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Vital signs
 

Vital signs

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    Vital signs Vital signs Presentation Transcript

    • Unit 14 Vital Signs Janet. J. Nelson RN, CMA
    • 14:1 Measuring and Recording Vital Signs (VS) 2Main vital signs (VS) oRespiration  Temperature  Rate  Oral  Rhythm  Rectal  Character  Axillary  Temporal oBlood pressure  Tympanic  Systolic  Pulse  diastolic  Rate  Rhythm  Volume
    • Other Assessments 3Pain – patients asked to rate on scale of 1 to 10 (1 is minimal and 10 is severe)Pulse oximetryColor of skinSize of pupils and reaction to lightLevel of consciousnessResponse to stimuli
    • VS Readings 4Accuracy is essentialReport abnormality or change immediatelyIf unable to get reading, ask another person to check.
    • 14:2 Measuring and Recording Temperature 5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 fluid balanceConversion between Fahrenheit and Celsius  Where do you find the formulas???
    • Variations in Body Temperature 6Normal rangeWhat can causes of variations? Increase/decreaseTemperature 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)
    • ABNORMAL CONDITIONS 8 Hypothermia Fever  Intermittent  Remittent  Relapsing  Constant Hyperthermia
    • Thermometers 9Clinical thermometers  Glass  Electronic  Tympanic  Temporal Scan  Plastic or paperReading 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) 10Avoid factors that could alter or change temperatureWait 15 minutes for oral temp
    • THINGS TO REMEMBER WITH TEMPS 11 ORAL- Check eating, drinking, smoking. It is understood the temp is oral unless otherwise indicated. RECTAL-Insert electronic thermometer ½-3/4 inch for peds and 1 inch for adult. Pt to lie on left side (Sims) Never with bradycardia. Record with a R.  What are some contraindications for rectal temp? AXILLARY-Dry axillary area. Record with AX  When would you use axillary temp?Copyrigt © 2004 by Thomson Delmar Learning.ALL RIGHTS RESERVED.
    • TYMPANIC (Aural) TEMPERATURES 12 Ear canal is not straight. You need to straighten the ear canal in an adult by pulling up & back on the ear.Copyriht © 2004 by Thomson Delmar Learning.ALL RIGHTS RESERVED.
    • Infant Tympanic Temps. 13An infants ear needs to be pulled straight backREMEMBER that earwax (cerumen) can obstruct the infrared rays coming from the tympanic membraneHearing aides need to be removed and wait 20 min.If bathing or swimming wait 20 minCopyright © 2004 by Thomson Delmar Learning.ALL RIGHTS RESERVED.
    • TEMPORAL ARTERY TEMPERATURES 14  High-resolution infrared image of a person’s temporal artery being scanned with the TAT-5000 Temporal Artery Thermometer. The measurement is obtained by swiping the thermometer probe across the forehead and behind the ear.Copyright © 2004 by Thomson Delmar Learning.ALL RIGHTS RESERVED.
    • 14:3 Measuring and Recording Pulse 15Pressure of the blood pushing against the wall of an artery as the heart beats and rests.Major arterial or pulse sitesPulse rate  Adults 60-90  Child (>7yr) 72-90  Child 1-7yr 80-120  Infant 90-140
    • Measuring and Recording Pulse (continued) 16Pulse volume…What does this mean?  Bounding  ThreadyFactors that change pulse rate…Like what?Basic principles for taking radial pulseRecording information: Date, time (military), P rate, any abnormalities, your first initial, last name & title.PulseTachycardia  Bradycardia
    • 14:4 Measuring and Recording Respirations 17Measures the inspiration and expiration= one breathNormal respiratory rate. What cause this to vary?  Adults 14-18 (20)Rhythm : o Dyspnea  Apnea  Cheynes Stokes Tachypnea  BradypneaCopyright © 2004 by Thomson Delmar Learning.ALL RIGHTS RESERVED.
    • Measuring and Recording Respirations (continued) 18Character of respirations  Rales  Hyperventilation  Hypoventilation  Orthopnea  WheezingRESPIRATIONS 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.
    • 14:5 Graphing TPR 19Graphic sheets are special records used for recording TPRPresents a visual diagramUsesColor codesFactors affecting VS are often noted on the graphCopyright © 2004 by Thomson Delmar Learning.ALL RIGHTS RESERVED.
    • Graphing TPR (continued) 20Graphic charts are legal recordsTo correct an errorBasic principles for completing
    • 14:6 Measuring and Recording Apical Pulse 24Pulse count taken at the apex of the heartReasons for taking an apical pulseProtect the patient’s privacy and avoid exposureHeart soundsAbnormal sounds or beats
    • Measuring and Recording Apical Pulse (continued) 25Pulse deficitUse the stethoscopePlacement of stethoscopeMeasuring apical pulseRecord all information
    • 14:7 Measuring and Recording Blood Pressure 26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 an instrument called a sphygmomanometerMeasurements read at two points http://www.pennmedicine.org/encyclopedia/em_DisplayAnimation.aspx?g
    • Measuring and Recording Blood Pressure (continued) 27Systolic pressureDiastolic pressurePulse pressureHypertension – high blood pressureHypotension – low blood pressureFactors influencing blood pressure readings
    • NEW RECOMMENDATIONS FROM AHASYSTOLIC LESS THAN 120DIASTOLIC LESS THAN 80
    • Measuring and Recording Blood Pressure (continued) 29Individual factors can all influence blood pressure readingsBlood pressure is recorded as fractionsTypes of sphygmomanometers  Mercury  Aneroid  Electronic
    • Manometers
    • Measuring and Recording Blood Pressure (continued) 31Factors 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/HgRecord 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 BPID patient and explain procedureObtain palpatory systolic pressureWait 30+ secInflate 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.