Download File - NURSING FUNDAMENTALS I

Pearson's
Nursing Assistant Today
CHAPTER
18
Measuring Vital
Signs
Vital Signs
• Vital signs:
– Measurements reflecting patient’s physical
well-being and condition.
 Temperature
 Pulse
 Respirations
 Blood pressure
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Vital Signs
• Vital signs should be obtained:
– Upon admission to health care facility.
– When ordered by doctor.
– Unusual situation, incident, patient fall.
– Physical examination or checkup.
– Pain or unusual symptoms.
– New medication or treatment.
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Body Temperature
• Amount of heat in body.
• Body creates heat when changes food into
energy.
• Loses heat through perspiration,
respiration, and exertion.
• Thermometer:
– Instrument used for measuring temperature.
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Body Temperature
• Body locations for temperature
– Mouth (orally - O)
– Ear (tympanic - T)
– Armpit (axilla - A)
– Forehead (temporal artery - TA)
– Rectum - R
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Figure 18-3 and 18-6
Tympanic thermometer. Forehead thermometer strip.
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Body Temperature
• Normal adult body temperature is 98.6°F
or 37°C.
• See Table 18-1: Normal Temperature
Readings
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Body Temperature
• See Procedure 18-1: Using a BatteryOperated Electronic Oral Thermometer
• See Procedure 18-2: Using a Tympanic
(Ear) Thermometer
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Body Temperature
• See Procedure 18-3: Using a BatteryOperated Electronic Rectal Thermometer
• See Procedure 18-4: Using an Electronic
Oral Thermometer to Measure Axillary
Temperature
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Figure 18-12
Points on the human body where the pulse may be taken.
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Pulse
• Pulse:
– Rhythmic expansion and contraction of
arteries caused by beating of heart.
• Pulse points:
– Areas where artery is close to body’s surface
and can be easily felt with fingers.
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Figure 18-13
Stethoscopes.
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Pulse
• Stethoscope:
– Instrument that amplifies sounds made by
body.
• Apical pulse provides
information about
blood flowing through
heart.
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Pulse
• Normal pulse rate for adults 60 to 80 beats
per minute; for infants 80 to 160 beats per
minute.
– Rate:
 Number of heartbeats per minute.
– Rhythm:
 Regularity of heartbeats.
– Force:
 Strength of heartbeat.
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Pulse
• See Procedure 18-5: Measuring the Radial
Pulse
• See Procedure 18-6: Measuring the Apical
Pulse
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Figure 18-18
How we breathe.
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Pulse
• Pulse deficit:
– Difference between apical heart rate and
pulse rate.
– See Advanced Procedure 18-7: Measuring
the Apical Pulse Deficit
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Respirations
• Inhaling:
– Air going into the lungs; breathing in.
• Exhaling:
– Air going out of the lungs; breathing out.
• Dyspnea:
– Abnormal respirations.
• Apnea:
– Absence of respirations; not breathing.
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Respirations
• Adults breathe at rate of 12 to 20 times per
minute; children more rapidly; elderly more
slowly.
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Respirations
• Abnormal respirations
– Stertorous
– Abdominal
– Irregular
– Cheyne-Stokes
• See Procedure 18-8: Measuring
Respiration
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Blood Pressure
• Blood pressure (BP):
– Measuring force of blood flowing through
arteries.
 Rate of heartbeat
 How easily blood flows through blood vessels
• Normal adult blood pressure less than 120
mm Hg systolic and less than 80 mm Hg
diastolic.
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Blood Pressure
• Systolic blood pressure:
– Heart is contracting, pressure is highest.
• Diastolic blood pressure:
– Heart is most relaxed, pressure is lowest.
• Hypertension:
– Blood pressure higher than normal.
• Hypotension:
– Blood pressure lower than normal.
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Blood Pressure
• Sphygmomanometer:
– Device used to measure blood pressure.
 Mercury
 Aneroid (dial)
 Electronic, digital
display
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Blood Pressure
• Select appropriately sized BP cuff.
• Do not take BP on arm that has IV
(intravenous) setup in it.
• Do not take BP on extremity that has
surgical site or from patient with AV shunt.
– See Procedure 18-9: Measuring Blood
Pressure Using a Sphygmomanometer
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Blood Pressure
• Noninvasive blood pressure (NIBP)
monitors used in operating rooms and with
critical care patients.
• Electronic blood pressure monitoring
apparatus uses infrared photoelectronic
system.
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Pain—the Fifth Vital Sign
• Pain measurement scales use numbers or
faces to rate patient pain intensity.
• Patient may use words such as dull, achy,
sharp, cramping, throbbing, unbearable, or
tearing.
• Patient may cry, moan, groan, guard, or
yell when touched.
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Pain—the Fifth Vital Sign
• OPQRST mnemonic
– Onset of the event
– Provocation or palliation
– Quality of the pain
– Region and radiation
– Severity
– Time
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Height
• Height used for assessing nutritional
status and monitoring health.
• Used to calculate:
– Ideal body weight (IBW) and Body Mass Index
(BMI).
• Used to plan patient’s daily calorie,
protein, and fluid needs.
– See Procedure 18-10: Measuring the Height
of a Patient in Bed
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Weight
• Measurement calculates dosages of
medications; assesses nutritional status;
monitors health.
• See Procedure 18-11:
Measuring the Weight
of a Patient in Bed
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French
Abdominal Girth Measurement
• Abdominal girth measures distance
around abdomen at specific point.
– See Procedure 18-12: Measuring the
Abdominal Girth
Pearson's Nursing Assistant Today
Francie Wolgin • Kate Smith • Julie French