Transcript Vital signs

Vital signs
Outline
Vital Signs Definition
Temperature
Pulse Rate
Respiratory Rate
Blood Pressure
Pain
Vital sign
physical signs that
provide data to
determine a person’s
state of health
indicate an individual is
alive, such as
temperature, pulse
rate, respiratory rate
(TPR), and blood
pressure (BP).
Measuring Body Temperature
Purposes
1-To establish baseline data for subsequent
evaluation .
2-To identify whether the core body temperature is
within normal range .
3-To determine changes in the core body
temperature in response to specific therapies (
antipyretic medication , immunosuppressive drugs,
invasive procedure )
4-To monitor clients at risk for imbalanced body
temperature ( clients at risk for infection , or
diagnosis of infection , or those who have been
exposed to temperature extreme)
Types of Thermometers
Electronic thermometers
Provide readings in less than
60 seconds
most accurate if placed in
sublingual pocket
There is a sensor on the end
of the thermometer that
touches the body part and
reads the body’s temperature.
Types of Thermometers
Tympanic membrane
thermometer
measures the temperature
inside of the ear.
It will read the infrared heat that
comes from inside of the ear.
Especially appropriate for infants
and young children
Readings are obtained in 2
seconds or less
Types of Thermometers
Glass and mercury thermometers
a glass tube with mercury inside of
the tube.
The tube goes underneath the tongue
and the body temperature will cause
the mercury to rise inside the tube.
DO NOT just throw away a mercury
thermometer.
Sites for taking the Temperature
SITE
ADVANTAGES
ORAL
DISADVANTAGES
Thermometers can be broken
Accessible and convenient Inaccurate if client has just ingested hot or cold fluid, or
smoked
RECTAL
Reliable measurement
Inconvenient and more unpleasant; difficult for client who
cannot turn to side
Could injure the rectum following surgery
Presence of stool may interfere with thermometer
placement
AXILLARY
Safe and noninvasive
Thermometer must be left in place for a long time
TYMPANIC
MEMBRANES
TEMPORAL
ARTERY
Readily accessible; reflects Can be uncomfortable and involves risk of injuring the
the core temperature, very membrane if inserted too far
Presence of cerumen can affect the reading
fast
Safe and non invasive ,
very fast
Requires electronic equipment (expensive / unavailable)
;
Variation in technique if the client has perspiration on the
forehead
Sites for taking theTemperature
Assessment :
 1-Clinical signs of fever .
 2-Clinical signs of hypothermia
 3-Site most appropriate for measurement .
 4-Factors that may alter body temperature.
Planning
Preparation of equipment :
1-Thermometer
2-Thermometer cover .
3-Water- soluble lubricant for a rectal
temperature .
4-Disposable gloves .
5- Towel for axillary temperature .
6-Tissue /wipes
Implementation
Preparation:
Check that all equipments functioning well .
Performance :
1- Introduce self , verify the client’s identity ,
explain to the client what will you do, why and
how ?
2- Hand washing .
3-Provide for client’s privacy .
4-Position the patient according to the method
will be practiced ( lateral or sim’s position for
rectal temperature )
5-Place the thermometer as the following :
Evaluation
Compare the temperature
measurement to baseline data ,
normal range of age of the client
and the client’s previous
temperature .
Analyze considering time of day
and any additional influence
factors and other vital signs .
Assessment of peripheral Pulse
Purpose :
– To establish baseline data for subsequent evaluation.
– To identify whether the pulse rate is within normal range
.
– To determine whether the pulse rhythm is regular and
the pulse volume is appropriate .
– To determine the equality of corresponding peripheral
pulse on each side of the body .
– To monitor and assess changes in the client’s health
status .
– To monitor client’s at risk for pulse alteration ( heart
disease , cardiac arrhythmia .
– To evaluate perfusion to the extremities
Assessment
`1-Clinical
signs of cardiovascular
alterations as: (dyspnea, cyanosis,
palpitations , syncope , cool skin )
2- Factors that may alter pulse rate
( e.g. emotional status , physical activity ) .
3- Which site is most appropriate for
assessment based on a purpose .
Pulse sites
Assessment of apical pulse :
Position the
patient in
comfortable
supine position
or in a sitting
position .
Locate the apex
of heart
Planning
Equipment :

-
Watch with a second hand or indicator .
 Implementation
Performance :
1- Introduce self , verify the client’s identity , explain to the
client what will you do, why and how ?
2- Hand washing .
3-Provide for client’s privacy .
4- Select the pulse point . Normally , the radial pulse is taken
unless it can’t be exposed .
5- Position the patient in a rest position
Implementation :
6- Palpate and count the pulse . Place 3 or 2
middle fingers lightly and squarely over the
pulse point .
7- Count for 15 seconds and multiply by 4 .
8- Record the pulse on the worksheet .
9- Assess the pulse rhythm and strength .
10- Document the pulse rate on the patient’s
record .
11- Hand wash
Evaluation
1-Compare the pulse rate to baseline
data or normal range for age of the
client .
2- Relate pulse volume , rate to other
vital signs , pulse rhythm and volume
to other baseline data and health status
.
3- Conduct appropriate follow up such
as notifying the primary care giver or
giving medication .
C-Assessment of Respiration :
Purposes :
To acquire baseline data against which future
measurements can be compared .
To monitor abnormal respiration and
respiratory patterns and identify changes .
To monitor respirations before or following the
administration of general anesthetic or any
medication that can influences respiration .
To monitor clients at risk for respiratory
alterations .
Assessment :
Skin and mucous membrane color ( cyanosis or
pallor )
Positions assumed for breathing ( using of
orthopneic position).
Signs of cerebral anoxia ( irritability , restlessness
drowsiness or loss of consciousness ) .
Chest movement .
Activity tolerance.
Chest pain .
Dyspnea
Medication that affect respiration .
Planning
Equipment:
Watch with a second or indicator .
Implementation :
Preparation:
For a routine assessment of respiration , determine the
client’s activity schedule and choose a suitable time to
monitor the respirations . A client who has been
exercising will need to rest for a few minutes to permit the
accelerated respiratory rate to return to normal .
Implementation :
1- Introduce self , verify the client’s identity , never to notify
the patient that you will assess respiration
2- Hand washing .
3-Provide for client’s privacy .
4-Observe and count the respiratory rate .
5- Observe the respiration for depth by watching the
movement of the chest , observe for regularity .
6- Document the respiratory rate , rhythm and depth in an
appropriate record
Evaluation
Relate respiratory rate to other vital signs , in
particular pulse , relate respiratory rhythm ,and
depth to baseline data and health status .
Report to the primary care provider a respiratory
rate significantly above or below the normal range
and any notable change in respiration from a
previous assessment .
Conduct appropriate follow up such as
administering oxygen, or other medications
Assessment of Blood Pressure
Purpose :
1-To obtain a baseline measure of arterial
blood pressure for subsequent evaluation .
2- To determine the client’s hemodynamic
status .
3- To identify and monitor changes in blood
pressure resulting from a disease processes
.
Equipment
Sphygmomanometer
• Aneroid
• Mercurial
Stethoscope
Sphygmomanometer
Pediatric
Adult
Parts of stethoscope
Earpieces- should fit snugly and follow
the natural curve of the ear canal, point
toward the face when it is in place
Tubing- 12-18 inches long, longer tubing
decreases the transmission of sound
waves
Parts of a stethoscope
Diaphragm= circular, flat surfacetransmits high pitched sounds ( Bowel,
lung, heart sounds
Bell= bowl shaped- transmits low pitched
sounds (heart and vascular sounds)
Assessment
1- Signs & symptoms of hypertension ( headache ,
ringing in the ears , flushing of the face
,nosebleeds, fatigue ).
2- Signs & symptoms of hypotension ( tachycardia
, dizziness, mental confusion , restlessness cool
and clammy skin, pale or cyanosis )
3- Factors affecting blood pressure ( stress ,
activity , pain and time of last caffeine .)
4- Some blood pressure cuffs contains latex .
Assess the client for latex allergy and obtain a
latex –free cuff if indicated .
Planning
Equipment :
1- stethoscope
2-Blood pressure cuff (appropriate size)
Sphygmomanometer
Preparation :
1-Ensure that the equipment is intact and functioning well
2- Make sure that the client has not smoked within 30
minutes
Implementation
Preparation :
1-Ensure that the equipment is intact and
functioning well
2- Make sure that the client has not smoked within
30 minutes
Performance :
1- Introduce self , verify the client’s identity ,
explain to the client what will you do, why and how
2- Hand washing .
3-Provide for client’s privacy .
4-Take the accurate reading of
blood pressure and Document the
finding in the client’s record .
5-Hand wash
Evaluation
1- Relate blood pressure to other vital
signs , to baseline data .
2- Report any significant changes in
client’s blood pressure .
3- Conduct appropriate follow up ,
medication administration .
THANK
TOU