Transcript Chapter_36 Patient Interview and History

CHAPTER
37
Vital Signs and
Measurements
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37-2
Learning Outcomes (cont.)
37.1 Describe the five vital signs.
37.2 Identify various methods of taking a
patient’s temperature.
37.3 Describe the process of obtaining pulse
and respirations.
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37-3
Learning Outcomes (cont.)
37.4 Carry out blood pressure
measurements.
37.5 Summarize orthostatic or postural vital
signs.
37.6 Illustrate various body measurements.
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37-4
Introduction
• Vital signs
– Temperature
– Pulse
– Respirations
– Blood pressure
– Pain assessment
• Body
measurements
– Height
– Weight
– Head
circumference
Vital signs and body measurements are used
to evaluate health problems.
Accuracy is essential.
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37-5
Vital Signs
• Provide information about patient’s overall
condition
• Taken at each visit
• Protected health information – HIPAA
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37-6
Vital Signs (cont.)
• Include
– Temperature
• Standard range of
values
– Pulse
– Respirations
• Patient baseline
– Blood pressure
– Pain assessment
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37-7
Vital Signs (cont.)
• Follow OSHA Guidelines
– Wash hands before and after patient contact
– Wear gloves as appropriate
– Dispose of waste appropriately
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37-8
Apply Your Knowledge
Why is accuracy important when taking vital
signs?
ANSWER: Vital signs provide information
about how a patient will adjust to changes
within the body and environment. They
may also help the physician make a
diagnosis.
Yahoo!
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37-9
Temperature
• Febrile – elevated temperature
– Fever ~ sign of inflammation or infection
– Hyperpyrexia ~ extremely high temperature
• Afebrile ~ normal temperature
• Balance between heat produced and lost
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37-10
Temperature (cont.)
Ear – tympanic
Mouth – oral
Temperature
Routes
Rectum - rectal
Axilla – axillary
Temporal Artery –
temporal
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37-11
Temperature (cont.)
• Measurements
– Degrees Fahrenheit (ºF)
– Degrees Celsius (centigrade; ºC)
• Normal adult oral temperature
– 98.6 ºF
– 37.0 ºC
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37-12
Electronic Digital Thermometers
• Electronic digital thermometer
• Tympanic thermometer
• Temporal scanner
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37-13
Disposable Thermometers
• Single use
• Indicators change color
• Oral, axillary or skin temperature measurements
• Not as accurate
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37-14
Taking Temperatures
• Measure to nearest tenth
of a degree
Heat pockets
• Oral temperatures
– Place under tongue in either
pocket just off-center in
lower jaw
– Wait at least 15 minutes
after eating, drinking, or
smoking
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37-15
Taking Temperatures (cont.)
• Tympanic temperatures
– Proper technique
essential
– Fit in ear must be
snug
• Adult – pull ear up
and back
• Child – pull ear
down and back
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37-16
Taking Temperatures (cont.)
• Rectal temperatures
– Use Standard Precautions
– Position patient on left side
– Slowly and gently insert tip
– Hold thermometer in place
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37-17
Taking Temperatures (cont.)
• Axillary temperature
– Have patient sit or lie down
– Place tip in middle of axilla
– Probe must touch skin on all sides
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37-18
Taking Temperatures (cont.)
• Temporal temperatures – stroke scanner
across forehead, crossing over the
temporal artery
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37-19
Apply Your Knowledge
Correct!
You are about to take the temperature of a 6-month-old
infant being seen at the pediatrician’s office for vomiting
and diarrhea. Which route will you use and why? What
special considerations do you need to keep in mind with
this specific patient situation and why?
Answer: Route would be either tympanic or temporal
since a 6-month-old would not be able to hold the
thermometer under his/her tongue. If using the
tympanic thermometer remember to use proper
technique and pull the ear down and back. Use
Standard Precautions to prevent the spread of
microorganisms.
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37-20
Pulse and Respiration
Circulatory
Respiratory
Pulse
Respirations
Pulse and respirations are related because the
heart and lungs work together.
Normally, an increase or decrease in one causes
the same effect on the other.
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37-21
Pulse
• Indirect measurement of cardiac output
• Problems if pulse is
– Abnormally fast ~ tachycardia
– Slow ~ bardycardia
– Weak or irregular
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37-22
Pulse (cont.)
• Measure at the radial artery
• Count for 1 minute
– Rhythm ~ regular or irregular
– Volume ~ weak, strong,
bounding
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37-23
Pulse (cont.)
• Other locations to obtain pulse
– Brachial artery
– Apex of the heart – using a stethoscope
– Additional arterial sites
•
•
•
•
•
•
Temporal
Carotid
Femoral
Popliteal
Posterior tibial
Dorsalis pedis
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37-24
Pulse (cont.)
• Electronic measurement devices
– Part of Blood pressure machine
– Pulse oximetry unit
• Attaches to finger,
nose or earlobe
• Infrared light measures
pulse and oxygen levels
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37-25
Respiration
• Respiratory rate – indication of how well the
body provides oxygen to the tissues
• Check by watching, listening, or feeling
movement
• May use stethoscope
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37-26
Respiration (cont.)
• Count for one full
minute
– Rate
• Irregularities include
– Hyperventilation
– Dyspnea
– Rhythm ~ regular
– Quality of effort ~
normal, shallow, or
deep
– Tachypnea
– Hyperpnea
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37-27
Respiration (cont.)
• Rales
• Rhonchi
– Crackling sounds
– Fluid in the lungs
– Pneumonia,
atelectasis,
pulmonary edema
– Deep snoring or
rattling
– Partial obstruction
of airway
– Asthma, acute
bronchitis
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37-28
Respiration (cont.)
• Cheyne-Stokes respirations
– Periods of increasing and decreasing depth of
respiration between periods of apnea
– Strokes, head injuries, brain tumors,
congestive heart failure
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37-29
Apply Your Knowledge
Correct!
A 26-year-old athlete visits the medical office for a routine
checkup. The medical assistant takes T-P-R and obtains
the following: Temperature 98.8°F, Pulse 52
beats/minute, and Respirations 18/minute. What should the
medical assistant do about these results?
ANSWER: The temperature and pulse are within
the normal range. The pulse of 52 is below the
normal range. Check the patient’s previous vital
sign results. Some patients normally have a low
pulse rate, so these results may be within normal
limits for this patient.
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37-30
Blood Pressure
• The force at which blood is pumped
against the walls of the arteries
• Standard unit of measurement is
millimeters of mercury (mmHg)
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37-31
Blood Pressure (cont.)
• Two pressure measurements
– Systolic pressure ~ measure of pressure
when left ventricle contracts
– Diastolic pressure
• Measure of pressure when heart relaxes
• Minimum pressure exerted against the artery walls
at all times
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37-32
Blood Pressure (cont.)
• Blood pressure classifications
– Normal
– Prehypertension
– Stage 1 hypertension
– Stage 2 hypertension
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37-33
Factors Affecting Blood Pressure
• Hypertension
– Classifications
• Essential
• Secondary
• Malignant
Hypertension
– Internal factors
•
•
•
•
Cardiac output
Blood volume
Vasoconstriction
Viscosity
• Hypotension
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37-34
Blood Pressure Measuring Equipment
• Sphygmomanometer
– Inflatable cuff
– Pressure bulb or
automatic device for
inflating cuff
– Manometer to read the
pressure
– Types
• Aneroid
• Electronic
• Mercury
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37-35
Blood Pressure Measuring Equipment (cont.)
• Aneroid sphygmomanometers
– Circular gauge for registering pressure
– Each line 2 mmHg
– Requires use of a
stethoscope
– Must be calibrated to
maintain accuracy
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37-36
Measurement Equipment (cont.)
• Electronic sphygmomanometers
– Digital readout
– Easy to use but costly
– Maintain equipment
according to
manufacturer’s
instructions
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37-37
Measurement Equipment (cont.)
• Mercury sphygmomanometers
– A column of mercury rises
with an increased pressure
as the cuff is inflated
– No longer available
for purchase
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37-38
Calibrating the Sphygmomanometer
• Calibrate – standardize a measuring
instrument
• Be certain sphygmomanometer is
calibrated prior to use
– To ensure it is working correctly
– To ensure accurate results
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37-39
The Stethoscope
• Amplifies body sounds
• Earpieces
• Chestpiece
– Diaphragm –
high-pitched sounds
– Bell – low-pitched
sounds
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37-40
Measuring Blood Pressure
• Place cuff on the
upper arm
• Palpatory method
• Release the air in cuff
and listen for vascular
sounds
• Inflate cuff 30 mmHg
above palpatory result
• Place the stethoscope
over the brachial pulse
point
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37-41
Measuring Blood Pressure (cont.)
• Korotkoff sounds
Phase 1 – tapping sound; systolic pressure
Phase 2 – change to softer swishing sound
Phase 3 – resumption of a crisp tapping sound
Phase 4 – sound becomes muffled
Phase 5 – sound disappears; diastolic pressure
• Record pressure – 120/76
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37-42
Measuring Blood Pressure (cont.)
• Adults – special considerations
– Allow patients to relax prior to obtaining a
measurement if
• Post exercise
• Ambulatory disabilities
• Obese
• Known blood pressure problems
• Anxiety or stress
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37-43
Measuring Blood Pressure (cont.)
• Adult considerations (cont.)
– Avoid measurement in an arm
• On the same side as a mastectomy
• With an injury or blocked artery
• With an implanted device under the skin
– Use the proper cuff size to obtain accurate
results
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37-44
Apply Your Knowledge
A 67-year-old patient is in the medical office
complaining of a headache. The blood pressure
reading was 212/142. What should the medical
assistant do in this situation?
ANSWER: This pressure reading is very high and
should be reported to the physician at once. The
complaint of headache should also be reported to the
physician. Hypertension is a major contributor to
stroke and heart attacks.
Very Good!
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37-45
Orthostatic or Postural Vital Signs
• Orthostatic or postural hypotension
– Blood pressure drops, pulse increases as
patient stands up
– Assess for by checking BP and pulse in three
positions
– Positive tilt test – pulse increases more than
10 bpm and BP drops more than 20 mmhg
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37-46
Apply Your Knowledge
Mr. Arnaz complained to the physician that he was dizzy
when he stood up. The physician asked you to do a “tilt
test”. Mr. Arnaz’s BP lying down is 128/80 and pulse is 88
bpm. You check his BP and pulse sitting and standing. His
standing BP is 110/58 and pulse is 100 bpm. What is his
problem and what may be the causes?
ANSWER: Mr. Arnaz has a positive tilt test so he has
orthostatic hypotension. This may be caused by
dehydration, heart disease, diabetes, some
medications, or a nervous system disorder.
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37-47
Body Measurements
• Adults and older
children
– Height
– Weight
• Infant
– Length
– Weight
– Head
circumference
Provide baseline values for current condition and enable
monitoring of growth and development of children.
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37-48
Body Measurements (cont.)
• Adult weight
– Each office visit
– Record to nearest
quarter of a pound
• Height of adults
– Initial visit and
yearly
– Record to nearest
quarter of an inch
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37-49
Body Measurements (cont.)
• Body mass index (BMI)
– Reliable indicator
of healthy weight
– Based on height
and weight
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37-50
Other Body Measurements
• Diameter of limb – measure both to
determine difference in size
• Wound, bruise, or other injury – length and
width
• Infant’s chest circumference
• Adult’s abdominal girth
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37-51
Apply Your Knowledge
The medical assistant is about to weigh a 6-month-old
infant using the infant scale. When the medical assistant
places the infant on the scale she notices the diaper is very
soiled. What should the medical assistant do?
ANSWER: The diaper could be changed prior to weighing. However,
if the infant is weighed with the soiled diaper, the medical assistant
should weigh the diaper after weighing the infant and subtract the
difference to obtain the infant’s accurate weight.
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37-52
In Summary
37.1 Vital signs include temperature, pulse,
respirations, blood pressure, and
assessment of pain.
37.2 Using either an electronic digital or
disposable thermometer, a patient’s
temperature may be measured by the oral,
tympanic, rectal, axillary, or temporal
method.
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37-53
In Summary (cont.)
37.3 Pressing lightly at the radial artery using your
fingers, count the number of beats you feel in
1 minute to get the pulse.
While still keeping fingers on the patient’s
pulse site, observe and feel the patient’s
respirations, and count the respirations for
one full minute. See Procedure 37-2.
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37-54
In Summary (cont.)
37.4 To obtain a blood pressure, have the patient
sit in a quiet area, rest his or her bared arm
on a flat surface at heart level, locate the
brachial artery, snugly secure the cuff above
the brachial artery, use the palpatory method
to determine the approximate systolic
pressure, use a stethoscope to auscultate
the systolic and diastolic blood pressure.
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37-55
In Summary (cont.)
37.5 Orthostatic or postural vital signs consist of
taking the blood pressure and pulse in different
positions, from lying to sitting to standing,
waiting 2 to 5 minutes between repositioning to
allow the body’s systems to adjust to the
change.
36.6 For adults and older children the
measurements obtained are the height and
weight; for infants they are the weight, length,
and head circumference. BMI, extremities and
wounds are also measured.
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37-56
End of Chapter 37
One way to get high blood
pressure is to go mountain
climbing over molehills.
~ Earl Wilson
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in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.