Vital Signs Procedure - Fundamental of Nursing Department - BUC - 2024-2025 Fall Semester PDF

[ ] **Edited By:** **T.A Amany Kamel Mohamed** **Revised By:** **Assist Prof. Lillian Narouz** **[Vital Signs Procedure]** **[Introduction:]** Vital signs are an objective measurement of the essential physiological functions of a living organism. They have the name \"vital\" as their measurem...

[ ] **Edited By:** **T.A Amany Kamel Mohamed** **Revised By:** **Assist Prof. Lillian Narouz** **[Vital Signs Procedure]** **[Introduction:]** Vital signs are an objective measurement of the essential physiological functions of a living organism. They have the name \"vital\" as their measurement and assessment is the critical first step for any clinical evaluation. Vital signs categorized into basic vital signs and additional vital signs. basic (body temperature (BT), pulse/ heart rate (HR), respiration/ breathing (BR), and blood pressure (BP), pain, and oxygen saturation (O2). Moreover, the additional vital signs are level of consciousness (LOC), urine output (UOP), weight (WH), and blood glucose level. Vital signs can be measured in a medical setting, at home, at the site of a medical emergency, or elsewhere. **[Objectives: ]** 1. To assess patient status. 2. To determine baseline values for future comparisons. 3. To detect changes or abnormalities in patient's condition. 4. To detect underlying health problems. 5. Indicators of a person's health condition and normal measurements provide assurance of proper [circulatory](https://www.physio-pedia.com/Cardiovascular_System), [respiratory](https://www.physio-pedia.com/Respiratory_System), [neural](https://www.physio-pedia.com/Introduction_to_Neurophysiology), and [endocrinal](https://www.physio-pedia.com/Hormones) functions. 6. To determine patients at risk of deterioration. 7. To regular monitoring of existing health issues, which lowers the risk of worsening symptoms or severe complications. **[1- Body Temperature: ]** +-----------+-----------+-----------+-----------+-----------+-----------+ | **Route** | **Site** | **Indicat | **Contrai | **Time** | **Reading | | | | ions** | ndication | | ** | | | | | s** | | | +===========+===========+===========+===========+===========+===========+ | **Oral** | Posterior | -Adult | \- | 3 minutes | As it is | | | sublingua | /Consciou | Children | | | | | l | s | | | (The same | | | | Patient. | \- | | reading) | | | | | Patient | | | | | | \- For | who | | | | | | patients | breath | | | | | | who | only by | | | | | | drink, | mouth | | | | | | eat, | | | | | | | smoke, or | | | | | | | chew gum | | | | | | | ***You | | | | | | | should | | | | | | | wait for | | | | | | | 15-20 | | | | | | | minutes** | | | | | | | * | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Axillar | In the | \- | \- | 5-10 | Add 0.5℃ | | y** | arm pit | Children | Axillary/ | minutes | | | | arm | | arm | | | | | across | \- | surgeries | | | | | chest | Unconscio | | | | | | | us | | | | | | | and | | | | | | | disorient | | | | | | | ed | | | | | | | patient | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Rectal* | (Rectum) | \- | \- | 2-3 | Decrease | | * | | Unconscio | Cardiac | minutes | /Subtract | | | Side | us | disease | | 0.5℃ | | | lying | and | patient | | | | | with | disorient | | | | | | upper leg | ed | \- | | | | | flexed | patient, | Anorectal | | | | | | | diseases | | | | | | Restless | | | | | | | patient | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Ear** | **Adult** | \- Fever | \- | For 2-3 | The same | | | -- pull | screening | Hearing | seconds | reading | | | pinna up | | disorders | | | | | & back. | \- | | | | | | | Inability | \- Ear | | | | | **Child** | to | Diseases | | | | | -- pull | utilize | | | | | | pinna | other | | | | | | down & | routes | | | | | | back | | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ **[1- Body Temperature Assessment: ]** ***Normal Body Temperature for Adult is 36.5 -- 37.5 ℃*** **Comment** **Grade** ----------------------- ----------------------- Hypothermia Less than 35 ℃ Subnormal Temperature 35℃: 36.4℃ Normal Temperature 36.5℃: 37.5 ℃ Hyperthermia 37.6℃: 38.3℃ Fever 38.4℃: 39.9℃ Hyperpyrexia 40℃ and more than 40℃ **[2- Pulse Rate Assessment:]** **1- Sites of Pulse: -**  **[2- Pulse Characteristics: ]** ***Normal Pulse/ heart Rate for adult is 60:100b/min*** **Comment** **Character** ------------- ----------------------- ------------------------------- Bradycardia Less than 60 b/min **Rate** Normal 60: 100 b/min Tachycardia Greater than 100b/min Regular **Rhythm** Irregular Absent 0 **Strength/ Volume/ Quality** Weak +1 Normal +2 Bounding +3 **[3- Respiration Characteristics:]** ***Normal Respiration Rate for adult is 12:20 c/min (Eupnoea)*** **Comment** **Character** ------------- ----------------------- ---------- Apnea No Breathing **Rate** Bradypnea Less than 12 c/min Normal 12: 20 c/min Tachypnea Greater than 20 c/min Regular **Rhythm** Irregular Shallow **Depth** Normal Deep **[4- Blood Pressure Assessment:]** ***Normal Blood Pressure Rate for adult is 120/80 mmHg*** **Comment** **Reading** ----------------------------------- ------------------------------------- Normal less than120/80 mmHg Elevated / Pre-Hypertension Stage 120-129/ 80 mmHg Stage I Hypertensive 130-139/ 80-89 mmHg Stage II Hypertensive 140 or greater / 90 or greater mmHg Hypertensive Crisis 180/120 mmHg or above **[Oxygen saturation categorization ranges: -]** Normal values: 95-98% Hypoxia: \