Transcript vital signs
VITAL SIGNS HST-1 Measuring & Recording VS • I. Vital Signs – A. Provide info about basic body conditions of the pts. – B. 4 main vital signs • 1. temperature • 2. pulse • 3. respirations • 4. blood pressure – C. 5th VS • 1. Pain ~ scale of 1-10 – D. Other important VS – E. Accuracy is essential • 1. report abnormal findings immediately • 2. have all questionable readings checked by another individual – F. Physician will decide if info can be told to a pt. • II. Temperature – A. defined: measurement of balance between heat lost and heat produced in the body • 1. heat loss = perspiration, respiration, and excretion (urine & feces) • 2. heat produced = body metabolism • 3. homeostasis = constant rate of fluid balance – B. Conversion between Fahrenheit & Celsius · formula: C = (F-32) X 0.5556 (or 5/9) – C. Conversion between Celsius & Fahrenheit · formula: F = (C X 9/5 or 1.8) + 32 – D. Variations in body temperature • 1. normal range 97F - 100F • 2. time of day affects temp. • 3. parts of the body where the temperature is taken –(a) ORAL = 98.6F (3-5 minutes) –(b) RECTAL = 99.6F (3-5 minutes) –(c) AXILLARY or GROIN = 97.6F (10 minutes) –(d) AURAL (TYMPANIC)= 4 settings (2-10sec.) Reading a Thermometer – E. Factors that cause an ↑ body temp. • 1. illness or infection • 2. exercise or excitement • 3. high temperature in the environment – F. Factors that cause a ↓ body temperature • 1. starvation or fasting • 2. sleep • 3. decrease muscle activity • 4. cold temperatures in the environment – G. Abnormal conditions • 1. hypothermia = temp. 95F • 2. fever = temp. 101F –(a) pyrexia –(b) febrile • 3. hyperthermia = temp. 104F – H. Types of thermometers • 1. clinical thermometers – glass –(a) mercury vs. alcohol • 2. electronic thermometer • 3. tympanic thermometer • 4. plastic or paper – I. Record results correctly • ~ (R), (Ax), (Gr), (T) Paper or Plastic Thermometers – J. Factors that could alter or change results • 1. Eating, drinking, or smoking → 15 min – K. Cleaning guidelines • 1. Clinical – (a) soak minimum of 30 min. – (b) paper/plastic sheaths • 2. Electronic & Tympanic • III. Pulse – A. defined: the pressure of the blood pushing against the wall of an artery as the heart beats and rests – B. Major arterial / pulse sites • 1. temporal • 2. carotid • 3. brachial • 4. radial • 5. femoral • 6. popliteal • 7. dorsalis pedis • ** Apex of – C. Rate = # of beats per minute • 1. varies according to age, sex or body size Pulse Sites – (a) adults = 60-90 beats/minute – (b) children over 7 = 70-90 beats/min. – (c) children from 1-7 = 80-110 beats/min. – (d) infants = 100-160 beats/min. • 2. bradycardia 60 beats/min. • 3. tachycardia 100 beats/min. – D. Rhythm = regularity of the pulse or spacing of the beat • 1. described: regular or irregular • 2. Arrhythmia – (a) caused by electrical conduction problem – E. Volume = strength or intensity of the pulse • 1. described: strong, weak, thready, bounding, – F. Various factors will change the pulse rate • 1. ↑ rates = exercise, stimulant drugs, • excitement, fever, shock, anxiety • 2. ↓ rates = sleep, depressant drugs, • heart disease, coma, physical training – G. Procedure: – H. Record all information – Ex: 10/12/06 800 P=82 strong & regular IV. Respirations A. defined: process of taking in oxygen and expelling carbon dioxide from the lungs and the respiratory tract • B. One respiration = one inspiration + one expiration • C. Normal respiratory rate – 1. adults = 14 – 18 breaths/min. – 2. children = 16 – 25 breaths/min. – 3. infants = 30 – 50 breaths/min. • D. Character of respirations – refers to depth and quality of respirations. – 1. described: deep, shallow, labored, moist, difficult, stertorous (abnormal sounds such as snoring.) • E. Rhythm of respirations – regularity or equal spacing between breaths. – 1. described: regular (even) or irregular • F. Abnormal respirations: – 1. Dyspnea – 2. Apnea – 3. Cheyne-Stokes – 4. Bradypnea – 5. Tachypnea – 6. Rales – 7. Orthopnea – 8. Wheezes – 9. Cyanosis (condition) • G. Procedure: pt must be unaware • H. Record all information – example: 12/14/__ 1500 R=18 deep & regular MILITARY TIME • VI. Apical Pulse – A. defined: heartbeat heard at the apex of the heart. – B. Reasons for taking apical pulse: • 1. ordered by the physician • 2. cardiac patients: irregular heart beats, hardening of the arteries or weak pulse • 3. prior to certain medications • 4. all infants = pulse is rapid & difficult to count – C. Heart sounds – caused by the closing of the heart valves as blood flows through the chambers of the heart. • 1. 1 beat = 1 lubb-dubb (2 distinct sounds) – D. Locating the apical pulse • 1. Place bell of stethoscope 2-3 inches to the left of the breastbone below the left nipple • 2. Listen for one full minute – E. Record all information correctly: – example: 05/05/06 1100 AP=84 strong & regular – F. Pulse deficit occurs if… • 1. Heart is weak & does not pump enough blood to produce a pulse in some cases. • 2. Tachycardia → not enough time to fill up the heart for every beat. – G. Measurement of pulse deficit • 1. measure apical & radial pulse at the same time (2 people) • 2. subtract radial rate from apical rate = pulse deficit • VII. Blood Pressure – A. defined: measurement of the pressure that the blood exerts on the walls of the arteries during the various stages of heart activity (or as the heart contracts and relaxes) – B. Instrument used: sphygmomanometer measured in millimeters of mercury – C. Measurements read at 2 points: • 1. Systolic –(a) pressure that occurs in the walls when the heart is contracting and pushing blood into the arteries –(b) normal: 120 mm.Hg (range is 100 – 140) –(c) noted as the reading on the sphygmomanometer when the first sound is heard • 2. Diastolic –(a) constant pressure that is in the walls of the arteries when the heart is at the rest or between contractions –(b) normal: 80 mm.Hg (range is 60 – 90) –(c) adults: noted as the reading on the sphygmomanometer gauge when the sound stops or becomes faint – D. • • • – E. • • • • – (d) children: noted as the reading on the sphygmomanometer gauge when the sound becomes soft or muffled Pulse Pressure 1. Defined: difference between systolic & diastolic pressure 2. Important indicator of the health & tone of the arterial walls 3. Normal range = 30-50 mm.Hg Factors influencing blood pressure readings 1. force of the heartbeat 2. resistance of the arterial system 3. elasticity of the arteries 4. volume of the blood in the arteries – F. Hypertension (↑ B/P) • 1. Indicated when systolic is > 140 mm.Hg & diastolic is > 90 mm.Hg • 2. Causes: stress, anxiety, obesity, highsalt intake, aging, kidney disease, thyroid deficiency, and CVD • 3. Ø treated → stroke, kidney disease, and/or heart disease – G. Hypotension (↓ B/P) • 1. Indicated when systolic is < 100 mm.Hg & diastolic is < 60 mm.Hg • 2. Causes: heart failure, dehydration, depression, severe burns, hemorrhage, & shock • 3. Orthostatic (postural hypotension) – (a) sudden drop in systolic & diastolic pressure when standing – H. Individual factors that can influence blood pressure • 1. factors that may ↑ B/P – (a) excitement, anxiety, nervous tension – (b) stimulant drugs – (c) exercise and eating • 2. factors that may ↓ blood pressure – (a) rest or sleep – (b) depressant drugs – (c) excessive loss of blood – I. Recorded as fractions: example = 120/80 – J. Types of sphygmomanometers = each line represents 2 mm/Hg • 1. mercury sphygmomanometer • 2. aneroid sphygmomanometer • 3. electronic sphygmomanometer – K. Cuff size may influence readings • 1. Too narrow = ↑ reading • 2. Width should be approx 20% wider than the diameter of the upper arm – L. Procedure: (palpatory systolic pressure) – M. Record all required information • example: 05/10/06 2030 BP =124/76