Figure this out… 1.The temperature in the classroom is 86  F. What is that in Celcius? 2.A pt drank 6 oz of juice, 3 cups of water and a half pint of milk. What is the total intake in mLs? 3.You measure a friend that is 5’3” tall. What is her height in centimeters? 4.Your friend weighs 110lbs. What is her weight in kg?

Unit 14 Vital Signs

Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.3 14:1 Measuring and Recording Vital Signs (VS)  Record information about the basic body conditions  Main vital signs (VS) –Temperature- Pain –Pulse- Intake & output –Respiration- Height –Blood pressure- Weight –Oxygen saturation- BMI

Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.4 Other Assessments  Color of skin  Size of pupils and reaction to light  Level of consciousness  Response to stimuli

Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.5 VS Readings  Accuracy is essential  Report abnormality or change immediately  If unable to get reading, ask another person to check

Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.6 14:2 Measuring and Recording Temperature  Measures balance between heat lost and heat produced in the body  Heat produced by metabolism of food and by muscle and gland activity  Homeostasis: constant state of fluid balance  Conversion between Fahrenheit and Celsius

Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.7 Variations in Body Temperature  Normal range  Causes of variations  Temperature measurements – oral, rectal, axillary or groin, and aural  Abnormal conditions affecting temperature

Thermometers  Clinical thermometers –Glass –Electronic –Tympanic –Plastic or paper Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.8

9 Thermometers (continued)  Reading thermometers and recording results  Avoid factors that could alter or change temperature  Cleaning thermometers  Paper/plastic sheath on glass thermometer

Normal Temperature Ranges  Oral:   F   C  Rectal:   F   C  Axillary or Groin:   F   C Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.10

So now…. 1.The temperature in the classroom is 86  F. What is that in Celcius? Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.11

How’d you do? 1.The temperature in the classroom is 86  F. What is that in Celcius? Answer: 30  C Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.12

Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.13 14:3 Measuring and Recording Pulse  Pressure of the blood pushing against the wall of an artery as the heart beats and rests  Major arterial or pulse sites  Pulse rate  Pulse rhythm

Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.14 Measuring and Recording Pulse (continued)  Factors that change pulse rate  Basic principles for taking radial pulse

Your turn…  Check your own pulse and record.  Check the pulse of the person next to you and record.  Now, compare. Are they similar? Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.15

Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.16 14:4 Measuring and Recording Respirations  Measures the breathing of a patient  Process of taking in oxygen and expelling carbon dioxide from the lungs and respiratory tract  One respiration: one inspiration (breathing in) and one expiration (breathing out)

Measuring and Recording Respirations (continued)  Normal respiratory rate –Adults: breaths per minute –Infants: breaths per minute  Words to remember –Dyspnea –Apnea –Tachypnea –Bradypnea Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.17

Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.18 Measuring and Recording Respirations (continued)  Character of respirations  Rhythm of respirations  Abnormal respirations  Voluntary control of respirations  Record information

Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.19 14:5 Graphing TPR  Graphic sheets are special records used for recording TPR  Presents a visual diagram  Uses  Color codes  Factors affecting VS are often noted on the graph

Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.20 Graphing TPR (continued)  Graphic charts are legal records  To correct an error  Basic principles for completing

Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.21 14:6 Measuring and Recording Apical Pulse  Pulse count taken at the apex of the heart  Reasons for taking an apical pulse  Protect the patient’s privacy and avoid exposure  Heart sounds  Abnormal sounds or beats

Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.22 Measuring and Recording Apical Pulse (continued)  Pulse deficit  Use the stethoscope  Placement of stethoscope  Measuring apical pulse  Record all information

Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.23 14:7 Measuring and Recording Blood Pressure  Measurement of the pressure the blood exerts on the walls of the arteries during the various stages of heart activity  Measurements read at two points  Blood pressure is recorded as fractions  Measured in millimeters of mercury on an instrument called a sphygmomanometer

Measuring and Recording Blood Pressure (continued) Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.24

Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.25 Measuring and Recording Blood Pressure (continued)  Types of sphygmomanometers –Mercury –Aneroid –Electronic  Values: SystolicDiastolic Normal Hypertension>140>90 Hypotension<100<70

Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.26 Measuring and Recording Blood Pressure (continued)  Systolic pressure (contraction of the atria)  Diastolic pressure (atria relaxation)  Hypertension – high blood pressure  Hypotension – low blood pressure  Factors influencing blood pressure readings  Individual factors can all influence blood pressure readings

Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.27 Measuring and Recording Blood Pressure (continued)  Factors to follow for accurate readings  Record all required information  Do not reveal the reading to the patient

Now… are these normal?  60/132  154/72  110/64  88/52  186/96 Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.28

Now… are these normal?  60/132 Abnormal (written incorrectly)  154/72Abnormal (systolic HTN)  110/64Abnormal (systolic hypotension)  88/52Abnormal (hypotension)  186/96Abnormal (HTN) Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.29

Measuring and Recording Oxygen Saturation  Measurement of the amount of oxygen carried by the RBCs throughout the body.  The percentage of RBCs that are fully saturated with oxygen is called blood oxygen saturation.  Standard reading is between %. Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.30

Measuring and Recording Pain  Pain is both subjective and objective.  It is assessed each time a staff member is in a patient room.  It is measured on a 0-10 scale. Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.31

Measuring and Recording Intake and Output  Intake and output are generally assessed in the hospital setting a minimum of q8hrs.  Intake: –Oral fluids (including jello, soups, BFs, etc) –IV fluids and IV antibiotics –Tube feedings and flushes  Output: –Urine (per volume or occurance) –Stool (per occurance) –Drain(s) Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.32

So now…. 2.A pt drank 6 oz of juice, 3 cups of water and a half pint of milk. What is the total intake in mLs? Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.33

So now…. 2.A pt drank 6 oz of juice, 3 cups of water and a half pint of milk. What is the total intake in mLs? Answer: 1140 mL Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.34

Measuring and Recording Height and Weight (BMI)  Height is general recorded in inches or centimeters in the health care setting.  It can be obtained using a measuring tape or scale attachment. Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.35

So now…. 3.You measure a friend that is 5’3” tall. What is her height in centimeters? Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.36

So now…. 3.You measure a friend that is 5’3” tall. What is her height in centimeters? Answer: cm Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.37

Measuring and Recording Height and Weight (BMI)  Weight is measured on admission and then daily in some instances.  Weight is generally recorded in kg in the hospital setting. Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.38

So now…. 4.Your friend weighs 110lbs. What is her weight in kg? Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.39

So now…. 4.Your friend weighs 110lbs. What is her weight in kg? Answer: 50 kg Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.40

Measuring and Recording Height and Weight (BMI)  BMI (Body Mass Index) Calculation Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.41

So now…  Using the friend from the previous questions, calculate her BMI. –Height 5’3” –Weight 110 lbs Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.42

So now…  Using the friend from the previous questions, calculate her BMI. Answer: Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED.43