Transcript Vital Signs

Vital Signs
Vital Signs
• Provide information about body
function
• Data is used to treat illness and
diagnose disease
• Include:
– temperature
– pulse
– respiration
– blood pressure
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• Changes may be the first
sign of disease or a change in
patient health status.
• Accuracy is imperative!
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Vital Signs
Temperature
Measurement of the balance between
heat lost and heat produced
Heat lost through:
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Perspiration
Respiration
Excretion
Heat produced by:
• Metabolism of food
• Muscle and gland activity
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Vital Signs
Temperature
Normal ranges
– 97º - 100º F
– 36.1º - 37.8º C
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Vital Signs
Temperature
Hypothermia
• Temperature below 95º F
• Death can occur if below 93º F
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Vital Signs
Temperature
Hypothermia
Temperature decreases with:
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environment
exposure to cold
inactivity
sleep
starvation
Symptoms:
– shivering
– cold skin
– confusion
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Vital Signs
Temperature
Hyperthermia
• Temperature 100-104º F
• Temperature above 104º F is
• life-threatening
• Prolonged hyperthermia may cause
brain injury.
• Sx – headache, confusion
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Vital Signs
Temperature
Hyperthermia
Temperature increases with:
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environment
exercise
illness, infection, injury
stress
Symptoms:
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hot, dry, red skin
nausea/vomiting
headache
low blood pressure
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Vital Signs
Temperature
Thermometers
Clinical
Non-mercury glass
Aural – good
with children
Electronic
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Vital Signs
Temperature
Sites to measure temperature:
• Aural – auditory canal
• Axillary – armpit
• Oral – mouth
• Rectal – rectum
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Vital Signs
Temperature
To record temperature:
– Oral 98.6º (O) – under tongue by
jaw line
– Rectal 99.6º (R) – lay pt on side
– Axillary 97.6º (ax)
– Aural 98.6º (T)
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Vital Signs
Temperature Measurement
Oral
• Ask the patient if they have
ingested hot or cold food or
drink, or smoked within the last
½ hour
• If yes, wait at least 15 minutes
before measuring the oral
temperature
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Vital Signs
REPORT
ABNORMAL RESULTS
OF ANY VITAL SIGN
IMMEDIATELY to supervisor
Combined VS (TPRBP) can indicate a life
threatening condition or a change in condition
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Vital Signs
Temperature Measurement
• Aural
• Pros:
– Measures core body temperature
– Fast and convenient
• Con:
– Inaccurate if not placed correctly in the
ear canal
– Ear infection
– Ear wax
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Vital Signs
Pulse
Pressure of blood on artery walls
as the heart beats and
Relaxes (contraction and relaxation)
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• Sites:
Temporal – side of the forehead
Carotid – side of the neck
Brachial – inner elbow
Radial – above the thumb at radius
Femoral – upper thigh
Popliteal – behind the knee
Dorsalis pedis – top of the arch of
the foot (good for checking lower
limb circulation)
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Vital Signs
Pulse
Normal rate
adult (male) 60 – 70 beats per minute
adult (female) 65 – 80 beats per minute
children (over 7) 70 – 100 beats per minute
children (1 – 7) 80 – 110 beats per minute
infants (less than 1 year) 100 – 160 beats per
minute
Rhythm regular or irregular
Volume strength of the pulse
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Vital Signs
Pulse
• Pulse can be increased by:
– exercise
– stimulant drugs
– excitement
– fever
– shock
– nervousness
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Vital Signs
Pulse
• Pulse can be decreased by:
– sleep
– depressant drugs
– heart disease
– coma
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Vital Signs
REPORT
ABNORMAL RESULTS
OF ANY VITAL SIGN
IMMEDIATELY
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Vital Signs
Apical Pulse
• Pulse count taken with the stethosco
• Use if the patient has:
– Irregular heartbeat
– Arteriosclerosis
– Weak or rapid radial pulse
– Infants and children
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Vital Signs
Respiration
Process of taking in oxygen and
expelling carbon dioxide
1 inspiration + 1 expiration = respiration
Normal rate:
adults – 12 – 20 breaths per minute
children – 16 – 30 breaths per minute
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• Evaluate for rhythm and
character
• Rhythm – regular or irregular
(i.e. fast, slow)
• Character – depth, ease of
breaths
• Check while appearing to count
pulse
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Vital Signs
Respiration
• Abnormal respiratory patterns
Apnea – periods of absent
breathing
Cheyne-stokes – periods of apnea
and dyspnea
Dyspnea – difficult breathing
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Vital Signs
REPORT
ABNORMAL RESULTS
OF ANY VITAL SIGN
IMMEDIATELY
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Vital Signs
Blood pressure
Pressure of blood on the arterial walls
Recorded as a fraction: 120/80
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• Systolic pressure – wall of left
ventricle is contracting
Normal range: 100-140 mm Hg
• Diastolic pressure– wall of left
ventricle is resting
Normal range: 60-90 mm Hg
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Vital Signs
Blood pressure
Factors that elevate blood pressure:
– anxiety
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eating
exercise
excitement
stimulant drugs
Factors that lower blood pressure:
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depressant drugs
excessive loss of blood
rest
shock
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Diagnostic Skills:
Height and Weight
Measured if warranted by patient’s age and physical
condition
• Measured routinely:
– on admission to health care facility
– as part of annual physical examination
– each provider visit for children
• Important for evaluation of laboratory tests
and calculation of medications
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Diagnostic Skills:
Daily Weights
• Daily weights are used to monitor patients w
chronic disease processes:
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Hormone disorders
Renal disorders
Heart disease
Cancer
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Diagnostic Skills:
Daily Weights
• Guidelines for daily weights:
use the same scales
at the same time
wearing the same type of clothing
patient voids to empty bladder
• Make sure to balance the scales before
weighing the patient.
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Diagnostic Skills:
Daily Weights
OBSERVE ALL SAFETY
PRECAUTONS!
Prevent injury from falls and the
protruding height lever.
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Diagnostic Skills:
Measure Visual Acuity
• Used to measure the ability to see
• Snellen charts: used to measure
distant vision
• Ishihara method tests for color
• Tonometer measures intraocular
pressure
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Diagnostic Skills:
Measure Visual Acuity
• OD – right eye (oculus dexter)
• OS – left eye (oculus sinister)
• OU – both eyes (oculus uterque)
• Myopia – nearsightedness, defect in
distant vision
• Hyperopia – farsightedness, defect in
near vision
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