1. Pearson's Nursing Assistant Today CHAPTER Measuring Vital Signs 18

2. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Vital Signs Vital signs: –Measurements reflecting patient’s physical well-being and condition.  Temperature  Pulse  Respirations  Blood pressure

3. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Vital Signs Vital signs should be obtained: –Upon admission to health care facility. –When ordered by doctor. –Unusual situation, incident, patient fall. –Physical examination or checkup. –Pain or unusual symptoms. –New medication or treatment.

4. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Body Temperature Amount of heat in body. Body creates heat when changes food into energy. Loses heat through perspiration, respiration, and exertion. Thermometer: –Instrument used for measuring temperature.

5. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Body Temperature Body locations for temperature –Mouth (orally - O) –Ear (tympanic - T) –Armpit (axilla - A) –Forehead (temporal artery - TA) –Rectum - R

6. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Figure 18-3 and 18-6 Tympanic thermometer. Forehead thermometer strip.

7. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Body Temperature Normal adult body temperature is 98.6°F or 37°C. See Table 18-1: Normal Temperature Readings

8. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Body Temperature See Procedure 18-1: Using a Battery- Operated Electronic Oral Thermometer See Procedure 18-2: Using a Tympanic (Ear) Thermometer

9. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Body Temperature See Procedure 18-3: Using a Battery- Operated Electronic Rectal Thermometer See Procedure 18-4: Using an Electronic Oral Thermometer to Measure Axillary Temperature

10. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Figure 18-12 Points on the human body where the pulse may be taken.

11. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Pulse Pulse: –Rhythmic expansion and contraction of arteries caused by beating of heart. Pulse points: –Areas where artery is close to body’s surface and can be easily felt with fingers.

12. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Figure 18-13 Stethoscopes.

13. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Pulse Stethoscope: –Instrument that amplifies sounds made by body. Apical pulse provides information about blood flowing through heart.

14. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Pulse Normal pulse rate for adults 60 to 80 beats per minute; for infants 80 to 160 beats per minute. –Rate:  Number of heartbeats per minute. –Rhythm:  Regularity of heartbeats. –Force:  Strength of heartbeat.

15. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Pulse See Procedure 18-5: Measuring the Radial Pulse See Procedure 18-6: Measuring the Apical Pulse

16. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Figure 18-18 How we breathe.

17. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Pulse Pulse deficit: –Difference between apical heart rate and pulse rate. –See Advanced Procedure 18-7: Measuring the Apical Pulse Deficit

18. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Respirations Inhaling: –Air going into the lungs; breathing in. Exhaling: –Air going out of the lungs; breathing out. Dyspnea: –Abnormal respirations. Apnea: –Absence of respirations; not breathing.

19. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Respirations Adults breathe at rate of 12 to 20 times per minute; children more rapidly; elderly more slowly.

20. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Respirations Abnormal respirations –Stertorous –Abdominal –Irregular –Cheyne-Stokes See Procedure 18-8: Measuring Respiration

21. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Blood Pressure Blood pressure (BP): –Measuring force of blood flowing through arteries.  Rate of heartbeat  How easily blood flows through blood vessels Normal adult blood pressure less than 120 mm Hg systolic and less than 80 mm Hg diastolic.

22. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Blood Pressure Systolic blood pressure: –Heart is contracting, pressure is highest. Diastolic blood pressure: –Heart is most relaxed, pressure is lowest. Hypertension: –Blood pressure higher than normal. Hypotension: –Blood pressure lower than normal.

23. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Blood Pressure Sphygmomanometer: –Device used to measure blood pressure.  Mercury  Aneroid (dial)  Electronic, digital display

24. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Blood Pressure Select appropriately sized BP cuff. Do not take BP on arm that has IV (intravenous) setup in it. Do not take BP on extremity that has surgical site or from patient with AV shunt. –See Procedure 18-9: Measuring Blood Pressure Using a Sphygmomanometer

25. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Blood Pressure Noninvasive blood pressure (NIBP) monitors used in operating rooms and with critical care patients. Electronic blood pressure monitoring apparatus uses infrared photoelectronic system.

26. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Pain—the Fifth Vital Sign Pain measurement scales use numbers or faces to rate patient pain intensity. Patient may use words such as dull, achy, sharp, cramping, throbbing, unbearable, or tearing. Patient may cry, moan, groan, guard, or yell when touched.

27. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Pain—the Fifth Vital Sign OPQRST mnemonic –Onset of the event –Provocation or palliation –Quality of the pain –Region and radiation –Severity –Time

28. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Height Height used for assessing nutritional status and monitoring health. Used to calculate: –Ideal body weight (IBW) and Body Mass Index (BMI). Used to plan patient’s daily calorie, protein, and fluid needs. –See Procedure 18-10: Measuring the Height of a Patient in Bed

29. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Weight Measurement calculates dosages of medications; assesses nutritional status; monitors health. See Procedure 18-11: Measuring the Weight of a Patient in Bed

30. Pearson's Nursing Assistant Today Francie Wolgin Kate Smith Julie French Abdominal Girth Measurement Abdominal girth measures distance around abdomen at specific point. –See Procedure 18-12: Measuring the Abdominal Girth