The document discusses measuring and recording vital signs, including temperature, pulse, respirations, blood pressure, and apical pulse. It describes how to take measurements of each vital sign, normal ranges, and factors that can influence readings. Proper techniques for recording readings using graphic sheets or electronic health records are also outlined.
The document discusses measuring and recording vital signs, including temperature, pulse, respirations, blood pressure, and apical pulse. It describes how to take measurements of each vital sign, normal ranges, and factors that can influence readings. Proper techniques for recording readings using graphic sheets or electronic health records are also outlined.
The document discusses measuring and recording vital signs, including temperature, pulse, respirations, blood pressure, and apical pulse. It describes how to take measurements of each vital sign, normal ranges, and factors that can influence readings. Proper techniques for recording readings using graphic sheets or electronic health records are also outlined.
May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 16:1 Measuring and Recording Vital Signs • Vital signs provide information about a patient’s basic body conditions • Temperature – Measure of balance between heat lost and produced by body – Usually measured on Fahrenheit scale
May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 16:1 Measuring and Recording Vital Signs • Pulse – Pressure of blood felt against wall of an artery – Rate: number of beats per minute – Rhythm: regularity – Volume: strength, force, or quality
May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 16:1 Measuring and Recording Vital Signs • Respirations – Patient’s breathing rate • Blood pressure – Force exerted by blood against arterial walls • Apical pulse – Taken with stethoscope at apex of heart
May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 16:1 Measuring and Recording Vital Signs • Pain – Acute or chronic – Patient should describe the feeling – Everyone tolerates pain differently – Use of a 0 to 10 scale
May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Variations in Body Temperature • Oral temperature • Rectal temperature • Axillary temperature • Aural temperature • Temporal temperature
May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Variations in Body Temperature • Hypothermia – Body temperature below 95°F • Pyrexia (fever) – Body temperature above 101°F • Hyperthermia – Rectal body temperature exceeding 104°F
May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Types of Thermometers • Clinical thermometers – Slender glass tube containing mercury – Used by few health care agencies – Danger of mercury contamination • Electronic thermometers – Used in most health care facilities
May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Types of Thermometers • Tympanic thermometers • Temporal scanning thermometers – Accurate and noninvasive for internal body temperature • Plastic or disposable thermometers
May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Reading and Recording Temperature • Record temperature to the nearest two-tenths of a degree • Refer to Figure 16-9 in text • Record to avoid error in reading
May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Cleaning Thermometers • Clean thermometers thoroughly after each use • Use cool water on glass thermometers to prevent breakage • Disposable plastic sheath may be used • Follow agency policies
May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 16:3 Measuring and Recording Pulse • Pulse – Pressure of blood pushing against the wall of an artery as the heart beats and rests • Major arterial or pulse sites – Refer to Figure 16-18 in text
May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 16:4 Measuring and Recording Respirations • Respiration – Process of taking in oxygen and expelling carbon dioxide from lungs and respiratory tract • One respiration – One inspiration (breathing in) and one expiration (breathing out)
May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 16:4 Measuring and Recording Respirations • Rate of respirations – Number of breaths per minute • Character of respirations – Depth and quality of respirations • Rhythm of respirations – Regularity of respirations/space between breaths
May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 16:5 Graphing TPR • Graphic sheets are used for recording temperature, pulse, and respirations (TPR) • Presents a visual diagram of variations in patient’s vital signs • May use color coding • Refer to Procedure 16:5 in text
May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 16:5 Graphing TPR • Factors affecting vital signs are often noted • Computerized graphs may be printed or kept in the electronic health record (EHR) • Graphic charts are legal medical records – Neat, legible, accurate – Correct all errors
May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 16:6 Measuring and Recording Apical Pulse • Pulse count taken with stethoscope at apex of the heart • Usually ordered by physician • Reasons for taking an apical pulse • Protect patient’s privacy and avoid exposure
May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 16:6 Measuring and Recording Apical Pulse • Two heart sounds • Pulse deficit – Difference between apical and radial pulse • Refer to Procedure 16:6 in text
May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 16:7 Measuring and Recording Blood Pressure • Measurement of pressure blood exerts on walls of arteries during various stages of heart activity • Read in millimeters (mm) of mercury (Hg) on a sphygmomanometer • Measurements read at two points
May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 16:7 Measuring and Recording Blood Pressure • Systolic pressure – Pressure in walls of arteries when left ventricle contracts • Diastolic pressure – Constant pressure in walls of arteries when left ventricle is at rest
May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 16:7 Measuring and Recording Blood Pressure • Pulse pressure – Difference between systolic and diastolic pressure • Hypertension (high blood pressure) – Greater than 140 mm Hg systolic, 90 mm Hg diastolic
May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 16:7 Measuring and Recording Blood Pressure • Hypotension (low blood pressure) – Less than 90 mm Hg systolic, 60 mm Hg diastolic • Refer to Table 16-2 in text for adult blood pressure classifications
May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 16:7 Measuring and Recording Blood Pressure • Individual factors can influence blood pressure readings, increase or decrease blood pressure • Types of sphygmomanometers – Mercury – Aneroid – Electronic
May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 16:7 Measuring and Recording Blood Pressure • AHA factors to observe for accurate readings – 5 minutes of quiet rest – Take two separate readings and average • Correct cuff size is essential for accuracy • Refer to Procedure 16:7 in text