3.01 vital signs

Vital SignsVital Signs

From –Mr.Amarjeet S.JadounB.Sc. {nursing},2nd yrs.

Vital SignsVital Signs• Provide information about body function • Data is used to treat illness and

diagnose disease• Include:

– temperature– pulse– respiration– blood pressure

3.01 Understand Diagnostic and Therapeutic Services

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Cont…

• Changes may be the first sign of disease or a change in

patient health status.

• Accuracy is imperative!


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Vital SignsVital SignsTemperature


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Measurement of the balance between heat lost and heat produced

Heat lost through:• Perspiration• Respiration• Excretion

Heat produced by:• Metabolism of food• Muscle and gland activity


Normal rangesNormal ranges

– 97º - 100º F – 36.1º - 37.8º C


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Hypothermia

•Temperature below 95º F

•Death can occur if below 93º F


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HypothermiaTemperature decreases with:

– environment– exposure to cold– inactivity– sleep– starvation

Symptoms:– shivering– cold skin– confusion


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Hyperthermia

•Temperature 100-104º F

•Temperature above 104º F is

•life-threatening

•Prolonged hyperthermia may cause brain

injury.

•Sx – headache, confusion


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HyperthermiaTemperature increases with:

– environment– exercise– illness, infection, injury– stress

Symptoms:– hot, dry, red skin– nausea/vomiting– headache– low blood pressure


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ClinicalNon-mercury glass

ElectronicAural – good with children

Thermometers



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Sites to measure temperature:•Aural – auditory canal

•Axillary – armpit

•Oral – mouth

•Rectal – rectum



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To record temperature:

– Oral 98.6º (O) – under tongue by

jaw line

– Rectal 99.6º (R) – lay pt on side

– Axillary 97.6º (ax)

– Aural 98.6º (T)

Vital SignsVital SignsTemperature Measurement

Oral Oral •Ask the patient if they have ingested hot or cold food or drink, or smoked within the last ½ hour•If yes, wait at least 15 minutes before measuring the oral temperature


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REPORT REPORT ABNORMAL RESULTS ABNORMAL RESULTS

OF ANY VITAL SIGN OF ANY VITAL SIGN IMMEDIATELY IMMEDIATELY to supervisorto supervisor

Combined VS (TPRBP) can indicate a life Combined VS (TPRBP) can indicate a life threatening condition or a change in threatening condition or a change in

conditioncondition

Vital SignsVital SignsTemperature Measurement

• AuralAural• Pros:

– Measures core body temperature– Fast and convenient

• Con:– Inaccurate if not placed correctly in the ear canal– Ear infection– Ear wax


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Vital SignsVital SignsPulse

Pressure of blood on artery walls as the heart beats and Relaxes (contraction and relaxation)


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• Sites: Temporal – side of the forehead Carotid – side of the neck Brachial – inner elbow Radial – above the thumb at radius Femoral – upper thigh Popliteal – behind the knee Dorsalis pedis – top of the arch of the foot

(good for checking lower limb circulation)


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Normal rate adult (male) 60 – 70 beats per minuteadult (female) 65 – 80 beats per minutechildren (over 7) 70 – 100 beats per minutechildren (1 – 7) 80 – 110 beats per minuteinfants (less than 1 year) 100 – 160 beats per

minute Rhythm regular or irregularVolume strength of the pulse



• Pulse can be increased by:– exercise– stimulant drugs– excitement– fever– shock– nervousness


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• Pulse can be decreased by:

– sleep

– depressant drugs

– heart disease

– coma


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OF ANY VITAL SIGN OF ANY VITAL SIGN IMMEDIATELYIMMEDIATELY


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Vital SignsVital SignsApical Apical Pulse

• Pulse count taken with the stethoscope.• Use if the patient has:

– Irregular heartbeat– Arteriosclerosis– Weak or rapid radial pulse– Infants and children


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Vital SignsVital SignsRespiration

3.01 Understand Diagnostic and Therapeutic Services 23

Process of taking in oxygen and expelling carbon dioxide

1 inspiration + 1 expiration = respiration

Normal rate: adults – 12 – 20 breaths per minute children – 16 – 30 breaths per minute

Cont…• Evaluate for rhythm and

character• Rhythm – regular or irregular (i.e.

fast, slow)• Character – depth, ease of breaths• Check while appearing to count

pulse


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Vital SignsVital SignsRespiration

• Abnormal respiratory patternsApnea – periods of absent breathing

Cheyne-stokes – periods of apnea and dyspnea

Dyspnea – difficult breathing


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OF ANY VITAL SIGN OF ANY VITAL SIGN IMMEDIATELYIMMEDIATELY


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Vital SignsVital SignsBlood pressure


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Pressure of blood on the arterial walls

Recorded as a fraction: 120/80

Cont…• Systolic pressure – wall of left ventricle is

contracting

Normal range: 100-140 mm Hg

• Diastolic pressure– wall of left ventricle is resting

Normal range: 60-90 mm Hg


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Vital SignsVital SignsBlood pressure

Factors that elevate blood pressure:– anxiety– eating– exercise– excitement– stimulant drugs

Factors that lower blood pressure:– depressant drugs– excessive loss of blood– rest– shock


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Diagnostic Skills:Diagnostic Skills:Height and WeightHeight and Weight

Measured if warranted by patient’s age and physical condition• Measured routinely: –on admission to health care facility –as part of annual physical examination–each provider visit for children

• Important for evaluation of laboratory tests and calculation of medications


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Diagnostic Skills:Diagnostic Skills:Daily WeightsDaily Weights

• Daily weights are used to monitor patients with chronic disease processes:– Hormone disorders– Renal disorders– Heart disease– Cancer


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• Guidelines for daily weights:use the same scalesat the same timewearing the same type of clothingpatient voids to empty bladder

• Make sure to balance the scales before weighing the patient.


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OBSERVE ALL SAFETY OBSERVE ALL SAFETY PRECAUTONS!PRECAUTONS!

Prevent injury from falls and the protruding height lever.


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Diagnostic Skills:Diagnostic Skills:Measure Measure Visual AcuityVisual Acuity

• Used to measure the ability to see

• Snellen charts: used to measure distant vision

• Ishihara method tests for color

• Tonometer measures intraocular pressure


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Diagnostic Skills:Diagnostic Skills:Measure Visual AcuityMeasure Visual Acuity

• OD – right eye (oculus dexter)

• OS – left eye (oculus sinister)

• OU – both eyes (oculus uterque)

• Myopia – nearsightedness, defect in distant vision

• Hyperopia – farsightedness, defect in near vision


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Health & Medicine

3.01 vital signs