vital signs (TPR)

Akshita Negi

1. Assessment of vital signs - By Akshita Negi From (Kinnaur ) BSc. Nursing 1 st year Govt .Nursing college SLBSGMCH Ner chowk Mandi ,(HP)

2. Definition Vital signs or cardinal signs are basic components of assessment of physiological and psychological health of client (it is an indication of vital organs ie Brain, Heart, Lungs, Liver & Kidney. it reflects the body’s physiological status.

3. It includes : Temperature Pulse Respiration Blood pressure Spo2 Hydration Pain .

4. Purposes for assessing vital signs To assess the health status of an individual . To plan and implement the nursing care . To recognize variation from normal and its significance . To understand the effectiveness of the treatment .

5. To modify or change the mode of treatment . To understand the present problem To assess the functioning of vital organs . To identify specific life threatening condition

6. Assessment of body temperature It includes the assessment of body temperature using clinical thermometer Definition : The body temperature is the difference between the amount of heat produced by body processes & the amount of heat lost to the external environment .

7. Temperature is the ‘hotness and coldness of the body . It is the somatic sensation of heat or cold .It is the degree of or intensity of heat of body in relation to external environment

8. Types of thermometer Mercury glass thermometer : Oral Rectal

9. Parts of glass thermometer

10. 2. Digital thermometer

11. 3.Tympanic membrane thermometer

12. 4.sensor touch thermometer

13. 5.Disposable single use thermometer

14. Purposes for assessing body temperature To assess the patient’s health status . To obtain the accurate temperature for making diagnosis . To monitor patients condition after invasive procedure . To help physician to prescribe right treatment .

15. To assess the patient’s condition . To assess for any alterations in health status . To determine whether measures should be implemented to reduce dangerously elevated body temperature and how to conserve body heat when body temperature is low

16. Common sites for assessing body temperature Oral Rectal Axillary tympanic membrane

17. Indications for assessing body temperature It is the routine part of assessment for establishing a baseline data upon admission . Any change in patient’s condition should be monitored according to the agency policy

18. Temperature should be checked before, during and after administration of any drugs that affects temperature control function . If there is any change in the general condition of the patient . It should be checked before and after any nursing intervention that affects the body temperature of the patient .

19. Contraindications for oral site Patients who are not able to hold a thermometer in their mouth . Patients who may bite the thermometer such as psychiatric patients . Infants and small children. Surgery /infection in oral cavity. Trauma to face /mouth . Mouth breathers.

20. Patients with history of convulsion . Unconscious /semiconscious /disoriented patients . Patients having chills . Uncooperative patients .

21. Contraindications for rectal method Patients after rectal surgery . Any rectal pathology (piles /tumor) Patients having difficulty in assuming the required position . Acute cardiac patients . Patients having diarrhea . Patients with reduced platelet count .

22. Contraindications for axillary method Patients with any surgery /lesion in axilla . Constricted peripheral blood vessel .

23. Articles required for assessing body temperature A clean tray containing : A bottle with disinfectant solution(Dettol 1:40/ Savlon 1:20) A bottle with water Thermometer ( rectal thermometer in case of rectal method )

24. Paper bag /kidney tray . A small bowl with cotton swabs ,pen . Flow sheet /graphic chart /paper ). Lubricant (for rectal method ). Use two bottles of antiseptic solution and one bottle of water if more than one thermometer is used . A bowl containing dry gauze pieces to wipe axilla .

25. Points to be remember It is always best to use the separate thermometer for each patient . When individual thermometer is not used in patient care units ,then axillary method is recommended . For converting temperature from centigrade to Fahrenheit ,following conversion formula can be used { C=5/9 *(F-32 )}

26. Document the reading on the graph chart with blue pen . A normal axillary temperature is between 90.6 degree Fahrenheit and 98 degree Fahrenheit . Normal axillary temperature is usually a degree lower than the oral temperature and 2 degree lower than the re ctal temperature .

27. Route Normal range (degree F/C) Sites Oral 98.6/37.0 Mouth Tympanic Rectal 99.6/37.6 99.6/37.6 Ear Rectum Axillary 97.6/36.6 Axilla or armpit Normal ranges of temperature

28. Alterations in body temperature Hypothermia : fall in body temperature below 95 degree Fahrenheit. Hyperthermia : elevation in body temperature above 99.5-100.9 degree Fahrenheit

29. Procedure Nursing action Before procedure Ascertain the method of taking temperature ,explain the procedure to patient ,and instruct him/her how to cooperate . a) in case of oral method ,ensure that the patient had not taken any hot or cold food and orally or smoked about 15-30 min prior to the procedure. Rationales Cause alteration in temperature reading

30. Nursing action b) for rectal method ,provide privacy and position the patient in sim’s position .position young children laterally with knees flexed or prone across lap. c) in axillary method ,expose axilla and pat dry with a towel . Avoid vigorous rubbing . Rationales Position of the body ensures easy access to insert thermometer . Friction produced by rubbing can increase in the temperature .

31. During procedure Nursing action Wash hands Prepare equipment a) If the glass thermometer is placed in disinfectant solution ,transfer it to a container containing plane water using dominant hand b) wipe the thermometer dry ,using the clean cotton swab by rotatory motion from bulb to stem Rational Ensures complete removal of disinfectant and reduces irritation to tissue Usage of dominant hand reduces chances of accidental breakage .

32. Nursing action C ) shake the thermometer to bring down the mercury level (if needed )by holding it between the thumb and fore finger at the tip of the stem .shake till the mercury is below 35 degree C (95 degree F) Rationales Wiping down the thermometer from an area of least contamination to an area of highest contamination prevents spread of organism .reduces the chances of erroneous reading of temperature .

33. Nursing action checking the temperature a) oral method 1. place the thermometer bulb at the base of tongue at the side of frenulum in the posterior sublingual pocket. Rationales Blood supply is more in this area and the reading reflects the temperature of blood in the larger blood vessels .

34. Nursing action 2. instruct the patient to close the lips and not the teeth around thermometer . 3. leave the thermometer in place for 2-3 min . b) Rectal method Don clean pair of gloves . .apply a lubricant on the bulb of the thermometer using a cotton ball . Rationales Clenching the teeth may break the thermometer and cause injury. Ensures accurate recording . Lubricant facilitates easy insertion of thermometer without irritating the mucus membrane.

35. Nursing action 3. with non dominant hand ,expose the anus raising upper buttocks . 4. instruct patient to breath deeply and insert thermometer into anus . 3.5-4cm in adults . 1.5cm in infant. 2.5 cm in child Do not force the insertion. 5. Hold the thermometer in place1-2minute. Rationales Deep breath helps to relax the external sphincter thereby facilitating easy insertion Ensures accurate recording .

36. Positioning patient for inserting rectal thermometer c) Axillary method : 1.Place thermometer bulb in the centre of axilla . 2.place the arm tightly across the chest to hold thermometer in place

37. Nursing action 3. Hold the thermometer for 2-3 minutes . Removal of thermometer : Wipe down the thermometer using a cotton ball from stem to bulb in rotatory manner . Rationales Wiping from an area of least contamination to most contamination will help in preventing spread of microorganisms

38. Nursing action Read the temperature by holding the thermometer at eye level and rotate it until till reading is visible ,read it accurately . Shake the thermometer to bring down he mercury level . Rationales Holding at eye level prevents error in reading

39. After procedure Clean the thermometer using soap and water . Dry and store it in a disinfectant solution . Document the temperature reading . Wash hands . Replace articles . This removes any organic material sticking to the thermometer . Normal body temperature is 37 degree C(98.6 degree F) Reduce the risk of transmission of microorganism.

40. Assessment of pulse Definition : Pulse is the regular expansion and recoil of an artery caused by the ejection of blood into the arterial system by the contraction of the heart . A pulse is a wave of blood created by the contraction of the left ventricle of the heart A pulse rate is measurement of the heart rate or the number of times the heart beats per minute .

41. Purposes for assessing pulse To establish baseline data. To check abnormalities in rate ,rhythm ,and volume . To monitor any change in health status of the patient . To check the peripheral circulation . To assess the response of heart to cardiac drugs .

42. Articles required for assessment of pulse Wrist watch with second’s hand . Pen as per agency policy . Vital sign chart Stethoscope

43. Points to be remember Never press both carotid at same time ,as this can cause reflex drop in blood pressure /pulse rate . Carotid pulse is used for victim of shock and cardiac arrest when pulse is not palpable at other sites . Brachial and femoral sites are used with cardiac arrest in infants .

44. Sites for assessing pulse Radial: commonly used Brachial: commonly used Temporal : children Carotid :check during emergency Apical : both adult and children Femoral :children

45. Popliteal Posterior tibial Dorsalis pedis : check to evaluate peripheral disease

46. Procedure Nursing action Before procedure Explain the procedure to the patient and inquire about patients recent activity .If the patient was involved in strenuous activity .Allow the patient to rest for the 10 min before taking pulse Rationales Activity may increase the pulse rate.

47. During procedure Nursing action Sanitize hands or wash hands as per hospital policy. Select pulse site . Assist to a patient in a comfortable position . Rationales Prevents cross infection . Usually radial pulse is selected .choice of site depends on the particular extremity to be assessed .

48. Nursing action For radial pulse ,keep the arm resting over chest or on the side with palm facing downward .in sitting position ,keep the arm resting over the thigh with pam facing downward . Rationales The relaxed position of the lower arm and extension of the wrist permits full exposure to the artery to palpation.

49. Nursing action Place tip of 3 fingers (except thumb ) lightly over the site where pulse needs to be assessed . After getting pulse regularly ,count the pulse for one whole minute looking at the second hand on the wrist watch . Assess for rate ,rhythm and volume of pulse and condition of blood vessels . Rationales Thumb is not used for assessing pulse as it has its own pulse which can mistaken for patient’s pulse Irregularities can be noticed only if pulse is counted for one whole minute . Normal pulse is regular and rate is 60-100 bpm

50. After procedure wash hands. Document and report patient data in the appropriate record .

51. Respiration Definition : Respiration is the process of breathing and consist of inspiration and expiration . Assessing respiration involves monitoring inspiration and expiration in patient .

52. Purposes for assessing respiration To assess rate ,rhythm ,volume of respiration . To assess for any change in condition and health status . To monitor effectiveness of therapy related to respiratory system .

53. Articles required for assessment of respiration Wrist watch with second hand . Graphic record . Pen .

54. Procedure Nursing action Before procedure Ensure that patient is relaxed and assess other vital signs such as pulse or temperature prior to counting respiration . Assess for factors that may affect respiration . Wait for 5-10 min before assessing respiration if patient had been active . Rationales Awareness of the procedure may alter the rate of respiration. Allow nurse to accurately assess for presence and significance of respiratory alteration Activity may increase the rate and depth of respiration .

55. Nursing action During procedure Position patient in sitting or supine with head elevated at 45-60 degree Keep your fingers over the wrist as if checking pulse ,and position patient’s hand over his lower chest or abdomen . Rationales Ensures proper assessment . Makes the patient less aware of his respiration .keeping hand over chest or abdomen makes the movement of chest more visible .

56. Nursing action Observe one complete respiratory cycle-inspiration and expiration Assess rate ,depth , rhythm and character of respiration . Count respiration for 1 whole min. After procedure Wash hands Record the finding and report any abnormal findings . Rationales Depth of respiration reveals volume of air moving in and out of lungs .abnormalities of rhythm and character reveals specific disease condition .

57. Thank you