Transcript Unit 14 - Home - Fremont RE

Chapter 14
Vital Signs
Objectives
• List the four main vital signs
• Convert Fahrenheit temperatures to Celsius,
or Celsius to Fahrenheit
• Read a clinical thermometer to the nearest
two-tenths of a degree
• Measure and record oral temperature
accurately
• Measure and record rectal temperature
accurately
• Measure and record axillary temperature
accurately
• Measure and record tympanic (aural)
temperature accurately
Objectives
• Count and record respirations to an accuracy
within + or – 1 respirations per minute
• Measure and record apical pulse to an
accuracy within + or – 2 beats per minute
• Measure and record blood pressure to an
accuracy within + or – 2 mm Hg
• State the normal range for oral temperature,
axillary temperature, rectal temperature,
pulse, respirations, systolic and diastolic
blood pressure
• Define, pronounce, and spell all the key
terms
Chapter 14:1 Measuring and Recording
Vital Signs
Vital signs:
• Defined as “various determinations that
provide information about the basic
body conditions of the patient”
• 4 main vital signs + pain
Temperature
• Measurement of the balance between
heat lost and heat produced by the
body
• Can be measured in the oral, rectal,
axillary, or aural areas
• Most reported in Fahrenheit but many
are now reporting in Celsius
Conversion Formulas
Fahrenheit temperature to Celsius:
• Subtract 32 from the Fahrenheit
temperature and then multiply the result
by 5/9 or 0.5556
• EX:
• 98.6 degrees (F)
• 98.6 – 32 = 66.6 X 0.5556 = 37
degrees (C)
Conversion Formula
Celsius temperature to Fahrenheit
Multiply the (C) temperature by 9/5 or 1.8
And then add 32 degrees
EX:
16 degrees (C) X 1.8 = 28.8 + 32 = 60.8
degrees (F)
Pulse
• Pressure of the blood felt against the wall of
an artery as the heart contracts and relaxes,
or beats
– Rate: number of beats/min
– Rhythm: regularity
– Volume: strength
• Any abnormality can indicate disease
Respirations
• Reflect the breathing rate of the patient
– Count: number
– Rhythm: regularity
– Character: type
• Abnormal respirations usually indicate
that a health problem or disease is
present
Blood Pressure
•
The force exerted by the blood against the
arterial walls when the heart contracts or
relaxes
• Two readings:
1. Systolic-measurement of blood pressure
taken when the heart is contracting and
forcing blood into the arteries
2. Diastolic-measurement of blood pressure
taken when the heart is at rest: Measure of
constant pressure in the arteries
Chapter 14:2
Measuring and Recording Temperature
• Constant state of fluid balance =
homeostasis
• Rates of chemical reactions in the body
are regulated by body temperature
• Normal body temperature is 97 – 100
degrees (F) or 36.1 – 37.8 (C)
Variations of body temperatures
• Individual differences
• Time of day
• Body sites
– Oral
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–
–
Rectal
Axillary and groin
Aural
Temporal
Increased Body Temperature
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Illness
Infection
Exercise
Excitement
High environment temperature
Fever (pyrexia)-temp >101
Hyperthermia-body temp >104
– Treat quickly
– Body temp>106 = seizures, coma, death
Decreased Body Temperature
•
•
•
•
•
Starvation or fasting
Sleep
Decreased muscle activity
Mouth breathing
Exposure to cold temperatures in the
environment
• Certain diseases
• Hypothermia-body temp <95
– Temp <93 = death
Types of Thermometers
• Clinical
• Glass
• Contains mercury or alcohol with red
dye
• Different types
Types of Thermometers
• Electronic Thermometers
• Can be used for oral, rectal,
axillary, and/or groin
temperatures
• Blue and Red probes
• Disposable covers used to
prevent cross contamination
• Will usually register the
temperature in about 60
seconds
Types of Thermometers
• Tympanic thermometers
• Specialized that record the aural
temperature in the ear
• Disposable plastic covers are used
• Temp recorded within 1-2 seconds
Reading & Recording Temperature
• Always recorded to the next nearest
two-tenths of a degree
• Recording Temperature
• Eating, drinking, or smoking can alter
temperature in the mouth
• Thermometers must be cleaned
thoroughly after use
• Know your facilities procedure for
cleaning
Chapter 14:3
Measuring and Recording Pulse
• Can be felt at different arterial sites on
the body
– Temporal
– Carotid
– Brachial
– Radial
– Femoral
– Popliteal
– Dorsalis Pedis
Normal Pulse Rates
• Vary among individuals, depending on age,
sex, and body size
Adults
-general range of 60 – 90 beats/min
Children
-over 7: 70 – 90 beats/min
-age 1 – 7: 80 – 110 beats/min
Infants
-100 -160 beats/min
Pulse
• Bradycardia-Rate under 60 beats/min
• Tachycardia-Rate over 100 beats/min
(except in children)
• Any variations of extremes in pulse
rates should be reported immediately
• Rhythm-regularity
– Regular or irregular (arrythmia)
• Volume-strength/intensity
– Strong, weak, thready, bounding
Factors that change pulse rates
Increased or accelerated:
• Exercise
• Stimulant drugs
• Excitement
• Fever
• Shock
• Nervous tension
• Other similar factors
Decreased or slower:
• Sleep
• Depressant drugs
• Heart disease
• Coma
• Physical training
• Other similar factors
Chapter 14:4
Measuring and Recording Respirations
• Respiration: the process of taking in O2
and expelling CO2 from the lungs and
respiratory tract
• Normal: 14-18 breaths/min (adult)
16-30 breaths/min (children)
30-50 breaths/min (infants)
Respirations
• Character:
• Refers to depth and quality of respirations
–
–
–
–
–
–
–
–
–
Dyspnea
Apnea
Tachypnea
Bradypnea
Orthopnea
Cheyne-Stokes
Rales
Wheezing
Cyanosis
Respirations
• Must be counted in such a way that the
patient is unaware of the procedure
• Leave your hand on the pulse site while
counting respirations
Chapter 14:5 Graphing TPR
• Graphic Sheets:
• Special records used for recording TPR
• The graphics are a medical record, so it
must be neat, legible, and accurate
• Double check your charting to be sure
they are accurate
Chapter 14:6
Measuring and Recording Apical Pulse
• Pulse count taken with a stethoscope at
the apex of the heart
• Actual heartbeat is heard and counted
• Usually ordered by physician for
patients with arrythmias, hardening of
the arteries, or weak, or rapid radial
pulses
**Important that you protect the patient’s
privacy. Avoid exposing the patient.
Apical Pulse
• Two separate heart sounds are heard
• “lubb-dupp” counts as one heartbeat
• Caused by the closing of the valves of the
heat as blood flows through the chambers of
the heart
• Located at the 5th intercostal space and
midclavicular line
• Any abnormal sounds should be reported
immediately
Pulse Deficit
• Conditions that occurs with some heat
conditions
• Most accurate:
• Have one person should check the apical
pulse while a second person checks another
pulse site (usually the radial)
• Subtract the rate of the radial pulse from the
rate of the apical pulse. The difference is the
pulse deficit
Chapter 14:7
Measuring and Recording Blood Pressure
• Read in mm Hg on a
sphygmomanometer
• Systolic
– Normal: 120 mm Hg
– Normal Range: 100-140 mm Hg
• Diastolic
– Normal: 80 mm Hg
– Normal range: 60 – 90 mm Hg
Pulse Pressure
• Difference between the systolic and
diastolic pressure
• Important indicator of the health and
tone of arterial walls
• Normal range in adults:
30 to 50 mm Hg
Hypertension
• High blood pressure (HBP or HTN)
• pressures > 140 mm Hg (systolic)
• pressures > 90 mm Hg (diastolic)
Common Causes:
• Stress
• Anxiety
• Obesity
• High-salt intake
• Aging
• Kidney disease
• Thyroid deficiency
• Vascular conditions (arteriosclerosis)
* If not treated, can lead to CVA, kidney disease, and/or
heart disease
Hypotension
• Low blood pressure
• Pressures < 100 mm Hg (systolic)
• Pressures < 60 mm Hg (diastolic)
May occur with:
• Heart failure
• Dehydration
• Depression
• Severe burns
• Hemorrhage
• Shock
Orthostatic Hypotension
• Postural
• Occurs when there is a sudden drop in both
systolic and diastolic pressure when an
individual moves for a lying to a sitting or
standing positions
• Caused by the inability of blood vessels to
compensate quickly to the change in position
• Symptoms:
• Dizziness, or blurred vision
• Last a few seconds until vessels compensate
Factors that Influence BP readings:
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•
•
•
Force of the heartbeat
Resistance of the arterial system
Elasticity of the arteries
Volume of the blood in the arteries
Recording BP
• Recorded as a fraction
• Systolic (top number)
• Diastolic (bottom number)