ch 25 ppp, with breakouts

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Which three body processes do Which three body processes do vital signs reflect?vital signs reflect?


Chapter 25Chapter 25

Measuring Vital SignsMeasuring Vital Signs


Vital signs reflect the function of three body Vital signs reflect the function of three body processes essential for life:processes essential for life:

• Regulation of body temperatureRegulation of body temperature

• BreathingBreathing

• Heart functionHeart function

The four vital signs of body function are:The four vital signs of body function are:• TemperatureTemperature

• PulsePulse

• RespirationsRespirations

• Blood pressureBlood pressure

Some agencies consider “pain” to be a vital sign.Some agencies consider “pain” to be a vital sign.


MEASURING AND REPORTING VITAL MEASURING AND REPORTING VITAL SIGNSSIGNS

A person’s vital signs vary within certain limits.A person’s vital signs vary within certain limits. Vital signs:Vital signs:

• Are measured to detect changes in normal body Are measured to detect changes in normal body functionfunction

• Tell about responses to treatmentTell about responses to treatment

• Often signal life-threatening eventsOften signal life-threatening events

• Are part of the assessment step in the nursing Are part of the assessment step in the nursing processprocess


Vital signs are measured:Vital signs are measured:• During physical examsDuring physical exams• When the person is admitted to a health care agencyWhen the person is admitted to a health care agency• As often as required by the person’s conditionAs often as required by the person’s condition• Before and after surgeryBefore and after surgery• Before and after complex procedures or diagnostic Before and after complex procedures or diagnostic

teststests• After some care measuresAfter some care measures• After a fall or other injuryAfter a fall or other injury• When drugs affect the respiratory or circulatory When drugs affect the respiratory or circulatory

systemsystem• When there are complaints of pain, dizziness, light-When there are complaints of pain, dizziness, light-

headedness, feeling faint, shortness of breath, a rapid headedness, feeling faint, shortness of breath, a rapid heart rate, or not feeling wellheart rate, or not feeling well

• As stated on the care planAs stated on the care plan


Vital signs show even minor changes in the Vital signs show even minor changes in the person’s condition.person’s condition.

• Accuracy is essential when you measure, record, and Accuracy is essential when you measure, record, and report vital signs.report vital signs.

Unless otherwise ordered, take vital signs with Unless otherwise ordered, take vital signs with the person lying or sitting.the person lying or sitting.

Report the following at once:Report the following at once:• Any vital sign that is changed from a prior Any vital sign that is changed from a prior

measurementmeasurement

• Vital signs above the normal rangeVital signs above the normal range

• Vital signs below the normal rangeVital signs below the normal range


BODY TEMPERATUREBODY TEMPERATURE Body temperature is a balance between the Body temperature is a balance between the

amount of heat produced and the amount lost amount of heat produced and the amount lost by the body.by the body.

Thermometers are used to measure Thermometers are used to measure temperature.temperature.

Temperature sites are the mouth, rectum, Temperature sites are the mouth, rectum, axilla, tympanic membrane, and temporal axilla, tympanic membrane, and temporal artery.artery.

• Each site has a normal range.Each site has a normal range. Always report temperatures that are above or Always report temperatures that are above or

below the normal range.below the normal range.


These types of thermometers are used:These types of thermometers are used:• Glass thermometersGlass thermometers

Oral, axillary, and rectal thermometersOral, axillary, and rectal thermometers

• Electronic thermometersElectronic thermometers Some with oral and rectal probes with disposable coversSome with oral and rectal probes with disposable covers Tympanic membrane thermometersTympanic membrane thermometers Temporal artery thermometersTemporal artery thermometers

• Digital thermometersDigital thermometers

• Disposable oral thermometersDisposable oral thermometers

• Temperature-sensitive tapeTemperature-sensitive tape


What do YOU think?What do YOU think?

Get into your groups!Get into your groups! Answer the following questions:Answer the following questions:

You need to measure a patient’s vital You need to measure a patient’s vital signs. The person is an 85-year-old man signs. The person is an 85-year-old man with dementia. He is confused and with dementia. He is confused and sometimes resists care. sometimes resists care. • Which temperature sites are best? Which temperature sites are best?

• Be ready to explain your answerBe ready to explain your answer


What is does the thermometer say?What is does the thermometer say?


NOW…Convert your temperature…NOW…Convert your temperature…

Fahrenheit to CelsiusFahrenheit to Celsius Subtract 32 from the Fahrenheit temperature. Subtract 32 from the Fahrenheit temperature. Divide by 1.8. An example: Divide by 1.8. An example:

• 74ºF = (74 - 32) / 1.8 = 23ºC 74ºF = (74 - 32) / 1.8 = 23ºC

Celsius to FahrenheitCelsius to Fahrenheit Multiply the Celsius temperature by 1.8. Multiply the Celsius temperature by 1.8. Add 32. An example:Add 32. An example:

• 30ºC = (30 x 1.8) + 32 = 86ºF30ºC = (30 x 1.8) + 32 = 86ºF


Let’s Practice!Let’s Practice!

In your groups, pair up with your shoulder In your groups, pair up with your shoulder partner.partner.

Practice taking your partner’s oral Practice taking your partner’s oral temperature using a glass, digital, & temperature using a glass, digital, & electronic thermometer.electronic thermometer.

SWITCH!SWITCH! Practice taking your partner's tympanic & Practice taking your partner's tympanic &

temporal temperature.temporal temperature. SWITCH!SWITCH! Don’t forget to RECORD your findings!Don’t forget to RECORD your findings!


PULSEPULSE The pulse is the beat of the heart felt at an The pulse is the beat of the heart felt at an

artery as a wave of blood passes through the artery as a wave of blood passes through the artery.artery.

Pulse sitesPulse sites• The temporal, carotid, brachial, radial, femoral, The temporal, carotid, brachial, radial, femoral,

popliteal, posterior tibial, and dorsalis pedis (pedal) popliteal, posterior tibial, and dorsalis pedis (pedal) pulses are on each side of the body.pulses are on each side of the body.

• The radial pulse is used most often.The radial pulse is used most often.

• The carotid pulse is taken during CPR and other The carotid pulse is taken during CPR and other emergencies. emergencies.

• The apical pulse is felt over the heart.The apical pulse is felt over the heart.


Do you know where your pulses are?Do you know where your pulses are?

Get out piece of paperGet out piece of paper Draw the human body showing 8 pulse Draw the human body showing 8 pulse

points on both side of the bodypoints on both side of the body You have 3 minutes, GO! You have 3 minutes, GO!


Does your Does your

picture lookpicture look

like this?like this?


The apical pulse is taken with a stethoscope.The apical pulse is taken with a stethoscope.• A stethoscope is an instrument used to listen to the A stethoscope is an instrument used to listen to the

sounds produced by the heart, lungs, and other body sounds produced by the heart, lungs, and other body organs.organs. It is used to take apical pulses and blood pressures.It is used to take apical pulses and blood pressures. The device makes sounds louder for easy hearing.The device makes sounds louder for easy hearing.


To use a stethoscope:To use a stethoscope:• Wipe the earpieces and diaphragm with antiseptic Wipe the earpieces and diaphragm with antiseptic

wipes before and after use.wipes before and after use.

• Place the earpiece tips in your ears with the bend of Place the earpiece tips in your ears with the bend of the tips pointing forward.the tips pointing forward. Earpieces should fit snugly to block out noises.Earpieces should fit snugly to block out noises. They should not cause pain or ear discomfort.They should not cause pain or ear discomfort.

• Tap the diaphragm gently.Tap the diaphragm gently. If you do not hear the tapping, turn the chest piese at the If you do not hear the tapping, turn the chest piese at the

tubing.tubing. Check with the nurse if you still do not hear the tapping.Check with the nurse if you still do not hear the tapping.

• Place the diaphragm over the artery. Hold it in place.Place the diaphragm over the artery. Hold it in place.

• Prevent noise.Prevent noise.


Let’s Practice!Let’s Practice! Partner with your shoulder partner and review Partner with your shoulder partner and review

the parts of the stethoscope.the parts of the stethoscope. Practice listening to your partner’s apical Practice listening to your partner’s apical

pulse for 1 minute. You do not need to count, pulse for 1 minute. You do not need to count, just LISTEN!just LISTEN!

SWITCH!SWITCH!


The pulse rate is the number of heartbeats or The pulse rate is the number of heartbeats or pulses felt in 1 minute.pulses felt in 1 minute.

• The rate varies for each age-group.The rate varies for each age-group.

The adult pulse rate is between 60 and 100 The adult pulse rate is between 60 and 100 beats per minute.beats per minute.

Report abnormal pulses to the nurse at once.Report abnormal pulses to the nurse at once.• Tachycardia is a heart rate of more than 100 beats per Tachycardia is a heart rate of more than 100 beats per

minute.minute.

• Bradycardia is a heart rate of less than 60 beats per Bradycardia is a heart rate of less than 60 beats per minute.minute.


Rhythm and force of the pulseRhythm and force of the pulse• The rhythm of the pulse should be regular.The rhythm of the pulse should be regular.

An irregular pulse occurs when the beats are not evenly An irregular pulse occurs when the beats are not evenly spaced or beats are skipped.spaced or beats are skipped.

• Force relates to pulse strength.Force relates to pulse strength. A forceful pulse is described as strong, full, or bounding.A forceful pulse is described as strong, full, or bounding. Hard-to-feel pulses are described as weak, thready, or Hard-to-feel pulses are described as weak, thready, or

feeble.feeble.

• Electronic blood pressure equipment can count pulses.Electronic blood pressure equipment can count pulses. Information is not given about pulse rhythm and force.Information is not given about pulse rhythm and force. You need to feel the pulse to determine rhythm and force.You need to feel the pulse to determine rhythm and force.


You will take radial, apical, and apical-radial You will take radial, apical, and apical-radial pulses.pulses.

You must:You must:• Count accuratelyCount accurately

• Report and record the pulse rate accuratelyReport and record the pulse rate accurately

The radial pulse is used for routine vital signs.The radial pulse is used for routine vital signs.


The apical pulse is on the left side of the chest The apical pulse is on the left side of the chest slightly below the nipple.slightly below the nipple.

• It is taken with a stethoscope.It is taken with a stethoscope.

• Count the apical pulse for 1 minute.Count the apical pulse for 1 minute.

• Count each lub-dub as one beat.Count each lub-dub as one beat.

• Apical pulses are taken on:Apical pulses are taken on: Infants and children up to about 2 years of ageInfants and children up to about 2 years of age Persons who have heart diseasePersons who have heart disease Persons who have irregular heart rhythmsPersons who have irregular heart rhythms Persons who take drugs that affect the heartPersons who take drugs that affect the heart


The apical and radial pulse should be equal.The apical and radial pulse should be equal.• To see if the apical and radial pulses are equal, two To see if the apical and radial pulses are equal, two

staff members are needed.staff members are needed.

• The pulse deficit is the difference between the apical The pulse deficit is the difference between the apical and radial pulse rates.and radial pulse rates. To obtain the pulse deficit, subtract the radial rate from To obtain the pulse deficit, subtract the radial rate from

the apical rate.the apical rate. The apical pulse rate is never less than the radial pulse The apical pulse rate is never less than the radial pulse

rate.rate.


Does that make sense?Does that make sense?

Take out a piece of paper.Take out a piece of paper. Work out the following:Work out the following:

You take Mrs. King’s radial pulse at the same time You take Mrs. King’s radial pulse at the same time your RN is taking her apical pulse.your RN is taking her apical pulse.

Her radial pulse you count is 82 bpm. The RN Her radial pulse you count is 82 bpm. The RN counts her apical pulse as 98 bpm.counts her apical pulse as 98 bpm.

What is your patient’s pulse deficit?What is your patient’s pulse deficit?


HOW do you RECORD VS?HOW do you RECORD VS?


Now it’s your turn!Now it’s your turn!

Practice taking a partner’s pulse (radial)Practice taking a partner’s pulse (radial) Partner up with your shoulder partner.Partner up with your shoulder partner. Find the radial pulse, count the beats for a full Find the radial pulse, count the beats for a full

minute, RECORD your findings.minute, RECORD your findings. SWITCH!SWITCH! Now, take your stethoscope and take your Now, take your stethoscope and take your

partner’s apical pulse for a full minute, partner’s apical pulse for a full minute, RECORD your findings.RECORD your findings.

SWITCH!SWITCH!


RESPIRATIONS RESPIRATIONS Respiration means breathing air into Respiration means breathing air into

(inhalation) and out of (exhalation) the lungs.(inhalation) and out of (exhalation) the lungs.• Oxygen enters the lungs during inhalation.Oxygen enters the lungs during inhalation.

• Carbon dioxide leaves the lungs during exhalation.Carbon dioxide leaves the lungs during exhalation.

Each respiration involves one inhalation and Each respiration involves one inhalation and one exhalation.one exhalation.

The healthy adult has 12 to 20 respirations per The healthy adult has 12 to 20 respirations per minute.minute.

Respirations are normally quiet, effortless, and Respirations are normally quiet, effortless, and regular.regular.


Count respirations when the person is at rest.Count respirations when the person is at rest. Position the person so you can see the chest Position the person so you can see the chest

rise and fall. rise and fall. The person should not know that you are The person should not know that you are

counting respirations.counting respirations.• Count respirations right after taking a pulse.Count respirations right after taking a pulse.

Keep your fingers or stethoscope over the pulse site. Keep your fingers or stethoscope over the pulse site.

To count respirations, watch the chest rise and To count respirations, watch the chest rise and fall.fall.


Now it’s your turn!Now it’s your turn! Partner up with your shoulder partner.Partner up with your shoulder partner. Count your partners respirations for a full Count your partners respirations for a full

minute, RECORD your findings. minute, RECORD your findings. One respiration is inhalation AND exhalation= 1 One respiration is inhalation AND exhalation= 1

respirationrespiration SWITCH!SWITCH! Practice at home counting someone’s radial Practice at home counting someone’s radial

pulse for 30 seconds, then counting their pulse for 30 seconds, then counting their respirations without letting them know! respirations without letting them know!


BLOOD PRESSUREBLOOD PRESSURE Blood pressure is the amount of force exerted Blood pressure is the amount of force exerted

against the walls of an artery by the blood.against the walls of an artery by the blood. Blood pressure is controlled by:Blood pressure is controlled by:

• The force of heart contractionsThe force of heart contractions

• The amount of blood pumped with each heartbeatThe amount of blood pumped with each heartbeat

• How easily the blood flows through the blood vesselsHow easily the blood flows through the blood vessels

The heart is pumping (muscle contraction) The heart is pumping (muscle contraction) blood during systole.blood during systole.

The heart is at rest (muscle relaxation) during The heart is at rest (muscle relaxation) during diastole.diastole.


The systolic pressure is the amount of force The systolic pressure is the amount of force needed to pump blood out of the heart into the needed to pump blood out of the heart into the arterial circulation.arterial circulation.

The diastolic pressure is the pressure in the The diastolic pressure is the pressure in the arteries when the heart is at rest.arteries when the heart is at rest.

Blood pressure is measured in millimeters (mm) Blood pressure is measured in millimeters (mm) of mercury (Hg).of mercury (Hg).

• The systolic pressure is recorded over the diastolic The systolic pressure is recorded over the diastolic pressure.pressure.

• Blood pressure has normal ranges:Blood pressure has normal ranges: Systolic pressure—less than 120 mm Hg Systolic pressure—less than 120 mm Hg Diastolic pressure—less than 80 mm HgDiastolic pressure—less than 80 mm Hg


You need to report the following blood pressure You need to report the following blood pressure measurements:measurements:

• Any systolic measurement at or above 120 mm HgAny systolic measurement at or above 120 mm Hg

• A diastolic pressure at or above 80 mm HgA diastolic pressure at or above 80 mm Hg

• A systolic pressure below 90 mm HgA systolic pressure below 90 mm Hg

• A diastolic pressure below 60 mm HgA diastolic pressure below 60 mm Hg


A stethoscope and a sphygmomanometer are A stethoscope and a sphygmomanometer are used to measure blood pressure.used to measure blood pressure.

• The sphygmomanometer has a cuff and a measuring The sphygmomanometer has a cuff and a measuring device.device.

• These types of sphygmomanometers are used:These types of sphygmomanometers are used: Aneroid typeAneroid type Mercury typeMercury type Electronic typeElectronic type

Blood pressure is normally measured in the Blood pressure is normally measured in the brachial artery.brachial artery.


Get into your GROUPS!Get into your GROUPS!

Read the following scenario. Answer the Read the following scenario. Answer the following question. Be ready to share with following question. Be ready to share with the entire class. You have 3 minutes…the entire class. You have 3 minutes… You need to take a male patient’s blood pressure. You need to take a male patient’s blood pressure.

The person is 6 feet tall and weighs 220 pounds. The person is 6 feet tall and weighs 220 pounds. He has an injured right arm. He is wearing a long-He has an injured right arm. He is wearing a long-sleeved shirt. The person just returned from a sleeved shirt. The person just returned from a walk. His television is on. The volume is turned up. walk. His television is on. The volume is turned up.

What measures will you take to make sure you What measures will you take to make sure you obtain an accurate blood pressure reading?obtain an accurate blood pressure reading?

ch 25 ppp, with breakouts

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