Vital Signs Measurement Guide PDF

Vital signs Temperature, pulse, blood pressure, respirations and oxygen saturation are the most frequent measurements obtained by health care practitioners. Body temperature Body temperature is the difference between the amount of heat produced by body...

Vital signs Temperature, pulse, blood pressure, respirations and oxygen saturation are the most frequent measurements obtained by health care practitioners. Body temperature Body temperature is the difference between the amount of heat produced by body processes and the amount of heat lost to the external environment. The core temperature, or temperature of the deep body tissues, is under control of the hypothalamus and remains within a narrow range. temperature range, from 36.0_C 37.5_C Core temperatures are measured at tympanic or rectal sites, surface body temperatures are measured at oral (sublingual), axillary, and skin surface sites. NOTE: - rectal temperatures are usually 0.5° C higher than oral temperatures. Axillary and tympanic temperatures are usually 0.5° C lower than oral temperatures. Assessment and implementation 1-Determine if the patient has a disease of the oral cavity; earache; significant ear drainage or a scarred tympanic membrane. 2-Determine if the patient has had surgery of the nose, mouth, or rectum; has diarrhea or diseases of the rectum; or scar tissue, open lesions, or abrasions in the temporal areas. 3-Ask the patient if he or she has recently smoked, has been chewing gum, or was eating and drinking. 5-If the thermometer is stored in a chemical solution, wipe the thermometer dry with a soft tissue, using a firm twisting motion. Wipe from the bulb toward the fingers 6- shake the thermometer until the chemical line reaches at least 35 C 7- Read the thermometer by holding it horizontally at eye level 8-For oral use, place the bulb of the thermometer within the back of the right or left pocket under the patient’s tongue and tell the patient to close the lips around the thermometer. 9-Leave the thermometer in place for 3 minutes (for oral use); 2 to 3 minutes (for rectal use); and 10 minutes (for axillary use) 10-Wash thermometer in soapy water. Rinse it in cool water. Oral temperature Advantages Easily accessible—requires no position change Comfortable for patient Provides accurate surface temperature reading Reflects rapid change in core temperature Hyperthermia: - is the elevation of body temperature above 37.5 C Hypothermia: - body temperature becomes under 36 C  Peripheral pulses by palpation The pulse is a throbbing sensation that can be palpated over a peripheral artery, such as the radial artery or the carotid artery. Characteristics of the pulse, including rate (regular or irregular) and rhythm (strong or weak) provide information about the effectiveness of the heart as a pump and the adequacy of peripheral blood flow. Pulse rates are measured in beats per minute. The normal pulse rate for adolescents and adults ranges from 60 to 100 beats per minute. Equipment Watch with second hand or digital readout Nonsterile gloves, if appropriate; additional PPE, as indicated Assessment and implementation 1- the most common site for obtaining a peripheral pulse is the radial pulse. 2-Apical pulse measurement is the preferred method of pulse assessment for infants and children less than 2 years of age 3-Place your first, second, and third fingers over the artery. Lightly compress the artery so pulsations can be felt and counted. 4-Using a watch with a second hand, count the number of pulsations felt for 30 seconds. Multiply this number by 2 to calculate the rate for 1 minute. NOTE: If the rate, rhythm of the pulse is abnormal in any way, palpate and count the pulse for 1 minute.  Assessing respiration It’s the number of breath per minute (inhalation and exhalation). healthy adults breathe about 12 to 20 times per minute. Characteristics of breath include depth (shallow or deep) Rhythm (regular or irregular)  Move immediately from the pulse assessment to counting the respiratory rate to avoid letting the patient know you are counting respirations.  Patients should be unaware of the respiratory assessment because, if they are conscious of the procedure, they might alter their breathing patterns or rate.  Implementation 1-While your fingers are still in place for the pulse measurement, after counting the pulse rate, observe the patient’s respirations. 2- Note the rise and fall of the patient’s chest 3- Using a watch with a second hand, count the number of respirations for 30 seconds. Multiply this number by 2 to calculate the respiratory rate per minute. 4- If respirations are abnormal in any way, count the respirations for at least 1 full minute.  Assessing Blood pressure by auscultation (brachial artery auscultation) 1-position the cuff (3-5cm) above elbow 2- position the cuff marker on the brachial artery 3- put the stethoscope on the brachial artery Blood pressure refers to the force of the blood against arterial walls. Blood pressure consists of systolic and diastolic Systolic pressure is the highest point of pressure on arterial walls when the ventricles contract and push blood through the arteries (pumping the blood) Diastolic pressure is the lowest pressure on the arterial wall it happens when the heart is relaxed (filling with blood) Blood pressure measured in millimeters of mercury (mm Hg) Equipment Stethoscope Sphygmomanometer Implementation 1-position the cuff (3-5cm) above elbow 2- position the cuff marker on the brachial artery 4-Wrap the cuff around the arm smoothly and snugly, and fasten it. Do not allow any clothing to interfere the proper placement of the cuff. 5-Palpate the pulse at the brachial or radial artery by pressing gently with the fingertips 6-Tighten the screw valve on the air pump. 7-Inflate the cuff while continuing to palpate the artery. Note the point on the gauge where the pulse disappears. 8-Deflate the cuff and wait 1 minute Now we can take blood pressure 8- put the stethoscope on the brachial artery 9-Pump the pressure 30 mm Hg above the point 10-open the valve gradually until you hear the first beat (it’s the systolic pressure) 11-continue to open the valve gradually until the sound of beats disappears completely (it’s the diastolic pressure)