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1 Vital Signs Adapted from: Health and Physical Assessment in Nursing D’amico & Barbarito.

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Presentation on theme: "1 Vital Signs Adapted from: Health and Physical Assessment in Nursing D’amico & Barbarito."— Presentation transcript:

1 1 Vital Signs Adapted from: Health and Physical Assessment in Nursing D’amico & Barbarito

2 Objectives By the end of this lesson, the student will: –Compare methods used to measure body temperature. –Describe the purpose of and methods for measuring heart rate. –Discuss techniques used for measurement of respiratory rate. –Describe the purpose of and methods for measuring blood pressure. –Recall the normal ranges of vital signs across age groups. –Discuss variables that affect the measurement of vital signs. 2

3 Vital Signs Vital signs include temperature, pulse, respiratory rate, blood pressure and pain 3

4 4 Vital Signs Vital signs are an outward clue to what is going on in the patient’s body

5 5 Vital Signs Baseline vital signs provide a basis for comparison of later sets of vital signs.

6 6 Vital Signs It is important to monitor “trends” in vital signs rather than individual sets of vital signs

7 7 Temperature Temperature is the measure of body heat. Heat is lost from the body by respiration, perspiration and excretion. Heat is generated by shivering, vasoconstriction and inhibition of sweating. The balance between the heat produced and the heat lost is the body temperature.

8 8 Factors Influencing Body Temp Exercise Age Diurnal variations Illness Stress Hormones

9 9 Types of Thermometers Glass (Mercury) – a hollow glass tube with calibration lines on it. Aural (Tympanic) – Sensor measures body temp. Chemically Treated Paper or Plastic – read by noting color it changes to. Electronic/Digital Thermometers – Temp is registered on a screen.

10 A SMALL HOLLOW GLASS TUBE THAT CONTAINS MERCURY OR A MERCURY-FREE SUBSTANCE IN A BULB AT ONE END.WHEN HEATED THE MERCURY RISES IN THE TUBE. Pear – shaped tip

11 o BATTERY OPERATED o HAVE AN ORAL PROBE AND A RECTAL PROBE o DISPOSABLE PROBE COVER IS PLACED ON THE PROBE o THE TEMPERATURE REGISTERS IN ABOUT 30 SECONDS

12 o MEASURES THE TEMPERATURE IN THE TYMPANIC MEMBRANE (EARDRUM) o FAST AND ACCURATE - 1 TO 3 SECONDS INFANTS – PULL THE EAR STRAIGHT BACK ADULTS AND CHILDREN OVER ONE YEAR – PULL THE EAR UP AND BACK

13 Temporal Thermometer Digital, takes temperature on forehead Press button down and sweep probe across forehead; This is fairly new technology, but seems to be relatively accurate and very quick and easy to use 13

14 14 Temperature Sites Oral – 98.6 or 37 Rectal – 99.6 or 38 Tympanic – 98.6 or 37 Axillary – 97.6 or 36.4 Temporal – 99.6 or 38

15 15 Terms Afebrile – temperature is within normal range. Febrile – temperature is elevated Hypothermia – temperature is below normal. Pyrexia – above normal temperature Pyrogenic – any substance that produces fever.

16 Pulse rate The number of time your heart beats per minute. 16

17 17 Pulse Pulse Points Carotid Brachial Radial Femoral Popliteal

18 18 Pulse Pulse Points Dorsal Pedal Posterior Tibial (Posterior and slightly inferior to medial Malleolus)

19 19 Pulse Rate bpm Less than 60 bpm is considered a slow pulse rate – bradycardia Over 100 bpm is considered fast – tachycardia.

20 20 Pulse –Rhythm Regular Irregular

21 21 Pulse –Quality Full (bounding) Weak (Thready) Elasticity

22 22 Factors Affecting Pulse Rate Age Gender Exercise Stress Fever Hemorrhage Medications Position changes

23 23 Terms Arrythmia – any deviation from the normal heart rate. Bradycardia – abnormally slow heartbeat. Pulsation – rhythmic beat. Tachycardia – abnormally fast heartbeat.

24 Respiration Respiratory rate is the number of respirations per minute. 24

25 25 Respirations Rate –Adult Resp/min –Child Resp/min

26 26 Respirations Rate –Newborn resp/min –3-9 y.o. – resp/min –10-15 y.o. – resp/min –16-adult – resp/min

27 27 Respirations –Rhythm Regular Irregular

28 28 Respiration –Quality Full Deep Shallow Labored Noisy

29 29 Factors Increasing Respiration Exercise Anxiety Respiratory Disease Medication Pain Heart disease (CHF)

30 30 Factors Decreasing Respiration Relaxation Depression Head injury Medication

31 31 Terms Dyspnea – Difficulty breathing. Apnea – Absence of respirations. Cheynes-Stokes – Periods of labored respirations followed by apnea. Rales – Bubbling or rattling sounds caused by mucus in the air passages.

32 32 Blood Pressure Systolic - Pressure on the arterial wall when the heart contracts Diastolic - Pressure on the arterial wall when the heart is at rest

33 The measurement of the amount of force blood exerts against the arterial walls. Systolic: Pressure exerted when the heart muscle contracts Diastolic: Pressure exerted when the heart muscle relaxes between beats. SYSTOLIC /DIASTOLIC 120/80 BP is measured in mm of Hg

34 Average adult systolic range is 100 to 140 Average adult diastolic range is 60 to 90 Hypertension Hypotension

35 o Do not take blood pressure on an arm with an IV, cast or shunt. o Do not take a blood pressure on the side of a mastectomy. o Blood pressure should be taken with the person sitting or lying. o Cuff should be applied to bare upper arm, should be the correct size and should be snug. oThe room should be quiet

36 36 Blood Pressure Auscultated BP - Listening for both the systolic and diastolic values Palpated BP - Feeling for the systolic pressure

37 o AGE o GENDER o BLOOD VOLUME o STRESS o PAIN o EXERCISE o WEIGHT o RACE o DIET o MEDICATIONS o POSITION

38 38 Terms Diastolic – least force of pressure exerted against the walls of arteries. Hypertension – high BP Hypotension – low BP Stethoscope –instrument used to amplify sound Systolic – greatest force of pressure exerted against the walls of the arteries

39 39 Sphygmomanometer Instrument used to measure BP Sphygmo – refers to pulse Mano – refers to pressure Meter – refers to measure

40 THE PROPER NAME FOR A BLOOD PRESSURE CUFF IS SPHYGMOMANOMETER MERCURYANEROID

41

42 Korotkoff Sounds First Phase –A clear tapping sound; onset of the sound for two consecutive beats is considered systolic Second Phase –The tapping sound followed by a murmur Third Phase –A loud crisp tapping sound

43 Korotkoff Sounds Cont. Fourth Phase –Abrupt, distinct muffling of sound, gradually decreasing in intensity Fifth Phase –The disappearance of sound, is considered diastolic blood pressure- two points below the last sound heard

44 Steps for Measuring Blood Pressure Seated for 5 minutes Patient Position Expose Upper arm Center of upper arm at heart level

45 Steps for measuring cont. Cuff applied 1 inch above crease at elbow Locate brachial artery Palpate radial pulse Inflate cuff until pulse disappears

46 Steps for measuring cont. Let air out Place stethoscope on brachial artery Pump up cuff to above point of obliteration Let air out at 2 mmHg per second

47 PAIN Pain means to ache, hurt, or be sore. Pain is a warning from the body. Pain is personal. Types of pain –Acute pain – felt suddenly from an injury, disease, trauma, or surgery –Chronic pain – lasts longer than 6 months. Pain can be constant or occur on and off. –Radiating pain – felt at the site of tissue damage and in nearby areas. –Phantom pain – felt in a body part that is no longer there.

48 Signs and symptoms –Location – Where is the pain? –Pattern – When did the pain start? –Intensity – Rate the pain on a scale of 1 to 10, with 10 as the most severe –Description – Can you use words to describe the pain? –Precipitating factors– What were you doing when the pain started? –Vital signs – Take the person’s vital signs when they complain of pain. –Other signs and symptom Body responses - ↑ vital signs, nausea, pale skin, sweating, vomiting Behaviors – crying, groaning, holding affected body part, irritability, restlessness

49 Pain Assessment Scales Pain can be assessed using scales. 49


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