Vital Signs.ppt

The aim of this module is to enable students :
1. To apply the nursing process to clinical practice.
2. To develop skills in writing nursing diagnosis.
3. To demonstrate a health assessment in a systematic
manner, identifying normal and abnormal findings
4. To practice skills in maintain nursing documents.
5. To demonstrate skills in basic nursing procedures.

VITAL SIGNS
• vital signs – YouTube

Vital signs???
• Because of the importance of these measurements they are
referred to as vital signs
They are important indicators of body’s response to physical,
environmental and psychological stressors
VS may reveal sudden change in a client’s condition in
addition to changes that occur progressively over time

Temperature
Pulse
Respirations
Blood Pressure
Vital signs must be measured, reported, and recorded
accurately.
If you are not sure of a measurement, recheck it

Vital signs cont’d
• Observing vital signs is an important aspect of assessment of
the condition of a patient
• Provide information about patients’ overall condition
• Vital signs indicate whether a person is alive or not
• Taken at each visit and compared to baseline
• These are in relation to cardiac functions, because of that
they are known as cardinal signs

Vital signs are taken when
oWhen a person is admitted to a health care facility
o Several times a day for hospitalized patients
o Before and after surgery
o After some nursing procedures
o before medications are given that affect the respiratory or
circulatory system
o Whenever the person complains of pain, shortness of
breath, rapid heart rate, or not feeling well
o With the person at rest in a lying or sitting position

Factors that affect vital signs
o Illness
o Emotions – Anger, Fear, Anxiety, Pain
o Exercise And Activity
o Age
o Sex
o Environment - Weather
o Food And Fluid Intake
o Medications
o Time Of Day – ↓ In The Morning, ↑ In The
Afternoon/Evening
o Noise

Nursing Responsibility
• One of the most frequent assessment modes as a nurse
• Nurse is responsible for
- measuring, interpreting and making decisions about care
- Knowing normal ranges
- Knowing history and other therapies that may affect VS
• Nurse must know environmental factors that affect vital sings
• Verify and communicate changes in vital signs
• Monitor vital signs regularly
• Frequency determined by ???

o Any vital sign is changed from a previous measurement
o Vital signs are above the normal range
o Vital signs are below the normal range

Reporting and recording of vital signs

Electronic Vital Signs Monitor

1. Body Temperature
•Body temperature is the amount of heat in the body.
It is a balance between the amount of heat produced
and the amount of heat lost
•Simply, body temperature measures the degree of
heat in the body

Heat Is Produced (thermogenesis)
• The contraction of muscles during exercise
• The breakdown of food during digestion
• The environmental temperature
Heat Is Lost Through :
- Convection
- Conduction
- Radiation
- Evaporation

Regulation of Body Temperature
1. Neural Control
2. Vascular control
3. Vasodilation
4. Body heat production (thermogenesis)

Factors that increases body temperature
1. Food metabolism
2. Strong emotions
3. Vigorous exercises
4. Environmental conditions
5. Excessive Clothing
6. Warm foods
7. Infection, Inflammation
8. Tissue destruction

Factors that decreases body temperature
1. Excessive Sweating
2. Coolness of the environment
3. Sleep
4. Starvation
5. Dehydration
6. BLEEDING
7. Anesthesia
8. Shock

Body temperature measuring sites
Body temperature is measured in one of four areas of the
body
• The Mouth – Oral
• The Rectum – Rectal
• The Axilla (Underarm) – Axillary
• The Ear – Tympanic
• We now also have the temporal site - Forehead
Most temperatures are taken orally
Rectal temperatures are the most accurate
Axillary temperatures are the least accurate

SITE NORMAL (F) RANGE
(F)
Oral 98.6 ° 97.6 ° to 99.6 °
Rectal 99.6 ° 98.6 ° to 100.6 °
Axillary 97.6 ° 96.6 ° to 98.6 °
Tympanic 98.6 ° 98.6 °
Temporal 98.6° 98.6°

A small hollow glass tube that contains mercury or a mercury-
free substance in a bulb at one end. When heated the mercury
rises in the tube.
Pear – shaped tip

•The scale is marked from 94°F to 108°F
•The long lines represent one degree
•The short lines represent two tenths of a degree
•Only every other degree is marked with a number

o Battery operated
o Have an oral probe and a rectal probe
o Disposable probe cover is placed on the probe
o The temperature registers in about 30 seconds

o Measures The Temperature In The Tympanic Membrane (Eardrum)
o Fast And Accurate - 1 To 3 Seconds
infants – pull the ear
straight back
adults and children
over one year –
pull the ear up and
back

GLASS THERMOMETER
o Rinse With Cold Water
o Check The Thermometer For Breaks And Chips
o Shake Down The Thermometer So The Mercury Is
Below The Lines And Numbers
o Place A Disposable Cover On The Thermometer
o Place The Thermometer Under The Person’s
Tongue

o Leave The Thermometer In Place For 2 – 3
Minutes
oIf The Person Has Been Eating, Drinking, Or
Smoking, Wait 15 Minutes Before Taking
Temperature

oAn unconscious patient
oA patient that has had oral surgery or an injury to the face, neck,
nose, or mouth
o A person receiving oxygen
o A patient with a nasogastric tube in place
o A patient who is confused or restless
o A patient who is paralyzed on one side of the body
o Has a history of seizures
o A patient who breathes through the mouth
NOT TAKEN

o Lubricate the thermometer before inserting into the rectum
o Place the person in a side-lying position
o Insert the thermometer 1 inch into the rectum
o Hold the thermometer in place for 2 minutes
o Remove the disposable cover and read the thermometer

Do Not Take a Rectal Temperature On:
o A person who has had rectal surgery or rectal injury
o If the person has diarrhea
o If the person is confused or agitated
o If the person has heart disease ( stimulates the vagus nerve which
slows the heart rate )

o Taken only when no other site can be
used.
o Make sure the underarm is clean and
dry.
o The arm is held close to the body.
o You need to hold the thermometer in
place while the temperature is being
taken.
o The thermometer is left in place for
3 minutes.

• Video -
https://www.ndsu.edu/pubweb/bismarcknursing/basic/skill/H001.html

o The beat of the heart felt at an artery as A wave of
blood passes through the artery
o A pulse is felt every time the heart beats
o More easily felt in arteries that come close to the
skin and can be gently pressed against A bone
o The pulse should be the same in all pulse sites on
the body

o The pulse is an indication of how the cardiovascular
system is meeting the body’s needs
o The pulse rate is affected by many factors – age,
fever, exercise, fear. Anger, anxiety, excitement,
heat, position, and pain.
o Medications can be taken that either increase or
decrease a person’s pulse rate.

We usually count a pulse for 30 seconds and multiply the
number times 2 to get the pulse rate for 1 minute.
We note the rhythm (pattern) of the heart
beat – if the heart beat is irregular we count
the pulse for a full minute.
We also observe the force (strength) of the
heartbeat.
Does the pulse feel :
Strong, full, bounding
Weak, thread, feeble

oCan be taken without disturbing or exposing the
person.
o Place the first two or three fingers of one hand
against the radial artery.
o The radial artery is on the thumb side of the wrist.
o Do not use your thumb to take a person’s pulse.
o Use gentle pressure.
o Count the pulse for 30 seconds and multiply by
two.

• Always clean the earpieces of the stethoscope with
alcohol before and after use.
• Warm the diaphragm in your hand before placing it
on the person.
• Hold the diaphragm in place over the artery.
• Do not let the tubing strike against anything while
the stethoscope is being used.

o Taken with a stethoscope.
o Counted by placing the stethoscope over the heart.
o counted for one full minute.
o The heart beat normally sounds like a lub-dub. each
lub-dub is counted as one heartbeat.
o Do not count the lub as one heartbeat and the dub
as another.
o The apical pulse is taken on patients who have heart
disease , an irregular pulse rate, or take medications that
can affect the heart.

Normal adult pulse rate is – 60 to 100 beats per min.
• Tachycardia – heart rate over 100
• Bradycardia – heart rate below 60
REPORT ABNORMAL HEART RATES TO THE NURSE
IMMEDIATELY

Assessing Apical Radial Pulse
• https://www.ndsu.edu/pubweb/bismarcknursing/basic/skill/H005.ht
ml

One respiration consists of one inspiration and one
expiration
o The chest rises during inspiration (breathing in) and
falls during expiration (breathing out)
o Count each time the chest rises
o Count for 30 seconds and multiply X 2

oDo not let the person know you are counting their
respirations
o Count after taking the pulse – keep your fingers on
the pulse site
o Normal respiratory rate for adult is 12 – 20 breaths
per min.

Tachypnea – Respiratory rate over 20
Bradypnea – respiratory rate below 12
Dyspnea – shortness of breath – difficulty in breathing
Apnea – no breathing
Hyperventilation – fast and deep respirations
Hypoventilation – slow and shallow respirations

Assessing Respiration
ml

The measurement of the amount of force the blood
exerts against the artery walls
o Systolic Pressure – Pressure exerted when the heart
muscle is contracting
o Diastolic Pressure – Pressure exerted when the heart
muscle is relaxing between beats

• Blood pressure is recorded as a fraction with the
systolic pressure on top and the diastolic
pressure on the bottom.
Systolic Systolic /Diastolic
Diastolic 120/80
• BP is measured in mm (millimeters) of Hg
(mercury)

Average Adult Systolic Range – 100 To 140
Average Adult Diastolic Range – 60 To 90

• Hypertension – Measurements above the normal
systolic or diastolic pressures
• Hypotension – Measurements below the normal
systolic or diastolic pressures

o Age – blood pressure increases as A person grows older.
o Gender – women usually have lower blood pressure than
men
o Blood volume – severe bleeding lowers the blood
pressure
o Stress – heart rate and blood pressure increase as part of
the body’s response to stress
o Pain – increases blood pressure

oExercise – increases heart rate and blood pressure
oWeight – blood pressure is higher in overweight
persons
o Race – black persons generally have higher blood
pressure than white persons do
o Diet – A high-sodium diet increases the fluid volume
in the body which increases blood pressure
o Medications – can be taken to raise or lower blood
pressure
o Position – blood pressure is lower when lying down

Sphygmomanometer
Mercury Aneroid

oDo not take a blood pressure on the side that a person
has had breast surgery on.
o Measure blood pressure with the person sitting or
lying.
o Apply the cuff to the bare upper arm. Do not apply the
cuff over clothing.
o Make sure the cuff is snug.

o Use a large cuff if necessary.
o Make sure the room is quiet.
o If you do not hear the blood pressure, wait 30 to 60
seconds and try again. If you still can not hear it or
are unsure of your readings, have the nurse check
your measurements.

1. Clean the stethoscope earpieces and diaphragm
with alcohol.
2. Locate the brachial pulse. This is where the
stethoscope will be placed.
3. Wrap the cuff above the elbow with the arrow
pointing to the brachial artery. Fasten the cuff so
it fits snugly.

4. Place the diaphragm of the stethoscope flat on the
pulse site, holding it in place with the index and
middle fingers of one hand.
5. Locate the radial pulse.
6. Close the valve on the BP cuff by turning it to the
right (clockwise).
7. Inflate the cuff until you can no longer feel the
radial pulse. ,Then inflate the cuff 30 mm hg
beyond this point.

8. Deflate the cuff slowly by opening the valve slightly
and turning it counterclockwise (to the left) with your
thumb and index finger. Allow the air to escape slowly
while listening for A pulse sound.
9. Note the reading at which you hear the first clear,
regular pulse sound. This number is the systolic
pressure.
10. Continue listening until the sound disappears. This
is the diastolic pressure. Note this reading.
11.Open the valve completely to deflate the cuff.
Remove the cuff from the patient.

Obtaining Blood Pressure by the One-Step
Method
ml

Obtaining Blood Pressure by the Two-step
Method
ml

Reference video
• https://youtu.be/gUWJ-6nL5-8

Vital Signs.ppt

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