1. Vital Signs and Observations (TPR)
Marija Buttery 2010

2. Examination Techniques
Visual inspection
Palpation
Percussion
Auscultation
Evaluation of Function

3. Examination Techniques
What is the relationship of observations to:
Anatomic structure?
Function?

4. Visual Inspection Systematic observation of the patient
Begins as you meet your patient
Symmetry
Color
Gait / posture
Discomforts

5. Palpation Pressing the structure to be examined to determine: Texture
Dimension
Consistency
Temperature
Function

6. Palpation
Tenderness
Superficial
Deep
Rebound
Referred
Pulsation

7. Percussion Percussion to detect fluid
Technique of striking the tissues with the fingers or an instrument to detect sounds of the tissues, or a cupped hand during the application of postural drainage, as a therapeutic measure.
Percussion to detect fluid
Percussion to enhance the removal of fluid from the lungs

8. Auscultation Listening Listening may be aided by a stethoscope
Sounds of wheezing, crackling, no sound
Listening may be aided by a stethoscope
Breath sounds on inspiration/expiration
Rales: gargly sounds; crackles on inspiration
Rhonchi: deeper rumbling sounds
Wheezes: squeeky whistles on expiration or inspiration

9. Olfaction
Detect odours that indicate metabolic, endocrine disease, poor hygiene, presence of blood or infection

10. VITAL SIGNS
Vital signs, observations, obs, TPR BP are all terminology used to describe the assessment and documentation of a patient’s –
Respirations (breathing rate)
Pulse (heart rate)
Temperature
Blood Pressure
Accurate documentation of the vital signs is essential to provide members of the health care team with information to make decisions.

11. VITAL SIGNS
Each of these assessments are taken in a specific way and each relate together to form a picture to aid in the diagnosis of a patient
They are taken at regular intervals depending on the reason for the patient to present to a health care facility or how unwell they are.

12. Baseline indicators of health status
Vital Signs
Temperature
Pulse
Respiration
Blood pressure
Baseline indicators of health status

13. TEMPERATURE

14. Temperature Temperature is lowest in the am upon arising
Range 35.5 – 37.2 Degrees Celsius in healthy individuals
Clue to severity of illness
Terminology
afebrile, febrile, temp, hyperthermia, pyrexia, temperature, hyperpyrexia, hypothermia

15. Temperature DECREASE Anaemia Alcoholism Chronic debilitating disease
INCREASE
Exercise
Infection
Ovulation
Inflammatory disorders
Hyperthyroidism
DECREASE
Anaemia
Alcoholism
Chronic debilitating disease
Hypothyroidism

16. TEMPERATURE Hypothermia – low temperature
Hyperthermia – high temperature
There are many influences on temperature which include:
Environment
Foods
Hormones
Time of day
Trauma
Age
Disease
Loss of Skin (burn)

17. TYPES of THERMOMETERS Mercury Tympanic Digital Infrared
ROUTES
Oral
Tympanic
Axilla
Groin
Rectal
Temporal/forehead
Kozier, B; Erb, G; Berman, A J & Burke, K., 6th Ed. Fundamentals of Nursing: concepts, process and practice (New Jersey: Prentice Hall Health; 2000) Fig P 507 17

18. Temperature Ranges Death Above 44oC Hyperpyrexia 41oC and above
Pyrexia 38oC - 40oC
Normal oC oC
Hypothermia Below 35oC
Death Below 34oC
Taylor, C; Lillis, C. & LeMone P., 4th Ed Fundamentals of Nursing The Art & Science of Nursing Care (Philadelphia: Lippincott; 2001) Fig 24-1 “The range of human body temperature, as measured orally.” P 422 18

19. PULSE

20. PULSE
Measuring a patients pulse is not just about counting the beats of the heart, as with all nursing practice we need to be assessing the patient constantly
Pulses can be felt at various locations on the body
Choosing the most appropriate location for the patient is important

21. Where can we check a pulse?
Why do we check different pulses?
Where and why do we usually check a patient’s pulse?

22. What is a pulse
The beat of the heart as felt through the walls of an artery
You are not actually feeling the blood pressure against the wall of the artery, you are feeling a shock wave that travels along the fibres of the arteries as the heart contracts

23. PULSE Identify the rate, rhythm and volume of the pulse
Rate is usually counted in 15 seconds, then multiplied by 4 to calculate the number of beats per minute
Rhythm is the frequency of the beats and their regularity
Volume is the depth of feeling, the volume of blood pulsing through the artery - whether it is weak or bounding etc.

24. Pulse Pulse used as a screening measure for heart rate (HR)
HR is number of cardiac cycles per minute
Use first 2 fingers (not thumb) over artery
Do not press too hard
Note the RATE, RHYTHM & VOLUME (amplitude, contour – bounding, weak)
Rate may vary with fever, cardiovascular disease, anxiety, medication, disease, exercise etc.

25. Pulse Regular: Sinus rhythm - heart beats are at regular intervals
Irregular: Atrial flutter (AF), ectopic beats - heart beats at irregular intervals.
Always count the pulse for 60seconds if irregular
Normal: beats/min adults
beats/min children

26. Pulse
Bradycardia: slow heart rate, less than 60/min with regular rhythm
Bradycardia with sweating, weakness, dyspnoea and chest pain are signs of heart attack or impending sudden death
Pacemakers regulate heart rate

27. Pulse Tachycardia: fast heart rate,
> 100/min (regular or irregular rhythm)
Anxiety, Hyperthyroidism, anaemia, fever, severe haemorrhage, debilitation, acute or chronic heart disease

28. Pulse Strength Absent No pulse is felt
Thready Not easily felt, and slight pressure
causes it to disappear
Weak Stronger than thready, light pressure
Normal Easily felt, moderate pressure
Bounding Strong and does not disappear with
moderate pressure
Taylor, C; Lillis, C. & LeMone, P., 4th Edition Fundamentals of Nursing. The Art & Science of Nursing Care (Philadelphia: Lippincott; 2001) Table 24-9 “Pulse Amplitude” P 437 28

29. RESPIRATIONS

30. RESPIRATIONS
It is important they are not aware of your observations as it may change their breathing pattern
Observations that need to be done when checking respirations
Rate
Rhythm
Depth
Sound
Effort

31. Respiration Measure by direct observation
Observe the rise & fall of the patient’s chest(or diaphragm)
Count the cycles per minute
Note regularity and rhythm
Note depth of respiration & if patient uses accessory muscles
Listen for abnormal breath sounds

32. Respiration Normal respiratory rate:
12-24 /min. Adults
24-28/min. Children
Up to 44/min. infants
Use of accessory muscles for respiration (neck, shoulder, intercostal) indicates air hunger
Airway obstruction
Congestive Heart Failure (CHF)
Asthma
Chronic Obstructive Pulmonary Disease (COPD)

33. Respiration Tachypnoea: increased rate & decreased depth
Hyperpnoea: increased rate and depth (hyperventilation)
Cheyne-Stokes: hyperpnoea with periods of apnoea
Sigh: prolonged inspiration

34. RESPIRATIONS What can effect the respiratory rate?
Effect resps: exercise, trauma, disease, infection, activity,age, smoker, fitness level, etc