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Chapter 38 Vital Signs and Measurements Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Height and Weight • Mensurations: the process of measuring • Purpose – The baseline for all measurements to follow – Can provide information about treatment • Obtained at the beginning of the visit – May not be taken at all visits Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Height and Weight • Additional infant measurements taken to ensure proper growth and development – Length of extremities – Circumference of head – Circumference of abdomen or chest Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Body Mass Index • Numerical correlation between height and weight • May be documented in patient’s chart • There are a number of ways to determine BMI Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Vital Signs • Measure body functions essential to life • Four vital indicators, TPR and B/P – Temperature: body’s ability to control heat – Pulse: rate, volume, and rhythm of the heart – Respirations: rate and quality of breathing – Blood pressure: force of the heart and condition of the blood vessels Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Temperature • The balance between heat production and heat loss – Heat is produced when food is changed to energy – Heat is lost through perspiration, breathing, and elimination of waste Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Temperature • Factors affecting temperature – Metabolic rate – Time of date – Amount of activity • Normal temperature may vary – Temperature above normal: febrile – Temperature below normal: afebrile Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Thermometers • • • • • Disposable Electronic (battery operated) Digital Tympanic infrared Temporal artery Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Oral Temperature Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Oral Temperature • Contraindications – Infants and young children – Certain respiratory conditions – Confused, disoriented, or unstable patients – Oral injuries or dental problems – Recent oral surgery – Facial paralysis – Nasal obstruction, sinus congestion, or colds Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Rectal Temperature • Very accurate method for measurement • Indicated for babies and young children • When documenting, record (R) following reading • Normal rectal temperature is one degree above normal oral temperature Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Axillary Temperature • Least accurate method for measurement • Indicated when oral and rectal temperatures are undesirable • When documenting, record (Ax) following reading • Normal axillary temperature is one degree below normal oral temperature Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Tympanic (Aural) Temperature • Thermometers are easy, safe, and fast • When documenting, record (Tym) following reading Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Temporal Artery Temperature • Very accurate method for measurement • Appropriate for all ages, infant through older adult • When documenting, record (TA) following reading • Normal TA temperature is one degree above normal oral temperature Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Temperature Conversions • Fahrenheit to Celsius • Celsius to Fahrenheit Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Pulse • Palpated in arteries close to body surface and lie over bone or firm structures • Can be felt in several locations on the body Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Pulse Sites • Radial – Most frequently used when measuring pulse rate • Apical • Brachial – Used to palpate and auscultate blood pressure • Carotid – Palpated during CPR Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Pulse Sites • Femoral • Dorsal pedalis • Popliteal – These three sites are palpated to evaluate circulation in the lower extremities Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Pulse • Pulse rates – Normal range is 60-100 beats per minute – Influenced by • • • • • Exercise Age Gender Size Physical condition of body Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Pulse • Pulse characteristics – Volume • Normal, full or bounding, weak, thready – Quality • Arrythmia, pulse lacks a specific rhythm • Intermittent Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Measuring Radial Pulse • Patient should be sitting or laying down – The arm should be well-supported • Use the tips of your fingers – Do not use the thumb • Typically count for 30 seconds, multiply by 2 – Count for 60 seconds if pulse is irregular – Measure respirations at the same time Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Measuring Apical Pules • Indicated for – Instances when radial pulse is not appropriate – Infants and small children – Patients with heart conditions • Listen to heart at its apex with a stethoscope – Palpate at fifth intercostal space • Count for 60 seconds • Document using [Ap] to indicate apical site Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Pulse Oximetry • Small device used to measure pulse and arterial oxygen saturation in blood • Clip attached to patient’s finger Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Respirations • Combination of inspiration (inhale) and expiration (exhale) • Normal respiration rate is 16-20 per minute • Observe rate and quality of respirations – Should be quiet, effortless, and regularly spaced – Breathing should be through the nose – Depth of respiration: normal, shallow, or deep Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Respirations • Abnormal respirations – Hyperventilation – Dyspnea – Rales (noisy breathing) – Apnea, absence of breathing – Cheyne-Stokes Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Blood Pressure • Measured in the brachial artery of the arm in the antecubital space – Uses stethoscope and sphygmomanometer to measure • Blood pressure phases – Systole, contraction phase – Diastole, relaxation phase • Expressed as a fraction, systolic/diastolic Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Normal Blood Pressure • Systolic pressure – 100-120 mm Hg • Diastolic pressure – 60-80 mm Hg Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Abnormal Blood Pressure • Hypertension – Consistent readings above 140/90 – Idiopathic (essential hyptertension) – Primary, secondary, malignant • Hypotension – Consistent readings below 90/60 Copyright ©2012 Delmar, Cengage Learning. All rights reserved.