Chapter 29 1/8/2018. Vital Signs. Measuring and Reporting Vital Signs. Key Terms

Transcription

1 Chapter 29 Vital Signs Key Terms Blood pressure Body temperature Diastolic pressure Hypertension Hypotension Pulse Pulse rate Respiration Sphygmomanometer Stethoscope Systolic pressure Vital signs Measuring and Reporting Vital Signs A person s vital signs vary within limits They are affected by sleep, activity, eating, weather, noise, exercise, drugs, anger, fear, anxiety, pain, and illness. Vital signs are measured to detect changes in normal treatment. Tell about persons response to treatment Signal life-threatening events 1

2 Vital signs are measured Accuracy is essential when you measure, record, and report vital signs If unsure of your measurements, promptly ask the nurse to take them again. Report to the nurse vitals outside the normal ranges Body Temperature Body temperature is the amount of heat in the body. Thermometers are used to measure temperature It is measured using Fahrenheit (F), and Centigrade or Celsius (C) scale. Temperature sites Box 29-2; P. 488 Mouth, rectum, ear (tympanic membrane), axilla (underarm), temporal artery Each site has a normal range 2

3 Normal body temperature ranges See table 29-1, p. 488 Rectal 99.6 R 98.6 to Oral to 99.6 Tympanic (37 C) Axillary 97.6 Ax 96.6 to 98.6 Temporal artery 99.6 NOT taken Orally if Infant or child younger than 6 years Person unconscious Surgery, or injury to the face, neck, nose, or mouth Receiving oxygen Breathes through the mouth Has an NG tube Is delirious, restless, confused, or disoriented Is paralyzed on one side Has a sore mouth Has a seizure disorder Glass thermometers See Fig. 29-4, p. 490 GENERALLY NOT USED, see safety alert on p. 491 Is a hollow glass tube filled with mercury, or a mercury free mixture Are reusable, but they take a long time to register minutes, depending on the site. 3

4 Different types of thermometers Electronic, p. 489 Tympanic, temporal Digital Disposable Temperature sensitive tape Tympanic Has fewer microbes than the mouth or rectum, reduces the risk of spreading infection. This site is not used if: An ear disorder Ear drainage Taking a oral temperature with a glass thermometer Before taking an oral temp, ask if the person has had anything to eat, drink, smoke, or chew gum in the last minutes, if they have wait minutes, than take the oral temp. P

5 Rectal Temperatures Are not taken if the person has: Diarrhea A rectal disorder or injury Had rectal surgery Confusion or is agitated Record Rectal Temp. Example T R Reading a thermometer See safety alerts on p. 491 See p reading/ using a glass thermometer. Your clinical instructor will demo this in lab and you will return demo Pulse Is the beat of the heart felt at an artery p. 497 Radial site is the most often used 5

6 Using a Stethoscope See fig , p.499 Pulse rate Is the number of heartbeats or pulses felt in 1 minute. Rate varies for each age-group Normal adult rate is beats/min. p. 498 Rhythm & Force of the Pulse Rhythm of the pulse should be regular An irregular pulse occurs when the beats are not evenly spaced or beats are skipped 6

7 Taking a Radial Pulse Radial pulse is used for routine vital signs Place the first 3 fingers of one hand against the radial artery. The radial artery is on the thumb side of the wrist, fig , p. 500 Count the pulse for 30 seconds, then multiply by 2. If pulse is irregular count for 1 minute Taking an Apical Pulse Is taken with a stethoscope Use on infants and children up to about 2 Count apical for 1 minute Also taken on older persons who have heart disease, who have irregular heart rhythms, or who take heart medications Located on the left side of the chest slightly below the nipple. Fig Taking an Apical-Radial Pulse This should be equal In person with heart disease the radial pulse is often less than the apical pulse rate. Fig , p

8 Respirations Means breathing air into (inhalation) and out of (exhalation) the lungs. Oxygen enters the lungs during inhalation Carbon dioxide leaves the lungs in exhalation. Each respiration involves one inhalation & one exhalation Count respirations when the person is at rest. Cont. Respirations are counted right after taking a pulse. Keep your fingers or stethoscope over the pulse site. Person thinks you are taking the pulse. Watch the chest rise and fall. Count for 30 seconds, 1 minute if abnormal pattern is noted. Cont. Normal adult rate is breaths per minute Respirations are normally quiet, effortless and regular. Infants and children count for 1 minute. 8

9 Blood pressure Is the amount of force exerted against the walls of an artery by the blood. Systolic is the first sound you hear. Diastolic is the last sound you hear. Normal & Abnormal B/P B/P can change from minute to minute Factors affecting b/p Box 29-5 Hypertension High blood pressure A systolic of 140 mmhg or greater Or a diastolic of 90 mmhg or greater Report any systolic pressure above 120 mmhg Report any diastolic above 80 mmhg 9

10 Hypotension Low blood pressure Systolic 90 mmhg or below Diastolic 60 mmhg or below Some people normally have low B/P Equipment A stethoscope A sphygmomanometer has a cuff and a measuring device. Measure blood pressure Do not take B/P on arm with IV, cast, dialysis access site, or if they had breast surgery, on that side. Cuff should fit snuggly Pump up to approx. 170, then release slowly, listen for first sound, note number, listen for last sound note number. if beat is heard immediately, deflate cuff, wait 1 minute, reinflate to a higher number. 10