Saturday, January 5, 2008

Assessment of Vital Signs

Assessing Vital Signs
Vital Signs or Cardinal Signs are:
 Body temperature
 Pulse
 Respiration
 Blood pressure
 Pain
I. Body Temperature
 The balance between the heat produced by the body and the heat loss from the body.
Types of Body Temperature
 Core temperature –temperature of the deep tissues of the body.
 Surface body temperature
Alteration in body Temperature
 Pyrexia – Body temperature above normal range( hyperthermia)
 Hyperpyrexia – Very high fever, 41ºC(105.8 F) and above
 Hypothermia – Subnormal temperature.
Normal Adult Temperature Ranges
 Oral 36.5 –37.5 ºC
 Axillary 35.8 – 37.0 ºC
 Rectal 37.0 – 38.1 ºC
 Tympanic 36.8 – 37.9ºC

Methods of Temperature-Taking
1. Oral – most accessible and convenient method.
a. Put on gloves, and position the tip of the thermometer under the patients tongue on either of the frenulun as far back as possible. It promotes contact to the superficial blood vessels and ensure a more accurate reading.
b. Wash thermometer before use.
c. Take oral temp 2-3 minutes.
d. Allow 15 min to elapse between client’s food intake of hot or cold food, smoking.
e. Instruct the patient to close his lips but not to bite down with his teeth to avoid breaking the thermometer in his mouth.
Contraindications
 Young children an infants
 Patients who are unconscious or disoriented
 Who must breath through the mouth
 Seizure prone
 Patient with N/V
 Patients with oral lesions/surgeries

2. Rectal- most accurate measurement of temperature
a. Position- lateral position with his top legs flexed and drape him to provide privacy.
b. Squeeze the lubricant onto a facial tissue to avoid contaminating the lubricant supply.
c. Insert thermometer by 0.5 – 1.5 inches
d. Hold in place in 2minutes
e. Do not force to insert the thermometer
Contraindications
 Patient with diarrhea
 Recent rectal or prostatic surgery or injury because it may injure inflamed tissue
 Recent myocardial infarction
 Patient post head injury

3. Axillary – safest and non-invasive
a. Pat the axilla dry
b. Ask the patient to reach across his chest and grasp his opposite shoulder. This promote skin contact with the thermometer
c. Hold it in place for 9 minutes because the thermometer isn’t close in a body cavity
Note:
 Use the same thermometer for repeat temperature taking to ensure more consistent result
 Store chemical-dot thermometer in a cool area because exposure to heat activates the dye dots.
4. Tympanic thermometer
a. Make sure the lens under the probe is clean and shiny
b. Stabilized the patient’s head; gently pull the ear straight back (for children up to age 1) or up and back (for children 1 and older to adults)
c. Insert the thermometer until the entire ear canal is sealed
d. Place the activation button, and hold it in place for 1 second
5. Chemical-dot thermometer
a. Leave the chemical-dot thermometer in place for 45 seconds
b. Read the temperature as the last dye dot that has change color, or fired.
Nursing Interventions in Clients with Fever
a. Monitor V.S
b. Assess skin color and temperature
c. Monitor WBC, Hct and other pertinent lab records
d. Provide adequate foods and fluids.
e. Promote rest
f. Monitor I & O
g. Provide TSB
h. Provide dry clothing and linens
i. Give antipyretic as ordered by MD

II. Pulse – It’s the wave of blood created by contractions of the left ventricles of the
heart.
Normal Pulse rate
1 year 80-140 beats/min
2 years 80- 130 beats/min
6 years 75- 120 beats/min
10 years 60-90 beats/min
Adult 60-100 beats/min

Tachycardia – pulse rate of above 100 beats/min
Bradycardia- pulse rate below 60 beats/min
Irregular – uneven time interval between beats.

What you need:
a. Watch with second hand
b. Stethoscope (for apical pulse)
c. Doppler ultrasound blood flow detector if necessary
Radial Pulse
a. Wash your hand and tell your client that you are going to take his pulse
b. Place the client in sitting or supine position with his arm on his side or across his
chest
c. Gently press your index, middle, and ring fingers on the radial artery, inside the patient’s wrist.
d. Excessive pressure may obstruct blood flow distal to the pulse site
e. Counting for a full minute provides a more accurate picture of irregularities
Doppler device
a. Apply small amount of transmission gel to the ultrasound probe
b. Position the probe on the skin directly over a selected artery
c. Set the volume to the lowest setting
d. To obtain best signals, put gel between the skin and the probe and tilt the probe 45 degrees from the artery.
e. After you have measure the pulse rate, clean the probe with soft cloth soaked in antiseptic. Do not immerse the probe
III. Respiration - is the exchange of oxygen and carbon dioxide between the atmosphere
and the body
Assessing Respiration
 Rate – Normal 14-20/ min in adult
 The best time to assess respiration is immediately after taking client’s pulse
 Count respiration for 60 second
 As you count the respiration, assess and record breath sound as stridor, wheezing, or stertor.
 Respiratory rates of less than 10 or more than 40 are usually considered abnormal and should be reported immediately to the physician.

IV. Blood Pressure
Adult – 90- 132 systolic
60- 85 diastolic
Elderly 140-160 systolic
70-90 diastolic
a. Ensure that the client is rested
b. Use appropriate size of BP cuff.
c. If too tight and narrow- false high BP
d. If too lose and wide-false low BP
e. Position the patient on sitting or supine position
f. Position the arm at the level of the heart, if the artery is below the heart level, you may get a false high reading
g. Use the bell of the stethoscope since the blood pressure is a low frequency sound.
h. If the client is crying or anxious, delay measuring his blood pressure to avoid false-high BP
Electronic Vital Sign Monitor
a. An electronic vital signs monitor allows you to continually tract a patient’s vital
sign without having to reapply a blood pressure cuff each time.
b. Example: Dinamap VS monitor 8100
c. Lightweight, battery operated and can be attached to an IV pole
d. Before using the device, check the client7s pulse and BP manually using the same arm you’ll using for the monitor cuff.
e. Compare the result with the initial reading from the monitor. If the results differ call the supply department or the manufacturer’s representative.
V. Pain
How to assess Pain
a. You must consider both the patient’s description and your observations on his behavioral responses.
b. First, ask the client to rank his pain on a scale of 0-10, with 0 denoting lack of pain and 10 denoting the worst pain imaginable.
c. Ask:
d. Where is the pain located?
e. How long does the pain last?
f. How often does it occur?
g. Can you describe the pain?
h. What makes the pain worse
i. Observe the patient’s behavioral response to pain (body language, moaning, grimacing, withdrawal, crying, restlessness muscle twitching and immobility)
j. Also note physiological response, which may be sympathetic or parasympathetic
Managing Pain
1. Giving medication as per MD’s order
2. Giving emotional support
3. Performing comfort measures
4. Use cognitive therapy
Height and weight
a. Height and weight are routinely measured when a patient is admitted to a health care facility.
b. It is essential in calculating drug dosage, contrast agents, assessing nutritional status and determining the height-weight ratio.
c. Weight is the best overall indicator of fluid status, daily monitoring is important for clients receiving a diuretics or a medication that causes sodium retention.
d. Weight can be measured with a standing scale, chair scale and bed scale.
e. Height can be measured with the measuring bar, standing scale or tape measure if the client is confine in a supine position.
Pointers:
a. Reassure and steady patient who are at risk for losing their balance on a scale.
b. Weight the patient at the same time each day. (usually before breakfast), in similar clothing and using the same scale.
c. If the patient uses crutches, weigh the client with the crutches or heavy clothing and subtract their weight from the total determined patient’ weight.

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