Patient Assessment Vital Signs Are

Patient Assessment

Vital Signs • • Are important indicators of health Detect changes in normal body function May signal life-threatening conditions Provide information about responses to treatment

Vital Signs • • Temperature Pulse Respirations Blood Pressure • Oxygen level per protocol – Pulse Oximeter

Vital Signs Are Measured: As often as required by the person’s condition or physician’s orders. Examples: – Upon admission – Before & after surgery and other procedures – After a fall or accident – When prescribed drugs that affect the respiratory or circulatory system – When there are complaints of pain, dizziness, shortness of breath, chest pain.

When Measuring Vital Signs • Usually taken with the person sitting or lying • The person is at rest • Always report: – A change from a previous measurement – Vital signs above or below the normal range – If you are unable to measure the vital signs

Temperature • Measurement of balance between heat lost and produced by the body. – Heat is produced by: • Metabolism of food • Muscle and gland activity – Heat may be lost through: • Perspiration, Respiration, Excretion • Measured with the Fahrenheit (F) or Celsius or Centigrade (C) scales

Body Temperature • Factors that body temperature • • • Illness Infection Exercise Excitement High temperatures in the environment • Temperature is usually higher in the evening • • Starvation or fasting Sleep Decreased muscle activity Exposure to cold in the environment

Temperature Sites • Oral - by mouth – most common method – May be affected by hot or cold food, smoking, oxygen, chewing gum – Wait 15 minutes or use alternate site • Rectal - in the rectum -most accurate site – Do not use if patient has rectal surgery or bleeding • Axillary - under arm – less reliable site – Used when other sites are inaccessible – Do not use immediately after bathing

Temperature Sites • Tympanic or aural - in the ear – Measures in 1 to 3 seconds • Temporal Artery – temporal artery on the forehead • Record route temperature was taken • • O - Oral R- Rectal T – Tympanic A – Axillary

Normal Body Temperature Oral 98. 6 ( 97. 6 - 99. 6) Rectal 99. 6 (98. 6 - 100. 6) Axillary 97. 6 (96. 6 - 98. 6) Typmanic 98. 6 (98. 6 - 100. 6) Temporal 99. 6 (98. 6 - 100. 6) Hypothermia – temperature below normal Hyperthermia – temperature above normal

Types of Thermometers • Electronic: Used orally, rectally, or axillary. Must use disposable probe covers. • Tympanic: Placed in auditory canal and must use disposable cover. • Strips: Strip that contains special chemicals or dots that change colors.

Pulse • The pressure of blood pushing against the wall of an artery as the heart beats and rests. • Measured for one minute while noting: Rate - beats per minute Rhythm - regular or irregular Volume - strength or intensity - described as strong, weak, thready, bounding

Pulse Sites Most Commonly Used: • • Carotid Apical Brachial Radial (most common site to check pulse) • • Femoral Popliteal Dorsalis Pedis Posterior tibial artery

Normal Ranges Age Pulse per Minute Birth to 1 year 80 -190 2 years 80 -160 6 years 75 -120 10 years 70 -110 12 years & older 60 -100 Bradycardia – Under 60 beats per minute Tachycardia – Over 100 beats per minute

Factors that Affect Pulse • Factors that pulse • • • Exercise Stimulant drugs Excitement Fever Shock Nervous tension Sleep Depressant drugs Heart disease Coma

Respirations • Process of breathing air into (inhalation) and out of (exhalation) the lungs. • Oxygen enters the lungs during inhalation. • Carbon dioxide leaves the lungs during exhalation. • The chest rises during inhalation and falls during exhalation. • Normal rate 12 -20 breaths per minute

Assessing Respiration • Respirations are measured when the person is at rest. • Rate may change if patient is aware that it is being counted. • To prevent this, count respirations right after taking a pulse. • Keep your fingers or stethoscope over the pulse site. • To count respirations, watch the chest rise and fall.

Assessing Respiration • Character and quality of respirations is also assessed: – – – Deep Shallow Labored or difficult Noises – wheezing, stertorous (a heavy, snoring type of sound) Moist or rattling sounds • Dyspnea – difficult or labored breathing • Apnea – absence of respirations • Cheyne-Stokes – periods of dyspnea followed by periods of apnea; often noted in the dying patient • Rales – bubbling or noisy sounds caused by fluids or mucus in the air passages

Blood Pressure • Measure of the pressure blood exerts on the walls of arteries • Blood pressure is controlled by: – The force of heart contractions • weakened heart drop in BP – The amount of blood pumped with each heartbeat • loss of blood drop in BP – How easily the blood flows through the blood vessels • Narrowing of vessels increase in BP • Dilatation of vessels decrease in BP

Factors that Affect Blood Pressure Factors that blood pressure • Excitement, anxiety, nervous tension • Stimulant drugs • Exercise and eating Factors that blood pressure • Rest or sleep • Depressant drugs • Shock • Excessive loss of blood

Measuring BP • A sphygmomanometer is used to measure BP – Aneroid – has a round dial and needle – Mercury – has a column of mercury – Electronic – automated device • BP is measured in millimeters (mm) of mercury (Hg). • The systolic pressure is recorded over the diastolic pressure.

Normal Range of Blood Pressure • Systolic: Pressure on the walls of arteries when the heart is contracting. • Diastolic: Constant pressure when heart is at rest • Hypertension—BP that remains above a systolic of 140 mm Hg or a diastolic of 90 mm Hg • Hypotension—Systolic below 90 mm Hg and/or a diastolic below 60 mm Hg

Measuring Height and Weight • Used to determine if patient is underweight or overweight • Height and weight charts are used as averages • BMI or Body Mass Index a statistical measure of body weight based on a person's weight and height. • BMI from 18. 5 to 24. 9 is considered normal

Measuring Height and Weight General Guidelines: • • Use the same scale every day Make sure the scale is balanced before use Weigh the patient at the same time each day Remove jacket, robe, and shoes before weighing OBSERVE SAFETY PRECAUTIONS! Prevent injury from falls and the protruding height lever. Some people are weight conscious. Make only positive comments when weighing patients

Types of Scales • Clinical scales: balanced manually or digital with an attached or detached measuring rod for height. • Bed scales or Chair scales: used for patients unable to stand • Infant scales: balanced manually or digital – When weighing an infant…keep one hand slightly over but not touching the infant – A tape measure is used to measure infant height.