Transcript PN1healthassessment\vital signs

Chapter 9
General Survey and
Vital Signs
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Competencies
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Describe initial assessment
observations.
Discuss factors affecting respiratory
rate.
Perform respiratory rate assessment.
Describe the characteristics that are
included in an assessment of pulse.
Measure apical, radial, and brachial
pulses.
(continues)
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Competencies
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Discuss factors influencing body
temperature.
Compare oral, rectal, axillary, and
tympanic methods for temperature
measurement.
(continues)
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Competencies
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Demonstrate body temperature
assessment techniques utilizing
glass, electronic, and tympanic
thermometers.
Describe factors influencing blood
pressure and blood pressure
measurement.
Describe two methods to measure
blood pressure.
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Vital Signs
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Respiration
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How to assess?
Count for 1 full minute
Normal findings
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Adult rate 12–20 per minute
Abnormal findings
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Tachypnea
Bradypnea
Apnea
(continues)
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Vital Signs
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Pulse
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How to assess?
Count for 1 full minute
Rate
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Rhythm
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Normal range for adults = 60–100 bpm
Regular vs. Irregular
Volume
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Absent to bounding
Use 3- or 4-point scale for measuring
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Factors Affecting Heart
Rate
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Age
Gender
Activity
Emotional status
Pain
Environmental factors
Stimulants
Medications
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Peripheral Pulses
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Pedal
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Dorsalis pedis
Posterior tibialis
Popliteal
Femoral
Brachial
Carotid
Temporal
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Pulses
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Radial
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Location?
How to find?
Count for 30 or 60 seconds
Apical
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Location?
How to find?
Count for 30 or 60 seconds
(continues)
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Pulses
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Rate
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Rhythm
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Tachycardia
Bradycardia
Asystole
Regular vs. Irregular
Dysrhythmias
Volume
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Weak vs. Strong
Copyright 2002, Delmar, A division of Thomson Learning
Vital Signs
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Temperature
Celsius
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How to convert?
5/9 x (temp in °F – 32 degrees)
Fahrenheit
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How to convert?
(9/5 x temp in °C) + 32 degrees
Copyright 2002, Delmar, A division of Thomson Learning
Routes
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Oral
Average
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Range
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36–38° C or 96.8–100.4° F
Advantages
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37.0° C or 98.6° F
Convenient, accessible
Disadvantages
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Safety, physical abilities, accuracy
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Rectal
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Average
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Range
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36.7–38.5° C or 98.0–101.6° F
Advantages
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0.7° C or 0.4° F higher than oral
Most accurate
Disadvantages
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Safety, invasive, uncomfortable
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Axillary
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Average
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Range
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35.4–37.4° C or 95.8–99.4° F
Advantages
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0.6° C or 1° F lower than oral
Safe, noninvasive
Disadvantages
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Accuracy? Length of time to obtain
measurement
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Tympanic
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Average
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Range
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Same as oral and rectal
Advantages
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Calibrated to oral or rectal scales
Convenient, fast, safe
Disadvantages
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Accuracy? Technique affects reading
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Variables Affecting
Body Temperature
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Circadian rhythms
Hormones
Age
Exercise
Stress
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Temperature Variations
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Hyperthermia
Hypothermia
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Blood Pressure
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Force exerted by the flow of blood
pumped into the large arteries
Korotkoff sounds
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Phase I
Phase II
Phase III
Phase IV
Phase V
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Measuring Blood
Pressure
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Systole
Diastole
Pulse pressure
Equipment
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Sphygmomanometer
Aneroid manometer
Mercury manometer
(continues)
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Measuring Blood
Pressure
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Sites
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Brachial
Thigh
Avoid AV shunts or fistulas,
affected arm of postmastectomy
patient
(continues)
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Measuring Blood
Pressure
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Documentation
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Normal findings
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Position of patient
Location where taken
100–140/60–90
Average = 120/80
Hypotension
Hypertension
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Common Errors in
Blood Pressure
Measurements
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Incorrect cuff size
Unrecognized auscultatory gap
Incorrect cuff placement
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Factors Influencing
Blood Pressure
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Stress
White coat syndrome
Medications
Hypervolemia
Hypovolemia
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