Download Ch38pptrevised

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
– Best if obtained from a balance beam scale
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
• You need to know how to determine BMI
– Multiply the patients weight in pounds by 703
– Divide this total by the patients height in inches
– Divide this total by the patients height in inches again and
then round to the nearest whole number
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. Fluctuating pressure that the
blood exerts against the arterial walls as the heart
alternately contracts and relaxes.
Copyright ©2012 Delmar, Cengage Learning.
All rights reserved.
Temperature
• The balance between heat production and
heat loss (body’s ability to control heat)
– Heat is produced when food is changed to energy
– Heat is lost through perspiration, breathing, and
elimination of waste
– Normal oral temperature is 97.6-99.6 (37 degrees
Celsius)
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
Patient must
not have
anything hot or
cold by mouth
for at least 15
minutes for an
oral
temperature to
be accurate.
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
• C=F-32/1.8
• Celsius to Fahrenheit
• F =(C x 1.8)+32
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 (feel) and auscultate (listen) 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 (force or strength of pulse)
• Normal, full or bounding, weak, thready
– Quality
• Arrythmia, pulse lacks a specific rhythm
• Intermittent
Bradycardia- consistent heart rate below 60 beats per
minute.
Tachycardia- consistent heart rate above 100 beats per
minute.
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 (NEVER)
• 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 Pulse
• 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
Respirations
• Abnormal respirations
– Hyperventilation
– Dyspnea (difficult or labored breathing)
– Rales (noisy breathing)
– Apnea, absence of breathing
– Cheyne-Stokes
– Bradypnea- slower than normal rate of respiration
– Tachypnea- faster than normal rate of respiration
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
Palpatory reading should be done before blood pressure is
taken. Cuff should be inflated to 30mm Hg above the
palpatory reading.
• 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
Auscultatory gap is the silent interval between
systolic and diastolic pressure.
Pulse pressure- difference between the systolic and
diastolic reading.
Copyright ©2012 Delmar, Cengage Learning.
All rights reserved.
Abnormal Blood Pressure
• Hypertension
– Consistent readings above 140/90
– Idiopathic (essential hypertension)
– Primary, secondary, malignant
• Hypotension
– Consistent readings below 90/60
– Orthostatic hypotension (drop in blood pressure
that occurs when you go from sitting to standing)
Copyright ©2012 Delmar, Cengage Learning.
All rights reserved.