MEASURING%20VITAL%20SIGNS

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MEASURING VITAL SIGNS

• UNIT 1
• TPR

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MEASURING VITAL SIGNS

• TEMPERATURE
• PULSE
• RESPIRATION
• (TPR)
• (BLOOD PRESSURE)

• Indicate how the body is functioning.
• When within normal limits homeostasis.
• Accuracy in measuring and recording.
• Patients treatment depends on this info.

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BODY TEMPERATURE

• The measure of body heat produced by the muscles
  and glands and by the oxidation of food
• The balance between the heat produced and the
  heat lost
• Measured with thermometer

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• Oral Cavity
• Simplest, most common, convenient, and
  comfortable site
• Avg. oral temp. is 98.6 F or 37 C
• Use whenever possible, and when the patient has
• Diarrhea
• Rectal surgery
• Fecal impaction

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• Rectal
• The most accurate temp. reading is in the rectum
• Normal rectal temp. is 99.6 F or 37.5 C
• Rectal temp. is taken when patients
• Are under 6 yrs. old
• Have difficulty breathing
• Are extremely weak
• Are confused, unconscious, or senile
• Are being given oxygen
• Experience partial paralysis of the face caused
  by a stroke or accident

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• Aural
• Also accurate, easy to use, and appropriate for
  patients listed under rectal
• Probe is positioned in the aural canal of the ear
• Normal aural temp. is 98.6 F or 37 C

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• Axillary
• Taken in the armpit
• Least accurate temp.
• Normal axillary temp. is 97.6 F or 36.4
• Use this technique only when the temp. cannot be
  taken orally, aurally, or rectally

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• ALWAYS REPORT A TEMPERATURE THAT IS ABOVE NORMAL
  TO YOUR SUPERVISOR

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FACTORS THAT INFLUENCE BODY TEMPERATURE

• INCREASE TEMPERATURE
• Exercise
• Digestion
• Increased environmental temp
• Illness
• Infection
• Excitement
• Anxiety

• DECREASE TEMPERATURE
• Sleep
• Fasting
• Exposure to cold
• Certain illnesses
• Decreased muscle activity
• Mouth breathing
• Depression

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Human Temperature Variation EffectsHOT

• 37C (98.6F) - Normal body temperature (which
  varies between about 36.12-37.5C (96.8-99.5F)
• 38C (100.4F) - Sweating, feeling very
  uncomfortable, slightly hungry.
• 39C (102.2F) - Severe sweating, flushed and
  very red. Fast heart rate and breathlessness.
  There may be exhaustion accompanying this.
  Children and people with epilepsy may be very
  likely to get convulsions at this point.
• 40C (104F) - Fainting, dehydration, weakness,
  vomiting, headache and dizziness may occur as
  well as profuse sweating.

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41C (105.8F) - (Medical emergency) - Fainting,
vomiting, severe headache, dizziness, confusion,
hallucinations, delirium and drowsiness can
occur. There may also be palpitations and
breathlessness. 42C (107.6F) - Subject may
turn pale or remain flushed and red. They may
become comatose, be in severe delirium, vomiting,
and convulsions can occur. Blood pressure may be
high or low and heart rate will be very fast.
43C (109.4F) - Normally death, or there may be
serious brain damage, continuous convulsions and
shock. Cardio-respiratory collapse will likely
occur. 44C (111.2F) or more - Almost certainly
death will occur however, patients have been
known to survive up to 46.5C (115.7F).
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Heat Exhaustion and Heat Stroke Overview Heat
exhaustion This condition often occurs when
people exercise (work or play) in a hot, humid
place and body fluids are lost through sweating,
causing the body to overheat. The person's
temperature may be elevated, but not above
104F. Heat stroke This medical condition is
life-threatening. The person's cooling system,
which is controlled by the brain, stops working
and the internal body temperature rises to the
point where brain damage or damage to other
internal organs may result (temperature may reach
105F).
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Heat Exhaustion and Heat Stroke Causes Heat
exhaustion is typically caused when people who
are not well adjusted to heat exercise in a hot,
humid environment. At high temperatures, the
body cools itself largely through evaporation of
sweat. When it is very humid, this mechanism
does not work properly. The body loses a
combination of fluids and salts (electrolytes).
When this is accompanied by an inadequate
replacement of fluids, disturbances in the
circulation may result that are similar to a mild
form of shock.
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Heat stroke may often develop rapidly. Medical
conditions or medications that impair the body's
ability to sweat may predispose people to this
problem. Heat stroke happens in the following
two ways The classic form occurs in people
whose cooling mechanisms are impaired. The
exertional form occurs in previously healthy
people who are undergoing strenuous activity in a
hot environment. Infants and the elderly are
more likely to have this problem, as are those
who are taking antihistamines and certain types
of medication for high blood pressure or
depression.
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Heat exhaustion symptoms Often pale with cool,
moist skin Sweating profusely Muscle cramps
or pains Feels faint or dizzy May complain of
headache, weakness, thirst, and nausea Core
(rectal) temperature elevated-usually more than
100F-and the pulse rate increased
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Heat stroke symptoms Unconscious or has a
markedly abnormal mental status (dizziness,
confusion, hallucinations, or coma) Flushed,
hot, and dry skin (although it may be moist
initially from previous sweating or from attempts
to cool the person with water) May have
slightly elevated blood pressure at first that
falls later May be hyperventilating Rectal
(core) temperature of 105F or more
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When to Seek Medical Care As with all other
medical problems, a doctor should be called if
you are not sure what is wrong, if you do not
know what to do for the problem, or if the person
is not responding to what you are doing for them.
Call a doctor for heat exhaustion if the person
is unable to keep fluids down or if their mental
status begins to deteriorate. Symptoms of
shortness of breath, chest pain, or abdominal
pain may indicate that the heat exhaustion is
accompanied by more serious medical problems.
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Suspected heat stroke is a true, life-threatening
medical emergency. Call for an ambulance and
request information as to what to do until the
ambulance arrives. A person with suspected heat
stroke should always go to the hospital (or call
for an ambulance) at once.
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For heat exhaustion, a person should go to the
hospital if any of the following are
present Loss of consciousness, confusion, or
delirium Chest or abdominal pain Inability to
drink fluids Continuous vomiting Temperature
more than 104F Temperature that is rising
despite attempts to cool the person Any person
with other serious ongoing medical problems
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For mild cases of heat exhaustion Rest in a
cool, shaded area. Give cool fluids such as
water or sports drinks (that will replace the
salt that has been lost). Salty snacks are
appropriate as tolerated. Loosen or remove
clothing. Apply cool water to skin. Do not
use an alcohol rub. Do not give any beverages
containing alcohol or caffeine.
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Heat stroke (do not attempt to treat a case of
heat stroke at home, but you can help while
waiting for medical assistance to arrive.) Call
911 immediatelyMove the person to a cooler
environment, or place him or her in a cool bath
of water (as long as he or she is conscious and
can be attended continuously). Alternatively,
moisten the skin with lukewarm water and use a
fan to blow cool air across the skin. Give cool
beverages by mouth only if the person has a
normal mental state and can tolerate it.
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COLD

• 37C (98.6F) - Normal body temperature (which
  varies between about 36-37.5C (96.8-99.5F)
• 36C (96.8F) - Mild to moderate shivering (it
  drops this low during sleep). May be a normal
  body temperature.
• 35C (95.0F) - (Hypothermia) is less than 35C
  (95.0F) - Intense shivering, numbness and
  bluish/grayness of the skin. There is the
  possibility of heart irritability.
• 34C (93.2F) - Severe shivering, loss of
  movement of fingers, blueness and confusion. Some
  behavioral changes may take place.
• 33C (91.4F) - Moderate to severe confusion,
  sleepiness, depressed reflexes, progressive loss
  of shivering, slow heart beat, shallow breathing.
  Shivering may stop. Subject may be unresponsive
  to certain stimuli.

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Severe Hypothermia

• 90º - 86ºF Shivering stops, exposed skin blue of
  puffy, muscle coordination very poor, inability
  to walk, confusion, incoherent/irrational
  behavior, but may be able to maintain posture and
  appearance of awareness
• 86º - 82ºF Muscle rigidity, semiconscious,
  stupor, loss of awareness of others, pulse and
  respiration rate decrease, possible heart
  fibrillation
• 82º - 78ºF Unconscious, heart beat and
  respiration erractic, pulse may not be palpable
• 78º - 75ºF Pulmonary edema, cardiac and
  respiratory failure,death. Death may occur before
  this temperature is reached.

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You may treat minor cold exposure at home with
blankets and home care techniques. Call a
doctor to ask about danger signs that might
warrant immediate transportation to a medical
facility.
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Any person who is at risk for hypothermia and is
suspected to have sustained a cold exposure
should be brought to a hospitals Emergency
Department. Look for these danger signs of cold
exposure Intense shivering, stiffness, and
numbness in the arms and legs, stumbling and
clumsiness, sleepiness, confusion, and amnesia.
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The adage that "a person is not dead until warm
and dead" means that victims may appear dead
because of cold exposure, but many of these
people have made complete recoveries when
rewarmed. All such victims in this situation
need rapid transport to a hospital so that
resuscitation attempts may be made.
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Self-Care at Home The first priority is to
perform a careful check for breathing and a pulse
and initiate cardiopulmonary resuscitation (CPR)
as necessary. If the person is unconscious,
having severe breathing difficulty, or is
pulseless, call 911 for an ambulance. Because
the victims heartbeat may be very weak and slow,
the pulse check should ideally be continued for
at least 1 minute before beginning CPR. Rough
handling of these victims may cause deadly heart
rhythms.
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The second priority is re-warming. Remove all
wet clothes and move the person inside. The
victim should be given warm fluids if he or she
is able to drink, but do not give the person
caffeine or alcohol. Cover the persons body
with blankets and aluminum-coated foils, and
place the victim in a sleeping bag. Avoid
actively heating the victim with outside sources
of heat such as radiators or hot water baths.
This may only decrease the amount of shivering
and slow the rate of core temperature increase.
Strenuous muscle exertion should be avoided.
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Medical Terminology

• afebrile temp. is within normal range
• febrile temp. is elevated
• hypothermia temp. is below normal
• pyrexia above normal temp.
• pyrogenic any substance that produces fever

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PULSE

• Indicates the number of times the heart beats in
  1 minute.
• Pressure of the blood against the wall of the
  artery as the heart contracts and relaxes.
• Indicates how well the blood is circulating
  through the body.

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• Place your fingers over an artery and squeeze
  gently against the bone
• The pulse rate should be the same at all pulse
  points

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• Radial pulse is the most common site
• Apical pulse
• Taken at the apex of the heart when the heart is
  too weak to transmit a pulse that you can feel
  along the arteries
• Place a stethoscope 2-3 inches to the left of the
  sternum, just below the nipple on the chest

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PULSE CHARACTERISTICS must be noted

• RATE number of pulse beats per minute.
• RHYTHM regular, steady or skipped beats?
• ARRHYTHMIA uneven intervals between pulses or
  heartbeats?
• FORCE OF BEAT (volume) weak, thready, or
  bounding?
• ALWAYS COUNT THE PULSE FOR 1 FULL MINUTE

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PULSE rate, rhythm force

• ALWAYS report a heartbeat lt 60 or gt 100.
• gt 100 tachycardia
• lt 60 bradycardia
• irregular arrhythmia
• thready weak, barely-felt pulse thin, like a
  thread.
• bounding leaping, very strong, or forceful
  pulse.

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FACTORS THAT AFFECT PULSE RATE

• INCREASE PULSE RATE
• Exercise
• Illness
• Anxiety
• Medication
• Shock

• DECREASE PULSE RATE
• High level of aerobic fitness
• Depression
• Medication

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NORMAL PULSE RATES

• Age

• Rate

• Before birth
• At birth
• First year of life
• Childhood years
• Adult

• 140 150
• 90 160
• 115 130
• 80 115
• 60 80

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Medical Terminology

• arrhythmia absence of rhythm
• bradycardia abnormally slow heartbeat
• pulsation rhythmic beat
• tachycardia abnormally fast heartbeat

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RESPIRATION

• The process of taking O2 into the body and
  expelling CO2 from the body
• One inspiration/inhalation (breathing in) and one
  expiration/exhalation (breathing out) one
  respiration
• DO NOT tell patient you are counting respirations
• Count pulse rate respirations while you are
  taking the temperature

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RESPIRATORY CHARACTERISTICS

• Rate number of respirations per minute.
• Rhythm regular or irregular?
• Dyspnea difficulty breathing?
• Apnea has breathing stopped?
• Cheyne-Stokes periods of labored respirations
  followed by apnea.
• Rales bubbling or rattling sounds caused by
  mucus in the air passages.
• Always report any unusual or abnormal
  respirations to your supervisor.

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Average respiratory rates, by age

• Newborns Average 44 breaths per minute
• Infants 20-40 breaths per minute
• Preschool children 20-30 breaths per minute
• Older children 16-25 breaths per minute
• Adults 14-18 (12-20) breaths per minute

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FACTORS THAT AFFECT RESPIRATION

• DECREASE RESPIRATION

• INCREASE RESPIRATION

• Exercise
• Anxiety
• Respiratory disease
• Medication
• Pain
• Heart disease (e.g., CHF)

• Relaxation
• Depression
• Head Injury
• Medication

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Medical Terminology

• apnea not breathing
• dyspnea difficulty breathing
• Cheyne-Stokes labored respirations followed by
  apnea
• rales bubbling or rattling sounds caused by
  mucus in the air passages
• tachypnea - abnormally fast respirations

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BLOOD PRESSURE

• The force of the blood pushing against the walls
  of the blood vessels.
• Depends on the volume of blood in the circulating
  system, the force of the heartbeat, and the
  condition of the arteries.
• When arteries lose their elasticity, they give
  more resistance, and the blood pressure increases.

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BLOOD PRESSURE

• DIASTOLIC PRESSURE

• SYSTOLIC PRESSURE

• The greatest force exerted on the walls of the
  arteries by the heart.
• Occurs when the heart is contracting.

• The least force exerted on the walls of the
  arteries by the heart.
• Occurs as the heart relaxes between contractions.

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RECORDING OF BLOOD PRESSURES

• 120/80 120 systolic
• 80 diastolic

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NORMAL BLOOD PRESSURE

• SYSTOLIC

• DIASTOLIC

• 90 140 mm mercury

• 60 90 mm mercury

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Categories for Blood Pressure Levels in Adults

• Normal Less than 120 And Less than 80
• Pre-hypertension 120139 Or 8089
• High blood pressure            
• Stage 1 140159 Or 9099     
•  Stage 2 160 or higher Or 100 or higher

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FACTORS THAT AFFECT BP

• INCREASE BP

• DECREASE BP

• Loss of elasticity in arteries
• Exercise
• Eating
• Stimulants (e.g., medication, coffee)
• Anxiety

• Hemorrhage
• Inactivity
• Fasting
• Suppressants (e.g., medications that cause BP to
  lower)
• Depression

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DIFFERENT KINDS OF BP APPARATUS

• Mercury
• Aneroid
• Electronic/digital

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• The mercury and aneroid apparatuses have a gauge
• The gauge is marked with a series of long and
  short lines
• The long lines are at 10 mm intervals
• The short lines indicate 2 mm intervals

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• When measuring BP, two things must be done at the
  same time
• Listen to the heartbeat pulsating through the
  artery
• Watch the gauge in order to take a reading

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BP APPARATUS

• SPHYGMOMANOMETER
• a cloth-covered rubber bladder that fills with
  air as the bulb is squeezed.
• Sphygmo refers to pulse
• Mano refers to pressure
• Meter refers to measure
• Commonly called a BP Cuff

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• When the cuff is inflated around the arm, it
  stops the flow of blood in the artery
• As the pressure is relieved, the flow returns and
  you hear a beatthis is the systolic pressure
• As the cuff continues to deflate, you hear a last
  beat and then silencethe last beat you hear is
  the diastolic pressure

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STETHOSCOPE

• Needed to listen to pulse sounds.
• Picks up sound when placed against the body.
• Contains earpieces, a spring to keep tension in
  the ears, flexible rubber tubing that carries
  sound.
• Magnifies sound with a bell or diaphragm.

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Medical Terminology

• asymptomatic without visible symptoms
• diastolic least force of pressure exerted
  against the walls of the arteries
• hypertension high blood pressure
• hypotension low blood pressure
• stethoscope instrument used to amplify sound
• systolic greatest force of pressure exerted
  against the walls of the arteries