natcep day 25 26 27
TRANSCRIPT
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Observing & Measuring Vital SignsNATCEP Day Twenty-Five through Twenty-Seven
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Why measure Vital Signs
• Means of getting information about the body’s condition
• Vital signs include– Temperature– Pulse– Respirations– Blood Pressure
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Objectives: Temperature
• Identify– Cause of body temperature– “Normal” range or average body temperature
• List situations that may cause the thermometer reading to vary from “normal or average”
• Identify types of thermometers and situations in which they are used
• Demonstrate how to care for thermometers• Describe each method of checking temperature
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Temperature is. . . . .
• A measurement of the amount of heat in the body, a balance between heat created and lost
• Created as the body changes food to energy
• Lost from the body to the environment by contact, perspiration, breathing and other means
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Normal Ranges (Fahrenheit)
• Oral: 97.5 – 99.5• Rectal: 98.5 – 100.5• Axillary: 96.6 – 98.6• Tympanic: 96.4 – 100• Temporal: 99.6• Baseline: range varies from person to
person• Peak: 6pm; Low: 6am• Normal decreases with age
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Variations High & Low: Causes
• Higher than normal– Eating warm food– Time of day– Infection– Disease
• Lower than normal– Eating cold food– Time of day– Dry mouth– Disease processes
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Types of Thermometers
• Electronic • Digital• Chemically treated paper• Tympanic: eardrum/ear• Temporal: temporal artery/forehead
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Care of Thermometers
• Probe Covers• Follow Manufacturer’s Instructions
– Electronic or Digital– Tympanic– Temporal
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Taking an Oral Temperature
• Most common temperature• Under tongue• Mouth and lips closed• Beeping indicates done• Electronic/Digital
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Taking an Axillary Temperature
• Least accurate– Safety prohibits other sites
• Under the arm• Tip placed in center of underarm• Arm should hold in place• Beeping indicates done• Electronic/Digital
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Taking an Tympanic Temperature
• Open ear canal by gently lifting the ear up and back
• Gently insert tip inside ear canal• Beeping indicates done
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Taking an Temporal Temperature
• Follow manufacturer’s instructions – Typical moved from center of forehead to
temporal artery site• Beeping indicates done
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Taking a Rectal Temperature
• Infants • Children & Adults
– Used when other methods unavailable or inaccurate
• Lubricate and insert about 1 inch with resident on their side – hold in place
• Beeping indicates done• Electronic/Digital
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Recording Temperature
• Use “ax” to indicate axillary• Use “r” to indicate rectal• Notify nurse
– Above or below normal range– Difficulty obtaining temperature
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Practice
• Follow my instructions to practice on your peers
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Objectives: Pulse
• State the “normal” or average pulse rate
• Identify variations from the “normal” pulse that should be reported
• Demonstrate the accurate taking of a radial pulse
• Discuss how to record and report pulse measurements
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Pulse
• A measurement of the number of times the heart beats per minute
• Normal/average– 60-100 minute (adult)– Regular in rate, rhythm, strength/force
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Variations in Pulse: Force
• Abnormal force can be distinguished by– Bounding pulse
• Cannot be occluded (blocked) by mild pressure
– Feeble, weak and thready• Occluded (blocked) by slight pressure• Thready: usually fast
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Variations in Pulse: Rate
• Abnormal rate distinguished by– Rate under 60 per minute: Bradycardia– Rate over 100 per minute: Tachycardia
• Can be caused by– Exercise/activity– Fever
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Variations in Pulse: Rhythm
• Abnormal rhythm distinguished by– Irregularity of beats– Feeling that beats are “skipped” when
pulse counted for one full minute
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Sites for Checking Pulse
• Apical
• Radial
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Report
• Pulse varies from “normals”• Difficulty obtaining pulse
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Practice
• Follow my instructions to practice on your peers– Apical pulse– Radial pulse
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Objectives: Respirations
• State the average respiratory rate• Describe how to measure respiratory
rate• Describe variations of respirations• Discuss how to record and report the
respiratory rate measurement
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Respirations
• Inspiration and expiration of air • Average rate is 12-20 per minute (adult)
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How to Count Respirations
• Look at chest or abdomen • Count for one full minute
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Variations
• Rate– Increased by
• Exercise/activity• Fever• Lung Disease• Heart Disease
– Report fewer than 12 or more than 20 breaths per minute
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Variations
• Character– Labored
• Difficulty breathing
– Noisy• Sounds of obstruction or wheezing
– Shallow• Small amounts of air exchange
– Irregular
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Report
• Record in the appropriate area of the worksheet per facility policy
• Variations from “normals” immediately
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Practice
• Follow my instructions to practice on your peers
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Objectives: Blood Pressure
• Describe blood pressure (BP)• State the “normal” or average BP• Describe variations in BP • Identify instruments to check BP • Demonstrate correct procedure for
obtaining a BP• Identify how to record and report BP
measurements
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Blood Pressure
• Force of blood against artery walls• Amount of pressure depends on
– Rate & strength of heart beat– Ease with which blood flows through the
blood vessels– Amount of blood within the system
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Terms
• Systolic Pressure– Force when the heart is contracted– Top number of the BP– First sound when measuring
• Diastolic Pressure– Force when the heart is relaxed– Lower number of the BP– Level at which pulse sound change or
cease
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Normal
• Adult is less than 120/80– Less than 120 systolic– Less than 80 diastolic
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Variations
• May slightly increase with age• Hypertension: Higher than normal• Hypotension: Lower than normal• Postural Hypotension (Orthostatic)
– Elderly person’s body & blood pressure unable to rapidly adjust when changing positions = dizziness or feeling faint
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Tools/Instruments
• Sphygmomanometer– Cuff and gauge
• Cuff– Correct size for the resident’s arm– Placed correctly over the brachial artery– Applied correctly
• Gauge: can be Aneroid: Dial or
Electronic: Digital
• Column of mercury• Stethoscope
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Tools/Instruments
• Stethoscope
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Factors that Influence Reading
• Proper clothing• Avoid smoking• Empty bladder• Allow time to rest & relax• Position body correctly
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Body Position
• Arm supported at heart level• Back supported• Feet flat on floor• No talking or movement
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Cautions
• DO NOT TAKE in arm with:– IV– Cast– Dialysis Shunt– Breast surgery on that side
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Report
• Higher or lower than his/her usual range
• Difficulty obtaining
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Blood Pressure – An OverviewCAUSE SYSTOLIC BP CORRECTIVE ACTION
Sit without back support + 6 to 10 Support back (sit in chair)
Full bladder + 15 Empty bladder before BP taken
Tobacco/caffeine use + 6 to 11 Don’t use before clinic appointment
BP taken when arm is:Parallel to bodyUnsupportedElbow too highElbow too low
+ 9 to 13 + 1 to 7 + 5 False low
While seated in chair, patient’s arm must be straight out and supported, with elbow at heart level
“White coat” reaction + 11 to 28 Have someone else take the BP
Talking or hand gestures + 7 No talking or use of hands during BP
Cuff too narrow/small + 8 to 10Right-sized cuff properly placed over bare upper armCuff too wide/large False low
Cuff not centered + 4
Cuff over clothing + 5 to 50(Pickering et al., 2005; Perry & Potter, 2006)
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Practice
• Follow my instructions to practice on your peers