PRESENTED BY :SONY VERMA

M.SC. (N) 1ST YEARPAEDIATRIC

DEFINITION

Vital signs are basic components of

assessment of physiological and psychological

health of client . Body temperature , pulse ,

respiration , blood pressure are the signs of

life. Vital signs are also known as ‘cardinal

signs’

1) TEMPERATURE = 98.6` F OR 37 `C IN ADULT

2) PULSE = 72 BEATS / MINUTES

3) RESPIRATION = 16 BREATHS / MINUTES

4) BLOOD PRESSURE = 120 / 80 mmHg

1) TO ASSESS THE NORMAL CONDITION OF VITAL ORGANS .

2) TO ASSESS THE CONDITION AND PROGGRESS MADE BY THE PATIENTS .

3) TO UNDERSTAND THE FEEECTIVENESS OF TREATMENTS .

4) TO CHANGE THE MODE OF TREATMENT .

5) IT HELP THE UNDERSTAND THE PRESENT PROBLEM .

ON ADMISSIO

N

CHANGE IN THE HEALTH STATUS

SURGICAL PROCEDURE

ADMINISTRATION OF DRUGS

INVASIVE DIAGNOSTIC PROCEDURE

1) VITAL SINGS ARE GOVERNED BY THE VITAL ORGANS AND OFTEN REVEAL EVEN THE SLIGHTEST DEVIATION FROM THE NOEMAL BODY FUNCTION .

2) THROUGHT VITAL SIGNS , SPECIFIC INFORMATION MAY BE OBTAINED THAD WILL HELP IN THE DIAGNOSTIC , TREATMENT , NURSING CARE .

3) THE CHANGES IN THE CONDITION OF PATIENT IMPROVEMENT OR REGRESSION MAY BE DETECTED BY THE OBSERVATION OF THESE SIGNS .

BODY TEMPERATURE MAY BE DEFINE AS THE DEGREE OF

HEAT MAINTAINED BY THE BODY OR ITS A BALANCE BETWEENTHE HEAT PRODUCTION ANDHEAT LOSS. HEAT REGULATIONCENTRE IS THE HYPOTHALAMUSSITUATED IN THE BRAIN.

ORAL = 98.6`F / 37`C

RECTAL = 99.6`F / 37.6`C

AXILLARY = 97.6`F/ 36.4`C

GLASS OR CLINICAL THERMOMETER

ELECTRONIC THERMOMETER

TYMPANIC MEMBRANE

THERMOMETER

DISPOSABLE PAPER THEMOMETER

TEMPERATURE SENSITIVE STRIPS AND CHEMICAL

DOT

Pulse is an alternate expansion and recoil ofan artery as the wave of blood is forcedthrough it during the contraction of the leftventricle . The pulse can be felt by the fingerson the point where an artery a crosses a boneclose to the surface of the skin .

RESPIRATION

Respiration is the act of breathing . It is the process of taking in oxygen and giving carbon-dioxide . Respiration constitutes inspiration , expiration and a pause .

Respiration may be internal and external . The exchange of gases between the blood and air in the lungs is called “ external / pulmonary respiration .” The exchange of gases between the blood and tissue is called “ internal respiration .“

ASSESSING RESPIRATION

1 ) WASH HAND BEFORE AND AFTER PROCEDURE .

2) BEFORE PROCEEDING , COLLECT ALL THE ARTICLES NEAR BEDSIDE OF THE PATIENTS

3) SELECT PROPER SITES FOR TEMPERATURE , PULSE AND BLOOD PRESSURE .

4) Maintain calm and quite environment while doing procedure.

5) Provide comfortable position to the position.

NEVER LEAVE THE CLIENT ALONE .

NEVER TELL THE CLIENT HIS TEMPERATURE AND BLOOD PRESSURE

PULSE SHOULD NOT BE CHECK IMMEDIATELY AFTER PROCEDURE.

NEVER COUNT THE RESPIRATION WHEN THE CLIENT IS IN A STATE OF TENSION.

PROCEDURE OF TAKING TPR

PREPARATION OF THE PATIENT

PREPARATION OF ARTICLES

Equipments required: 1. Oral/ axilla / rectal thermometer (1) 2. Stethoscope (1) 3. Sphygmomanometer with appropriate cuff size (1) 4. Watch with a second hand (1) 5. Spirit swab or cotton (1) 6. Sponge towel (1) 7. Paper bag (2): for clean (1) for discard (1) 8. Record form 9. Ball- point pen: blue (1) black (1) red (1) 10. Steel tray (1): to set all materials

NURSING ACTIONS

RATIONAlE SCIENTIFICPRINCIPLE

NURSING PRINCIPLE

1) Wash hand and take the articles to patients bedsides and wear gloves in case of rectal temperature.

Reducestransmission of micro-organism and prevent cross c0ntamination.

Microbiology Safety

2)Explain theprocedure to the patient.

Promote co-operation and reduces anxiety

Psychology Comfort individuality.

3)Take a thermometer and clean with spirit swab

Prevent cross infection

Microbiology Safety

NURSINGACTION

RATIONALE SCIENTIFICPRINCIPLES

NURSING PRINCIPLES

Shake down the mercury byholding the thumb and fingers.

To record the temperature correctly.

Mercury level in the tube will come down only by shaking .

Therapeutic effectiveness

Place the thermometer at the base of tongue . Ask the patients to hold the thermometer in place by closing the lips for two minutes.

Heat from superficial blood vessels in sublingual pocket produces temperature readings.

Physics mercury expands on heating

Therapeutic effectiveness

Count the pulse and respiration while the thermometer is still in place.

To allow enough time to register the body temperature

“ Therapeutic effectiveness

NURSINGACTION

RATIONALE SCIENTIFIC PRINCIPLES

NURSING PRINCIPLES

4)Place the clients hand over his chest with the wrist extended and palm downwards.5) Place the finger tips over the pulse point.

Arm placed overthe chest helps to count the respiration without the clients knowing.

Help to count the pulse and respiration

Therapeuticeffectiveness

6)Holding the watch or pulsometer in the left hand . Star to count the pulse rate with zero then 1 ,2 ….

Zero being the time interval and the next pulse felt is 1 of the sequence

“ “

If the pulse is regular , count the number of pulsations for half minutes and multiply by the two . If the pulse is irregular count the rate for one full minutes

“ “ “

With the righthand still on the pulse , count respiration by watching the rise and fall of the chest , without the knowing of the patient.

Client may be hold the breath and the rate may be altered .

Therapeutic effectiveness

If the respiration are normal , count the number of respiration in 30 seconds and multiply by the 2. if it is abnormal count for full one minutes

Remove the thermometer aftertwo minutes . And check the temperature at the eye level in opposite site of light and wipe it from stem to bulb with rotating movements

Wipe from the area of least contaminated to that of greatest contamination.

Wash hands Prevent cross infection

Therapeutic effectiveness

recording

SUMMARU AND CONCLUSION