3.01 vital signs

transcript

Vital SignsVital Signs

From –Mr.Amarjeet S.JadounB.Sc. {nursing},2nd yrs.

Vital SignsVital Signs• Provide information about body function • Data is used to treat illness and

diagnose disease• Include:

– temperature– pulse– respiration– blood pressure

3.01 Understand Diagnostic and Therapeutic Services

Cont…

• Changes may be the first sign of disease or a change in

patient health status.

• Accuracy is imperative!

Vital SignsVital SignsTemperature

Measurement of the balance between heat lost and heat produced

Heat lost through:• Perspiration• Respiration• Excretion

Heat produced by:• Metabolism of food• Muscle and gland activity

Normal rangesNormal ranges

– 97º - 100º F – 36.1º - 37.8º C

Hypothermia

•Temperature below 95º F

•Death can occur if below 93º F

HypothermiaTemperature decreases with:

– environment– exposure to cold– inactivity– sleep– starvation

Symptoms:– shivering– cold skin– confusion

Hyperthermia

•Temperature 100-104º F

•Temperature above 104º F is

•life-threatening

•Prolonged hyperthermia may cause brain

injury.

•Sx – headache, confusion

HyperthermiaTemperature increases with:

– environment– exercise– illness, infection, injury– stress

Symptoms:– hot, dry, red skin– nausea/vomiting– headache– low blood pressure

ClinicalNon-mercury glass

ElectronicAural – good with children

Thermometers

Sites to measure temperature:•Aural – auditory canal

•Axillary – armpit

•Oral – mouth

•Rectal – rectum

To record temperature:

– Oral 98.6º (O) – under tongue by

jaw line

– Rectal 99.6º (R) – lay pt on side

– Axillary 97.6º (ax)

– Aural 98.6º (T)

Vital SignsVital SignsTemperature Measurement

Oral Oral •Ask the patient if they have ingested hot or cold food or drink, or smoked within the last ½ hour•If yes, wait at least 15 minutes before measuring the oral temperature

REPORT REPORT ABNORMAL RESULTS ABNORMAL RESULTS

OF ANY VITAL SIGN OF ANY VITAL SIGN IMMEDIATELY IMMEDIATELY to supervisorto supervisor

Combined VS (TPRBP) can indicate a life Combined VS (TPRBP) can indicate a life threatening condition or a change in threatening condition or a change in

conditioncondition

Vital SignsVital SignsTemperature Measurement

• AuralAural• Pros:

– Measures core body temperature– Fast and convenient

• Con:– Inaccurate if not placed correctly in the ear canal– Ear infection– Ear wax

Vital SignsVital SignsPulse

Pressure of blood on artery walls as the heart beats and Relaxes (contraction and relaxation)

• Sites: Temporal – side of the forehead Carotid – side of the neck Brachial – inner elbow Radial – above the thumb at radius Femoral – upper thigh Popliteal – behind the knee Dorsalis pedis – top of the arch of the foot

(good for checking lower limb circulation)

Normal rate adult (male) 60 – 70 beats per minuteadult (female) 65 – 80 beats per minutechildren (over 7) 70 – 100 beats per minutechildren (1 – 7) 80 – 110 beats per minuteinfants (less than 1 year) 100 – 160 beats per

minute Rhythm regular or irregularVolume strength of the pulse

• Pulse can be increased by:– exercise– stimulant drugs– excitement– fever– shock– nervousness

• Pulse can be decreased by:

– sleep

– depressant drugs

– heart disease

– coma

OF ANY VITAL SIGN OF ANY VITAL SIGN IMMEDIATELYIMMEDIATELY

Vital SignsVital SignsApical Apical Pulse

• Pulse count taken with the stethoscope.• Use if the patient has:

– Irregular heartbeat– Arteriosclerosis– Weak or rapid radial pulse– Infants and children

Vital SignsVital SignsRespiration

3.01 Understand Diagnostic and Therapeutic Services 23

Process of taking in oxygen and expelling carbon dioxide

1 inspiration + 1 expiration = respiration

Normal rate: adults – 12 – 20 breaths per minute children – 16 – 30 breaths per minute

Cont…• Evaluate for rhythm and

character• Rhythm – regular or irregular (i.e.

fast, slow)• Character – depth, ease of breaths• Check while appearing to count

Vital SignsVital SignsRespiration

• Abnormal respiratory patternsApnea – periods of absent breathing

Cheyne-stokes – periods of apnea and dyspnea

Dyspnea – difficult breathing

OF ANY VITAL SIGN OF ANY VITAL SIGN IMMEDIATELYIMMEDIATELY

Vital SignsVital SignsBlood pressure

Pressure of blood on the arterial walls

Recorded as a fraction: 120/80

Cont…• Systolic pressure – wall of left ventricle is

contracting

Normal range: 100-140 mm Hg

• Diastolic pressure– wall of left ventricle is resting

Normal range: 60-90 mm Hg

Vital SignsVital SignsBlood pressure

Factors that elevate blood pressure:– anxiety– eating– exercise– excitement– stimulant drugs

Factors that lower blood pressure:– depressant drugs– excessive loss of blood– rest– shock

Diagnostic Skills:Diagnostic Skills:Height and WeightHeight and Weight

Measured if warranted by patient’s age and physical condition• Measured routinely: –on admission to health care facility –as part of annual physical examination–each provider visit for children

• Important for evaluation of laboratory tests and calculation of medications

Diagnostic Skills:Diagnostic Skills:Daily WeightsDaily Weights

• Daily weights are used to monitor patients with chronic disease processes:– Hormone disorders– Renal disorders– Heart disease– Cancer

• Guidelines for daily weights:use the same scalesat the same timewearing the same type of clothingpatient voids to empty bladder

• Make sure to balance the scales before weighing the patient.

OBSERVE ALL SAFETY OBSERVE ALL SAFETY PRECAUTONS!PRECAUTONS!

Prevent injury from falls and the protruding height lever.

Diagnostic Skills:Diagnostic Skills:Measure Measure Visual AcuityVisual Acuity

• Used to measure the ability to see

• Snellen charts: used to measure distant vision

• Ishihara method tests for color

• Tonometer measures intraocular pressure

Diagnostic Skills:Diagnostic Skills:Measure Visual AcuityMeasure Visual Acuity

• OD – right eye (oculus dexter)

• OS – left eye (oculus sinister)

• OU – both eyes (oculus uterque)

• Myopia – nearsightedness, defect in distant vision

• Hyperopia – farsightedness, defect in near vision

3.01 vital signs

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