Step by step procedure on VITAL SIGNS YEAR1.pptx

The procedure of taking vital signs and management of abnormal findings

1. DCN-2021 ‹#› BY E. CHAULUKA BASIC NURSING SKILLS -VITAL SIGNS-

2. INTRODUCTION This unit introduces the basic nursing skills the nurse will need to measure and record the patient’s vital signs. The vital signs provide information about changes in normal body function and the patient’s response to treatment. DCN-2021 ‹#›

3. DCN-2021 ‹#› Vital Signs

4. By the end of the lesson, student’s should be able to: Assess body temperature, pulse rate, respirations and blood pressure Describe factors that affect vital signs Able to identify equipment used to assess vital signs DCN-2021 ‹#› Learning outcomes

5. Identify normal values of vital signs in an adult, child and infant Identify the abnormal values of vital signs in adults, children and infant Importance of monitoring vital signs DCN-2021 ‹#›

6. PURPOSE OF VITAL SIGNS To monitor essential physiologic function of vital signs To evaluate health status of patient To give baseline information regarding patient’s health. To allow the nurse to identify nsg diagnoses to implement plan interventions and evaluate the success of nsg interventions DCN-2021 ‹#›

7. WHEN TO TAKE VITAL SIGNS On admission Per hospital routine or physician’s order Before and after surgery or diagnostic procedure Before administration of some medications or nursing interventions affecting vital signs. DCN-2021 ‹#›

8. Before, during and after blood product transfusion When there is a change in client’s condition or a report of physical distress. DCN-2021 ‹#›

9. VITAL SIGNS Reflect the function of three body processes that are essential for life. Regulation of body temperature Heart function Breathing DCN-2021 ‹#›

10. VITAL SIGNS (CONTINUED) Abbreviations: Temperature – T Pulse – P Respirations – R Blood Pressure – BP Vital signs - TPR and BP DCN-2021 ‹#›

11. VITAL SIGNS (CONTINUED) Measurement (taken at rest) Temperature - measures body heat Pulse - measures heart rate Respiration - measures how often resident inhales and exhales Blood Pressure - measures pressure against walls of arteries DCN-2021 ‹#›

12. DCN-2021 ‹#› Measurement Of Body Temperature

13. TEMPERATURE – MEASUREMENT OF BODY HEAT Heat production muscles glands oxidation of food Heat loss respiration perspiration excretion DCN-2021 ‹#›

14. TEMPERATURE – MEASUREMENT OF BODY HEAT (CONTINUED) DCN-2021 ‹#› Balance between heat production and heat loss is body temperature

15. REGULATION OF BODY TEMPERATURE body temp requires coordination of many body systems. Hypothalamus – body’s built in thermostat controls core temperature It can sense small changes in body temp Stimulates the necessary responses in the circulatory system, skin and sweat glands to maintain homeostasis DCN-2021 ‹#›

16. HEAT PRODUCTION A by-product of chemical reactions in body cells- metabolism Thermoregulation keeps core temperature fairy constant despite of where heat is being produced Physical exercise Increased production of thyroid hormones, stimulation of sympathetic nervous system increases heat production. DCN-2021 ‹#›

17. HEAT LOSS Heat is continously lost through: Radiation- is diffusion of heat through infrared heat rays- exposure to cold environment increases radiant heat loss Conduction – transfer of heat through direct contact Convection- loss of heat through air currents- such as breeze from a fan Evaporation- heat loss as water is transformed to gas- sweating (diaphoresis) DCN-2021 ‹#›

18. FACTORS AFFECTING TEMPERATURE Exercise Hormones Age Time of day Medication Cold or hot fluids Infection Emotions/ stress Hydration Clothing Environment Smoking Alcohol DCN-2021 ‹#›

19. EQUIPMENT - THERMOMETER Instrument used to measure body temperature Types Glass mercury Oral –tip is slender Rectal-tip is blunt to avoid trauma DCN-2021 ‹#›

20. EQUIPMENT - THERMOMETER Types (continued) chemically treated paper – disposable plastic – disposable electronic - probe covered with disposable shield tympanic - electronic probe used in the ear DCN-2021 ‹#›

21. NORMAL TEMPERATURE RANGE FOR ADULTS Oral - 97.6° - 99.6° F (Fahrenheit) or 36.5° -37.5° C (Celsius) Rectal - 98.6° - 100.6° F or 37.0° - 38.1° C Axillary - 96.6° - 98.6° F or 36.0° - 37.4° C DCN-2021 ‹#›

22. TO READ A MERCURY GLASS THERMOMETER Hold eye level Locate solid column of liquid in the glass Observe lines on scale at upper side of column of liquid in the glass DCN-2021 ‹#›

23. TO READ A MERCURY GLASS THERMOMETER (CONTINUED) Read at point where liquid ends If liquid falls between two lines, read it to closest line long line represents degree celcius DCN-2021 ‹#›

24. SITES TO TAKE A TEMPERATURE Oral – most common Rectal – registers one degree Fahrenheit higher than oral Axillary – least accurate; registers one degree Fahrenheit lower than oral Tympanic – probe inserted into the ear canal DCN-2021 ‹#›

25. SITES TO TAKE A TEMPERATURE (CONTINUED) DCN-2021 ‹#› Condition of patient determines which is the best site for measuring body temperature

26. TEMPERATURE: SAFETY PRECAUTIONS Hold rectal and axillary thermometers in place  Stay with patient when taking temperature  Prior to use, shake liquid in glass down  Shake thermometer away from patient and hard objects  DCN-2021 ‹#›

27. TEMPERATURE: SAFETY PRECAUTIONS (CONTINUED) Wipe from end to tip of thermometer prior to reading  Delay taking oral temperature for 10 - 15 minutes if patient has been smoking, eating or drinking hot/cold liquids. DCN-2021 ‹#›

28. TEMPERATURE CALCULATION Change degree celcius to Fahrenheit Multiply the degree celcius by 9/5 and add 32 to the result F= (9/5 X degree celcius) +32 Degree celcius (F-32) X 5/9 DCN-2021 ‹#›

29. PROCEDURE FOR TAKING BODY TEMP Equipment: Thermometer Second hand watch Record of documentation Container of cotton wool swabs Receiver for dirty swabs Methylated spirit Gloves for wet wounds or infectious diseases DCN-2021 ‹#›

30. PROCEDURE Assemble the equipment Explain procedure to patient Maintain privacy- screen or draw curtains Wash hands to prevent transmission of microorganisms Remove thermometer from storage container Wipe it dry with cotton wool swabs DCN-2021 ‹#›

31. Make sure patient is in comfortable position Check temp reading on thermometer by holding it at eye level to see if it is above 35 degree celcius. If above 35 degree celcius, shake it to return it to 35 degree celcius before inserting it on patient DCN-2021 ‹#›

32. Insert thermometer in the middle of the patient’s axilla Ask patient to lower the arm and fold it across the chest. This helps to maintain the correct position of thermometer against blood vessels in the axilla Patient should hold it for 2-3 minutes Remove thermometer to check reading DCN-2021 ‹#›

33. Record the reading on the temperature chart Communicate the findings to patient Report findings to senior members. DCN-2021 ‹#›

34. DCN-2021 ‹#› Measurement Of Pulse

35. MEASUREMENT OF PULSE Pulse is pressure of blood pushing against wall of artery as heart beats and rests Pulse easier to locate in arteries close to skin that can be pressed against bone DCN-2021 ‹#›

36. SITES FOR TAKING PULSE Radial – base of thumb Temporal – side of forehead Carotid – side of neck Brachial – inner aspect of elbow Femoral – inner aspect of upper thigh DCN-2021 ‹#›

37. SITES FOR TAKING PULSE (CONTINUED) Popliteal - behind knee Dorsalis pedis – top of foot Apical pulse – over apex of heart taken with stethoscope left side of chest DCN-2021 ‹#›

38. FACTORS AFFECTING PULSE Age Sex Position Drugs Emotions Activity level Temperature Fever Caffeine DCN-2021 ‹#›

39. NORMAL PULSE RATES Age pulse rates New born 70-190 beats/min Infant(>1month) 80- 160 Toddler 80-130 Preschooler 80-120 School-age 75-110 Adolescent 60-90 Adult 60-100 DCN-2021 ‹#›

40. METHOD OF ASSESSMENT Palpation Use 2 nd ,3 rd finger of one hand 2. Auscultation The lub-dub sound makes 1 heart beat DCN-2021 ‹#›

41. PROCEDURE Equipment: Stethoscope A wrist watch with a second hand Record for documentation DCN-2021 ‹#›

42. PROCEDURE Explain procedure to patient Wash hands Position patient comfortably with the forearm across the chest or at the thigh but the wrist extended for easy palpation Place your fingertips of the 1 st 3 fingers along the groove at the base of the thumb on the patient’s wrist. DCN-2021 ‹#›

43. Press against the radial artery to obtain/feel the pulse then gradually release the pressure until pulse is felt. Assess the pulse for regularity and strength. Count the pulse for 60seconds Chart the reading Communicate findings DCN-2021 ‹#›

44. MEASUREMENT OF PULSE Normal pulse range/characteristics: 60 -100 beats per minute and regular Documenting pulse rate Noted as number of beats per minute Rhythm - regular or irregular Volume - strong, weak, thready, bounding DCN-2021 ‹#›

45. DCN-2021 ‹#› Measuring Respirations

46. MEASURING RESPIRATIONS Respiration – process of taking in oxygen and expelling carbon dioxide from lungs and respiratory tract DCN-2021 ‹#›

47. MEASURING RESPIRATIONS (CONTINUED) Age Activity level Position Drugs DCN-2021 ‹#› Sex Illness Emotions Temperature Factors Affecting Rate

48. MEASURING RESPIRATIONS (CONTINUED) Qualities of normal respirations 12-20 respirations per minute Quiet Effortless Regular DCN-2021 ‹#›

49. MEASURING RESPIRATIONS (CONTINUED) Documenting respiratory rate Noted as number of inhalations and exhalations per minute (one inhalation and one exhalation equals one respiration) Rhythm – regular or irregular Character: shallow, deep, labored DCN-2021 ‹#›

50. PROCEDURE Equipment: Wrist watch Chart for documentation DCN-2021 ‹#›

51. PROCEDURE NB. Don’t tell patient about procedure to avoid altering the breathing pattern After assessing pulse rate, keep fingers resting on patient’s wrist and observe the rising and falling of chest with a respiration When 1 complete cycle( inspiration and expiration) has been observed, look at the watch and start counting. DCN-2021 ‹#›

52. Take note of the depth and rhythm of the respiratory cycle Document the reading Inform patient about the findings Report to seniors. DCN-2021 ‹#›

53. DCN-2021 ‹#› Measuring Blood Pressure

54. MEASURING BLOOD PRESSURE Blood pressure is the force of blood pushing against walls of arteries Systolic pressure: greatest force exerted when heart contracting Diastolic pressure: least force exerted as heart relaxes DCN-2021 ‹#›

55. Systolic Bp- Bp measured during(lub sound) ventricular contraction Diastolic Bp- Bp measured during ventricular relaxation (dub sound) DCN-2021 ‹#›

56. NORMAL VALUES Age systolic diastolic Newborn 60-90mmHg 20-60 Infant 74-100 50-70 Toddler 80-112 50-80 Preschooler 82-100 50-78 School-age 84-120 54-80 Adolescent 94-140 62-88 Adult 90-139 60-90 DCN-2021 ‹#›

57. FACTORS INFLUENCING BLOOD PRESSURE Weight Sleep Age Emotions Sex Heredity Viscosity of blood Illness/Disease DCN-2021 ‹#›

58. BLOOD PRESSURE: EQUIPMENT Sphygmomanometer (manual) cuff - different sizes pressure control bulb pressure gauge – marked with numbers aneroid mercury DCN-2021 ‹#›

59. BLOOD PRESSURE: EQUIPMENT (CONTINUED) Stethoscope magnifies sound has diaphragm DCN-2021 ‹#›

60. MEASURING BLOOD PRESSURE Normal blood pressure range Systolic: 90-140 millimeters of mercury Diastolic: 60-90 millimeters of mercury DCN-2021 ‹#›

61. GUIDELINES FOR BLOOD PRESSURE MEASUREMENTS Measure on upper arm Have correct size cuff Identify brachial artery for correct placement of stethoscope DCN-2021 ‹#›

62. GUIDELINES FOR BLOOD PRESSURE MEASUREMENTS (CONTINUED) First sound heard – systolic pressure Last sound heard or change - diastolic pressure DCN-2021 ‹#›

63. GUIDELINES FOR BLOOD PRESSURE MEASUREMENTS (CONTINUED) Record - systolic/diastolic Resident in relaxed position, sitting or lying down Blood pressure usually taken in left arm DCN-2021 ‹#› 118 76

64. GUIDELINES FOR BLOOD PRESSURE MEASUREMENTS (CONTINUED) Do not measure blood pressure in arm with IV, A-V shunt (dialysis), cast, wound, or sore DCN-2021 ‹#›

65. GUIDELINES FOR BLOOD PRESSURE MEASUREMENTS (CONTINUED) Apply cuff to bare upper arm, not over clothing Room quiet so blood pressure can be heard Sphygmomanometer must be clearly visible DCN-2021 ‹#›

66. BLOOD PRESSURE: READING GAUGE Large lines are at increments of 10 mmHg Shorter lines at 2 mm intervals Take reading at closest line DCN-2021 ‹#›

67. BLOOD PRESSURE: READING GAUGE (CONTINUED) Gauge should be at eye level Mercury column gauge must not be tilted Reading taken from top of column of mercury DCN-2021 ‹#› 300 280 260 240 220 200 180 160 140 120 100 80 60 40 20 290 270 250 230 210 190 170 150 130 110 90 70 50 30 10

68. PROCEDURE Equipment: sphygmomanometer Stethoscope Documentation chart DCN-2021 ‹#›

69. PROCEDURE Explain procedure to patient Wash hands Assist patient to comfortable position( sitting or lying) with forearm supported at heart level with palm of hand facing upwards Expose upper arm completely Place the cuff so that the inflatable bag is centered over the brachial artery. DCN-2021 ‹#›

70. PROCEDURE Feel for pulsations of the brachial artery using fingertips of the left hand. Ensure that the pointer on the manometer or mercury is at zero Close the screw valve on the pressure bulb Place the stethoscope earpieces in the ears DCN-2021 ‹#›

71. Pump air into cuff to let mercury rise or pointer to move until pulsations are no longer felt or heard. Release pressure slowly at the rate of 2mmHg falls Listen for the first beat(systolic pressure) noting the mercury reading on the manometer DCN-2021 ‹#›

72. Take note of the reading at which the beat changes or stops(diastolic pressure) Remove the stethoscope from the ears Release all pressure from the cuff Remove the machine by untying the cuff Record, interpret findings Communicate and interpret findings. DCN-2021 ‹#›

73. DCN-2021 ‹#› The End