Vital Signs PDF

Vital signs (Body Temperature, Pulse Rate, Respiration Rate, Blood Pressure) What are vital signs? Vital signs are measurements of the body's most basic functions. The four main vital signs routinely monitored by medical professionals and health care providers include the following: Body temp...

Vital signs (Body Temperature, Pulse Rate, Respiration Rate, Blood Pressure) What are vital signs? Vital signs are measurements of the body's most basic functions. The four main vital signs routinely monitored by medical professionals and health care providers include the following: Body temperature Pulse rate Respiration rate (rate of breathing) Blood pressure (Blood pressure is not considered a vital sign, but is often measured along with the vital signs.) When to take vital signs (Indications) 1- On a client's admission. 2- According to physician's order. 3- When assessing the client during home visit. 4- Before & a surgical or invasive diagnostic procedure. 5- Before& after the administration of therapy that affect cardiovascular, respiratory& temperature control functions. 6- When the client's general physical condition changes as (loss of consciousness, pain). Vital signs are useful in detecting or monitoring medical problems. Vital signs can be measured in a medical setting, at home, at the site of a medical emergency, or elsewhere. Factors affecting vital signs: Activity, Age, Anger, anxiety, drug, eating, exercise, fear, illness, noise pain, sleep, smoking, stress, weather, weight. Body Temperature What is body temperature? The normal body temperature of a person varies depending on gender, recent activity, food and fluid consumption, time of day, and, in women, the stage of the menstrual cycle. Normal body temperature can range (36.5 º C, or Celsius) to 37.5º C) for a healthy adult. A person's body temperature can be taken in any of the following ways: Orally: Temperature can be taken by mouth using either the classic glass thermometer, or the more modern digital thermometers that use an electronic probe to measure body temperature ( 36.5º C, or Celsius to 37.5º C)  Rectally: Temperature taken rectally (using a glass or digital thermometer) tend to be 0.5 higher than when taken by mouth (37º C, or Celsius) to 38.1º C). Axillary: Temperature can be taken under the arm using a glass or digital thermometer. Temperature taken by this route tend to be 0.5º C lower than those temperatures taken by mouth(35.9 º C, or Celsius) to 37º C) By ear: A special thermometer can quickly measure the temperature of the ear drum, which reflects the body's core temperature (the temperature of the internal organs) (37º C). By skin: A special thermometer can quickly measure the temperature of the skin on the forehead or temporal (37.5º C). Body temperature may be abnormal due to hyperthermia or fever (high temperature) or hypothermia (low temperature). A fever is indicated when body temperature rises about one degree or more over the normal temperature. Hypothermia is defined as a drop in body temperature below 35º C degrees Contra -Indication 1- Do not take oral temperatures on preschool children(Infant) patients receiving oxygen delirious, confused, disoriented, distress patients comatose patients  convulsive patient patients with a naso-gastric tube in place patients who have had oral surgery or mouth sore patients who are vomiting or are quite nauseated 2- Do not take rectal temperatures on ❖ infants or children unless a core temperature is needed ❖ patients who have had rectal surgery or diarrhea ❖ heart disease Duration of taking temperature 1. Tympanic – a couple of seconds – long enough to gently press a Button. 2. Oral (glass thermometer) – three minutes. 3. Axillary (glass thermometer) – five minutes 4. Electronic temperatures – when beep sounds, temperature is obtained 5. Rectal (glass thermometer) - one minute Gather Equipment/Supplies: Thermometer tray consisted of: 1- Dry cotton in alcohol container. 2-Cotton soaked with alcohol. 3- Clean thermometer. 4-Kidney basin for un clean thermometer.  5- Container with water and soap. 6- Watch with seconds. 7- Nursing record. 8- Lubricant (If assessing temperature rectally) 9- Gloves Assess temperature one of the following routes: A. Measuring a Tympanic Membrane Temperature 1. Push the “on” button and wait for the “ready” signal on the unit. 2. Slide disposable cover onto the tympanic probe. 3. Insert the probe snugly into the external ear using gentle but firm pressure, angling the thermometer toward the patient’s jaw line. Pull pinna up and back to straighten the ear canal in an adult. 4. Activate the unit by pushing the trigger button. The reading is immediate (usually within 2 seconds). Note the reading. B. Assessing Oral Temperature Steps Rationale 1-Do thorough hand washing -To reduce number of microorganisms. 2- Clean thermometer in its container with the dry cotton to the patient. 3-Hold thermometer from bottom parallel at eye level. 4-Check the thermometer mercury -Mercury level should be below level. 35ºc to have a correct reading. 5-Ask the patient to open mouth and -The space below the tongue place the bulb under the patient's contains superficial blood vessels tongue directed toward either check. that will transfer the heat. 6-Count three minutes then remove -Secretions on glass will cover the thermometer, wipe it from end to reading. bulb with dry cotton and read it. 7-Shake thermometer down. -Mercury is returned back to its chamber for reuse. 8-Wash with soap under running -Soap, running water& friction water. helps the removal of microorganisms 9-Dry with cotton sponge. -Moist environment helps in the growth of microorganisms 10-Store in its container. - Thermometer made of glass can break easily. 11-Record the temperature on the -Record provides accurate patient's chart. documentation. 12- Collect equipment. C. Assessing Axillary Temperature Steps Rationale 1-Do thorough hand washing -To reduce number of microorganisms 2- Bring clean thermometer in its container with the dry cotton to the patient. 3-Hold thermometer from bottom parallel at eye level. 4-Check the thermometer -mercury level should be mercury level. below 35ºc to have a correct reading. 5- Make sure the axilla is dry and -close contact of the clean, place thermometer bulb in thermometer with the the notch. superficial blood vessels in axilla ensures a more accurate registration of temperature. 6-The forearm is crossing chest and hand resting on opposite shoulder. 7- Hold end of thermometer in place. 8. Count five minutes then -It takes longer to get an remove thermometer. accurate temperature reading. 9- Wipe it from end to bulb with -perspiration on glass will dry cotton and read it. cover on reading. 10- Shake thermometer down. -mercury is returned back to its chamber for reuse. 11 -Wash with soap under -Soap, running water& running water. friction helps the removal of microorganisms. 12- -Dry with cotton sponge. -Moist environment helps in the growth of microorganisms. 13-Store in its container. -Thermometer made of glass can break easily. 14- Record the temperature on - Record provides accurate the patient's chart. documentation. 15-Collect equipments. D. Assessing Rectal Temperature Steps Rationale 1-Do thorough hand -To reduce number of washing microorganisms. 2- Bring clean thermometer in its container with the dry cotton to the patient. 3-Hold thermometer from bottom parallel at eye level. 4-Check the thermometer -mercury level should be below mercury level. 35°c to have a correct reading. 5-Lubricate the bulb and the -lubrication reduced friction area above bulb to (1.5-2.5 and makes it is easier without inches) with lubricant. injuring tissues. 6-Insert the thermometer about 0.5 -1.5 inches ,and hold end of thermometer in place 7- Count one minute then -It take little to get an accurate remove thermometer. temperature reading 8-Wipe it from end to bulb -Fecal matter on glass will with dry cotton and read it. distort reading 9- Shake thermometer - Mercury is returned back to down. its chamber for reuse. 10 -Wash with soap under -Soap, running water& friction running water. helps the removal of microorganisms.  11- Dry with cotton sponge. -Moist environment helps in the growth of microorganisms. 12-Store in its container. -Thermometer made of glass can break easily. 13- Record the thermometer - Record provides accurate on the patient's chart. documentation. 14-Collect equipment. Pulse rate Definition of pulse The pulse is the palpable bounding of the blood flow in the peripheral artery The pulse rate It’s the number of pulsing sensation occurring in one minute. Also it is defined as the measurement of the heart rate, or the number of times the heart beats per minute. As the heart pushes blood through the arteries, the arteries expand and contract with the flow of the blood. Taking a pulse not only measures the heart rate, but also can indicate the following (Heart rhythm &Strength of the pulse) The normal pulse for healthy adults ranges from 60 to 100 beats per minute (b/m). The pulse rate may fluctuate and increase with exercise, illness, injury, and emotions. Females ages 12 and older, in general, tend to have faster heart rates than do males. Athletes, such as runners, who do a lot of cardiovascular conditioning, may have heart rates near 40 beats per minute and experience no problems. Characteristics of pulse ❖ Rate: Normal range is 60 – 100 beats per minute. - Tachycardia (> than 100 b/m) - Bradycardia. (< than 60 b/m) ❖ Quality of pulse is determined as well as rate -Rhythm – regular or irregular -Strength – Bounding or thread (weak) ❖ Circumstances affecting pulse rate. Body temperature Emotions Sites for taking the pulse: 1. Radial artery Felt in wrist at the base of thumb. 2.Brachial Felt in cubital fossa at the median line of artery the arm 3. Apical pulse Heard in left center of chest just below the level of nipple. 4.Temporal Felt in front of ear. artery  5. Dorsal pedis Felt on the back of foot. artery(pedal pulse) 6. Femoral Felt on the groin. artery 7. Carotid On each side at front of neck. artery 8. Popliteal Felt on the back on the knee. artery Posterior tibial Felt behind and below the medial pulse malleolus Equipments: (Watch& nursing record) Procedure for peripheral pulse Steps Rationale 1-Do thorough hand washing. -To reduce number of microorganisms. 2-Explain procedure to patient 3-Place patient in comfortable position either -Uncomfortable position can sitting or lying increase pulse rate. 4-Let patient's hand and arm rest on the bed table or patient's chest 5-Put two or three fingers on the wrist at the base of patient's thumb 6- Do not use thumb to palpate -the thumb has its own pulse because of a main artery present 7-Count pulse for a full minute -Irregularities can be detected more accurately in full minute. 8- Record characteristics of pulse on the - Record provides accurate patient's chart documentation. 9- Report any abnormalities of rate, rhythm and volume Respiration Rate What is the respiration rate? The respiration rate is the number of breaths a person takes per minute. Respiration is normally quiet, effortless, and regular.The rate is usually measured when a person is at rest and simply involves counting the number of breaths for one minute by counting how many times the chest rises. Respiration rates may increase with fever, illness, and with other medical conditions such as (respiratory and heart disease). When checking respiration, it is important to also note whether a person has any difficulty breathing. Assessing Respiration A. Each breath includes inspiration and expiration. B. Measure by observing chest rise and fall. C. Measured in breaths per minute. D. Normal range = 12-20 cycle per minute. E. abnormal increase> than 20 = Tachypnea – if breathing in great depth then called hyperpnoea F. abnormal decrease< than 12 = Bradypnea G. Difficulty in breathing is called dyspnea H.A absence of breathing is called apnea J. Quality of breathing is determined as well as the rate of breathing Depth (deep or shallow) Clarity of breath sounds Pain with breathing Procedure for measuring respiration rate Steps Rationale 1-Do thorough hand washing. 2-Hold patient's hand as if counting the pulse. Don’t tell the person you are counting respiration.  3-Place arm of patient with your hand holding wrist a cross patient's chest. 5-Observe as well abdominal wall. 6-Count inspirations for a full minute 7- Record characteristics of respiration on the patient's chart 8- Report any abnormalities of rate, rhythm and depth. Blood Pressure Definition: The amount of force exerted against the wall of an artery by the blood.you measure systolic and diastolic pressure.The systolic pressure (when the heart contracts) is the pressure in the arteries when the heart contracts.it is the higher pressure. The diastolic pressure (when the heart is at rest) is the pressure in the arteries when the heart is at rest. It is the lower pressure. Purpose: To assess the force of blood ejected against the walls of the vessels i.e. Systolic and diastolic blood pressure. Normal and abnormal blood pressure Systolic pressure: 90mmhg or higher but lower than 120mmhg. Diastolic pressure: 60mmHg or higher but lower than 80 Treatment is indicated for: Hypertension: the systolic pressure is 130mmhg or higher or the diastolic pressure is 80mmhg or higher Hypotension: the systolic pressure is below 90mmhg or the diastolic pressure is below 60mmhg. Principles: 1-Choose a cuff of appropriate size for the patient. A cut which is too large or too small will give false reading. 2- Using the left arm. 3-Cuff should be applied over bare arm; don't place the cuff over clothing..a mercury column should be read at eye level to obtain accurate reading. 4-Brachial pulse is located on the medial aspect of the antecubital apace. 5-Avoid taking blood pressure in case of radical mastectomy and in arm with cast. Equipments: 1- Sphygmomanometers either mercury, aneroid and digital. 2- A stethoscope 3- Alcohol swab 4- Nursing record Procedure: 1-Wash your hands, explain the procedures and assemble equipment. 2-Place the patient in comfortable lying or sitting position.expose left arm.keep it at the level of the heart and the palm is up. 3- Roll the cuff around the upper arm with the cuff's lower edge one inch above the antecubital fossa. 5- Clean ear tips and stethoscope with alcohol swab, place ear tips of stethoscope in your ears pointing forward. Feel the brachial pulse with your fingertips. Place the stethoscope over the artery where you felt the beat.  6- Close the valve of the Sphygmomanometer bulb, and palpate radial pulse ,then pump the bulb 6- Rapidly inflate the cuff to 30mmHg above level previously determined by palpation. 7-Releases pressure to let air come out gradually. 8-Listen with the stethoscope and simultaneously observe the sphygmomanometer. The first knocking sound is the subject's systolic pressure. When the knocking sound disappears, that is the diastolic pressure (such as 120/80mmhg). 9- Records at least systolic and diastolic first and second sounds heard 10- Record reading in patients note. 11-Return equipment to proper place.wash your hands. Medication administration Goals: To improve student the knowledge, skills and positive attitude toward medication administration. Definition: Medication administration is defined as preparing, giving and evaluating the effectiveness of prescription drug. The ten “rights” of drug administration: 1. The right medication