Transcript 535552203131314c41422032205653

SUR 111
LAB WEEK 2
Vital Signs
Vital Signs
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Temperature
Pulse
Respiration
Blood Pressure
All are done initially before any surgical
procedure to establish a baseline for the
patient
• The baseline allows the caregivers to
easily detect abnormalities during the
surgical procedure
Routine Procedure for all Vital
Signs Assessment
• Before coming in contact with any
patient:
• Wash your hands, performing the
basic handwash
• Assemble your needed supplies
• Use clean gloves if necessary
• Identify your self to the patient and
tell them what you need to do
• Identify the patient verbally and by
their hospital identification armband
Supplies Needed For VS
Assessment
• Clean Gloves
• Thermometer
• Thermometer probe covers
• Watch with a Second Hand
• Stethoscope
• Sphygmomanometer
• Black ink pen
• Paper or chart
Sphygmomanometer
Temperature
• Temperature controlled by the Hypothalamus in
the brain which controls heat loss and heat
production
• Purpose:
• Establish baseline
• Determine if in normal range
• Normal range 98 to 99.5°F or 36.6-37.5°C
• Conversions:
• C→F
• C° x 9/5 + 32 (36°C x 9/5 = 64.2 + 32 = 96.2°F)
• F→C
• F° - 32 x 5/9 (98.6°F-32=66.6 x 5/9=37°C)
Causes of Temperature
Variations
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Bacterial infections
Viral infections
Low physical activity
Increased physical activity
Age
Metabolism
Drugs/Medications
Exposure to cold or heat
Pregnancy
Stress
In the OR: it’s cold, the patient is exposed, prep solutions
are cold, anesthesia drugs are being administered
What to Call Variations
• Normal = Normothermia
• Below Normal = Hypothermia
• Above Normal = Hyperthermia
Types of Thermometers
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Mercury (time for 3 to 5 minutes before reading)
Digital (requires turning on just before use)
Tympanic
Disposable strip
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Places to Take Temperature:
Orally
Rectally (need lubricant) will place about 1 inch into anus
Axillary
Ear / Tympanic (plastic probe cover)
Skin
FYI: Esophageal and bladder temps monitor body core
temp
Temperature Procedure
• Wash hands
• Assemble supplies (put probe cover on)
• Identify self, patient, explain what you’re going to
do
• Position the patient prn
• Place probe depending on site
• Hold probe prn
• Time prn
• Remove when reading complete
• Remove sheath and discard
• Wash your hands
• Record reading and method used to take
temperature
• Disinfect device, return to storage location
Pulse
• With every beat of the heart, blood is
pumped into the aorta, the force creates a
pressure wave called the pulse or
heartrate and is felt in various locations of
the periphery
• We can palpate or feel this pulse
• Locations include the following:
• Temporal, Carotid, brachial, radial,
femoral, popliteal, dorsalis pedis, and
posterior tibial arteries
• Apically (apex of the heart)
Pulse
• Purpose:
• Establish baseline
• Determine if in normal range
• Normal: Adult 60 – 100
Child (1 to 7 yrs) 80120/minute
Infant (<1 yr) 110130/minute
Birth 130-160/minute
Pulse
• Palpating each beat you feel for one full
minute
• If rhythm is regular may count for 30
seconds and multiply x two
• Notice characteristics such as rhythm
(regularity of the beat-note regular or
irregular) and strength (weak, strong,
bounding)
• Below normal range is called bradycardia
• Above normal range is called tachycardia
Pulse Variations
• Age
• Infection
• Level of activity
• Pain
• Medication (caffeine, alcohol,
nicotine)
• Stress or anxiety (patients in OR are
anxious
• Sleep deprivation
Pulse Taking Procedure
• Wash hands
• Assemble supplies: watch with second hand,
clean gloves prn, stethoscope if doing apical
• Identify self, patient, explain what you’re going to
do
• Position the patient prn
• Locate the site, using first two or three fingers
(do not use the thumb)
• Count pulse rate, note rhythm and strength or
volume,
• Wash hands
• Record pulse, note regular or irregular, weak or
strong or bounding
• Clean supplies prn (stethoscope), return items to
storage
Respiration
• Is the exchange of oxygen
and carbon dioxide
between the atmosphere
and the body
• All cells in the body must
have oxygen to function
• Respiration is controlled by
the medulla oblongata and
is involuntary
• Inspiration is inhaling
• Expiration is exhaling
• Respiration is counted as
one for each inhalation and
exhalation
Respiration
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Purpose:
Establish baseline
Determine if in normal range
Determine rhythm and depth
Normal: Adult 12-20/minute
Child (1 to 7 yrs) 18-30/minute
Infant (<1 yr) 30-60/minute
Normal = eupnea
Not breathing = apnea
Below normal = bradypnea
Above normal=tachypnea
Respiration
• Should be even or regular, not labored, silent,
relaxed
• Do not mention that you will be counting
respiration as the pattern might be altered sue to
their being self-conscious about it
• Take after taking pulse, maintaining your pulse
taking method, but look at the person’s chest
• You’ll have to remember the pulse rate and
respiration rate to record
• Each complete breath (inhalation and exhalation
is recorded as one)
• Count for one full minute if breathing abnormal
• If normal, may count for 30 seconds and multiply
x two
• Note rate, and regular, unlabored, and silent
Respiration Variations
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Age
Infection
Stress or anxiety
Medications
Exercise
Sleeping
Airway obstruction
Damage to respiratory system (medulla
oblongata or lung disease)
Respiration Procedure
• Wash hands
• Assemble supplies (watch with second
hand)
• Identify self, patient, and explain
procedure prn
• Position patient prn
• Note rate, depth, rhythm and breath
sounds (should be clear)
• Wash your hands
• Record rate and any irregularities
• Return items to storage prn
Blood Pressure
• The force or pressure of blood against the
sides of arterial wall, its container
• Purpose:
• Establish baseline
• Determine abnormalities/deviations from
the norm
• Is expressed as two numbers: systolic
and diastolic
• Systolic = contraction of the heart
• Diastolic = relaxation of the heart
Blood Pressure
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Normal Values:
Adult 130/85 (130=systolic/85=diastolic)
Measured in mm Hg
Adolescent 118/75
Child (6-10) 100/65
Child (< 6) 95/62
Newborn 50-52/25-30
Adult >140 S = hypertension
> 90 D = hypertension
• Below normal range called hypotension
Blood Pressure Variations
• Age
• Sex
• Race
• Diurnal (lower in the morning than in
the afternoon)
• Weight
• Exercise
• Stress/anxiety
Blood Pressure Monitoring
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Can be assessed:
Manually
Automatically
Arm preferred lower third of upper arm with
stethoscope over the brachial artery
• Can use the thigh (reading will be higher)
will wrap cuff around lower third of thigh and
place stethoscope over the popliteal artery/ will
require patient to be in prone position (on their
stomach)
• Intra-arterially (femoral or radial) with a catheter
inserted into that artery, monitored by anesthesia
machine
Supplies Needed to Assess
BP
• Stethoscope
• Sphygmomanometer (cuff’s bladder
should be 40% of the circumference
of the patient’s arm and length
should be 80% of this circumference)
• Cuff size (too small or too large) can
alter the blood pressure reading
Blood Pressure Procedure
• Wash your hands
• Equipment assembled (stethoscope,
sphygmomanometer, clean gloves prn)
• Identify self, patient, explain procedure
• Position patient, expose site
• Person should be sitting or lying down with the
arm at the level of the heart
• Try to take the BP in the left arm as that is
closest to the heart
• Apply cuff
• Palpate brachial arterial pulse at antecubital area
using first two fingers (do not use thumb)
Blood Pressure Procedure
• Inflate cuff 20 to 30 mm Hg above
where pulse is no longer palpable
• Place stethoscope over site where
you palpated pulse, hold in place
with first two fingers
• Slowly release valve, listening
carefully for “Korotkoff” sounds
Korotkoff’s Korotkoff’s
Sounds
• Phase I Hearing initial tapping
sound, you will record this as the
systolic reading
• Phase II Hear soft swishing sound
as cuff deflates
• Phase III Hear rhythmic tapping as
more blood passes through the
vessels
• Phase IV Sound disappears (last
sound heard is the diastolic reading)
Blood Pressure Procedure
• Continue to deflate cuff
• Wash hands
• Record results
• Care for equipment and put back in
storage area
Summary
• Vital Signs
• Temperature
• Pulse
• Respirations
• Blood Pressure