Transcript 46 - Quia
Chapter 46 Vital Signs Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Vital Signs • *Vital signs (or cardinal symptoms) – Temperature, pulse, respiration, and blood pressure – Indicators of functions of the body that are necessary, and within normal limits, to maintain life – Pulse oximetry is often included. – Pain is considered to be the fifth vital sign. – Documentation is essential to collecting information regarding the client’s status and well-being. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Recording Vital Signs • Graphic record – Documents large amounts of information – Vital signs must be recorded accurately and promptly to provide continuous and current documentation. – Helps providers diagnose and respond to the client’s changing condition • Paper record • Electronic graphic record • Frequent vital signs sheet Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Regulation of Body Temperature • Body temperature – Measure of core temperature on the Celsius (centigrade—C) or the Fahrenheit (F) scale. • Hypothalamus controls body temperature by controlling blood temperature. • Normal body temperature • Elevated body temperature: Fever or pyrexia Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Range of Temperatures** • Oral – 35.5-37.5C or 95.9-99.5F • Rectal – 36.6-38C or 97.9-100.4F • Axillary – 34.7-37.3C or 94.5-99.1F • Tympanic • Temporal Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Fever • Intermittent fever • Alternates between a fever and a normal or subnormal reading • remittent fever • Temp that rises several degrees above normal and return to normal or near normal • constant fever Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Fever • crisis • Sudden drop form fever to normal • lysis • Elevated temp that gradually returns to normal • relapsing fever • Fever that returns to normal for at least a day and then occurs again Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Regulation of Body Temperature (cont’d) • Lowered body temperature or hypothermia – A temperature significantly below normal • Clinical hypothermia – Used to perform some surgical procedures • Accidental hypothermia – Life threatening and requires immediate treatment Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Equipment for Measuring Temperature • Electronic or automatic thermometer – Probes are encased in a new cover for each client. – Discarded according to agency protocol • Disposable single-use thermometer – Made of paper, often used in isolation units* Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Measuring Body Temperature • Several locations are used to measure body temperature. – Oral (O)—mouth – Rectal (R)—anus – Axillary (Ax)—armpit – Tympanic, aural, or otic • (TM—tympanic membrane)—ear canal – Temporal artery (TA)—forehead Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Measuring Body Temperature (cont’d) • Oral Temperature: Measures the temperature within the lingual arteries under the tongue (sublingual) • More accurate than axillary and less accurate than rectal measurement • Not used for – Infants and children, clients with active seizure disorder, clients who had oral surgery • Wait 15 minutes before measuring temperature. – If client has had a hot or cold drink or has been smoking Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Measuring Body Temperature (cont’d) • Rectal temperature – Highly accurate – Contraindicated after rectal surgery (and often after vaginal surgery) and in conditions such as diarrhea, colitis, or cancer of the rectum • Axillary temperature – Least accurate measurement – Used to take temperature of newborns Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Measuring Body Temperature (cont’d) • Tympanic temperature – Tympanic thermometer is placed snugly into the client’s outer ear canal. – Ideal site for measuring the body’s core temperature • Temporal artery temperature – Quickest, noninvasive* – Temporal artery temperature scanner – Calculates core body temperature or peak body temperature Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Glass Thermometer • Glass mercury-containing thermometers are illegal in the United States. • Patient education – Properly dispose of any mercury-containing items. • Extended-care facility – May use thermometers containing alcohol Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins The Pulse • Pulse – Every heartbeat produces a wave of blood that causes pulsations through the arteries. – Temporal pulse – Mandibular pulse – Carotid artery pulse – Femoral pulse – Radial pulse Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Regulation of Pulse • Pulse Rate: The normal adult pulse rate is 60 to 80 beats per minute (bpm). Women have a slightly higher average rate than men* Newborns range from 120-140bpm*, toddlers range 80-140* – Tachycardia – Bradycardia • Pulse volume • Pulse rhythm – Apical-radial pulse Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Methods and Equipment • Palpation – To assess the radial, temporal, mandibular, carotid, and femoral pulses • Auscultation and counting the apical pulse will usually give the most accurate assessment of pulse rate. For this assessment, use a stethoscope. • An ultrasonic vascular Doppler device is sometimes used to detect peripheral pulses. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Measuring the Pulse • Radial pulse • Apical pulse (AP) – More accurate than radial, always used for children younger than 2 years of age** • Apical-radial pulse (A-R) – It is impossible for the apical pulse to be lower than the radial. – If radial is less than apical pulse, a pulse deficit occurs! • Pedal pulse • Popliteal pulse • Carotid pulse – DO NOT reach across the persons neck to obtain!! Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Respiratory rates at various ages** • Newborn – 30-80 • Early childhood – 20-40 • Late childhood – 15-25 • Adults – 12-18 – 16-20 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Regulation of Respiration • Respiratory control – Apnea • Rate and depth – Eupnea, tachypnea, bradypnea – Kussmaul’s respirations • Labored breathing, deep and gasping* • Respiration sounds – Snoring – Stertorous breathing – Obstruction near the glottis causes a hissing, crowing sound** Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Difficult Breathing • Dyspnea: Difficult or painful breathing • Orthopnea: Can breathe only when in an upright position • Asthma: Spasms and edema of the bronchi cause breathing difficultly. • Characteristic signs of breathing difficulty – Heaving of the chest and abdomen, a distressed expression, and cyanosis in the skin • Cheyne-Stokes respirations – Regular pattern with alternating deep and shallow breaths with apnea* Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Regulation of Blood Pressure • Blood pressure is determined by cardiac output and peripheral resistance. • Cardiac output: – Combination of heart rate and stroke volume – Measured over 1 minute • Systolic blood pressure (SBP) • Diastolic blood pressure (DBP) • AHA says normal BP is 115/75* • Pulse pressure – Difference of systolic pressure minus diastolic pressure Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Blood Pressure: Methods and Equipment • Measure in both arms – Difference of 5-10 points may exists, but if more than 10 points exist, this indicates and arterial occlusion in the arm with the lower pressure* • Sphygmomanometer • Aneroid manometer • Electronic blood pressure apparatus • Palpation • Doppler ultrasound* – Used when sounds are difficult to hear or indistinct – Amplifies sound Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Measuring Blood Pressure • Korotkoff’s sounds – Sounds heard in the stethoscope when taking BP* • Physical exertion or emotional stress will affect BP. • Orthostatic blood pressure measurement – Older clients – Those who are taking certain medications • Orthostatic or postural hypotension Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Pulse Oximetry • Pulse oximetry – Component of baseline vital signs – Noninvasive procedure – Uses a photoelectric impulse to measure the amount of light transmitted or reflected by deoxygenated versus oxygenated hemoglobin • Pulse oximeter or transducer Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins