TEMPERATURE PULSE RESPIRATIONS BLOOD PRESSURE VITAL SIGNS MUST BE MEASURED, REPORTED, AND RECORDED...
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Transcript of TEMPERATURE PULSE RESPIRATIONS BLOOD PRESSURE VITAL SIGNS MUST BE MEASURED, REPORTED, AND RECORDED...
TEMPERATURE
PULSE
RESPIRATIONS
BLOOD PRESSURE
VITAL SIGNS MUST BE MEASURED, REPORTED, AND RECORDED ACCURATELY
IF YOU ARE NOT SURE OF A MEASUREMENT, RECHECK IT
o WHEN A PERSON IS ADMITTED TO A HEALTH CARE FACILITY
o SEVERAL TIMES A DAY FOR HOSPITALIZED PATIENTS
o BEFORE AND AFTER SURGERY
o AFTER SOME NURSING PROCEDURES
o BEFORE MEDICATIONS ARE GIVEN THAT AFFECT THE RESPIRATORY OR CIRCULATORY SYSTEM
o WHENEVER THE PERSON COMPLAINS OF PAIN, SHORTNESS OF BREATH, RAPID HEART RATE, OR NOT FEELING WELL
o WITH THE PERSON AT REST IN A LYING OR SITTING POSITION
o ILLNESS
o EMOTIONS – ANGER, FEAR, ANXIETY, PAIN
o EXERCISE AND ACTIVITY
o AGE
o SEX
o ENVIRONMENT - WEATHER
o FOOD AND FLUID INTAKE
o MEDICATIONS
o TIME OF DAY – ↓ IN THE MORNING, ↑ IN THE AFTERNOON/EVENING
o NOISE A CHANGE IN ONE VITAL SIGN WILL CAUSE A CHANGE IN
THE OTHERS
o ANY VITAL SIGN IS CHANGED FROM A PREVIOUS MEASUREMENT
o VITAL SIGNS ARE ABOVE THE NORMAL RANGE
o VITAL SIGNS ARE BELOW THE NORMAL RANGE
MANY AGENCIES HAVE TEMP BOARDS OR TPR BOOKS
RECORD VITAL SIGN MEASUREMENTS AS SOON AS POSSIBLE
CARRY A SMALL NOTEBOOK IN YOUR POCKET SO YOU CAN RECORD THEM AS YOU TAKE THEM
ABBREVIATIONS
TEMPERATURE – T
PULSE – P
RESPIRATIONS – R
BLOOD PRESSURE - BP
RESPOND TO PATIENT OR VISITOR QUESTIONS ABOUT VITAL SIGNS
ACCORDING TO FACILITY POLICY
REFER THEIR QUESTIONS TO THE NURSE
BODY TEMPERATURE IS THE AMOUNT OF HEAT IN THE BODY
IT IS A BALANCE BETWEEN THE AMOUNT OF HEAT PRODUCED AND THE AMOUNT OF HEAT LOST
HEAT IS PRODUCED BY :
THE CONTRACTION OF MUSCLES DURING EXERCISE
THE BREAKDOWN OF FOOD DURING DIGESTION
THE ENVIRONMENTAL TEMPERATURE
HEAT IS LOST THROUGH :
URINE FECES
RESPIRATIONS PERSPIRATION
BODY TEMPERATURE IS MEASURED IN ONE OF FOUR AREAS OF THE BODY
THE MOUTH – ORAL
THE RECTUM – RECTAL
THE AXILLA (UNDERARM) – AXILLARY
THE EAR – TYMPANIC
WE NOW ALSO HAVE THE TEMPORAL SITE - FOREHEAD
MOST TEMPERATURES ARE TAKEN ORALLY
RECTAL TEMPERATURES ARE THE MOST ACCURATE
AXILLARY TEMPERATURES ARE THE LEAST ACCURATE
SITE NORMAL RANGE
ORAL 98.6 ° 97.6 ° TO 99.6 °
RECTAL 99.6 ° 98.6 ° TO 100.6 °
AXILLARY 97.6 ° 96.6 ° TO 98.6 °
TYMPANIC 98.6 ° 98.6 °
TEMPORAL 98.6° 98.6°
A SMALL HOLLOW GLASS TUBE THAT CONTAINS MERCURY OR A MERCURY-FREE SUBSTANCE IN A BULB AT ONE END.WHEN HEATED THE MERCURY
RISES IN THE TUBE.
Pear – shaped tip
o THE SCALE IS MARKED FROM 94° TO 108°
o THE LONG LINES REPRESENT ONE DEGREE
o THE SHORT LINES REPRESENT TWO TENTHS OF A DEGREE
o ONLY EVERY OTHER DEGREE IS MARKED WITH A NUMBER
o BATTERY OPERATED
o HAVE AN ORAL PROBE AND A RECTAL PROBE
o DISPOSABLE PROBE COVER IS PLACED ON THE PROBE
o THE TEMPERATURE REGISTERS IN ABOUT 30 SECONDS
USE A DISPOSABLE SHEATH
o MEASURES THE TEMPERATURE IN THE TYMPANIC MEMBRANE (EARDRUM)
o FAST AND ACCURATE - 1 TO 3 SECONDS
INFANTS – PULL THE EAR
STRAIGHT BACK
ADULTS AND CHILDREN OVER
ONE YEAR –
PULL THE EAR UP AND BACK
GLASS THERMOMETER
o RINSE WITH COLD WATER
o CHECK THE THERMOMETER FOR BREAKS AND CHIPS
o SHAKE DOWN THE THERMOMETER SO THE MERCURY IS BELOW THE LINES AND NUMBERS
o PLACE A DISPOSABLE COVER ON THE THERMOMETER
o PLACE THE THERMOMETER UNDER THE PERSON’S TONGUE
o LEAVE THE THERMOMETER IN PLACE FOR 2 – 3 MINUTES
o IF THE PERSON HAS BEEN EATING, DRINKING, OR SMOKING, WAIT 15 MINUTES BEFORE TAKING TEMPERATURE
DO NOT TAKE AN ORAL TEMPERATURE ON:o AN INFANT OR YOUNG CHILD ( UNDER AGE 6)
o AN UNCONSCIOUS PATIENT
o A PATIENT THAT HAS HAD ORAL SURGERY OR AN INJURY TO THE FACE, NECK, NOSE, OR MOUTH
o A PERSON RECEIVING OXYGEN
o A PATIENT WITH A NASOGASTRIC TUBE IN PLACE
o A PATIENT WHO IS CONFUSED OR RESTLESS
o A PATIENT WHO IS PARALYZED ON ONE SIDE OF THE BODY
o HAS A HISTORY OF SEIZURES
o A PATIENT WHO BREATHES THROUGH THE MOUTH
o LUBRICATE THE THERMOMETER BEFORE INSERTING INTO THE RECTUM
o PLACE THE PERSON IN A SIDE-LYING POSITION
o INSERT THE THERMOMETER 1 INCH INTO THE RECTUM
o HOLD THE THERMOMETER IN PLACE FOR 2 MINUTES
o REMOVE THE DISPOSABLE COVER AND READ THE THERMOMETER
DO NOT TAKE A RECTAL TEMPERATURE ON:o A PERSON WHO HAS HAD RECTAL SURGERY OR RECTAL INJURY
o IF THE PERSON HAS DIARRHEA
o IF THE PERSON IS CONFUSED OR AGITATED
o IF THE PERSON HAS HEART DISEASE ( STIMULATES THE VAGUS NERVE WHICH SLOWS THE HEART RATE )
o TAKEN ONLY WHEN NO OTHER SITE CAN BE USED
o MAKE SURE THE UNDERARM IS CLEAN AND DRY
o THE ARM IS HELD CLOSE TO THE BODY
o YOU NEED TO HOLD THE THERMOMETER IN PLACE WHILE THE TEMPERATURE IS BEING TAKEN
o THE THERMOMETER IS LEFT IN PLACE FOR 10 MINUTES
THE PULSE IS:o THE BEAT OF THE HEART FELT AT AN ARTERY AS A WAVE OF BLOOD PASSES THROUGH THE ARTERY
o A PULSE IS FELT EVERY TIME THE HEART BEATS
o MORE EASILY FELT IN ARTERIES THAT COME CLOSE TO THE SKIN AND CAN BE GENTLY PRESSED AGAINST A BONE
o THE PULSE SHOULD BE THE SAME IN ALL PULSE SITES ON THE BODY
o THE PULSE IS AN INDICATION OF HOW THE CARDIOVASCULAR SYSTEM IS MEETING THE BODY’S NEEDS
o THE PULSE RATE IS AFFECTED BY MANY FACTORS – AGE, FEVER, EXERCISE, FEAR. ANGER, ANXIETY, EXCITEMENT, HEAT, POSITION, AND PAIN.
o MEDICATIONS CAN BE TAKEN THAT EITHER INCREASE OR DECREASE A PERSON’S PULSE RATE.
WE USUALLY COUNT A PULSE FOR 30 SECONDS AND MULTIPLY THE NUMBER TIMES 2 TO GET THE PULSE
RATE FOR 1 MINUTEWE NOTE THE RHYTHM (PATTERN)
OF THE HEART BEAT – IF THE HEART BEAT IS IRREGULAR WE COUNT THE PULSE FOR A FULL
MINUTE
WE ALSO OBSERVE THE FORCE (STRENGTH) OF THE HEARTBEAT.
DOES THE PULSE FEEL :
STRONG FULL BOUNDING
WEAKTHREADY FEEBLE
o MOST COMMON SITE USED FOR TAKING A PULSE
o CAN BE TAKEN WITHOUT DISTURBING OR EXPOSING THE PERSON
o PLACE THE FIRST TWO OR THREE FINGERS OF ONE HAND AGAINST THE RADIAL ARTERY
o THE RADIAL ARTERY IS ON THE THUMB SIDE OF THE WRIST
o DO NOT USE YOUR THUMB TO TAKE A PERSON’S PULSE
o USE GENTLE PRESSURE
o COUNT THE PULSE FOR 30 SECONDS AND MULTIPLY BY TWO
ALWAYS CLEAN THE EARPIECES OF THE STETHOSCOPE WITH ALCOHOL BEFORE AND AFTER USE
WARM THE DIAPHRAGM IN YOUR HAND BEFORE PLACING IT ON THE PERSON
HOLD THE DIAPHRAGM IN PLACE OVER THE ARTERY
DO NOT LET THE TUBING STRIKE AGAINST ANYTHING WHILE THE STETHOSCOPE IS BEING USED
o TAKEN WITH A STETHOSCOPE
o COUNTED BY PLACING THE STETHOSCOPE OVER THE HEART
o COUNTED FOR ONE FULL MINUTE
o THE HEART BEAT NORMALLY SOUNDS LIKE A LUB-DUB. EACH LUB-DUB IS COUNTED AS ONE HEARTBEAT.
o DO NOT COUNT THE LUB AS ONE HEARTBEAT AND THE DUB AS ANOTHER.
o THE APICAL PULSE IS TAKEN ON PATIENTS WHO HAVE HEART DISEASE , AN IRREGULAR PULSE RATE, OR TAKE MEDICATIONS THAT CAN AFFECT THE HEART.
THE APICAL AND RADIAL PULSE RATES SHOULD BE EQUAL
SOMETIMES THE HEART BEAT IS NOT STRONG ENOUGH TO CREATE A PULSE IN THE RADIAL ARTERY
THIS WOULD CAUSE THE RADIAL PULSE TO BE LESS THAN THE APICAL PULSE
ONE PERSON COUNTS THE APICAL WHILE THE OTHER PERSON COUNTS THE RADIAL
THE DIFFERENCE IN PULSES IS CALLED THE PULSE DEFICIT
NORMAL ADULT PULSE RATE IS – 60 TO 100 BEATS PER MIN.
TACHYCARDIA – HEART RATE OVER 100
BRADYCARDIA – HEART RATE BELOW 60
REPORT ABNORMAL HEART RATES TO THE NURSE IMMEDIATELY
ONE RESPIRATION CONSISTS OF ONE INSPIRATION AND ONE EXPIRATION
o THE CHEST RISES DURING INSPIRATION (BREATHING IN) AND FALLS DURING EXPIRATION (BREATHING OUT)
o COUNT EACH TIME THE CHEST RISES
o COUNT FOR 30 SECONDS AND MULTIPLY X 2
o DO NOT LET THE PERSON KNOW YOU ARE COUNTING THEIR RESPIRATIONS
o COUNT AFTER TAKING THE PULSE – KEEP YOUR FINGERS ON THE PULSE SITE
o NORMAL RESPIRATORY RATE FOR ADULT IS 12 – 20 BREATHS PER MIN.
TACHYPNEA – RESPIRATORY RATE OVER 20
BRADYPNEA – RESPIRATORY RATE BELOW 12
DYSPNEA – SHORTNESS OF BREATH – DIFFICULTY IN BREATHING
APNEA – NO BREATHING
HYPERVENTILATION – FAST AND DEEP RESPIRATIONS
HYPOVENTILATION – SLOW AND SHALLOW RESPIRATIONS
THE MEASUREMENT OF THE AMOUNT OF FORCE THE BLOOD EXERTS AGAINST THE ARTERY WALLS
o SYSTOLIC PRESSURE – PRESSURE EXERTED WHEN THE HEART MUSCLE IS CONTRACTING
o DIASTOLIC PRESSURE – PRESSURE EXERTED WHEN THE HEART MUSCLE IS RELAXING BETWEEN BEATS
BLOOD PRESSURE IS RECORDED AS A FRACTION WITH THE SYSTOLIC PRESSURE ON TOP AND THE DIASTOLIC PRESSURE
ON THE BOTTOM
SYSTOLIC SYSTOLIC /DIASTOLIC
DIASTOLIC 120/80
BP IS MEASURED IN MM (MILLIMETERS) OF HG (MERCURY)
AVERAGE ADULT SYSTOLIC RANGE – 100 TO 140
AVERAGE ADULT DIASTOLIC RANGE – 60 TO 90
HYPERTENSION – MEASUREMENTS ABOVE THE NORMAL SYSTOLIC OR DIASTOLIC PRESSURES
HYPOTENSION – MEASUREMENTS BELOW THE NORMAL SYSTOLIC OR DIASTOLIC PRESSURES
o AGE – BLOOD PRESSURE INCREASES AS A PERSON GROWS OLDER.
o GENDER – WOMEN USUALLY HAVE LOWER BLOOD PRESSURE THAN MEN
o BLOOD VOLUME – SEVERE BLEEDING LOWERS THE BLOOD PRESSURE
o STRESS – HEART RATE AND BLOOD PRESSURE INCREASE AS PART OF THE BODY’S RESPONSE TO STRESS
o PAIN – INCREASES BLOOD PRESSURE
o EXERCISE – INCREASES HEART RATE AND BLOOD PRESSURE
o WEIGHT – BLOOD PRESSURE IS HIGHER IN OVERWEIGHT PERSONS
o RACE – BLACK PERSONS GENERALLY HAVE HIGHER BLOOD PRESSURE THAN WHITE PERSONS DO
o DIET – A HIGH-SODIUM DIET INCREASES THE FLUID VOLUME IN THE BODY WHICH INCREASES BLOOD PRESSURE
o MEDICATIONS – CAN BE TAKEN TO RAISE OR LOWER BLOOD PRESSURE
o POSITION – BLOOD PRESSURE IS LOWER WHEN LYING DOWN
THE PROPER NAME FOR A BLOOD PRESSURE CUFF IS SPHYGMOMANOMETER
MERCURY ANEROID
o DO NOT TAKE A BLOOD PRESSURE ON AN ARM WITH AN IV, A CAST, OR A DIALYSIS SHUNT.
o DO NOT TAKE A BLOOD PRESSURE ON THE SIDE THAT A PERSON HAS HAD BREAST SURGERY ON.
o MEASURE BLOOD PRESSURE WITH THE PERSON SITTING OR LYING.
o APPLY THE CUFF TO THE BARE UPPER ARM. DO NOT APPLY THE CUFF OVER CLOTHING.
o MAKE SURE THE CUFF IS SNUG.
o USE A LARGE CUFF IF NECESSARY.
o MAKE SURE THE ROOM IS QUIET.
o IF YOU DO NOT HEAR THE BLOOD PRESSURE, WAIT 30 TO 60 SECONDS AND TRY AGAIN. IF YOU STILL CAN NOT HEAR IT OR ARE UNSURE OF YOUR READINGS, HAVE THE NURSE CHECK YOUR MEASUREMENTS.
1. CLEAN THE STETHOSCOPE EARPIECES AND DIAPHRAGM WITH ALCOHOL.
2. LOCATE THE BRACHIAL PULSE. THIS IS WHERE THE STETOSCOPE WILL BE PLACED.
3. WRAP THE CUFF ABOVE THE ELBOW WITH THE ARROW POINTING TO THE BRACHIAL ARTERY. FASTEN THE CUFF SO IT FITS SNUGLY.
4. PLACE THE DIAPHRAGM OF THE STETHOSCOPE FLAT ON THE PULSE SITE, HOLDING IT IN PLACE WITH THE INDEX AND MIDDLE FINGERS OF ONE HAND.
5. LOCATE THE RADIAL PULSE.
6. CLOSE THE VALVE ON THE BP CUFF BY TURNING IT TO THE RIGHT (CLOCKWISE).
7. INFLATE THE CUFF UNTIL YOU CAN NO LONGER FEEL THE RADIAL PULSE. ,THEN INFLATE THE CUFF 30 MM HG BEYOND THIS POINT.
8. DEFLATE THE CUFF SLOWLY BY OPENING THE VALVE SLIGHTLY AND TURNING IT COUNTERCLOCKWISE (TO THE LEFT) WITH YOUR THUMB AND INDEX FINGER. ALLOW THE AIR TO ESCAPE SLOWLY WHILE LISTENING FOR A PULSE SOUND.
9. NOTE THE READING AT WHICH YOU HEAR THE FIRST CLEAR, REGULAR PULSE SOUND. THIS NUMBER IS THE SYSTOLIC PRESSURE.
10. CONTINUE LISTENING UNTIL THE SOUND DISAPPEARS. THIS IS THE DIASTOLIC PRESSURE. NOTE THIS READING.
11. OPEN THE VALVE COMPLETELY TO DEFLATE THE CUFF. REMOVE THE CUFF FROM THE PATIENT.
MEASURING WEIGHT AND HEIGHT
• Standing, chair, and lift scales are used.
• Measuring weight and height – The person only wears a gown or pajamas.– The person voids before being weighed.– Weigh the person at the same time of day.– Use the same scale.– Balance the scale at zero before weighing the
person.
PAIN • Pain means to ache, hurt, or be sore.• Pain is a warning from the body.• Pain is personal.• Types of pain
– Acute pain – felt suddenly from an injury, disease, trauma, or surgery
– Chronic pain – lasts longer than 6 months. Pain can be constant or occur on and off.
– Radiating pain – felt at the site of tissue damage and in nearby areas.
– Phantom pain – felt in a body part that is no longer there.
• Signs and symptoms– Location – Where is the pain?– Onset and duration – When did the pain start?– Intensity – Rate the pain on a scale of 1 to 10, with 10 as the
most severe– Description – Can you use words to describe the pain?– Factors causing pain – What were you doing when the pain
started?– Vital signs – Take the person’s vital signs when they complain of
pain.– Other signs and symptom
• Body responses - ↑ vital signs, nausea, pale skin, sweating, vomiting
• Behaviors – crying, groaning, holding affected body part, irritability, restlessness
