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nursing (NCM116)
De La Salle Lipa
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NCM-
Care of Clients with Problems in Oxygen, Fluid, Electrolytes, Infectious, Inflammatory,
Immuno (RLE)
(Vital Signs) | SEM 1 2022
VITAL SIGNS
● very useful tool in maintaining optimum health status ● Helpful in detecting medical problems ● Critical during emergencies to ensure current health status and prevent deterioration
FOUR MAIN VITAL SIGNS - Temperature - Pulse - Respiratory rate - Blood pressure
BODY TEMPERATURE
● measurement of the balance between heat lost and heat produced by the body ● Can be an indicator of the body’s metabolic status ● Can be a sign of infection or an invasion of harmful organisms
Devices used to Measure Body Temperature: Thermometer
- Use the appropriate probe cover for the device you are using. This protects the patient from unnecessary exposure to harmful organisms
TAKING AN ORAL TEMPERATURE
Place the temperature probe under the tongue
Make sure that the patient has not had anything to eat or drink or has not smoked before taking an oral temperature
TAKING AN AXILLARY TEMPERATURE
Wipe away any perspiration
Place the temperature probe under the axilla or “armpit” Be sure that clothing does not interfere with skin-to- thermometer contact under the arm
Document the results Keep the thermometer in place until an audible “beep” is heard or until the temperature stops flashing. Read and record the temperature according to facility policy
PULSE
● wave of blood created by the heart pumping as it travels along arteries ● felt when an artery is partially occluded by two fingers ● Never use the thumb because it has a pulse and can be confused with the patient’s pulse
NORMAL PULSE RATE
● Normal pulse for adult ranges from 60 to 90 beats per minute
● Normal pulse for a child or infant will be higher than an adult ● BRADYCARDIA - pulse that is lower than normal ● TACHYCARDIA - pulse that is higher than normal
MEASURING THE PULSE
- Using two fingers, find the radial pulse along the thumb-side of the wrist
- Count each pulse for thirty-seconds/ one full minute while watching the second hand of a watch or clock
RESPIRATIONS
NORMAL RESPIRATORY RATE
● Normal respiratory rate for an adult ranges from 12 to 20 ● Normal respiratory rate for a child or infant will be higher than an adults ● BRADYPNEA - respiratory rate that is lower than normal ● TACHYPNEA - respiratory rate that is higher than normal
MEASURING RESPIRATIONS
After counting the pulse for 30 seconds/1 full minute, leave fingers in place to count the respirations
Do not tell the patient you are counting respirations.
1 respiration = 1 inspiration (rise of the chest) and 1 exhalation fall
of the chest
Count each respiration for 30 seconds /1 minute
Document the results. Record the pulse and respirations according to facility policy
BLOOD PRESSURE
● pressure exerted against the walls of an artery ● When the heart contracts, the pressure is the greatest = systolic pressure ● When the heart is at rest, the pressure is the lowest = diastolic pressure ● Devices used to Measure Blood Pressure: Sphygmomanometer
Blood Pressure Cuff Placement - Place the cuff securely around the upper arm about ½ to 2 inches above the elbow - Align the artery arrow along the inner aspect of the upper arm
Inflating the Blood Pressure Cuff - Close the valve control knob - Inflate the cuff by squeezing and releasing the bulb
NORMAL BLOOD PRESSURE
● Normal systolic blood pressure for an adult is 100- 120 ● Normal diastolic blood pressure for an adult is 50- ● HYPOTENSION- blood pressure that is lower than normal ● HYPERTENSION- blood pressure that is higher than normal
MEASURING BLOOD PRESSURE
Put the stethoscope in place with the earpieces in your ears
feel the patient’s pulse while inflating the cuff
place the bell of the stethoscope over the brachial artery
VS notes
Course: nursing (NCM116)
University: De La Salle Lipa
