Download Unit 102.2 - Vital Signs Characteristics/Normals

Unit 102.2
Vital Signs Characteristics and
Norms
Objectives
• Describe the basic body functions that
produce each vital sign.
• Describe normal and abnormal characteristics,
normal measures, methods and sites for
measuring.
• Discuss related terminology.
Vital Signs
• Measurable, concrete indicators that pertain
to and are essential for life
• Vital signs are the signs of life!
• They are:
– Temperature
– Pulse
– Respirations
– Blood Pressure
Temperature
• measured degree of body heat
• balance maintained between heat produced
and heat lost by the body
• can’t be changed at will
• lower in morning
• elevated more in evenings
Temperature
• heat produced by oxidation of food
• heat lost through
– skin (perspiration)
– lungs (breathing)
– excretions ( urine, saliva)
Fever
• an elevated temperature from normal
– everyone has a temperature
– ill people have a fever
Normal Temperature
•
•
•
•
Type: oral thermometer
Time: 3 minutes
98.6 F or 37 C
easiest to obtain
Normal Temperature
•
•
•
•
Type: rectal thermometer
Time: 5 minutes
99.6 F or 37.6 C
most accurate
Normal Temperature
•
•
•
•
Type: axillary placement of thermometer
Time: 10 minutes
97.6 F or 36.4 C
most inaccurate
Normal Temperature
•
•
•
•
Type: Thermoscan
Time: 1 second
Ranges of 96.6 F - 99.7 F or
35.9 C - 37.6 C
very accurate when circumstances and
technique are correct
Glass Thermometers
• glass hollow tube (stem) with a bulb
containing mercury, that expands and is
read on scale on the stem
– Fahrenheit 212 is boiling, 32 is freezing
– scale measured in .20 (ea. little line
represents .20)
– Celsius (Centigrade) 100 is boiling, 0 is
freezing
– scale measured in .10 (ea. little line
represents .10)
Basic Rules for Glass Thermometers
– rinse off glass thermometer in cold water if
stored in a disinfectant
– shake mercury of glass thermometer down to 94F
or 35C
– use disposable sheath/cover over bulb end of
thermometer inserted in mouth
– no cold or hot food or drinks 15 min. prior to
procedure & no smoking
– Keep in place for 3-5 minutes.
Glass Thermometer
If mercury
falls between
two lines,
round up to
next line for
temperature
reading
Glass Thermometer
Celcius thermometers
are graduated in
increments of 0.1
therefore, each line
represents 0.1
Celcius Mercury Thermometer
Glass Thermometer
Fahrenheit thermometers
are graduated in
increments of 0.2
Fahrenheit Mercury Thermometer
therefore, each line
represents 0.2
How to Read
Glass Thermometer
• hold the thermometer at eye level, rotate
until you can see the column of mercury
• observe the lines on the scale at the upper
side of the mercury
• read the whole number and the tenths
when present
Key Factors
Glass Thermometers
– guard against breaking a mercury thermometer.
Mercury is hazardous material and requires
special handling for disposal
– if thermometer breaks in a patient’s mouth, give
them soft bread to eat and notify the physician
immediately
– very few glass thermometers used today because
of the above hazard
Oral Thermometers
– always place protective sheath over oral
thermometer
– don’t use if patient can’t breathe through their
nose
– ask patient not to talk with thermometer in their
mouth
– place under the tongue
– be sure patient has had nothing hot or cold & not
smoked 15 min. prior
– don’t use if patient can’t cooperate
Conversion between Celsius and
Fahrenheit
• C = (F-32) x 5/9
• F=C x 9/5 + 32
Other Thermometers
• electronic or battery operated
thermometers, cover probe with plastic
sheath, reads and prints out in 10-45
seconds(oral & rectal units)
• disposable patches for forehead
• disposable plastic strip placed in mouth,
turns colors according to degree of
temperature
• tympanic thermometers, for the ear with
results in a second
Digital Oral Thermometer
use according to
the manufacture’s
instructions
lab practice
Thermoscan
Tympanic (ear)
thermometer.
Use according to
manufacture’s
instructions
lab practice
Pull pinna up an
Back before
inserting
Tympanic Temperatures
– reflects body core temperature
– the eardrum shares same blood supply as
hypothalmus
– measures infrared heat of eardrum &
surrounding tissue
– scans eight (8) measurements per reading &
displays highest as the temperature
External Factors
Influencing Accuracy
– lying on ear for extended period of time
– ears covered with cap, scarf, ear muffs
– exposure to extreme heat/cold
– recent swimming/bathing
– Wait 20 minutes if the above are factors to be
considered
Key Factors
Thermoscans
– temperature should be taken in same ear for
duration of an illness
– ear must be free of obstructions to get an
accurate reading (earwax, drainage, etc.)
– if right ear is used, right hand should hold
Thermoscan & visa versa on left
– over age 1 year, pinna of ear should be pulled
up and back
– under 1 year, pinna of ear back only, NOT UP
Recommendation
– Take tympanic temperature 3 times in the
same ear and use the highest reading when:
• *the patient is an infant less than 90 days old
• *a child is less than 3 years & has a compromised
immune system. A fever is critical in these
situations, therefore one must be sure
• *if you are an inexperienced user of the
Thermoscan thermometer
When NOT to use
Thermoscan
– *blood/drainage present in external ear canal
– *ear is painful/swollen/red
– *ear is plugged with earwax
– *ear drops are being used
– *facial deformities involving the ear
– *when hearing aids are present (must wait 20
minutes after removing for an accurate
temperature)
Rectal Temperature
• use in young children and mentally disabled
individuals who may bite
• patients having difficulty breathing
• confused patients
• unconscious patients
• patients on oxygen
• the Thermoscan thermometer could be used
for above situations & reduce risk of rectal
tears
Key Factors
Rectal Temperature
• apply a lubricating jelly, K-Y, Vaseline, or even
shortening (not a medicated jelly like Vicks)
to approximately 1/2 of length
• have adults lay on their side
• infants lay on stomach or over parent’s knees
• insert the thermometer gently
• 1 1/2” into rectum
• hold gently in place for 5 minutes
Key Factors
Rectal Temperature
• wipe from stem to bulb
• wash thermometer with cool water and soap,
rinse , dry and place in container with
disinfectant
• Rectal temperature is the most accurate
temperature.
Key Factors
Axillary Temperature
• use on infants with diarrhea and/or well
infants
• axillary area should be dry (DO NOT rub)
• 10 minutes required for accurate reading
• could be used for someone unable to tolerate
or understand the concept of oral
thermometers
Signs & Symptoms
of Fever
• Early Signs:
– shivering
– increased metabolism
– increased pulse
– feeling cold
– goose bumps
Signs & Symptoms
of Fever
• Later Signs:
– skin warm to the touch
– flushed
– dehydration
• dry skin, sunken dull eyes, poor skin turgor
– diaphoresis
• profuse sweating, indicating hypovolemic shock
– weakness
– thirsty
– rapid respirations
Documentation
• when recording temperature on chart
indicate:
–
–
–
–
the degree
whether it is Fahrenheit or Celsius
whether the left or right ear was used
what site was used. Oral is universal, if other sites
used, an indicator must be shown
• R for rectal
• A for axillary
• T with circle around it for tympanic
Pulse
• a rhythmic beat or vibration detected by
palpating an artery over a bony prominence
that indicates the heart rate
• should be the same at all arterial pulse sites
Pulse Sites
• areas where you can
compress an artery
against a bone
• Temporal
– side of the head
Pulse Site
• Carotid
– neck
Pulse Site
• Brachial (not shown)
– distal upper arm, just
above elbow, medial
aspect
• Radial
– wrist, thumb side
– Most common site for
conscience adult
patients
Pulse Sites
• Apex
– point of heart
• Femoral
– groin
• Popliteal
– behind knee
• Dorsalis pedis
– top of the foot
Normal Pulse Range
• varies with age, gender, activity, physical
conditions
• General rule: The younger the patient the
faster the heartbeat
Pulse Ranges
Normal
• Prenatal
– 120-160
• Infant
– 115-130
• Child
– 80-115
• Adult
– 60-100
Tachycardia
• Definition: pulse rate greater than 100
– Causes of tachycardia:
•
•
•
•
•
•
•
•
stimulant drugs
coffee, tea, soda
elevated temperature
pain
anxiety
shock
diseases like hyperthyroidism
digestion and exercise
Bradycardia
• Definition: heart rate less than 60
– Causes of bradycardia:
•
•
•
•
•
poisons
sleeping pills, tranquilizers
resting or fasting
accidents or disease causing brain pressure
mental depression
Force of Pulse
• How does the pulse force feel against your
finger pressure?
– Weak or thready (difficult to detect)
– Strong (easily detected)
– Bounding (very strong, so much so that your
fingers feel as though they are being pushed off
the artery)
Pulse Rhythm
• Definition: Intervals between heart beats
should be regularly spaced
– when describing the rhythm on chart, note
whether the rhythm is regular or irregular
directly after the rate
Arrhythmia
• Definition: Irregular heart beat
Apical Pulse
• apex of heart is the pointed end of heart or
its’ base
• found at the 5th intercostal space at mid left
chest just below left nipple
• heard with a stethoscope
• frequently used with infants or when a pulse
is difficult to detect
Procedure Reminders
• never use your thumb to detect & count
pulse (thumb has own pulse)
• Use a watch with a second hand and count
pulse for 60 seconds
– this may vary in some facilities. You may count
for 30 seconds and multiply by 2, or 15 seconds
and multiply by 4, etc. Know protocol
• when an arrhythmia is detected, the pulse
must be taken for 60 seconds
Respirations
• the act of inhaling oxygen and exhaling
carbon dioxide
– Inspiration= breathing in
– Expiration= breathing out
Normal Respirations
Rates
• Adult
– 12-20
• Child/Infant
– 20-30
• Newborn
– 35-50
Factors that Affect Respirations
• Increases rate:
–
–
–
–
–
–
–
–
–
diseases of lungs & circulatory system
hemorrhage
pain
shock
fever
vigorous exercise
anxiety, excitement
altitude
atropine
Factors that Affect
Respirations
• Decreases Rate:
– sleep or relaxation
– narcotic analgesics
• morphine
– kidney failure
– brain tumors
– injuries
Respiratory Terminology
– Pnea
• respirations
– Eupnea
• normal respirations
– Bradypnea
• slow respirations
– Tachypnea
• fast respirations
– Apnea
• Cessation or absence of respirations
– Hyperventilation
• rapid breathing depleting carbon dioxide
Various Qualities of Respirations
• Shallow
– very little air inhaled
– little chest movement
• Deep
–
–
–
–
more air inhaled
seen in brain injuries
often chest pathology in progress
seen with exersion
• Full
– viewed as normal breathing
Procedure Reminders
– patients can alter
breathing pattern,
– count respirations
without the patient
being aware
– count for 60 seconds
while still appearing
to take pulse
– record rate & quality
of breathing
Immediately begin counting
respirations after counting
pulse with NO perceivable
break
What to do if Breathing is
Difficult to Detect
• while appearing to take pulse, watch chest
rise and fall
• place arm across chest, take pulse, and then
count each rise and fall of chest
• assume patients breathing pattern and count
your own
• watch abdomen rise and fall
Vital Signs
View Video KHO 17
“Temperature, Pulse, Respirations”
approximately 23 minutes
Blood Pressure
• the force of blood pushing against the walls
of the arteries
Blood Pressure
Terminology
• Systolic
– greatest force exherted as heart is contracting
“heart at work”
– top number
– quick to change
– affected by
•
•
•
•
•
exercise
emotions
illness
medications
illegal drugs
Blood Pressure
Terminology
• Diastolic
– least force exherted during relaxation phase of
cycle “heart at rest”
– bottom number
– affected by
• disease
• medications
• slower to change
Blood Pressure
Adult Normal Ranges
• Systolic
– 90-140
• Diastolic
– 60-90
• record as a fraction systolic/diastolic and in
even numbers, unless using digital BP
equipment
Abnormalities
• Hypertension
– Elevated or high blood pressure
– usually greater then 140/90
• Hypotension
– decreased blood pressure
– usually less than 90/60
Factors that Increase
Blood Pressure
– loss of elasticity of arteries (disease)
– exercise, eating
– stimulants like coffee, caffinated beverages,
drugs
– emotional disturbances
– gender (females often not affected until after
menopause)
– excess weight (not hard rule)
– family history
Factors that Decrease
Blood Pressure
•
•
•
•
depressants like sleeping pills
narcotic pain relievers, tranquilizers
fasting
shock caused from blood or body fluid losses
Sphygmomanometer
(Blood Pressure Cuff)
• measures arterial
pressure in mm of
mercury (Hg) or its
equivalent
• rubber bladder
covered with
unyielding material
• hand bulb with
stop cock to inflate
cuff
• aneroid dial or
mecurial column to
measure
cuff inflated 180 - 200 mm Hg
release at rate of 4 mm Hg per
second and listen for first heat
beat & last heartbeat
Key Factors
Blood Pressure
– remove clothing from above the elbow when possible
– cuff size should be 2/3 length of upper arm (humerus)
• too small of a cuff may give false high blood pressure reading
• too large of a cuff may give false low blood pressure reading
• The valve is turned clockwise to inflate the cuff
– support extremity at heart level to get an accurate
reading
– listen over brachial artery pulse site
– if repeating is necessary, wait 1 full minute before reinflating the cuff
Stethoscope
– bell and/or
diaphragm placed on
organ/vessel to
auscultate
– the diaphragm must
be in full contact with
organ/vessel for
maximum audibility
– use two fingers, NOT
thumb only to make
contact
diaphragm
Key Factors
Stethoscope
– diaphragm (flat side) is used to auscultate blood
pressure, lung sounds, bowel sounds, bruits
– bell is used for heart sounds and pediatric patient
assessment
– ear pieces point to nose when in ears
– minimize tube noise to maximize ability to hear
sounds
– clean the diaphragm/bell between patients (do
not transmit germs this way) & keep ear tips
clean
Vital Signs
Unit 102.3
Recording Vitals
• Record findings
– charting shows comparisons quickly
– Narrative
• write down pulse rate (beats per minute), quality of pulse, and
rhythm
• write down respiration rate (breaths per minute) & quality of
breath
• describe abnormal (be specific)
• To correct an error
– DO NOT erase or obliterate any info
Correction of a Handwritten Entry
• draw line through the error
• insert correction above or immediately
following the error
• in the margin, write “correction” or “corr”,
your initials and date
Knowledge Assessment
• Give normal temperatures for oral, rectal, and
axillary temperatures.
• List and describe the different types of
thermometers.
• Define pulse and list all pulse sites.
• Define respirations, normal rates, and factors that
affect respiration counts.
• Contrast systolic and diastolic.
• Define blood pressure, give normal ranges,
abnormalities, and equipment.