Transcript 3.01 Vital Signs

Vital Signs
Vital Signs
• Provide information about body function
• Include:
– temperature
– pulse
– respiration
– blood pressure
• Changes may be the first
sign of disease
• 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.
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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
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)
– Rectal 99.6º (R)
– 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
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Vital Signs
Oral
Temperature
Demonstrate the skill
Provide for guided practice
Provide for independent practice
Verify student passing
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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
Aural
Temperature
Demonstrate the skill
Provide for guided practice
Provide for independent practice
Verify student passing
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Vital Signs
Pulse
Pressure of blood on artery walls as the heart
beats and relaxes
• 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
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Vital Signs
Pulse
When would you use these pulse sites?
Temporal
Carotid
Brachial
Radial
Femoral
Popliteal
Dorsalis pedis
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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
Radial Pulse
Demonstrate the skill
Provide for guided practice
Provide for independent practice
Verify student passing
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Vital Signs
Apical Pulse
• Pulse count taken with the stethoscope.
• Use if the patient has:
– Irregular heartbeat
– Arteriosclerosis
– Weak or rapid radial pulse
– Infants and children
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Vital Signs
Apical Pulse
Demonstrate the skill
Provide for guided practice
Provide for independent practice
Verify student passing
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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
Evaluate for rhythm and character
Rhythm – regular or irregular
Character – depth, ease of breaths
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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
Respirations
Demonstrate the skill
Provide for guided practice
Provide for independent practice
Verify student passing
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Vital Signs
Blood pressure
Pressure of blood on the arterial walls
Recorded as a fraction: 120/80
http://www.csuchico.edu/atep/bp/bp.html
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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Vital Signs
REPORT
ABNORMAL RESULTS
OF ANY VITAL SIGN
IMMEDIATELY
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Vital Signs
Blood Pressure
Demonstrate the skill
Provide for guided practice
Provide for independent practice
Verify student passing
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Vital Signs
Combined Vital Signs
TPR BP
Demonstrate the skill
Provide for guided practice
Provide for independent practice
Verify student passing
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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 with
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 SAFETY PRECAUTONS!
Prevent injury from falls and the
protruding height lever.
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Diagnostic Skills
Measuring Height and Weight
Demonstrate the skill
Provide for guided practice
Provide for independent practice
Verify student passing
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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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Diagnostic Skills
Measure Visual Acuity
Demonstrate the skill
Provide for guided practice
Provide for independent practice
Verify student passing
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