTOLIC LESS THAN 120DIASTOLIC LESS THAN 80
Measuring and Recording Blood Pressure (continued) 29Individual factors can all influence blood pressure readingsBlood pressure is recorded as fractionsTypes of sphygmomanometers Mercury Aneroid Electronic
Measuring and Recording Blood Pressure (continued) 31Factors to follow for accurate readings Pt sit quietly with arm at heart level Width of cuff about same diameter as arm Support forearm on surface Do NOT use thumb on stethoscope Place stethoscope medial antecubital space Cuff on bare skin Determine plapatory systolic pressure…wait 30-60sec and blow up to +30 mm/HgRecord all required information. Write BP in fraction.Do not reveal the reading to the patient
How many errors can you find in this picture?
Procedure for BPID patient and explain procedureObtain palpatory systolic pressureWait 30+ secInflate cuff 30 mm/Hg over palpatory systolic pressure.Listen and remember the first number you hear and last number you hear. In case of a child the diastolic is the where the sound changes.Finish with patient and record date, time, BP systolic/diastolic, name and title.