What 3 body processes do vital signs reflect?

When: PE admission per pt. conditions surgery dx. tests falls/injuries certain medications- BP meds, heart meds complaints as ordered- q4 hours, etcTake: sitting or layingRecord : on graphic sheets

A very important indicator of health of body

Measurement of amt of heat in body Balance b/t heat lost & created Created when body changes food to energy Lost from the body to the environment by:

◦ Contact◦ Perspiration◦ Breathing

◦ Time of day◦ Age◦ Weather◦ Exercise◦ Emotions◦ Stress◦ Illness◦ Pregnancy◦ Menstrual cycle

Glass- break easy, clean Electronic-disposable covers Digital Chemically treated paper Tympanic

You need to take a temperature on a 85 year-old male with dementia. He is very confused and sometimes resists care. Which is the best site to take his temperature?

Taken:* PO-mouth

* Axillary * Rectal * Tympanic * Forehead

PO: do not take if:◦ < 6 years old◦ Unconscious◦ OR to neck/mouth◦ On O2◦ Confused◦ Paralyzed on 1 side◦ *If smoke, eat or

drink wait 15-20 minutes

Rectal: used if PO not optional DO not use if:

◦ Diarrhea◦ Rectal disorders◦ Rectal OR◦ Confusion◦ Head trauma◦ * Must hold in place

Axillary:

◦ Not as realible ◦ Easy to use on

children◦ Can’t be diaphoretic

(sweaty)

Glass thermometers:

If broken follow If broken follow guidelines- can guidelines- can cause problems if cause problems if they have mercury they have mercury in itin it

Route Normal range Time(take for)

Rectal 98.6 - 100.6 2 minutes

PO 97.6 - 99.6 2-3 minutes

Tympanic 98.6 Until beeps

Axillary 96.6 – 98.6 5-10 minutes

a.100.3 Rb.100.1 tympanicc. 97 Ax.d.100.5 PO

Answer- 100.5 po

a.Read thermometer after 30 secondsb.Use plastic covers to reduce the spread of

germsc. Sterilize after each used.Place just the tip of the tympanic

thermometer in the ear

Answer: B

Take your own oral temp.- read thermometer

Take your partners- temperature with the tympanic and forehead thermometer

Number of heart beats/minute

Normal range- 60-100/minute

Check rate, rhythm and strength/force

Radial- Brachial- Carotid- Dorsalis pedis-

Body temperature Exercise Emotions Heat Position Pain Drugs

A. coma B. fever C. sleep D. depressant drugs

Answer: B. fever

Feel for:

Rhythm-regular, irregular

Force- weak, strong

Use 2 fingers not thumb

Abnormal force:◦ Bounding/ strong-Weak/thready/feeble

Abnormal rate:-bradycardia <

60/minuteTachycardia> 100

Abnormal rhythm:◦ Skipping beats◦ Not evenly spaced

apart

Inhaling & exhaling # breaths/minuteNormal Rate:Normal Rate:

◦ 12-20/minute –Adult12-20/minute –Adult◦ Quiet, effortlessQuiet, effortless

Counting respirations

1 inhale & exhale= 1 respiration

Rate: Bradypnea- < 10 Tachypnea > 24

Character: Labored Noisy Shallow irregular

Normal= 12-20/minute

Tachypnea= >24/min

Bradypnea=< 10/min

Apnea= no breathing

Hypoventilation-slow & shallow

Hyperventilation: rapid & deep

Dyspnea: difficulty breathing

Cheyne –stokes: irregular breathing

Cyanosis-

Definition: amount of force exerted against the walls of an artery by blood

Controlled by:

1. Force of heart contraction

2. Amt. Of blood pumped with each heart beat

3. Ease of blood flowing through the vessels

Systole

Heart Contracts

1st sound

Heard

Diastole Heart

resting

2nd sound heard

Normal: 120-90 80-60

Hypertension= high BP > 120/80

Hypotension= low BP < 90/60

*Age- increase c age*Sex- higher in male*Blood volume*Stress*Pain*Exercise- increase during decrease overall

*Wgt.- obese/overwgt.

increases*Race- higher in

blacks*Diet- increase c NA,

caffiene

*Position*Smoking- raises BP*Alcohol- raises BP

Don’t take immediately after exercise Check position dr. wants BP taken in-

sitting, laying, standing Put cuff on bare arm Make sure cuff fits properly Place diaphragm over brachial pulse site Reduce noise Make sure you can see sphygmomanometer Keep arm at heart level, palm up

Find radial pulse, inflate cuff until you can’t feel pulse, deflate cuff then pump up 30mm/hg more

If unsure of BP recheck in 30-60 seconds If still unsure ask someone to verify Use arm only 2x, then use other arm

Do not take BP in arm if pt has had: *mastectomy on that side *had recent blood draw in that arm *paralyzed on that side *has IV in that arm

Stethoscope Sphygmomanometer

◦ Aneroid◦ Electronic◦ Mercury

You need to take routine vital signs on a nursing home resident. The pt. tells you that her husband just left & she is very upset b/c they had an argument. She tells you “I just need to get up & walk around for awhile, I am so angry at him.” What should you do?

How can you apply an awareness of vital signs & other health indicators to your everyday life & the lives of those around you?

Compare/contrast the types of thermometers, which is easiest to use?

You have just measured a pt. vital signs & it doesn’t seem normal to you. What should you do?

Why & how should health care workers be sensitive & provide privacy for a pt. when taking & recording body measurements?