vital signs
DESCRIPTION
Vital Signs. NEO 111 Melanie Jorgenson, RN, BSN. Vital Signs. Temperature (T) Pulse (P) Respiration (R) Blood pressure (BP) Pain (often called the fifth vital sign ) Oxygen Saturation. Occasions for Measuring Vital Signs. Upon admission to a healthcare setting - PowerPoint PPT PresentationTRANSCRIPT
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Vital SignsNEO 111
Melanie Jorgenson, RN, BSN
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Vital Signs Temperature (T) Pulse (P) Respiration (R) Blood pressure (BP) Pain (often called the fifth vital sign) Oxygen Saturation
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Occasions for Measuring Vital Signs
Upon admission to a healthcare setting When certain medications are given Before and after diagnostic and
surgical procedures Before and after certain nursing
interventions In emergency situations
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Body Temperature
Definition: the heat of the body measured in degrees› The difference between production of heat and
loss of heat› Normal temperature: 97.0ºF (36.0ºC) to 99.5ºF
(37.5ºC) Process: heat is generated by metabolic
processes in the core tissues of the body, transferred to the skin surface by the circulating blood, and dissipated to the environment
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Sites for Measurement of Temperatures
Core temperatures› Tympanic and rectal› Esophagus and pulmonary (invasive
monitoring devices) Surface body temperatures
› Oral (sublingual) › Axillary
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Inserting Tympanic Thermometer into Patient’s Ear
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Contraindications to Temperature Measurement sites
Oral: impaired cognitive functioning, inability to close lips around thermometer, diseases of the oral cavity, and oral or nasal surgery
Rectal: newborns, small children, patients who have had rectal surgery, or have diarrhea or disease of the rectum, and certain heart conditions
Tympanic: earache, ear drainage, and scarred tympanic membrane
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Characteristics of the Pulse
Pulse rate› Measured in beats per minute
Pulse quality (amplitude)› The quality of the pulse in terms of its
fullness Pulse rhythm
› Pattern of the pulsations and the pauses between them Normally regular
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Methods of Assessing the Pulse
Palpating the peripheral arteries Auscultating the apical pulse with a
stethoscope Using a portable Doppler ultrasound
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Common Pulse Sites Temporal Carotid Brachial Radial Femoral Popliteal Posterior tibial Dorsalis pedis
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Palpating the Radial Pulse
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Assessing an Apical Pulse
Indications› Patient is receiving medications that alter
heart rate and rhythm› A peripheral pulse is difficult to assess
accurately because it is irregular, feeble, or extremely rapid
Method› Count the apical rate 1 full minute by listening
with a stethoscope over the apex of the heart › Most reliable method for infants and small
children; can be palpated with fingertips
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Assessing Respirations (Normal Findings)
Rate› Adults: 12 to 20 times per minute› Infants and children breathe more rapidly
Depth› Varies from shallow to deep
Rhythm› Regular: each inhalation/exhalation and
the pauses between occur at regular intervals
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Assessing Respiratory Rate, Depth, and Rhythm
Method› Inspection (observing and listening)› Listening with the stethoscope› Counting the number of breaths per minute
Considerations› If respirations are very shallow and difficult
to detect visually, observe sternal notch › Patients should be unaware of the
respiratory assessment to prevent altered breathing patterns
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Factors Affecting Respirations
Exercise Medications Smoking Chronic illness or conditions Neurologic injury Pain Anxiety
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Signs of Respiratory Distress
Retractions Nasal flaring Grunting Orthopnea (breathing more easily in an
upright position) Tachypnea (rapid respirations)
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Sample Nursing Diagnoses Related to Respiratory Status
Ineffective Breathing Pattern Impaired Gas Exchange Risk for Activity Intolerance Ineffective Airway Clearance Excess Fluid Volume Ineffective Tissue Perfusion
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Blood Pressure
Definition› The force of the blood against arterial walls
Systolic pressure › The highest point of pressure on arterial
walls when the ventricles contract Diastolic pressure
› The lowest pressure present on arterial walls during diastole (Taylor, 2007).
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Measuring Blood Pressure
Blood pressure is measured in millimeters of mercury (mm Hg)
Blood pressure is recorded as a fraction› The numerator is the systolic pressure› The denominator is the diastolic pressure
Pulse pressure› The difference between the systolic and
diastolic pressure
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Blood Pressure Assessment (Methods)
Using a stethoscope and sphygmomanometer
Using a Doppler ultrasound Estimating by palpation Assessing with electronic or automated
devices
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Measuring Blood Pressure
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Ensuring an Accurate Blood Pressure Reading
Use a cuff that is the correct size for the patient
Ensure correct limb placement Use recommended deflation rate Correctly interpret the sounds heard
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Factors Affecting Blood Pressure Reading
Age Exercise Position Weight Fluid balance Smoking Medications
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Using a Pulse Oximeter Purpose
› Measure the arterial oxyhemoglobin saturation of arterial blood
Method› A sensor or probe, uses a beam of red and
infrared light which travels through tissue and blood vessels
› The oximeter calculates the amount of light absorbed by arterial blood
› Oxygen saturation is determined by the amount of each light absorbed
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Uses for Pulse Oximetry Monitoring patients receiving oxygen
therapy Titrating oxygen therapy Monitoring those at risk for hypoxia Monitoring postoperative patients
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Questions?