Baseline Vital Signs & SAMPLE History CHAPTER 5. Baseline Vital Signs.
3.01 Vital Signs
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Transcript of 3.01 Vital Signs
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Vital SignsVital Signs
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3.01 Understand Diagnostic and Therapeutic Services
Vital SignsVital Signs
• Provide information about body function• Include:
– temperature– pulse– respiration– blood pressure
• Changes may be the first sign of disease• Accuracy is imperative!
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3.01 Understand Diagnostic and Therapeutic Services
Vital SignsVital SignsTemperature
Measurement of the balance between heat lost and heat produced
Heat lost through:• Perspiration• Respiration• Excretion
Heat produced by:• Metabolism of food• Muscle and gland activity
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3.01 Understand Diagnostic and Therapeutic Services
Vital SignsVital SignsTemperature
Normal rangesNormal ranges
– 97º - 100º F – 36.1º - 37.8º C
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3.01 Understand Diagnostic and Therapeutic Services
Vital SignsVital SignsTemperature
Hypothermia
•Temperature below 95º F
•Death can occur if below 93º F
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Vital SignsVital SignsTemperature
HypothermiaTemperature decreases with:
– environment– exposure to cold– inactivity– sleep– starvation
Symptoms:– shivering– cold skin– confusion
3.01 Understand Diagnostic and Therapeutic Services
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3.01 Understand Diagnostic and Therapeutic Services
Vital SignsVital SignsTemperature
Hyperthermia
•Temperature 100-104º F
•Temperature above 104º F is life-threatening
•Prolonged hyperthermia may cause brain
injury.
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Vital SignsVital SignsTemperature
Hyperthermia
Temperature increases with: – environment– exercise– illness, infection, injury– stress
Symptoms:– hot, dry, red skin– nausea/vomiting– headache– low blood pressure
3.01 Understand Diagnostic and Therapeutic Services
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3.01 Understand Diagnostic and Therapeutic Services
Vital SignsVital SignsTemperature
Clinical
Non-mercury glass
ElectronicAural
Thermometers
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3.01 Understand Diagnostic and Therapeutic Services
Vital SignsVital SignsTemperature
Sites to measure temperature:
•Aural – auditory canal
•Axillary – armpit
•Oral – mouth
•Rectal – rectum
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3.01 Understand Diagnostic and Therapeutic Services
Vital SignsVital SignsTemperature
To record temperature:
– Oral 98.6º (O)
– Rectal 99.6º (R)
– Axillary 97.6º (ax)
– Aural 98.6º (T)
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3.01 Understand Diagnostic and Therapeutic Services
Vital SignsVital SignsTemperature Measurement
Oral Oral
•Ask the patient if they have ingested hot or cold food or drink, or smoked within the last ½ hour
•If yes, wait at least 15 minutes before measuring the oral temperature
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3.01 Understand Diagnostic and Therapeutic Services
REPORT REPORT
ABNORMAL RESULTS ABNORMAL RESULTS
OF ANY VITAL SIGN OF ANY VITAL SIGN
IMMEDIATELYIMMEDIATELY
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Vital SignsVital Signs
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TemperatureTemperature
3.01 Understand Diagnostic and Therapeutic Services
Demonstrate the skillProvide for guided practice
Provide for independent practiceVerify student passing
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Vital SignsVital Signs
OralOral
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Vital SignsVital SignsTemperature Measurement
• AuralAural
• Pros:– Measures core body temperature– Fast and convenient
• Con:– Inaccurate if not placed correctly in the ear
canal– Ear infection– Ear wax
3.01 Understand Diagnostic and Therapeutic Services
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TemperatureTemperature
3.01 Understand Diagnostic and Therapeutic Services
Demonstrate the skillProvide for guided practice
Provide for independent practiceVerify student passing
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Vital SignsVital Signs
AuralAural
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3.01 Understand Diagnostic and Therapeutic Services
Vital SignsVital SignsPulse
Pressure of blood on artery walls as the heart beats and relaxes•Sites: Temporal – side of the forehead
Carotid – side of the neck
Brachial – inner elbow
Radial – above the thumb at radius
Femoral – upper thigh
Popliteal – behind the knee
Dorsalis pedis – top of the arch of the foot17
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Vital SignsVital SignsPulse
When would you use these pulse sites?
Temporal
Carotid
Brachial
Radial
Femoral
Popliteal
Dorsalis pedis 3.01 Understand Diagnostic and Therapeutic Services
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3.01 Understand Diagnostic and Therapeutic Services
Normal rate adult (male) 60 – 70 beats per minute
adult (female) 65 – 80 beats per minute
children (over 7) 70 – 100 beats per minute
children (1 – 7) 80 – 110 beats per minute
infants (less than 1 year) 100 – 160 beats per minute
Rhythm regular or irregular
Volume strength of the pulse
Vital SignsVital SignsPulse
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3.01 Understand Diagnostic and Therapeutic Services
Vital SignsVital SignsPulse
• Pulse can be increased by:– exercise– stimulant drugs– excitement– fever– shock– nervousness
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3.01 Understand Diagnostic and Therapeutic Services
Vital SignsVital SignsPulse
• Pulse can be decreased by:
– sleep
– depressant drugs
– heart disease
– coma
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3.01 Understand Diagnostic and Therapeutic Services
REPORT REPORT
ABNORMAL RESULTS ABNORMAL RESULTS
OF ANY VITAL SIGN OF ANY VITAL SIGN
IMMEDIATELYIMMEDIATELY
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Vital SignsVital Signs
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Radial PulseRadial Pulse
3.01 Understand Diagnostic and Therapeutic Services
Demonstrate the skillProvide for guided practice
Provide for independent practiceVerify student passing
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Vital SignsVital Signs
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Vital SignsVital SignsApical Apical Pulse
• Pulse count taken with the stethoscope.
• Use if the patient has:– Irregular heartbeat– Arteriosclerosis– Weak or rapid radial pulse– Infants and children
3.01 Understand Diagnostic and Therapeutic Services
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Apical PulseApical Pulse
3.01 Understand Diagnostic and Therapeutic Services
Demonstrate the skillProvide for guided practice
Provide for independent practiceVerify student passing
25
Vital SignsVital Signs
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3.01 Understand Diagnostic and Therapeutic Services
Vital SignsVital SignsRespiration
Process of taking in oxygen and expelling carbon dioxide
1 inspiration + 1 expiration = respiration
Normal rate: adults – 12 – 20 breaths per minute children – 16 – 30 breaths per minute
Evaluate for rhythm and characterRhythm – regular or irregularCharacter – depth, ease of breaths
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3.01 Understand Diagnostic and Therapeutic Services
Vital SignsVital SignsRespiration
• Abnormal respiratory patternsApnea – periods of absent breathing
Cheyne-stokes – periods of apnea and dyspnea
Dyspnea – difficult breathing
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3.01 Understand Diagnostic and Therapeutic Services
REPORT REPORT
ABNORMAL RESULTS ABNORMAL RESULTS
OF ANY VITAL SIGN OF ANY VITAL SIGN
IMMEDIATELYIMMEDIATELY
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Vital SignsVital Signs
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RespirationsRespirations
3.01 Understand Diagnostic and Therapeutic Services
Demonstrate the skillProvide for guided practice
Provide for independent practiceVerify student passing
29
Vital SignsVital Signs
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3.01 Understand Diagnostic and Therapeutic Services
Vital SignsVital SignsBlood pressure
Pressure of blood on the arterial walls
Recorded as a fraction: 120/80
Systolic pressure – wall of left ventricle is contractingNormal range: 100-140 mm Hg
Diastolic pressure– wall of left ventricle is restingNormal range: 60-90 mm Hg
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3.01 Understand Diagnostic and Therapeutic Services
Factors that elevate blood pressure:– anxiety
– eating– exercise– excitement– stimulant drugs
Factors that lower blood pressure:– depressant drugs
– excessive loss of blood
– rest
– shock
Vital SignsVital SignsBlood pressure
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3.01 Understand Diagnostic and Therapeutic Services
REPORT REPORT
ABNORMAL RESULTS ABNORMAL RESULTS
OF ANY VITAL SIGN OF ANY VITAL SIGN
IMMEDIATELYIMMEDIATELY
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Vital SignsVital Signs
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Blood PressureBlood Pressure
3.01 Understand Diagnostic and Therapeutic Services
Demonstrate the skillProvide for guided practice
Provide for independent practiceVerify student passing
33
Vital SignsVital Signs
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Combined Vital SignsCombined Vital SignsTPR BPTPR BP
3.01 Understand Diagnostic and Therapeutic Services
Demonstrate the skillProvide for guided practice
Provide for independent practiceVerify student passing
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Vital SignsVital Signs
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3.01 Understand Diagnostic and Therapeutic Services
Diagnostic Skills:Diagnostic Skills:Height and WeightHeight and Weight
Measured if warranted by patient’s age and physical condition• Measured routinely: –on admission to health care facility
–as part of annual physical examination
–each provider visit for children
• Important for evaluation of laboratory tests
and calculation of medications
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3.01 Understand Diagnostic and Therapeutic Services
Diagnostic Skills:Diagnostic Skills:Daily WeightsDaily Weights
• Daily weights are used to monitor patients with chronic disease processes:– Hormone disorders– Renal disorders– Heart disease
– Cancer
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3.01 Understand Diagnostic and Therapeutic Services
Diagnostic Skills:Diagnostic Skills:Daily WeightsDaily Weights
• Guidelines for daily weights:use the same scales
at the same time
wearing the same type of clothing
patient voids to empty bladder
• Make sure to balance the scales before weighing the patient.
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3.01 Understand Diagnostic and Therapeutic Services
Diagnostic Skills:Diagnostic Skills:Daily WeightsDaily Weights
OBSERVE SAFETY PRECAUTONS!OBSERVE SAFETY PRECAUTONS!
Prevent injury from falls and the
protruding height lever.
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Measuring Height and WeightMeasuring Height and Weight
3.01 Understand Diagnostic and Therapeutic Services
Demonstrate the skillProvide for guided practice
Provide for independent practiceVerify student passing
39
Diagnostic SkillsDiagnostic Skills
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Diagnostic Skills:Diagnostic Skills:Measure Measure Visual AcuityVisual Acuity
• Used to measure the ability to see
• Snellen charts: used to measure distant vision
• Ishihara method tests for color
• Tonometer measures intraocular pressure
3.01 Understand Diagnostic and Therapeutic Services
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Diagnostic Skills:Diagnostic Skills:Measure Measure Visual AcuityVisual Acuity
• OD – right eye (oculus dexter)
• OS – left eye (oculus sinister)
• OU – both eyes (oculus uterque)
• Myopia – nearsightedness, defect in distant vision
• Hyperopia – farsightedness, defect in near vision
3.01 Understand Diagnostic and Therapeutic Services
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Measure Visual Acuity Measure Visual Acuity
3.01 Understand Diagnostic and Therapeutic Services
Demonstrate the skillProvide for guided practice
Provide for independent practiceVerify student passing
42
Diagnostic SkillsDiagnostic Skills