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vital signs procedure 10 11 22.pptx

The document outlines the importance of vital signs—body temperature, pulse, respiration, and blood pressure—as key indicators of a client's health status. It details methods for measuring these signs, the normal ranges, and necessary nursing interventions in various scenarios, including fever management. Additionally, it provides guidelines for preparing patients and recording vital signs accurately.

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VITAL SIGNS MONITORING Dr. Anjalatchi Muthukumaran Vice principal Era College of Nursing
Definition These are indices of health, or signposts in determining client’s condition. This is also known as cardinal signs and it includes body temperature, pulse, respirations, and blood pressure. These signs have to be looked at in total, to monitor the functions of the bod
Different considerations in taking Vital signs The frequency of taking TPR and BP depends upon the condition of the client and the policy of the institution. The procedure should be explained to the client before taking his TPR and BP. Obtain baseline data.
body temperature?  The normal body temperature of a person varies depending on gender, recent activity, food and fluid consumption, time of day, and, in women, the stage of the menstrual cycle.  Normal body temperature can range from 97.8 degrees F (or Fahrenheit, equivalent to 36.5 degrees C, or Celsius) to 99 degrees F (37.2 degrees C) for a healthy adult. A person's body temperature can be taken in any of the following ways:
 Orally. Temperature can be taken by mouth using either the classic glass thermometer, or the more modern digital thermometers that use an electronic probe to measure body temperature.  Rectally. Temperatures taken rectally (using a glass or digital thermometer) tend to be 0.5 to 0.7 degrees F higher than when taken by mouth.  Axillary. Temperatures can be taken under the arm using a glass or digital thermometer. Temperatures taken by this route tend to be 0.3 to 0.4 degrees F lower than those temperatures taken by mouth.  By ear. A special thermometer can quickly measure the temperature of the ear drum, which reflects the body's core temperature (the temperature of the internal organs).  By skin. A special thermometer can quickly measure the temperature of the skin on the forehead.
Vital Signs or Cardinal Signs are:  Body temperature  Pulse  Respiration  Blood pressure  Pain
Body Temperature The balance between the heat produced by the body and the heat loss from the body. Types of Body Temperature Core temperature –temperature of the deep tissues of the body. Surface body temperature
Normal Adult Temperature Ranges Oral 36.5 –37.5 ºC Axillary 35.8 – 37.0 ºC Rectal 37.0 – 38.1 ºC Tympanic 36.8 – 37.9ºC
Methods of Temperature-Taking  I. Oral – most accessible and convenient method.  Put on gloves, and position the tip of the thermometer under the patients tongue on either of the frenulun as far back as possible. It promotes contact to the superficial blood vessels and ensures a more accurate reading.  Wash thermometer before use.  Take oral temp 2-3 minutes.  Allow 15 min to elapse between client’s food intakes of hot or cold food, smoking.  Instruct the patient to close his lips but not to bite down with his teeth to avoid breaking the thermometer in his mouth.
Nursing Interventions in Clients with Fever  Monitor V.S  Assess skin color and temperature  Monitor WBC, Hct and other pertinent lab records  Provide adequate foods and fluids.  Promote rest  Monitor I & O  Provide TSB  Provide dry clothing and linens  Give antipyretic as ordered by MD
Pulse  This is a wave of blood created by contraction of the left ventricle of the heart. The heart is a pulsating pump, and the blood enters the arteries with each heartbeat, causing pressure pulses or pulse waves. Generally, the pulse wave represents the stroke volume and the compliance of the arteries.  Stroke volume is the amount of blood that enters the arteries with each contraction in a healthy adult.  Compliance of the arteries is their ability to contract and expand. When a person’s arteries lose their distensibility, greater pressure is required to pump the blood into the arteries.  Peripheral pulse is the pulse located in the periphery of the body, for example in the foot, hand and neck. Apical pulse is a central pulse. It is located at the apex of the heart.
How to check your pulse  As the heart forces blood through the arteries, you feel the beats by firmly pressing on the arteries, which are located close to the surface of the skin at certain points of the body. The pulse can be found on the side of the neck, on the inside of the elbow, or at the wrist. For most people, it is easiest to take the pulse at the wrist. If you use the lower neck, be sure not to press too hard, and never press on the pulses on both sides of the lower neck at the same time to prevent blocking blood flow to the brain. When taking your pulse:  Using the first and second fingertips, press firmly but gently on the arteries until you feel a pulse.  Begin counting the pulse when the clock's second hand is on the 12.  Count your pulse for 60 seconds (or for 15 seconds and then multiply by four to calculate beats per minute).  When counting, do not watch the clock continuously, but concentrate on the beats of the pulse.
Normal Pulse rate 1 year 80-140 beats/min 2 years 80- 130 beats/min 6 years 75- 120 beats/min 10 years 60-90 beats/min Adult 60-100 beats/min
Respiration Is the exchange of oxygen and carbon dioxide between the atmosphere and the body The respiration rate is the number of breaths a person takes per minute. The rate is usually measured when a person is at rest and simply involves counting the number of breaths for one minute by counting how many times the chest rises. Respiration rates may increase with fever, illness, and other medical conditions. When checking respiration, it is important to also note whether a person has any difficulty breathing.
Assessing Respiration  Rate – Normal 14-20/ min in adult  The best time to assess respiration is immediately after taking client’s pulse  Count respiration for 60 second  As you count the respiration, assess and record breath sound as stridor, wheezing, or stertor.  Respiratory rates of less than 10 or more than 40 are usually considered abnormal and should be reported immediately to the physician.  Resting respirations should be assessed when the client is at rest because exercise affects respirations, and increase their rate and depth as well. Respiration may also need to be assessed after exercise to identify the client’s tolerance to activity. Before assessing a client’s respirations, a nurse should be aware of:  The client’s normal breathing pattern.  The influence of the client’s health problems on respirations.  Any medications or therapies that might affect respirations.  The relationship of the client’s respirations to cardiovascular function.
Blood Pressure  This is the force exerted by the blood against a vessel wall. Arterial blood pressure is a measure of the pressure exerted by the blood as it flows through the arties. There are two blood pressure measures:  Systolic pressure. This is the pressure of the blood because of contraction of the ventricles, which is the height of the blood wave.  Diastolic pressure. This is the pressure when the ventricles are at rest. It is the lower pressure present at all times within the arteries.
NORMAL BLOOD PRESSURE  Adult – 90- 132 systolic 60- 85 diastolic Elderly– 140-160 systolic 70-90 diastolic Blood pressure is the force of the blood pushing against the artery walls during contraction and relaxation of the heart. Each time the heart beats, it pumps blood into the arteries, resulting in the highest blood pressure as the heart contracts. When the heart relaxes, the blood pressure falls.
 High blood pressure, or hypertension, directly increases the risk of heart attack, heart failure, and stroke. With high blood pressure, the arteries may have an increased resistance against the flow of blood, causing the heart to pump harder to circulate the blood.  Blood pressure is categorized as normal, elevated, or stage 1 or stage 2 high blood pressure:  Normal blood pressure is systolic of less than 120 and diastolic of less than 80 (120/80)  Elevated blood pressure is systolic of 120 to 129 and diastolic less than 80  Stage 1 high blood pressure is systolic is 130 to 139 or diastolic between 80 to 89  Stage 2 high blood pressure is when systolic is 140 or higher or the diastolic is 90 or higher
VITAL SIGNS TRAY  A tray containing
Necessary Equipment for Taking Vital Signs vital sign trays  Typically, the supplies for taking vital signs include the following items:  Thermometers-to check the temperature  Stethoscopes-to listen body sounds  Blood Pressure Devices-to check the blood pressure  Combo Kits (Stethoscope + Blood Pressure)-  Pulse Oximetry-to check the pulse rate and saturation  Electrocardiogram (ECG)-to check the ECG rythem  Penlights-to visualize the physical parts while examine  Spirit /chlorohexidine gluconate- to disinfect the devices  Cotton pack/bowl- to keep the dry cotton  Kidney tray –to discard the wet waste  Paper bags- to collect dry waste  Watch – to monitor the vital sign
Preparation of the patients  Explain procedure to the patients  get inform consents  Tell the clients not to drink hot or cold , eat smoke, chew the petal leaves 15 min prior to the procedure  Provide privacy  Place the client comfortable position  Ensure proper ventilation  Stand at patients right side  Arrange the article ready
PROCEDURE  Taking Vital Signs Steps  Here are the general guidelines you should follow:  Pulse  Wash your hands thoroughly.  Ensure that your patient is relaxed before you begin.  Use the radial artery to find their pulse. You can find it on the inside of their wrist (closest to their thumb).  Place your first and second fingertips—not your thumb—in a firm yet gentle manner on the patient’s wrist.  Look at a clock or watch and wait for the second hand to hit the 12.  Start counting the beats of their pulse.  Count the patient’s pulse for 60 seconds or until the second-hand returns to the 12.  While counting, remember not to watch the clock constantly but instead concentrate on your patient’s pulse beats.
 Respiration Rate  Wash your hands thoroughly.  Put your fingers on the patient’s wrist (either side is fine).  Count their breaths for one minute. Keep in mind that an inhale plus an exhale equals one respiration.  Document their respiration rate. Include any relevant observations, such as wheezing, agitation, etc.  Temperature / Digital Thermometer  Wash your hands thoroughly.  Encase the thermometer mouth tip with a sanitary plastic shield.  Press the button to turn on the thermometer.  Put the thermometer under your patient’s tongue and ask them to keep their mouth closed.  Remove the thermometer after it beeps to signal completion.  Record their temperature, including necessary information like the date, time, and method used.  Always clean and sterilize the thermometer.
 Blood Pressure / Stethoscope, Cuff, or Aneroid Monitor  Wash your hands thoroughly.  Disinfect the stethoscope.  Ensure that the blood pressure monitor is working correctly.  Place your fingers on the underside of the patient’s elbow to locate their pulse (referred to as the brachial pulse).  Wrap the deflated cuff snugly around the patient’s upper arm. This should be at least one inch above where you detected the brachial pulse.  Place the stethoscope earpieces in your ears and put the diaphragm (disk) over the brachial pulse.  Twist the knob on the air pump clockwise to close the valve.  Pump air and inflate the cuff until the dial pointer hits 170.  Turn the knob on the air pump counterclockwise so that you can open the valve to deflate the cuff.  When the dial pointer falls, closely observe the number and listen for a thumping sound.  Record the number displayed as the first thump is heard (systolic pressure).  Record the number displayed as the last thump is heard (diastolic pressure).  Deflate and remove the cuff from the patient.  Document these results and include any unusual observations.
AFTER CARE
RECORDIONG/ REPORTING  Record the vital sign observed from the patient  Temp-98.6F  Pulse rate -78 beats/mt  Respiration rate-24 breath /mt  Blood pressure – 130/80 mmofHg  Saturation -98%  With date--------------------time------------------sign---------------
THANKYOU