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Vital sign

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it also help in providing comprehensive care to patient.....with update knowledge.....

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Vital sign

  1. 1. PRESENTED BY: MR.J.G SAMBAD MSC.NURSING IKDRC COLLEGE OF NURSING
  2. 2.  INTRODUCTION : Vital sign are the indicator of the body’s physiologic status and response to physical environment and psychological stressor.The vital sign or the cardinal sign are temperature, pulse, respiration, and blood pressure. The findings are governed by the vital organs.
  3. 3. 1. Temperature 2. Pulse 3. Respiration 4. Blood pressure 5. oxygen saturation 6. Pupillary reaction/ pain
  4. 4.  Vital sign are otherwise called cardinal signs. These are the indicator of health status, as these indicate the effectiveness of circulatory, respiratory, neural, & endocrine body functions.
  5. 5.  To determine change in client status.  To recognize variation from normal and its significance.  To help physician to prescribe right treatment.  To identify specific life threatening condition.  To detect changes in client health status.  To help in diagnosis of disease, the result of treatment and medication.
  6. 6.  Upon admission.  On a routine basis.  Before and after invasive procedure.  Before and after administration of medication.  Any detoraition of patient’s general condition.  Before and after nursing intervention that may influence vital sign.  Prior to medical emergency call MET team.
  7. 7.  Body temperature – 98.6˚F or 37˚C in adults Pulse – 72/minute in adults  Respiration – 16/ minute in adult  Blood pressure – 120/80 mm of Hg
  8. 8. Thermometer is the equipment ,that use to monitor the temperature. 4 types of thermometer. • Clinical thermometer • Rectal thermometer • Digital thermometer • Lotion thermometer
  9. 9.  Two parts of thermometer-bulb and stem  Blub is fragile part, containing mercury, sensitive to temperature.  Stem is hollow tube in which mercury can rise.  there are two scales, Fahrenheit and Celsius (centigrade). 
  10. 10.  Mercury, a liquid metal, with silvery appearance is used in thermometers, because it is very sensitive to a small changes in temperature, expansion of mercury is uniform, easily visible.  CELSIUS AND FAHRENHEIT SCALES – • C = (F-32) × 5/9 • F = (C × 9/5 )+32
  11. 11.  Shake the mercury down, grasp securely, hold it from the upper end of the stem.  Be careful from fall, shake it away from all articles and furniture.  Never wash it with hot water  Never store it in disinfectant solution.
  12. 12. NAME OF THE DISINFECTION STRENGTH TIME Dettol 1:40 5 min. Savlon 1:20 5 min Lysol 1:40 3min. Fairgenol 1:40 5 min.
  13. 13. CLINICALTHERMOMETER -  ELECTRONICTHERMOMETER –  TYMPANIC MEMBRANE -THERMOMETER  DISPOSABLETHERMOMETER – CHEMICAL DOT -
  14. 14. • Definition : It is a measurement of the average kinetic energy of the molecules in an object or system and can be measured with a thermometer or calorimeter. It is determining the internal energy contained within the system. Body temperature is the difference between the amount of heat produced by body process and the amount of heat lost to the external environment.
  15. 15.  To get accurate temperature , the bulb of thermometer must be placed surrounded by body tissue and more blood circulation, air and moisture should be avoid. COMMON SITES: - Mouth - Groin - Axilla -Vagina and Rectum
  16. 16.  There is good blood supply under tongue, so correct temperature is recorded.  There is less chance of bulb coming in contact with air.  Thermometer can held easily under tongue.  No privacy is needed
  17. 17.  If patient keep it in oral cavity not under tongue, then possibility of false temperature recording.  If thermometer is not adequately disinfected then chances of cross infection.  children can bite thermometer.  Patient feels bad test, if disinfectant is not properly removed.  Patient feels tired by keeping it in mouth
  18. 18. 1. Explain the procedure to the patient also find out if the patient has taken cold or hot food or fluids or has smoked. fso, the nurse should wait for 30 minutes. 2. Perform hand hygiene. 3. Place the patient in a comfortable position. 4. Read mercury level while gently rotating thermometer at eye level. Shake it until reading lowers mercury level to 35.6 C.
  19. 19. 5. Ask client to open mouth and gently place thermometer and the tongue in posterior sublingual pocket lateral to center of lower jaw. 6. Wait for 3 minutes. 7. Remove the thermometer ,clean from steam to bulb and read at eye level.
  20. 20. 8. Shake gently so that mercury level falls below 35 C. 9. Place the thermometer in disinfectant solution. 10. Discard used tissue paper/ cotton balls. 11. Record temperature on the graph sheet of TPR record.
  21. 21.  Unconscious patient, children under 6year.  Patient with convulsion and mouth breather,  Patient with injury, inflammation or operation of mouth.  Extremely week person who can not hold.  Patient suffering from frequent attack of cough.
  22. 22.  Causes less discomfort to the patient.  Its useful in children and in the client who cannot hold it properly.  Taking hot and cold drink will not affect the temperature.  No chance of cross infection, bad test and biting of thermometer.
  23. 23.  Neonates, infants, toddlers, & children, intubated and sick patients.  Patient with oral inflammation or wired jaws.  Patients recovering from oral surgery.  Those who cannot breathe through their nose, irrational patients and those for whom other temperature sites are contraindicated.  Mentally challenged or compromised individuals.
  24. 24. 1. Explain the procedure to the patient. 2. Perform hand hygiene. 3. Place the patient in a comfortable position. 4. Read mercury level while gently rotating thermometer at eye level. Shake it until reading lowers mercury level to 35.6 C. 5. Dry axilla with towel / tissue paper. 6. Place the thermometer in axilla so that the bulb of thermometer is well in contact with the skin, while the patients hand is held across the chest.
  25. 25. 7. Wait for 5 minutes. 8. Remove the thermometer, clean from stem to bulb and read at eye level. Add 1F for 0.3 C. 9. Shake gently so that mercury level falls below 95 F or 35 C. 10. Place the thermometer in disinfectant solution. 11. Discard used tissue paper/cotton balls. 12. Record temperature on the graph sheet ofTPR record.
  26. 26.  The axilla is the moist area, so due to moisture there is chance of false reading.  If the bulb is not placed properly, go beyond the skin fold and come in contact of air, then chance of false reading.
  27. 27. The rectum method is used when oral method is contraindicated. It is most reliable method because there is large amount of blood supply and less chance of air contact.
  28. 28.  Its needs privacy.  Its needs lubrication.  Chances of soiling of hands If the rectum is loaded with fecal matter, we get false reading.
  29. 29.  Patient with rectal surgery and inflammation. Patient with diarrhoea.  when rectum is loaded with fecal matter.  patient is treatment with enema and bowel wash.
  30. 30.  Tympanic membrane receives same blood supply which supplies to hypothalamus, So it reflects core body temperature (deep body tissue ).  The ear is readily accessible.  It permits rapid temperature reading in younger, confused, unconscious.  Cerumen or otitis media doesn’t significantly affects the temperature.
  31. 31.  HYPERPYREXIA –The fever goes above 105 F HYPOTHERMIA – If the temperature falls below 95 F Which gland regulate our body temperature?
  32. 32. DEFINITION :  Pulse is a palpable bounding of the blood flow noted at various points on the body where the artery is passes over a bone.When blood is pumped into the arteries by the contraction of the left ventricle.  Normal pulse rate is 70 -80 per minute.
  33. 33.  Pulse is regulated by the Autonomic Nervous System through the sino-atrial node.( Often called pace maker.)  Para sympathetic stimulation decreases the heart rate and sympathetic stimulates increase the heart rate.  The quantity of blood forced out of the left ventricle during each contraction is called stroke volume.(70 ml for an average adult).  Cardiac output = Stroke volume × Pulse rate 
  34. 34.  To determine the number of heart beats occurring per minutes.  To establish baseline data for subsequent evaluation.  To gather information about the heart’s rhythm and pattern of beats.  To evaluate amplitude of pulse.  To assess heart’s ability deliver blood to the various organs.
  35. 35.  To assess response of the heart to cardiac medications, activity, blood volume, gas exchange.  To assess the vascular status of limbs.  To compare the equality of peripheral pulses on each side of the body.  To monitor and assess the patients risk for alterations in pulse.
  36. 36.  A watch that has a second hand.  A pen with red ink.  A stethoscope.  Nurses notes
  37. 37.  Temporal artery  Facial artery  Carotid artery  Apical pulse  Brachial artery  Radial artery  Femoral artery  Popliteal artery  Posterior tibial artery.  Dorsalis pedis.
  38. 38.  Explain the procedure.  Wash and dry the hand.  Encourage the patient to relax and not speak also find out if the patient has been ambulated or done any such activity within the previous 15 minutes.  Explain and discuss the procedure with the patient.  Where possible measure the pulse under the same condition each time.
  39. 39.  Place the index, middle and ring finger along the appropriate artery and apply light pressure until the pulse is felt.  Press gently against the peripheral artery being used to record the pulse.  The pulse should be counted for 60 second.
  40. 40. If the apical pulse is going to be checked explain to the patient and expose the sternum and the left of the chest. Place the diaphragm of the stethoscope over the point of maximal impulses (PMI) at the 5th intercostal space, medial to the mid-clavicular line. If the beat's regular count for 30 seconds and multiple by two. If irregular auscultate for one full minute.
  41. 41. Tachycardia – pulse rate is above 100 beats/min. Bradycardia – Pulse rate is below 60 beats/min
  42. 42.  Definition: Monitoring the involuntary process of inspiration of oxygen and expiration of carbon-dioxide of a person. Respirations constitute inspiration, expiration, and a pause. Respiration is the mechanism the body uses to exchange gases between atmosphere and blood (external respiration) and the blood and the cells(internal respiration).
  43. 43.  To determine a baseline respiratory rate for comparisons.  To monitor changes in oxygenation or in respiration.  To evaluate the patient’s response to medications or treatments that affects the respiratory system.  Equipment: a watch that has a second’s hand.
  44. 44. 1. Observe the pattern: rate, rhythm, volume and ease or effort of respiration. 2. Encourages the patient to place his hand over the abdomen or chest.The nurses place their hand directly over patient’s upper abdomen. 3. Observe complete respiratory cycle. 4. After the cycle is observed look at the second in the watch and begin to count rate from 0, 1, 3.
  45. 45. 5. If rhythm is regular count the number of respiration in 30 second and multiple by two. If it is irregular less than 12, or greater than 20, count for one full minute. 6. Observe for signs of respiratory efforts; Nasal flaring Pursed lips Use of accessory such as the shoulder or the neck muscles. 7. Record the respiratory rate on appropriate documentation,
  46. 46.  DEFINITION: Blood pressure is the force on the wall of blood vessel by blood as it is pumped around the body by the force of ventricular contraction. SBP: pressure of the blood as a result of contraction of ventricles. DBP: it is the pressure when the ventricles are at rest.
  47. 47.  To determine the patients blood pressure at initial assessment as a base for subsequent evaluation.  To monitor fluctuations in blood pressure.  To assess the cardiac status.  To identify and monitor changes resulting from a disease process and medical surgical therapy.  To determine patients hemodynamic status.
  48. 48.  A well maintained sphygmomanometer.  Stethoscope
  49. 49. 1. Wash hand and dry hands. 2. Prepare the patient for the procedure. 3. Ask the patient if he or she has ingested caffeine or has smoked within 30 minutes prior to measurement. 4. Allow the patient to rest for 5 minutes either supine or seated in a quiet room with comfortable temperature.
  50. 50. 5. Comfortably position the patient sitting with the arm supported on the table at heart level or lying down with the arms resting on the bed and has the palm of the hand facing upwards. Position the knee slightly flexed. (popliteal BP checking). 6. They should instruct to keep their feet flat. 7. Remove tight clothing from the limb to be used and support the limb.
  51. 51. 8. Apply the correct sized sphygmomanometer cuff 2.5 cm above the anticubital fossa directly over the patient’s skin, and in level with the heart. 9. Ensure the level of mercury meniscus in the manometer is at the nurse’s level. 10. Locate the radial or brachial artery and inflate the cuff until the pulse can no longer be felt. Deflate and wait 15-30 seconds before proceeding.
  52. 52. 11. Palpate the brachial artery and place the stethoscope gently over the brachial artery. Inflate the cuff to 30 mm Hg above from the previous step. 12. The cuff is deflated at a rate of2-3 mm Hg per second and the korotkoff sounds listened for - korotkoff I minus when sounds first heard is equal to systolic value. - korotkoffV minus when last sound is heard is equal to diastolic value.
  53. 53. 13. Record the systolic and diastolic pressures in the nurses chart and on the vitals record. Document the arm used and patient’s position. Compare with previous readings. Inform the appropriate personnel of any irregularities. 14. When BP has to be read from a continuous cardiac monitor do the following. - The cuff has to be tied constantly. - The cuff needs to be changed from one arm to another second hourly. - Set the monitor to read the BP as per patient condition.
  54. 54.  The arm has an intra venous infusion/transfusion.  The arm injured or diseased.  The arm has a shunt or fistula for renal dialysis.  On the same wide of the body where a female patient has had mastectomy.
  55. 55.  Definition: Oxygen saturation is the measurement of oxygen attached to the hemoglobin cell in the circulatory system. The normal spo2 is 90 to 100% .
  56. 56.  To monitor the adequacy of arterial hemoglobin saturation.
  57. 57.  Oximeter probe  Acetone or nail polish remover
  58. 58.  Perform hand hygiene.  Explain procedure to patient.  Assess the appropriate site.  If nail polish are applied, remove it using acetone or nail polish remover.  Attach sensor probe to monitoring site. Explain the patient that he/she will like a clothespin on the finger but will not hurt.  Turn on Oximeter. Observe pulse wave form on display.
  59. 59.  Leave the probe in place until Oximeter read out reaches constant value. Read spo2 on digital display. Record.  If continuous spo2 is monitoring planned preset spo2 alarm limits and volume.  Assess skin integrity and re locate the sensor probe every four hours.  Discuss the finding with the patient as needed.  Record spo2 value on nurses notes.
  60. 60. Definition: Observation of pupils construction and dilation in response to light and accommodation Purpose: To establish baseline data for subsequent evaluations. To assess the eye structure and visual acuity. To monitor patients neurological status. To identify the deviations from normal.
  61. 61.  Pen torch
  62. 62.  Partially darken the room .  Wash hands and dry hands.  Explain and discuss the procedure with the patient.  Ask the patient to look straight ahead.  Using a pen torch approach from the side shine a light on the pupil.  Observe the response of the illuminated pupil. It should constrict. (direct response)  Shine the light on the pupil again, and observe the response of the other pupil. It should also constrict.
  63. 63. 1. Oral/ axilla / rectal thermometer (1) 2. Stethoscope (1) 3. Sphygmomanometer with appropriate cuff size(1) 4.Watch with a second hand (1) 5. Spirit swab or cotton (1) 6. Sponge towel (1) 7. Paper bag (1): for discard dry waste (1) 8. Record form 9. Ball- point pen: blue (1) black (1) red (1) 10. Steel tray (1): to set all materials
  64. 64. 88

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