1. Chapter 26 Measuring Vital Signs
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2. Vital Signs The four vital signs of body function are: Temperature
Pulse
Respirations
Blood pressure
Vital signs reflect the function of three body processes essential for life: regulation of body temperature, breathing, and heart function.
Vital signs are often called TPR (temperature, pulse, and respiration) and BP (blood pressure). Some centers include “pain” as a vital sign.
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3. Measuring and Reporting Vital Signs
Are measured to detect changes in normal body function
Tell about responses to treatment
Often signal life-threatening events
Are part of the assessment step in the nursing process
A person’s vital signs vary within certain limits. They are affected by sleep, activity, eating, weather, noise, exercise, medications, anger, fear, anxiety, pain, and illness.
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4. Vital Signs (Cont’d) Vital signs are measured: During physical exams
When the person is admitted to the nursing center
As often as required by the person’s condition
Before and after surgery
Before and after complex procedures or diagnostic tests
After some care measures, such as ambulation
After a fall or other injury
When drugs affect the respiratory or circulatory system
When there are complaints of pain, dizziness, lightheadedness, shortness of breath, rapid heart rate, or not feeling well
As stated on the care plan
Vital signs are often measured after ambulation.
Vital signs are usually taken daily or weekly in nursing centers.
Vital signs show even minor changes in the person’s condition.
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5. Vital Signs (Cont’d)
Accuracy is essential when you measure, record, and report vital signs.
Unless otherwise ordered:
Take vital signs with the person lying or sitting.
The person is at rest when vital signs are measured.
Report the following at once:
Any vital sign that is changed from a prior measurement
Vital signs above the normal range
Vital signs below the normal range
If you cannot measure vital signs, tell the nurse right away.
If unsure of your measurements, promptly ask the nurse to take them again.
Vital signs are recorded in the person’s medical record. If measured often, a flow sheet is used. The doctor or nurse compares current and previous measurements.
Review Residents With Dementia: Measuring and Reporting Vital Signs on p. 439.
Review Focus on Communication: Measuring and Reporting Vital Signs on p. 439.
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6. Body Temperature Body temperature is the amount of heat in the body.
Thermometers are used to measure temperature.
It is measured using the Fahrenheit (F) and centigrade or Celsius (C) scales.
Temperature sites are the mouth, rectum, axilla, tympanic membrane, and temporal artery.
Fever means an elevated body temperature.
Always report temperatures that are above or below the normal range.
Heat is produced as cells use food for energy.
Heat is lost through the skin, breathing, urine, and feces.
Older persons have lower body temperatures than younger persons. An oral temperature of 98.6 F may signal fever in an older person.
Review Box 26-1 on p. 440.
Review Table 26-1 on p. 440.
Review Promoting Safety and Comfort: Temperature Sites on p. 439.
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7. Types of Thermometers These types of thermometers are used:
Glass thermometers have been eliminated from health care settings.
Electronic thermometers
Some have oral and rectal probes
Tympanic membrane thermometers
Temporal artery thermometers
Digital thermometers
Disposable oral thermometers
Temperature-sensitive tape
Glass thermometers take a long time to register. They break easily. The person may bite down and break an oral thermometer and be injured. They pose an environmental hazard because of mercury.
Review Focus on Communication: Taking Temperatures on p. 439.
Review Delegation Guidelines: Taking Temperatures on p. 440 and Promoting Safety and Comfort: Taking Temperatures on p. 439.
Review Figures 26-1 through on pp
Electronic thermometers are battery-operated. They measure temperature in a few seconds.
Review Residents With Dementia: Electronic Thermometers on p. 442.
Review Teamwork and Time Management: Electronic Thermometers on p. 442.
Review Taking a Temperature With an Electronic Thermometer procedure on pp
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8. Pulse A pulse is felt every time the heart beats.
The pulse is the beat of the heart felt at an artery as a wave of blood passes through the artery.
Pulse sites
The temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis (pedal) pulses are on each side of the body.
The radial pulse is used most often.
The carotid pulse is taken during CPR and other emergencies.
The apical pulse is felt over the heart.
This pulse is taken with a stethoscope.
You can take a radial pulse without disturbing or exposing the person. See (Fig , p. 444) for pulse sites. Pulses are on each side of the body.
The apex (apical) of the heart is at the tip of the heart, just below the left nipple.
A stethoscope is an instrument used to listen to the sounds produced by the heart, lungs, and other body organs (Fig , p. 445). It is used to take apical pulses and blood pressures.
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9. Using a Stethoscope To use a stethoscope:
Wipe the earpieces and diaphragm with antiseptic wipes before and after use.
Place the earpiece tips in your ears.
Place the diaphragm over the artery.
Prevent noise.
The pulse rate is the number of heartbeats or pulses felt in 1 minute.
The rate varies for each age group.
The adult pulse rate is between 60 and 100 beats per minute (bpm).
Report abnormal pulses to the nurse at once.
Tachycardia: pulse rate greater than 100 bpm
Bradycardia: pulse rate less than 60 bpm
The earpiece tips should not cause pain or ear discomfort.
When using a stethoscope, ask the person to be silent.
Review Focus on Communication: Using a Stethoscope on p. 445.
Review Promoting Safety and Comfort: Using a Stethoscope on p. 445.
Review Table 26-2 on p. 445 in the textbook. The pulse rate is affected by many factors (p. 445).
A rate of less than 60 or more than 100 is considered abnormal.
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10. Rhythm and Force The rhythm of the pulse should be regular.
An irregular pulse occurs when the beats are not evenly spaced or beats are skipped.
Force relates to pulse strength.
A forceful pulse is described as strong, full, or bounding.
Hard-to-feel pulses are described as weak, thready, or feeble.
You must count pulses accurately.
You must report and record the pulse rate accurately.
Review Delegation Guidelines: Taking Pulses on p. 446.
Review Promoting Safety and Comfort: Taking Pulses on p. 446.
Review the Taking a Radial Pulse procedure on pp
The radial artery is on the thumb side of the wrist (Fig , p. 446). Count the pulse for 30 seconds. Then multiply the number by 2. If the pulse is irregular, count it for 1 minute. In some agencies, all radial pulses are taken for 1 minute.
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11. Apical-Radial Pulse
The apical pulse is on the left side of the chest slightly below the nipple.
It is taken with a stethoscope.
Count the apical pulse for 1 minute.
Count each lub-dub as one beat.
The apical and radial pulses should be equal.
To see if the apical and radial pulses are equal, two staff members are needed.
The pulse deficit is the difference between the apical and radial pulse rates.
Taking the apical and radial pulses at the same time is called the apical-radial pulse.
Apical pulses (Fig , p. 448) are taken on persons who:
Have heart disease
Have irregular heart rhythms
Take drugs that affect the heart
Review the procedure Taking an Apical Pulse on p. 447.
Review the procedure Taking an Apical-Radial Pulse on p. 448.
Sometimes heart contractions are not strong enough to create pulses in the radial artery. Then the radial rate is less than the apical rate. Heart disease is a common cause.
The radial rate is never greater than the apical rate.
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12. Respirations
Respiration means breathing air into (inhalation) and out of (exhalation) the lungs.
Oxygen enters the lungs during inhalation.
Carbon dioxide leaves the lungs during exhalation.
The chest rises during inhalation and falls during exhalation.
The healthy adult has 12 to 20 respirations per minute.
Each respiration involves one inhalation and one exhalation.
Heart and respiratory diseases usually increase the respiratory rate.
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13. Respirations (Cont’d)
Respirations are normally quiet, effortless, and regular.
Both sides of the chest rise and fall equally.
Count respirations when the person is at rest.
Count respirations right after taking a pulse.
Keep your fingers or stethoscope over the pulse site.
To count respirations, watch the chest rise and fall.
People tend to change their breathing patterns when they know their respirations are being counted. Therefore do not tell the person that you are counting them.
Count respirations for 30 seconds. Multiply the number by 2 for the number of respirations in 1 minute. If you note an abnormal pattern, count the respirations for 1 minute. See Chapter 25 for abnormal respiratory patterns.
In nursing centers, respirations may be counted for 1 minute. Follow center policy.
Review Delegation Guidelines: Respirations on p. 449.
Review the Counting Respirations procedure on p. 449.
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14. Blood Pressure
Blood pressure (BP) is the amount of force exerted against the walls of an artery by the blood.
Blood pressure is controlled by:
The force of heart contractions
The amount of blood pumped with each heartbeat
How easily the blood flows through the blood vessels
Systole is the period of heart muscle contraction.
Diastole is the period of heart muscle relaxation.
Blood pressure is measured in millimeters (mm) of mercury (Hg).
The systolic pressure is recorded over the diastolic pressure.
You measure systolic and diastolic pressures.
The systolic pressure is the pressure in the arteries when the heart contracts. It is the higher pressure. The diastolic pressure is the pressure in the arteries when the heart is at rest. It is the lower pressure.
A systolic pressure of 120 mm Hg (millimeters of mercury) and a diastolic pressure of 80 mm Hg is written as 120/80 mm Hg.
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15. Normal and Abnormal Blood Pressure
Blood pressure has normal ranges:
Systolic pressure—less than 120 mm Hg
Diastolic pressure—less than 80 mm Hg
Hypertension—blood pressure measurements that remain above a systolic pressure of 140 mm Hg or a diastolic pressure of 90 mm Hg
Hypotension—when the systolic blood pressure is below 90 mm Hg and the diastolic pressure is below 60 mm Hg
A stethoscope and a sphygmomanometer are used to measure blood pressure.
Blood pressure is normally measured in the brachial artery.
You use a stethoscope and a sphygmomanometer to measure blood pressure.
The sphygmomanometer has a cuff and a measuring device. There are aneroid, mercury, and electronic types. Blood pressure is measured as the cuff is deflated.
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16. Blood Pressure (Cont’d)
Blood pressure can change from minute to minute.
Report any systolic measurement at or above 120 mm Hg. Also report a diastolic pressure at or above 80 mm Hg.
This is hypertension.
Report a systolic pressure below 90 mm Hg. Also report a diastolic pressure below 60 mm Hg.
This is hypotension.
Some people normally have low blood pressures. Older persons are at risk for orthostatic hypotension (see Chapter 23). However, hypotension can signal a life-threatening problem.
Review the contents of Box 26-2 on p. 450.
Review Delegation Guidelines: Measuring Blood Pressure on p. 451.
Review the Measuring Blood Pressure procedure on pp
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17. Quality of Life
You must protect the right to privacy when measuring vital signs.
Always keep resident information confidential.
Vital signs are just as private as other information. Do not share the information with family, visitors, and roommates.
The right to personal choice is important.
Expose the person only to the extent needed when taking axillary or rectal temperatures and apical and apical-radial pulses.
Unless directed otherwise, vital signs are measured with the person sitting or lying down. Let the person choose the position.
The person may also prefer that you use the right or left arm for pulses and blood pressure. If safe to do so, use the arm the person prefers.
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