Observing & Measuring Vital Signs
NATCEP Day Twenty-Five through Twenty-Seven
Why measure Vital Signs
• Means of getting information about
the body’s condition
• Vital signs include
– Temperature
– Pu...
Objectives: Temperature
• Identify
– Cause of body temperature
– “Normal” range or average body temperature
• List situat...
Temperature is. . . . .
• A measurement of the amount of heat
in the body, a balance between heat
created and lost
• Creat...
Normal Ranges (Fahrenheit)
•
•
•
•
•
•
Oral: 97.5 – 99.5
Rectal: 98.5 – 100.5
Axillary: 96.6 – 98.6
Tympanic: 96.4 – 100
...
Variations High & Low: Causes
• Higher than normal
– Eating warm food
– Time of day
– Infection
– Disease
• Lower than no...
Types of Thermometers
•
•
•
•
•
Electronic
Digital
Chemically treated paper
Tympanic: eardrum/ear
Temporal: temporal arte...
Care of Thermometers
• Probe Covers
• Follow Manufacturer’s Instructions
– Electronic or Digital
– Tympanic
– Temporal
Taking an Oral Temperature
•
•
•
•
•
Most common temperature
Under tongue
Mouth and lips closed
Beeping indicates done
El...
Taking an Axillary Temperature
• Least accurate
– Safety prohibits other sites
•
•
•
•
•
Under the arm
Tip placed in cen...
Taking an Tympanic Temperature
• Open ear canal by gently lifting the ear
up and back
• Gently insert tip inside ear canal...
Taking an Temporal Temperature
• Follow manufacturer’s instructions
– Typical moved from center of forehead to
temporal ar...
Taking a Rectal Temperature
• Infants
• Children & Adults
– Used when other methods unavailable or
inaccurate
• Lubricate...
Recording Temperature
• Use “ax” to indicate axillary
• Use “r” to indicate rectal
• Notify nurse
– Above or below normal ...
Practice
• Follow my instructions to practice on
your peers
Objectives: Pulse
• State the “normal” or average pulse
rate
• Identify variations from the “normal”
pulse that should be ...
Pulse
• A measurement of the number of
times the heart beats per minute
• Normal/average
– 60-100 minute (adult)
– Regular...
Variations in Pulse: Force
• Abnormal force can be distinguished by
– Bounding pulse
• Cannot be occluded (blocked) by mil...
Variations in Pulse: Rate
• Abnormal rate distinguished by
– Rate under 60 per minute: Bradycardia
– Rate over 100 per min...
Variations in Pulse: Rhythm
• Abnormal rhythm distinguished by
– Irregularity of beats
– Feeling that beats are “skipped” ...
Sites for Checking Pulse
• Apical
• Radial
Report
• Pulse varies from “normals”
• Difficulty obtaining pulse
Practice
• Follow my instructions to practice on
your peers
– Apical pulse
– Radial pulse
Objectives: Respirations
• State the average respiratory rate
• Describe how to measure respiratory
rate
• Describe variat...
Respirations
• Inspiration and expiration of air
• Average rate is 12-20 per minute (adult)
How to Count Respirations
• Look at chest or abdomen
• Count for one full minute
Variations
• Rate
– Increased by
•
•
•
•
Exercise/activity
Fever
Lung Disease
Heart Disease
– Report fewer than 12 or mo...
Variations
• Character
– Labored
• Difficulty breathing
– Noisy
• Sounds of obstruction or wheezing
– Shallow
• Small am...
Report
• Record in the appropriate area of the
worksheet per facility policy
• Variations from “normals” immediately
Practice
• Follow my instructions to practice on
your peers
Objectives: Blood Pressure
•
•
•
•
•
Describe blood pressure (BP)
State the “normal” or average BP
Describe variations in...
Blood Pressure
• Force of blood against artery walls
• Amount of pressure depends on
– Rate & strength of heart beat
– Eas...
Terms
• Systolic Pressure
– Force when the heart is contracted
– Top number of the BP
– First sound when measuring
• Dias...
Normal
• Adult is less than 120/80
– Less than 120 systolic
– Less than 80 diastolic
Variations
•
•
•
•
May slightly increase with age
Hypertension: Higher than normal
Hypotension: Lower than normal
Postura...
Tools/Instruments
• Sphygmomanometer
– Cuff and gauge
• Cuff
– Correct size for the resident’s arm
– Placed correctly over...
Tools/Instruments
• Stethoscope
Factors that Influence Reading
•
•
•
•
•
Proper clothing
Avoid smoking
Empty bladder
Allow time to rest & relax
Position ...
Body Position
•
•
•
•
Arm supported at heart level
Back supported
Feet flat on floor
No talking or movement
Cautions
• DO NOT TAKE in arm with:
– IV
– Cast
– Dialysis Shunt
– Breast surgery on that side
Report
• Higher or lower than his/her usual
range
• Difficulty obtaining
Blood Pressure – An Overview
CAUSE
SYSTOLIC BP
CORRECTIVE ACTION
Sit without back support
+ 6 to 10
Support back (sit...
Practice
• Follow my instructions to practice on
your peers
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Natcep day 25 26 27

Published on: Mar 3, 2016
Published in: Education      Technology      Business      
Source: www.slideshare.net


Transcripts - Natcep day 25 26 27

  • 1. Observing & Measuring Vital Signs NATCEP Day Twenty-Five through Twenty-Seven
  • 2. Why measure Vital Signs • Means of getting information about the body’s condition • Vital signs include – Temperature – Pulse – Respirations – Blood Pressure
  • 3. 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
  • 4. 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
  • 5. 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
  • 6. 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
  • 7. Types of Thermometers • • • • • Electronic Digital Chemically treated paper Tympanic: eardrum/ear Temporal: temporal artery/forehead
  • 8. Care of Thermometers • Probe Covers • Follow Manufacturer’s Instructions – Electronic or Digital – Tympanic – Temporal
  • 9. Taking an Oral Temperature • • • • • Most common temperature Under tongue Mouth and lips closed Beeping indicates done Electronic/Digital
  • 10. 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
  • 11. Taking an Tympanic Temperature • Open ear canal by gently lifting the ear up and back • Gently insert tip inside ear canal • Beeping indicates done
  • 12. Taking an Temporal Temperature • Follow manufacturer’s instructions – Typical moved from center of forehead to temporal artery site • Beeping indicates done
  • 13. 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
  • 14. Recording Temperature • Use “ax” to indicate axillary • Use “r” to indicate rectal • Notify nurse – Above or below normal range – Difficulty obtaining temperature
  • 15. Practice • Follow my instructions to practice on your peers
  • 16. 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
  • 17. 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
  • 18. 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
  • 19. 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
  • 20. Variations in Pulse: Rhythm • Abnormal rhythm distinguished by – Irregularity of beats – Feeling that beats are “skipped” when pulse counted for one full minute
  • 21. Sites for Checking Pulse • Apical • Radial
  • 22. Report • Pulse varies from “normals” • Difficulty obtaining pulse
  • 23. Practice • Follow my instructions to practice on your peers – Apical pulse – Radial pulse
  • 24. 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
  • 25. Respirations • Inspiration and expiration of air • Average rate is 12-20 per minute (adult)
  • 26. How to Count Respirations • Look at chest or abdomen • Count for one full minute
  • 27. Variations • Rate – Increased by • • • • Exercise/activity Fever Lung Disease Heart Disease – Report fewer than 12 or more than 20 breaths per minute
  • 28. Variations • Character – Labored • Difficulty breathing – Noisy • Sounds of obstruction or wheezing – Shallow • Small amounts of air exchange – Irregular
  • 29. Report • Record in the appropriate area of the worksheet per facility policy • Variations from “normals” immediately
  • 30. Practice • Follow my instructions to practice on your peers
  • 31. 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
  • 32. 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
  • 33. 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
  • 34. Normal • Adult is less than 120/80 – Less than 120 systolic – Less than 80 diastolic
  • 35. 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
  • 36. 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
  • 37. Tools/Instruments • Stethoscope
  • 38. Factors that Influence Reading • • • • • Proper clothing Avoid smoking Empty bladder Allow time to rest & relax Position body correctly
  • 39. Body Position • • • • Arm supported at heart level Back supported Feet flat on floor No talking or movement
  • 40. Cautions • DO NOT TAKE in arm with: – IV – Cast – Dialysis Shunt – Breast surgery on that side
  • 41. Report • Higher or lower than his/her usual range • Difficulty obtaining
  • 42. Blood Pressure – An Overview CAUSE 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 body Unsupported Elbow too high Elbow 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 10 Cuff too wide/large False low Cuff not centered +4 Cuff over clothing + 5 to 50 Right-sized cuff properly placed over bare upper arm (Pickering et al., 2005; Perry & Potter,
  • 43. Practice • Follow my instructions to practice on your peers