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VITALSIGNSPPMay 2023 Lowvision

The document provides guidelines on assessing vital signs, including blood pressure, temperature, heart rate, respiration rate, and oxygen saturation. It outlines the procedures for taking these measurements and highlights normal and abnormal ranges, as well as when to notify medical providers. Proper techniques and considerations for accurate readings are emphasized throughout the document.

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9 views24 pages

VITALSIGNSPPMay 2023 Lowvision

The document provides guidelines on assessing vital signs, including blood pressure, temperature, heart rate, respiration rate, and oxygen saturation. It outlines the procedures for taking these measurements and highlights normal and abnormal ranges, as well as when to notify medical providers. Proper techniques and considerations for accurate readings are emphasized throughout the document.

Uploaded by

diaspora.link23
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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INTRODUCTION

You may need to assess vital signs on clients in


your care.
• You need to know how to do this.
• You also need to know if results are abnormal or
should be reported to someone.
• Protocols regarding vital signs should be written
for each client.
VITAL SIGNS – how many are there?

’ Blood pressure
’ Temperature
’ Heart rate
’ Respiration rate
’ Oxygen saturation (pulse oximetry)
BLOOD
PRESSURE
TAKING A BLOOD PRESSURE

Before e takingg a blood d pressure,, payy attention n to


o the e size
e andd
placementt off the e cuff,, thee person’ss position,, andd technique..
’ Cufff size
e – iff tooo smalll the e systolicc pressuree willl be
e high..
’ Cufff placementt – ideallyy above e thee elboww overr a bare e arm..
o Mayy take e overr thinn clothing g butt thick
k clothing
g should d bee
removed.. Do o nott rolll up
p thee sleeve..
’ Bodyy position
o Crossing g legss orr sitting g withoutt a back k supportt can n cause e
higherr readings..
POSITIONING
BLOOD PRESSURE DEVICES

Blood
d pressure e cuffss thatt take
e thee
pressuree in
n the
e upperr armm (overr thee
elbow)) give
e the
e mostt accurate e resultss
whetherr taken n on
n an
n automated d
m orr manually..
system
Wristt devicess are e often
n used d on
n
someone e who o iss obese.. Wristt
readingss are
e often n falselyy elevated..
Bloodd pressure e measurementss on n the
e
fingerr are
e nott recommended d ass thee
resultss are
e quitee inaccurate..
OVER THE ELBOW BLOOD PRESSURE DEVICE
W ith
h automated d blood
d pressuree cuffs,, the
e cufff iss
inflatedd to
o the
e correctt amountt and d automaticallyy
givess the
e bloodd pressure e reading..
Withh manuall blood d pressure e cuffs,, inflatee to
o aboutt
1800 mm m Hg g and d thenn allow w too deflate e slowly..
• Listenn forr the
e pulse e overr thee brachiall arteryy
using g a stethoscope..
’ When n thee pulsee iss firstt heard,, thatt iss the
e
systolicc pressure e reading.
’ Ass the
e airr escapes,, the e sound d off thee pulse e willl
disappear.. The e pointt thatt the e sound d disappearss
iss the
e diastolicc pressure e reading..
NORMAL
AND
ABNORMAL
BLOOD
PRESSURE
READINGS
TEMPERATURE
TAKING A TEMPERATURE
’ A person should not smoke, eat, or drink
for at least 10 minutes before taking an
oral temperature as the body temperature
will be altered.
’ Document which part of the body was
used when taking a temperature.
’ Ear and rectal temperatures are one half
to one degree F higher than oral
temperatures.
’ Axillary (armpit) and forehead
temperatures are usually one half to one
degree F lower than oral temperatures.
NORMAL AND ABNORMAL TEMPERATURES
Normal 97 to 99 degrees Fahrenheit (fF)
Fever Anything over 100.4 fF
• Notify medical provider if temperature is over 103fF
• Notify medical provider if fever more than 3 consecutive days
• Notify medical provider if fever accompanied by severe sore throat
swelling, vomiting, headache, stiff neck, rash, severe cough or
shortness of breath.
o Individual protocols may differ. Follow the protocols of your agency.

Hypothermia Temperatures below 95fF


HEART
RATE
(pulse)

The pulse is the number


of times the heart beats
per minute
TAKING A PULSE
’ Using your first and second fingertips, gently
press down on the artery until you feel the pulse.
Never use your thumb as you will be feeling your
own pulse.
’ The radial pulse is located on the thumb side of
the wrist, where the wrist bends.
’ Count the heartrate for 30 seconds and multiply
by 2 to obtain the pulse which is always recorded
as beats per minute.
’ Note if the pulse is regular or irregular (rhythm).
’ Record the rate and rhythm.
NORMAL AND ABNORMAL HEART RATES
Normal 60 to 90 beats per minute (BPM)
Tachycardia Over 100 BPM
• Rate normally increases with exercise, sickness, injury, emotions.
• Seek medical attention if rate is over 130 or very irregular.
• Seek medical attention if accompanied by shortness of breath,
lightheadedness, or chest discomfort.
Bradycardia Abnormally low heart rate
• Heart rates are slower when sleeping.
• Concerning symptoms (report):
o Feeling lightheaded, dizzy, faint
o Weakness, fatigue, confusion
• Seek immediate attention if accompanied by chest pain, trouble
breathing, low blood pressure, or fainting.
RESPIRATION
RATE

Respiration rate is the number


of breaths per minute.
PROCEDURE

1. Count how many times the chest rises over a minute.


2. To get an accurate reading, do this without the person knowing it is being
done so they don’t change their breathing rate.
NORMAL & ABNORMAL BREATHING RATES
Normal 12 TO 20 Breaths per minute
• Rate increases with fever, illness, lung disease

Respiratory Seek Immediate Medical Attention if:


distress • Struggling to breath
• Pain with breathing
• Turning blue
• Irregular or very shallow breaths.
PULSE
OXIMETRY

Pulse oximetry is a non-


invasive way to monitor
the amount of oxygen in
the blood.
FALSE READINGS

’ Low blood pressure


’ Nail polish, artificial nails
’ Hypothermia (vessels constrict)
’ Motion (shivering, seizures, etc.)
’ Dark skin color
’ Dirt on hands
’ Intense light (bright sunlight,
fluorescent lights)
BLOOD OXYGEN LEVELS
Pulse Oximeter Reading

95 to 100% Normal blood oxygen levels

91 to 95% “Concerning” blood oxygen levels - monitor

Under 90% Low blood oxygen levels – notify medical provider

80 to 85% Seek Medical attention


x Brain is affected at these levels and below

80% and lower Cyanosis


SYMPTOMS OF HYPOXIA

’ Restlessness
’ Headache
’ Confusion
’ Difficulty breathing
’ Rapid heart rate
’ Rapid breathing
’ Anxiety
SYMPTOMS OF SEVERE HYPOXIA

’ Slow heartrate

’ Extreme restlessness

’ Blue skin (cyanosis)


THANK YOU

JEAN JUSTAD, MD, MEDICAL DIRECTOR, DDP

CLIPART ON ALL SLIDES FROM CLIPART-LIBRARY.COM EXCEPT:


SLIDE 5 SUNTECHMED.COM AND AINTLUKESKC.ORG/HEALTH-LIBRARY
SLIDE 6 TOPPNG.COM/FREE-IMAGE/BLOOD-PRESSURE
SLIDE 7 CLASSROOMCLIPART.COM
SLIDE 16 CLIPART.EMAIL
SLIDE 22 AND 23 MY.CLEVELANDCLINIC.ORG

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