Vital Signs PDF

**Vital Signs** [Learning Objectives:] After successful completion of this lecture, the students will be able to: 1. Interpret different value of vital signs. 2. Measuring vital signs to a child. **[Measuring body temperature (oral method)]:** Equipment: ---------- 1. 2. 3. +----------...

**Vital Signs** [Learning Objectives:] After successful completion of this lecture, the students will be able to: 1. Interpret different value of vital signs. 2. Measuring vital signs to a child. **[Measuring body temperature (oral method)]:** Equipment: ---------- 1. 2. 3. +-----------------------------------------------------------------------+ | **Procedure: Learning guide for measuring oral body temperature** | +=======================================================================+ | **Getting ready:** | +-----------------------------------------------------------------------+ | 1. Wash hands | +-----------------------------------------------------------------------+ | 2. Prepare the Equipment | +-----------------------------------------------------------------------+ | 3. Verify the correct child using two identifiers | +-----------------------------------------------------------------------+ | 4. Explain the procedures to the child and his parents | +-----------------------------------------------------------------------+ | 5\. Assess the risk factors, medical history, and cause of the | | child\'s underlying condition. | +-----------------------------------------------------------------------+ | 5. Review current medication therapy | +-----------------------------------------------------------------------+ | 6. Check thermometer to see the reading. | +-----------------------------------------------------------------------+ | 7. Clean thermometer from bulb to the tip. | +-----------------------------------------------------------------------+ | 8. Shake down the level of mercury to below 35 C. | +-----------------------------------------------------------------------+ | 9.Wait several minutes after the child takes oral medication, | | receives mouth care, or drinks hot or cold fluids. | +-----------------------------------------------------------------------+ | **DURING THE PROCEDURE** | +-----------------------------------------------------------------------+ | 1. Insert the oral thermometer under the tongue, slightly off the | | midline in the sublingual pocket. | +-----------------------------------------------------------------------+ | 2. Remind the child to close the lips and mouth and not to bite or | | talk with the thermometer in place for 3 minutes. | +-----------------------------------------------------------------------+ | 3. Remove thermometer and wipe it from up to down to the bulb (from | | the tip to the bulb). | +-----------------------------------------------------------------------+ | 4. Hold the thermometer at eye level and rotate it slowly until | | mercury column is visible | +-----------------------------------------------------------------------+ | 5. Take the reading. | +-----------------------------------------------------------------------+ | **After The Procedure** | +-----------------------------------------------------------------------+ | 1\. Record the temperature | +-----------------------------------------------------------------------+ | 2\. Wash thermometer with soap and water. | +-----------------------------------------------------------------------+ | 3\. Keep equipment in their place | +-----------------------------------------------------------------------+ **[Measuring body temperature (Axillary method):]** Equipment --------- 1. Mercury glass thermometer. 2. Alcohol swabs, dry swabs, and receptacle for used swabs. 3. Watch and kidney basin for used thermometer. +-----------------------------------------------------------------------+ | Procedure: Learning guide for measuring axillary body temperature | | | |  | +=======================================================================+ | 1\. Repeat steps (1-9) from the previous procedure. | +-----------------------------------------------------------------------+ | **During the procedure** | +-----------------------------------------------------------------------+ | 1\. Rinse and dry axilla. | +-----------------------------------------------------------------------+ | 2\. Place the bulb of the thermometer in the apex of the axilla, | | ensuring contact between the skin of the arm and skin of the chest. | +-----------------------------------------------------------------------+ | 3\. Hold the arm next to the side of the chest, keeping the | | thermometer under the arm for 5 minutes. | +-----------------------------------------------------------------------+ | 4\. Remove thermometer and wipe it from up to down to the bulb. | +-----------------------------------------------------------------------+ | 5\. Hold the thermometer at eye level and rotate it slowly until | | mercury column is visible | +-----------------------------------------------------------------------+ | 6\. Take the reading. | +-----------------------------------------------------------------------+ | **After The Procedure** | +-----------------------------------------------------------------------+ | 1\. Record the temperature | +-----------------------------------------------------------------------+ | 2\. Wash thermometer with soap and water. | +-----------------------------------------------------------------------+ | 3\. Keep equipment in their place | +-----------------------------------------------------------------------+ **N.B:** Axillary temperature prevents intrusive procedures and rectal perforation. Temperature may be affected by poor perfusion or use of radiant warmers in neonates. **[\ Measuring body temperature (Rectal method):]** Rectal temperature is not recommended in children with rectal surgery, diarrhea, or those receiving chemotherapy that affects mucosa. Equipment --------- 1. Mercury glass thermometer, 2. Alcohol swabs, dry swabs receptacle for used swabs, 3. Watch, kidney basin for used thermometer. 4. Lubricant (Vaseline). +-----------------------------------------------------------------------+ | **Learning guide for measuring rectal body temperature** | | | |  | +=======================================================================+ | ##### Getting Ready | +-----------------------------------------------------------------------+ | 1\. Repeat steps (1-9) from the previous procedure. | +-----------------------------------------------------------------------+ | 2\. Ensure adequate privacy. | +-----------------------------------------------------------------------+ | ##### During The Procedure | +-----------------------------------------------------------------------+ | 1\. Rinse and dry the anal area. | +-----------------------------------------------------------------------+ | 2\. Place the child in the side-lying position with the hips flexed | | or, if preferred, the prone or supine position. The side-lying | | position with the hips flexed is the optimal position. | +-----------------------------------------------------------------------+ | 3\. Expose only the necessary area during the procedure | +-----------------------------------------------------------------------+ | 4\. Separate the buttocks with the thumb and forefinger of one hand | | while gently inserting a well-lubricated rectal thermometer with | | the other hand. | +-----------------------------------------------------------------------+ | 5\. Insert it through the anal sphincter into the rectum for one | | minute a maximum of 2.5 cm (1 inch) for children and 1.5 cm | | (approximately ½ inch) for infants; do not force the thermometer if | | there is resistance | +-----------------------------------------------------------------------+ | 6\. Remove the thermometer and wipe with swab from up to down the | | bulb. | +-----------------------------------------------------------------------+ | 7\. Hold the thermometer at eye level and rotate it slowly until | | mercury column is visible | +-----------------------------------------------------------------------+ | 8\. Take the reading. | +-----------------------------------------------------------------------+ | **After the Procedure** | +-----------------------------------------------------------------------+ | 1\. Record the temperature | +-----------------------------------------------------------------------+ | 2\. Wash thermometer with soap and water. | +-----------------------------------------------------------------------+ | 3\. Keep Equipment in their place | +-----------------------------------------------------------------------+ **[Other forms of measuring temperature ]** 1.  2. **[Tympanic temperature: ]** **[\ Measuring (Apical pulse)]** #### Pulse can be measured, apical, femoral, temporal and brachial. Apical pulse is most popular for infants and children under 2-3 years. Pulse should not be measured after crying, bathing, feeding. **[Purposes]** 1. To count pulse rate per one minute 2. Assess pulse characteristics (rate, rhythm, strength). Equipment: **Watch, stethoscope, alcohol swab** +-----------------------------------------------------------------------+ | **Learning guide for measuring (Apical pulse)** | | | | aid5493318-v4-728px-Take-an-Infant\'s-Pulse-Step-7 | +=======================================================================+ | **GETTING READY** | +-----------------------------------------------------------------------+ | 1.Wash hands | +-----------------------------------------------------------------------+ | 2\. Prepare the Equipment | +-----------------------------------------------------------------------+ | 3\. Verify the correct child using two identifiers. | +-----------------------------------------------------------------------+ | 4\. Explain the procedures to the child and his parents | +-----------------------------------------------------------------------+ | 5\. Determine the need to assess the apical pulse. An apical HR | | should be assessed in the following circumstances: | | | | - When the child is younger than 2 years of age | | | | - When the child is on a digitalis preparation (toxicity can cause | | arrhythmias) | | | | - When the child had a known cardiac arrhythmia | | | | - When the child has an irregular radial pulse | | | | - When there is concern regarding the ability to assess the radial | | pulse accurately | +-----------------------------------------------------------------------+ | 6.Assess for risk factors for alterations in apical pulse. | +-----------------------------------------------------------------------+ | **DURING THE PROCEDURE** | +-----------------------------------------------------------------------+ | 1\. Wipe earpieces and diaphragm with alcohol swab. | +-----------------------------------------------------------------------+ | 2\. Help the child to relax as much as possible. | +-----------------------------------------------------------------------+ | 3\. Warm the diaphragm of the stethoscope by placing it in the palm | | of the hand for 5 to 10 seconds. | +-----------------------------------------------------------------------+ | 4\. Put the diaphragm between the fourth and the fifth intercostals | | spaces just below the nipple. | +-----------------------------------------------------------------------+ | 5\. Auscultate for normal S1 and S2 heart sounds (heard as | | "lub-dub"). | +-----------------------------------------------------------------------+ | 6\. If apical rate is regular, count for 30 seconds and multiply by | | 2. If apical rate is irregular, or if the child is younger than 2 | | years of age or is receiving cardiovascular medication, count for a | | full minute (60 seconds). | +-----------------------------------------------------------------------+ | **AFTER THE PROCEDURE** | +-----------------------------------------------------------------------+ | 1\. Wipe the earpieces and the diaphragm with alcohol. | +-----------------------------------------------------------------------+ | 2\. Record your finding | +-----------------------------------------------------------------------+ | 3\. Return used equipment | +-----------------------------------------------------------------------+ | 4\. Wash hands | +-----------------------------------------------------------------------+ #### Radial Pulse Equipment**: Watch with a second hand** #### +-----------------------------------------------------------------------+ |  | +=======================================================================+ | **GETTING READY** | +-----------------------------------------------------------------------+ | 1.Wash hands | +-----------------------------------------------------------------------+ | 2\. Prepare the Equipment | +-----------------------------------------------------------------------+ | 3\. Verify the correct child by using two identifiers. | +-----------------------------------------------------------------------+ | | +-----------------------------------------------------------------------+ | 5\. Determine the need to assess pulse rate and quality. | +-----------------------------------------------------------------------+ | 6\. Assess for risk factors for alterations in radial pulse. | +-----------------------------------------------------------------------+ | **DURING THE PROCEDURE** | +-----------------------------------------------------------------------+ | 1\. Place the tips of the first two or middle three finger over the | | groove along the radial side of the child\' inner wrist | +-----------------------------------------------------------------------+ | 2\. Lightly compress against the radius, and then relax the pressure | | so that the pulse becomes palpable. | +-----------------------------------------------------------------------+ | 3\. After the pulse can be felt regularly, use watch second to count | | the rate. | +-----------------------------------------------------------------------+ | 4\. If pulse rate is regular, count for 30 seconds and multiply by 2 | | | | If pulse rate is irregular, or if the child is younger than 2 years | | of age or is receiving cardiovascular medication, count for a full | | minute (60 seconds). | +-----------------------------------------------------------------------+ | **AFTER THE PROCEDURE** | +-----------------------------------------------------------------------+ | 1. Record your finding | +-----------------------------------------------------------------------+ | 2. Return used Equipment | +-----------------------------------------------------------------------+ | 3\. Wash hands | +-----------------------------------------------------------------------+ Purposes 1. 2. Equipment: **Hand watch with a second** +-----------------------------------------------------------------------+ | | +-----------------------------------------------------------------------+ | | +-----------------------------------------------------------------------+ | #### 2. Prepare Equipment (hand watch with a second or clock) | +-----------------------------------------------------------------------+ | | +-----------------------------------------------------------------------+ | | +-----------------------------------------------------------------------+ | 1. | +-----------------------------------------------------------------------+ | 2. | +-----------------------------------------------------------------------+ | 3. | +-----------------------------------------------------------------------+ | 4. | +-----------------------------------------------------------------------+ | 5. | +-----------------------------------------------------------------------+ | 6. | +-----------------------------------------------------------------------+ | 7. | +-----------------------------------------------------------------------+ | 8. 9. 10. | +-----------------------------------------------------------------------+ | 11. | +-----------------------------------------------------------------------+ | 12. | +-----------------------------------------------------------------------+ | 13. | +-----------------------------------------------------------------------+ | ##### After The Procedure | +-----------------------------------------------------------------------+ | ##### **1. Record on patent's chart respiration for rate, depth, and | | rhythm** | +-----------------------------------------------------------------------+ | | +-----------------------------------------------------------------------+ | | +-----------------------------------------------------------------------+ Note: Respiratory rate should be measured before measuring temperature and pulse since the child may cry during these procedures