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MEASURING OF VITAL SIGNS
Definitions of Vital Signs Alterations in body function often are reflected in body temperature, the pulse, respiration, and the pressure. • Physiological mechanisms governing them are very sensitive and normally keep them regulated within a narrow range.
MEASURING OF VITAL SIGNS
• Any change from normal is considered to be an indication of the person’s state of health. • Hence, these signs provide excellent clues to the physiological functioning of the body. • That is why they are called vital signs or cardinal signs.
Frequency of obtaining vital signs
• Obtaining a person’s vital signs is part of most agency admission procedures. • These data provide part of the baseline information from which a plan of care is developed.
Frequency of obtaining vital signs
• After patient is admitted to a health agency, local policies govern when and how frequently vital signs are to be obtained. • It is common policy for patient having elevated temperatures and for those who are in the post operative period to have vital signs obtained every 4 hours. • Severely ill patients may have these observations made more frequently. • In some self – care and psychiatric unit. • Temperature, or other vital signs disturbances, there seems to be little justification for observations these signs several times a day.
.• The introduction of monitoring devices has made it possible to keep patients vital signs under constant surveillance in hospital setting. • This has been a lifesaving measure for many patients because it provides a far more accurate means of observations the effects of pathology and therapy.
blooded animals are poikilothermic. frogs and reptiles are poikilothermic. .BODY TEMPERATURE • Humans are homoeothermic. Fish . • Cold. that is they are warm – blooded and maintain body temperature independently of their environment.. meaning their body temperature is the same as their environment.
• There are various ways in which the body’s thermal balance is maintained.Temperature Regulation • Body temperature is maintained through a balance between heat production and heat loss. .
• Exercise produces heat by stimulating metabolism. More heat is produced when metabolism is increased. . norepinephrine and thyroxin. • Heat production is increased by the body’s secretions of epinephrine . and less when metabolism is decreased.Temperature Regulation • Heat is produced through the metabolism of food.
. but this is of lesser significance that heat produced chemically. • As much as 95% is lost through radiation convection and through evaporation of water from the lungs and skim. • Heat is dissipated from the body primarily through physical processes.• The body gains heat physically from its environment.
• Heat is loss in small amounts through the urine and feces and in raising the temperature if inspired air to body temperature. . • The construction of smooth muscles when gooseflesh occurs and when the involuntary movement of skeletal muscles when shivering is present. produce heat by stimulating metabolism and conserve heat by constricting superficial vessels in the skin. • Changes in the vascularity of the skin modify body temperature.
.Normal Body Temperature • A thermometer is placed in the patient’s: – mouth to obtain an oral temperature – in the anal canal to obtain a rectal temperature – in axilla to obtain an axillary temperature – and in the esophagus to obtain a core temperature. for optimal functioning. • The body’s organs require a fairly constant internal or core temperature.
6 0 F RECTAL 37.6 0F ESOPHAGEAL 37. 5 0C 99.5 0F AXILLARY 36.Average Normal Temperature Well Adults in various Body Sites ORAL 37 0C 98.5 0 C 97.3 0C 99.2 0F .
usually above 41 0C (106 0F )and survival is rare when it reaches 44 0C ( 110 0F ). The lay term is fever. • Pyrexia is a common symptom of illness. . • and there is sufficient evidence to indicate that an elevation in temperature helps the • temperature helps the body fights disease.Elevated Body Temperature • Pyrexia is am elevation of normal body temperature. • Hyperpyrexia is a high fever.
• Observing for other signs as body temperature rises is important.Elevated Body Temperature • The patient with fever usually experiences: – – – – – – – – loss of appetites headache hot dry skin flushed face Thirst general malaise depression and occasionally periods of delirium. such as decreased urinary output and dehydration of the skin and mucous membranes .
the bulb and the stem. which. will expand when exposed to heat and therefore.2 0 C ( 1080 F ). The stem is calibrated in degrees and tenths of a degrees. It has two parts. The range is approximately 34 0 C.The Thermometer • A glass clinical thermometer is most commonly used to measure body temperature. • The bulb contains mercury. since it is metal. . rise in the stem. (94 0 F ) to approximately 42. • The bulb and the stem.
2.4. abbreviated C and F. it is common practice to report to the nearest tenth of a degree.8 • If the mercury appears to be a bit more or less than an even tenth.6 and 0. 0.The Thermometer • Fractions of degrees usually are recorded in tenths such as 0.0. . • The thermometer is calibrated in either degrees of centigrade ( Cesius ) or Farenheit.
irrational and seizure prone patients • Infants and young children • Persons who breath through the mouth • Persons with diseases of the oral cavity • Patients who have had surgery • If pt. has had either hot or cold food or fluids • If pt. Receiving nasal oxygen • Pts receiving oxygen by mask . Contraindication: • Unconscious.Selecting Site for Obtaining Body Temperature Obtaining an Oral Temperature – This is most common. has been smoking or chewing gum • Pts.
This is ordinarily recommended whenever obtaining an oral temperature is contraindicated.Selecting Site for Obtaining Body Temperature Obtaining a Rectal Temperature . Some hospitals require rectal readings on small patients with an elevated temperature. Contraindications: • Patients having rectal surgery • Diarrhea • Any disease of the rectum • Patients with certain heart diseases . It is also a recommended practice to check the temperature rectally if the body temperature of the patient having an oral temperature obtained regularly changes considerably and unexpectedly.
• However this opinion is being challenged by some authorities. . since the temperature of water and the friction created by drying the skin can influence the temperature can be influenced by the presence of fecal matter to cause a false high reading.Selecting Site for Obtaining Body Temperature • A rectal temperature has been considered to be more accurate than an oral or axillary temperature. since studies have that rectal temperature should be delayed.
Some hospitals obtain temperature by axillary method on normal newborns.This is generally obtained only when both oral rectal temperatures are contraindicated or when the sites are not accessible.Selecting Site for Obtaining Body Temperature • Obtaining an Axillary Temperature . .
Selecting Site for Obtaining Body Temperature • If the axilla has just been washed. obtaining temperature should be delayed. since the temperature of water and the friction created by drying the skin can influence the temperature. • Most authorities believe that when proper procedure is used. axillary temperature are as accurate as oral rectal temperatures .
which on Palpation. can be felt as an impact or light up. This expansion of the sends a wave through the walls of the arterial system. the arterial walls in the blood system expand or distend to compensate for the increase in pressure. which is the upper part of the atrium.PULSE • The stimulus for contraction of the hearts in the sinoauricular or sinoatrial node. . Because the node sets the pace of the beat. it is often called the pacemaker. • Each time the left ventricle of the heart contracts to ejects blood into an already full aorta. The sensation of impact or tap is called the pulse.
. • The pulse rate of average healthy adult man is approximately 60 to 65 beats per minute.Pulse Rate • Upon awakening in the morning. • The pulse rate women is slightly faster about 7 to 8 beats per minute more than me.
. slender. • It has been noted than the body size and built of a person may affect the pulse rate.Pulse Rate • Pulse rate varies with age. gradually diminishing from birth to adulthood and then increasing somewhat in old age. stout ones. • Tall. persons often have a slower rate than short.
trained athletes may have a normal resting rate of 45 to 50 beats per minute . • Many authorities accept 60 to 100 beats per minute at rest as a normal pulse rate. However it has been noted that well.Pulse Rate • Very wide variations in pulse rate have been noted in normal people.
anger.anxiety.Factors that will cause an increase in pulse rate: • • • • • • • Pain Strong emotions ( fear. surprise ) Exercise Prolonged application of heat Decrease in blood pressure Elevated temperature Condition resulting to poor oxygenation of blood .
Average Pulse Rate per Minute for Well Persons AGE Birth PULSE RATE PER MINUTE 120 1 Year 5 Year 10 years Adolescent Adult 110 95 85 80 75 .
. • A site should not produce or discomfort to the patient because this could alter the pulse rate.Common Sites for Palpating Pulse • Most commonly. • If is not possible to palate the pulse at the wrist. because it is easily accessible and it can be pressed against the radius. the radial artery at the wrist is used for palpating the pulse rate. other superficial arteries of the body that overlie a bone may be use .
facial and temporal arteries are the most common alternate sites to obtain the pulse rate.Common Sites for Palpating Pulse • The carotid. .
.RESPIRATION • Respiration. begins with act of breathing and includes the body’s use of oxygen and the elimination of carbon dioxide. in its broader sense.
• Internal respiration . and the elimination of carbon dioxide. • External respiration includes lung ventilation. the absorption of oxygen. . sometimes called tissue respiration includes the use of oxygen by body cells for the production of heat through oxidation and the liberation of energy from the food we eat.RESPIRATION • Inspiration or inhalation is the act of breathing. and expiration or exhalation is the act of breathing out.
the ratio. • The respiratory rate is more rapid in infants and young children. healthy adults breathe approximately 16 to 20 times a minute. . being one respiration to approximately four heart beats. • It has been noted that the relationship between the pulse rate and the respiratory rate is fairly consistent in well persons.Respiratory Rate • Under normal conditions.
6 C ( 1 F ) the temperature rises above normal. • The rate will increase as much as four breaths per minute with every 0. . • When body temperature is elevated.Respiratory Rate • During illness. the reparatory rate increases as the body attempt to rid itself of excess heat and as metabolism increases. the respiratory rate may very from normal.
. • An increase in intracranial pressure will depress the respiratory center. • Certain drugs also depress the respiratory rate. morphine sulfate being an example. slow breathing or both. resulting in irregular or shallow. • There are conditions that characteristically predispose to slow breathing.Respiratory Rate • Any conditions involving an accumulation of carbon dioxide and a decrease in oxygen in the blood will tend to increase the rate and depth of respiration.
VITAL SIGNS: PROCEDURE .
Assess patients readiness for the procedure.Procedure 1. Wash your hands . Anxiety may alter the result of the procedure. Identify factors that may alter 3. 2. Identify the patient – Rationale: Be sure that the patient is well informed regarding of the procedure.
Procedure 4. Prepare the necessary equipment: – Thermometer – Sphygmomanometer – Cotton balls – Stethoscope – Receptacle for used cotton balls – Alcohol – Watch with second hand – Small notebook and pen .
Explain the procedure 6. To read the calibration accurately. Be sure that the room. – Rationale. lightning is adequate. 7.Procedure 5. Proceed with the following . it must be held in a good light.
portion where your fingers are. – Rationale. wipe It with one firm rotary motion from the bulb to stem. If disinfectant has not been rinsed.Temperature A.Oral A. Discard the cotton balls. Direction of wipe is from the cleanest. Take the thermometer from its container. Note the difference here in direction in wiping thermometer AFTER it has been used .
Repeat if necessary until the mercury falls to 35 0 C . Hold thermometer firmly between thumb and first two fingers. Shake down the thermometer this way: – Rationale. O0 C or lower. Check to see that the mercury is 35. Keep then wrist loose bring hand upward then give the wrist a quick Vigorous jerk downward.Temperature B. If thermometer are requisitioned from central supply they will have to be shaken down. Stand in a clear space away from furniture.
Wait for 5-7 minutes then remove . on a chair while the temperature is being taken. Place the thermometer on the sublingual base of the tongue. have him sit. If the patient is out on bed. .Temperature C. Rationale. wipe with cotton on a Twisting motion from fingers to the bulb and read.
. Shake down the thermometer and lubricate the bulb end. then read and clean. Remove.5 inches into the rectum. Rectal A. Insert at least 1.Temperature B. Hold in place for 3-5 minutes.
do not bear weight on the chest. –Rationale. Place tip of the thermometer in the center of the armpit and keep the arm tight against side of the chest for 3-5 minutes. If patient is weak.Temperature C. . Axillary A. Remove and read.
pulse • PULSE . .While waiting for the time for the temperature to lapsed. You can proceed taking the pulse – Rationale. Avoid grasping patient’s wrist in palm of your hand and clamping your fingers tightly around it. Too much pressure can easily erase pulse.
Position patient’s arms along side of the body. • Rationale. • The selection of the site for taking the pulse will depend on the condition of the patient. . Use your watch with second hand. Lightly. Never use thumb as it has a pulse of its own that may easily be confused with that of the patient.pulse • RADIAL PULSE . place two fingers over radial pulse with arm across the chest. Count Pulse for I full minute.
– Rationale. Breathing is easily controlled by the Individual and it is difficult for the patient to breathe naturally if he knows his respiration is being counted.RESPIRATORY RATE a) Respiration is counter without the patient knowing it. .
Counting respiration is just as important as taking temperature and counting pulse. c) the respiration and count them by looking at the chest as it rises and falls. You may be the first person to notice a sudden change in the breathing rate which may be very important to your patient. – Rationale.RESPIRATORY RATE b) Leave your hand on the wrist after finish counting with the pulse. .
BLOOD PRESSURE A. Place the patient in a comfortable lying or sitting position with the forearm supported at the level of the heart. – Rationale. B. Check if the BP cuff is appropriate for the patient . Reading will be more accurate when person is in reclining position. .
BLOOD PRESSURE C. . which means you can take a more accurate reading. when you are sitting. – Rationale. Bending over the arm is a poor body mechanic and places strain on the back. Position yourself so that the BP apparatus will be on eye level. the thermometer on either type of apparatus will be more nearly at eye level. Also.
– Rationale. and a misleading reading may result.BLOOD PRESSURE D. If the rubber bag inside the material of cuff is twisted. Place the cuff snugly at about 1-2 inch above the inner elbow of the patient. the pressure over the artery may be uneven. .
The tips of the earpieces should be at the ear not against the skin elsewhere. – Rationale.BLOOD PRESSURE E. . Place the stethoscope earpieces in your ears and close the screw of the bulb.
Inflate accordingly: If the patient is hypersensitive. inflate as much as 200 mmHg or higher and 160 mmHg if not. – Rationale.BLOOD PRESSURE G. the blood is cut off entirely ( no sound is heard via the stethoscope ) Inflating the cuff slowly or sending mercury to a higher level than necessary is very uncomfortable for the patient. When the cuff is inflated. .
. Therefore. – Rationale.BLOOD PRESSURE F. the stethoscope must be over the artery. Palpate for the pulse beat over brachial artery on the inner aspect of the elbow and place the diaphragm of the stethoscope. To obtain an accurate reading. Do not allow the stethoscope to touch the clothing or cuff. it is necessary to know where the artery (bronchial) is and where the pulsation is usually strong.
Allow the remaining to escape quickly then remove the cuff – Rationale. If air released too fast. Note the first soft but distinctive sound as the systolic and the last soft but Distinctive sound as the diastolic. when the first sound was heard. To deflate. . there is no way to tell at what level the mercury column was. release the screw evenly and slowly.BLOOD PRESSURE H.
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