Vital signs

1
Vital signs
2
Outline

• Vital Signs Definition
• Temperature
• Pulse Rate
• Respiratory Rate
• Blood Pressure
• Pain

3
Vital sign

• physical signs that provide data to determine a
  persons state of health
• indicate an individual is alive, such as
  temperature, pulse rate, respiratory rate (TPR),
  and blood pressure (BP).

4
Measuring Body Temperature

• Purposes
• 1-To establish baseline data for subsequent
  evaluation .
• 2-To identify whether the core body temperature
  is within normal range .
• 3-To determine changes in the core body
  temperature in response to specific therapies (
  antipyretic medication , immunosuppressive drugs,
  invasive procedure )
• 4-To monitor clients at risk for imbalanced body
  temperature ( clients at risk for infection , or
  diagnosis of infection , or those who have been
  exposed to temperature extreme)

5
Types of Thermometers

• Electronic thermometers
• Provide readings in less than 60 seconds
• most accurate if placed in sublingual pocket
• There is a sensor on the end of the thermometer
  that touches the body part and reads the bodys
  temperature.

6
Types of Thermometers

• Tympanic membrane thermometer
• measures the temperature inside of the ear.
• It will read the infrared heat that comes from
  inside of the ear.
• Especially appropriate for infants and young
  children
• Readings are obtained in 2 seconds or less

7
Types of Thermometers

• Glass and mercury thermometers
• a glass tube with mercury inside of the tube.
• The tube goes underneath the tongue and the body
  temperature will cause the mercury to rise inside
  the tube.
• DO NOT just throw away a mercury thermometer.

8
Sites for taking the Temperature
SITE ADVANTAGES DISADVANTAGES
ORAL Accessible and convenient Thermometers can be broken
ORAL Accessible and convenient Inaccurate if client has just ingested hot or cold fluid, or smoked
     
RECTAL Reliable measurement Inconvenient and more unpleasant difficult for client who cannot turn to side
RECTAL Reliable measurement Could injure the rectum following surgery
RECTAL Reliable measurement Presence of stool may interfere with thermometer placement
     
AXILLARY Safe and noninvasive Thermometer must be left in place for a long time
     
TYMPANIC MEMBRANES Readily accessible reflects the core temperature, very fast Can be uncomfortable and involves risk of injuring the membrane if inserted too far
TYMPANIC MEMBRANES Readily accessible reflects the core temperature, very fast Presence of cerumen can affect the reading
     
TEMPORAL ARTERY Safe and non invasive , very fast Requires electronic equipment (expensive / unavailable)
TEMPORAL ARTERY Safe and non invasive , very fast Variation in technique if the client has perspiration on the forehead
  Safe and non invasive , very fast Variation in technique if the client has perspiration on the forehead

9
Sites for taking theTemperature

10
Assessment

• 1-Clinical signs of fever .
• 2-Clinical signs of hypothermia
• 3-Site most appropriate for measurement .
• 4-Factors that may alter body temperature.

11
Planning

• Preparation of equipment
• 1-Thermometer
• 2-Thermometer cover .
• 3-Water- soluble lubricant for a rectal
  temperature .
• 4-Disposable gloves .
• 5- Towel for axillary temperature .
• 6-Tissue /wipes

12
Implementation

• Preparation
• Check that all equipments functioning well .
• Performance
• 1- Introduce self , verify the clients identity
  , explain to the client what will you do, why and
  how ?
• 2- Hand washing .
• 3-Provide for clients privacy .
• 4-Position the patient according to the method
  will be practiced ( lateral or sims position for
  rectal temperature )
• 5-Place the thermometer as the following

13
Evaluation

• Compare the temperature measurement to baseline
  data , normal range of age of the client and the
  clients previous temperature .
• Analyze considering time of day and any
  additional influence factors and other vital
  signs .

14
Assessment of peripheral Pulse

• Purpose
• To establish baseline data for subsequent
  evaluation.
• To identify whether the pulse rate is within
  normal range .
• To determine whether the pulse rhythm is regular
  and the pulse volume is appropriate .
• To determine the equality of corresponding
  peripheral pulse on each side of the body .
• To monitor and assess changes in the clients
  health status .
• To monitor clients at risk for pulse alteration
  ( heart disease , cardiac arrhythmia .
• To evaluate perfusion to the extremities

15
Assessment

• 1-Clinical signs of cardiovascular alterations
  as (dyspnea, cyanosis, palpitations , syncope ,
  cool skin )
• 2- Factors that may alter pulse rate
• ( e.g. emotional status , physical activity ) .
• 3- Which site is most appropriate for assessment
  based on a purpose .

16
Pulse sites
17
(No Transcript)
18
Assessment of apical pulse

• Position the patient in comfortable supine
  position or in a sitting position .
• Locate the apex of heart

19
Planning

• Equipment
• -Watch with a second hand or indicator .
• Implementation
• Performance
• 1- Introduce self , verify the clients identity
  , explain to the client what will you do, why and
  how ?
• 2- Hand washing .
• 3-Provide for clients privacy .
• 4- Select the pulse point . Normally , the
  radial pulse is taken unless it cant be exposed
  .
• 5- Position the patient in a rest position

20
Implementation

• 6- Palpate and count the pulse . Place 3 or 2
  middle fingers lightly and squarely over the
  pulse point .
• 7- Count for 15 seconds and multiply by 4 .
• 8- Record the pulse on the worksheet .
• 9- Assess the pulse rhythm and strength .
• 10- Document the pulse rate on the patients
  record .
• 11- Hand wash

21
Evaluation

• 1-Compare the pulse rate to baseline data or
  normal range for age of the client .
• 2- Relate pulse volume , rate to other vital
  signs , pulse rhythm and volume to other baseline
  data and health status .
• 3- Conduct appropriate follow up such as
  notifying the primary care giver or giving
  medication .

22
C-Assessment of Respiration

• Purposes
• To acquire baseline data against which future
  measurements can be compared .
• To monitor abnormal respiration and respiratory
  patterns and identify changes .
• To monitor respirations before or following the
  administration of general anesthetic or any
  medication that can influences respiration .
• To monitor clients at risk for respiratory
  alterations .

23
Assessment

• Skin and mucous membrane color ( cyanosis or
  pallor )
• Positions assumed for breathing ( using of
  orthopneic position).
• Signs of cerebral anoxia ( irritability ,
  restlessness drowsiness or loss of consciousness
  ) .
• Chest movement .
• Activity tolerance.
• Chest pain .
• Dyspnea
• Medication that affect respiration .

24
Planning

• Equipment
• Watch with a second or indicator .
• Implementation
• Preparation
• For a routine assessment of respiration ,
  determine the clients activity schedule and
  choose a suitable time to monitor the
  respirations . A client who has been exercising
  will need to rest for a few minutes to permit the
  accelerated respiratory rate to return to normal
  .

25
Implementation

• 1- Introduce self , verify the clients identity
  , never to notify the patient that you will
  assess respiration
• 2- Hand washing .
• 3-Provide for clients privacy .
• 4-Observe and count the respiratory rate .
• 5- Observe the respiration for depth by watching
  the movement of the chest , observe for
  regularity .
• 6- Document the respiratory rate , rhythm and
  depth in an appropriate record

26
Evaluation

• Relate respiratory rate to other vital signs , in
  particular pulse , relate respiratory rhythm ,and
  depth to baseline data and health status .
• Report to the primary care provider a respiratory
  rate significantly above or below the normal
  range and any notable change in respiration from
  a previous assessment .
• Conduct appropriate follow up such as
  administering oxygen, or other medications

27
Assessment of Blood Pressure

• Purpose
• 1-To obtain a baseline measure of arterial blood
  pressure for subsequent evaluation .
• 2- To determine the clients hemodynamic status .
• 3- To identify and monitor changes in blood
  pressure resulting from a disease processes .

28
Equipment

• Sphygmomanometer
• Aneroid
• Mercurial
• Stethoscope

29
Sphygmomanometer

Pediatric
Adult
30
Parts of stethoscope

• Earpieces- should fit snugly and follow the
  natural curve of the ear canal, point toward the
  face when it is in place
• Tubing- 12-18 inches long, longer tubing
  decreases the transmission of sound waves

31
Parts of a stethoscope

• Diaphragm circular, flat surface- transmits high
  pitched sounds ( Bowel, lung, heart sounds
• Bell bowl shaped- transmits low pitched sounds
  (heart and vascular sounds)

32
Assessment

• 1- Signs symptoms of hypertension ( headache ,
  ringing in the ears , flushing of the face
  ,nosebleeds, fatigue ).
• 2- Signs symptoms of hypotension ( tachycardia
  , dizziness, mental confusion , restlessness cool
  and clammy skin, pale or cyanosis )
• 3- Factors affecting blood pressure ( stress ,
  activity , pain and time of last caffeine .)
• 4- Some blood pressure cuffs contains latex .
  Assess the client for latex allergy and obtain a
  latex free cuff if indicated .

33
Planning

• Equipment
• 1- stethoscope
• 2-Blood pressure cuff (appropriate size)
• Sphygmomanometer
• Preparation
• 1-Ensure that the equipment is intact and
  functioning well
• 2- Make sure that the client has not smoked
  within 30 minutes

34
Implementation

• Preparation
• 1-Ensure that the equipment is intact and
  functioning well
• 2- Make sure that the client has not smoked
  within 30 minutes
• Performance
• 1- Introduce self , verify the clients identity
  , explain to the client what will you do,
  why and how
• 2- Hand washing .
• 3-Provide for clients privacy .

35
(No Transcript)
36

• 4-Take the accurate reading of blood pressure and
  Document the finding in the clients record .
• 5-Hand wash

37
Evaluation

• 1- Relate blood pressure to other vital signs ,
  to baseline data .
• 2- Report any significant changes in clients
  blood pressure .
• 3- Conduct appropriate follow up , medication
  administration .

38
THANK TOU