Measuring Vital Signs: Temperature, Pulse, Respirations & Blood Pressure

CHAPTER 29 Measuring Vital Signs 1 CHAPTER 33 OBJECTIVES 1. Define the key terms and key abbreviations in this chapter. 2. Explain why vital signs are measured. 3. List the factors affecting vital signs. 4. Identify the normal ranges for each temperature site. 5. Explain when to use e...

CHAPTER 29 Measuring Vital Signs 1 CHAPTER 33 OBJECTIVES 1. Define the key terms and key abbreviations in this chapter. 2. Explain why vital signs are measured. 3. List the factors affecting vital signs. 4. Identify the normal ranges for each temperature site. 5. Explain when to use each temperature site. 6. Explain how to use thermometers. 7. Identify the pulse sites. 8. Perform the procedures described in this chapter. 9. Know the normal vital signs for the different age-groups. 10. Describe a normal pulse and normal respirations. 11. Describe the practices to follow when measuring blood pressure. 12. Perform the procedures described in this chapter. 13. Know the normal vital signs for the different age-groups. VITAL SIGNS  Vital signs reflect the function of three body processes essential for life.  Regulation of body temperature  Breathing  Heart function  The four vital signs of body function are:  Temperature (T)  Pulse (P)  Respirations (R)  Blood pressure (BP)  Pain--consider to be a vital sign“5th vital sign” MEASURING & REPORTING VITAL SIGNS  A person’s vital signs vary within certain limits.  Vital signs are affected  Vital signs: by:  Are measured to detect  activity,age, anger, changes in normal body anxiety, drugs, eating, function exercise, fear, illness,  Tell about treatment noise, pain, sleep, response smoking, stress and  Often signal life- weight threatening events  Are part of the assessment step in the nursing process MEASURING AND REPORTING VITAL SIGNS (CONT’D)  Vital signs are measured:  During physical exams  When the person is admitted to a health care agency  As often as the person’s condition requires  Before and after surgery, complex procedures, and diagnostic tests  After some care measures, such as ambulation (walking)  After a fall or other injury  When medications affect the respiratory or circulatory system  When the person complains of pain, dizziness, light- headedness, feeling faint, shortness of breath, a rapid heart rate, or not feeling well  LTC-as stated in the care plan MEASURING AND REPORTING VITAL SIGNS (CONT’D)  Vital signs show even minor changes in the person’s condition.  Accuracy is essential when you measure, record, and report vital signs.  If unsure of your measurements, promptly take them again still question-ask the nurse  Vital signs are recorded in the person’s medical record.  The doctor or nurse compares past and current measurements-treatments can be based on measurements  Take vital signs with the person at rest—lying or sitting, unless otherwise ordered.  Report the following at once:  Any vital sign that is changed from a prior measurement  Vital signs above or below the normal range BODY TEMPERATURE  Body temperature is a balance between amount of heat produced and amount lost by the body.  Thermometers measure temperature.  Fahrenheit (F) and centigrade (C) scales are used.  Temperature sites include:  Mouth, rectum, axilla (underarm), tympanic membrane (ear), and temporal artery (forehead)  Each site has a normal range.  Always report temperatures that are above or below the normal range.  Fever means an elevated body temperature.  Body temperature is lower in the morning and higher in the afternoon and evening.  Body temperature is affected by many factors including pregnancy and the menstrual cycle. BODY TEMPERATURE (CONT’D)  Types of thermometers used:  Standard electronic thermometers  Tympanic membrane thermometers  Temporal artery thermometers  Digital thermometers  Disposable oral thermometers  Temperature-sensitive tape  Pacifier thermometers THERMOMETER TYPES: A, STANDARD ELECTRONIC THERMOMETER. B, TYMPANIC MEMBRANE THERMOMETER. C, TEMPORAL ARTERY THERMOMETER. BODY TEMPERATURE (CONT’D)  Electronic thermometers are commonly used.  Standard electronic thermometers  Measures temperature in a few seconds  They have oral (blue) and rectal (red) probes.  Tympanic membrane thermometers  Measures temperature in 1 to 3 seconds  Risk of spreading infection is reduced.  Hearing aides & hair  Temporal artery thermometers  Measures temperature in 3 to 4 seconds  Measures the temperature of the blood in the temporal artery, which is the same temperature of the blood coming from the heart BODY TEMPERATURE (CONT’D)  Glass thermometers are color coded.  Blue—oral and axillary  Red—rectal  Glass thermometers are reusable. However, the following are problems:  They take a long time to register-3 to 10 minutes depending on the site.  They break easily.  The person may bite down and break an oral thermometer.  If the thermometer contains mercury, swallowed mercury can cause mercury poisoning. PULSE  A pulse is felt every time the heart beats.  The pulse is the beat of the heart felt at an artery as a wave of blood passes through the artery.  Radial pulse is used most often.  Carotid pulse is taken during CPR and other emergencies. PULSE  Pulse sites:  Temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis (pedal) pulses are on each side of the body.  Radial pulse is used most often.  Carotid pulse is taken during CPR and other emergencies.  The apical pulse is felt over the heart.  This pulse is taken with a stethoscope. PULSE (CONT’D)  A stethoscope is an instrument used to listen to the sounds produced by the heart, lungs, and other body organs.  It is used to take apical pulses and blood pressures.  To use a stethoscope:  Wipe the earpieces and diaphragm with antiseptic wipes before and after use.  Place the earpiece tips in your ears.  Ear-pieces should fit snugly to block out noises. They should not cause pain or ear discomfort.  Tap the diaphragm gently.  Place the diaphragm over the pulse site.  Prevent noise. PULSE (CONT’D)  The pulse rate is the number of heart beats or pulses felt in 1 minute.  The rate varies for each age-group.  The adult pulse rate is between 60 and 100 beats per minute. Report abnormal pulses to the nurse at once.  Tachycardia is a heart rate of more than 100 beats per minute.  Bradycardia is a heart rate of less than 60 beats per minute. PULSE (CONT’D)  Rhythm and force of the pulse  Pulse rhythm should be regular (felt in a pattern with the same interval between beats).  An irregular pulse occurs when the beats are not evenly spaced or beats are skipped.  Force relates to pulse strength.  A forceful pulse is described as strong, full, or bounding.  Hard-to-feel pulses are described as weak, thready, or feeble.  Electronic blood pressure equipment can also count pulses.  Some show if the pulse is regular or irregular.  You need to feel the pulse to determine its force. PULSE (CONT’D)  You will take radial most often:  You must accurately:  Count.  Report and record.  The radial pulse is used for routine vital signs.  Count the pulse for 1 full minute  APICAL PULSE Slide 18 PULSE (CONT’D)  The apical pulse is on the left side of the chest slightly below the nipple.  It is taken with a stethoscope.  Count the apical pulse for a full minute.  Count each lub-dub as one beat.  Apical pulses are taken on persons who:  Have heart disease.  Have irregular heart rhythms.  Are taking medications that affect the heart.  Pediatric patients under the age of 2 y/o Slide 19 PULSE (CONT’D)  Taking an apical-radial pulse  The apical and radial pulse rates should be the same.  To see if the apical and radial pulses are equal, two staff members are needed.  One takes the radial pulse.  The other takes the apical pulse.  Doing this at the same time is called the apical-radial pulse.  The pulse deficit is the difference between the apical and radial pulse rates.  To obtain the pulse deficit, subtract the radial rate from the apical rate. Slide 22 PULSE (CONT’D)  Checking pedal pulses  Pedal (dorsalis pedis) pulse is used to check circulation in the foot.  Doppler ultrasound stethoscope (DUS) is used when the pedal pulse cannot be felt.  Your role may include using a DUS. Make sure you:  Have received the necessary training.  Follow the nurse’s directions.  Follow the manufacturer’s instructions. Slide 23 RESPIRATIONS  Respiration means breathing air into (inhalation) and out of (exhalation) the lungs.  Oxygen enters the lungs during inhalation.  Carbon dioxide leaves the lungs during exhalation.  Each respiration involves one inhalation and one exhalation.  The chest rises during inhalation.  The chest falls during exhalation.  The healthy adult has 12 to 20 respirations/min.  Respirations are normally quiet, effortless, and regular. Slide  Heart and respiratory diseases often increase the 26 respiratory rate. RESPIRATIONS (CONT’D)  Count respirations when the person is at rest.  Position the person so you can see the chest rise and fall.  Both sides of the chest rise and fall equally.  The person should not know that you are counting respirations.  Count respirations right after taking a pulse.  Keep your fingers or stethoscope over the pulse site.  To count respirations, watch the chest rise and fall. Slide 27 BLOOD PRESSURE  Blood pressure (BP) is the amount of force exerted against the walls of an artery by the blood.  Blood pressure is controlled by:  The force of heart contractions  The amount of blood pumped with each heartbeat  How easily the blood flows through the blood vessels  Systole is the period of heart muscle contraction-pumping blood  Diastole is the period of heart muscle relaxation. Slide 28 BLOOD PRESSURE (CONT’D)  Systolic pressure—the pressure in the arteries when the heart contracts  Diastolic pressure—the pressure in the arteries when the heart is at rest  Blood pressure is measured in millimeters (mm) of mercury (Hg).  The systolic pressure is recorded over the diastolic pressure.  Blood pressure has normal ranges.  Systolic pressure—90 mm Hg or higher but lower than 120 mm Hg  Diastolic pressure—60 mm Hg or higher but lower than 80 mm Hg Slide 29 BLOOD PRESSURE (CONT’D)  Treatment is indicated for:  Hypertension—When the systolic blood pressure is 140 mm Hg or higher (hyper), or the diastolic blood pressure is 90 mm Hg or higher  Report any systolic measurement at or above 120 mm Hg.  Report any diastolic pressure at or above 80 mm Hg.  Hypotension—Systolic blood pressure is below (hypo) 90 mm Hg, or the diastolic blood pressure is below 60 mm Hg  Report a systolic pressure below 90 mm Hg.  Report a diastolic pressure below 60 mm Hg. Slide 30 BLOOD PRESSURE (CONT’D)  A stethoscope and a sphygmomanometer are used to measure blood pressure.  The sphygmomanometer has a cuff and a measuring device.  These types of sphygmomanometers are used (follow the manufacturer’s instructions):  Aneroid type  Mercury type  Electronic type  Wrist monitor  Blood pressure is normally measured in the brachial artery. Slide 31 STETHOSCOPE: Slide 32 Slide 33 MEASURING BLOOD PRESSURE (BP):  Do NOT take BP on an arm:  With IV infusion  Cast  With dialysis access site  On the side of breast surgery  That is injured  Let the person rest 10-20 minutes  Apply cuff to bare upper arm  Make sure the cuff is snug & size is appropriate  Make sure the room is quiet  Place the entire diaphragm of the stethoscope firmly over the brachial artery MEASURING BLOOD PRESSURE (BP):  Tighten the air-release  Pump the inflation bulb to 180mm Hg (students)  Slowly release the air-release & listen  Measure the systolic & diastolic pressures:  1st sound-systolic  Last sound-diastolic ORTHOSTATIC HYPOTENSION  Orthostatic hypotension (postural hypotension) is abnormally low (hypo) blood pressure when the person suddenly stands  When a person moves from lying or sitting to a standing positions, the B/P drops  Symptoms:  Dizzy and weak,  Sees spots  Syncope (fainting) can occur  Measure blood person supine (Lying)  Position them sitting measure the B/P again  Assist them to stand and recheck B/P again  Report the B/P in the lying, sitting & standing positions and symptoms the patient has  Prevention: Change positions SLOWLY! HEIGHT & WEIGHT  Height and Weight  Then the person is weighed daily, weekly, or monthly to measure weight gain or loss.  Scales used: standing, chair, wheelchair, bed, and lift  Follow these guidelines.  The person wears only a gown or pajamas.  The person voids before being weighed.  A dry incontinence product is worn (if applicable).  Weigh the person at the same time of day-usually in the morning before breakfast  Use the same scale for daily, weekly, and monthly weights.  Balance the scale at zero (0) before weighing the person CIRCULATION PROMOTION  Circulation must be stimulated for blood flow in the legs.  Ifblood flow is sluggish, blood clots may form.  Blood clot (thrombus)—can break loose and travel through the bloodstream  Embolus—a blood clot that travels through the vascular system until it lodges in a blood vessel  Pulmonary embolism—embolus from a vein lodges in the lungs. Severe respiratory problems and death may occur. CIRCULATION Slide 41 CIRCULATION CIRCULATION PROMOTION  Elastic Stockings, Anti-embolism, TED (thrombo- embolic disease) hose  Exert pressure on veins promoting venous blood return to the heart  Prevent blood clots (thrombi, DVT,