Vital Signs
Ø
Temperature (NV 36 –
37.5 C)
ü
Elderly
people are at risk of hypothermia
ü
Hard
work or strenuous exercise can increase body temperature
ü
Oral:
most accessible 2-3 mins. * 15 minutes interval after ingestion of hot or cold
drinks
ü
Rectal:
most accurate 2-3 mins.
ü
Axillary:
most safest 6-9 mins.
Ø
Pulse (NV 60-100 bpm)
ü
Wave
of blood created by contraction of the left ventricle of the heart
ü
Radial:
best site for adult
ü
Brachial:
best site for children
ü
Apical:
best site for 3 years old below
Ø
Respiration (NV
12/16-20)
Normal Breath Sound
Vesicular
|
Soft, low pitch
|
Lung periphery
|
Broncho-vesicular
|
Medium pitch
|
Larger airway blowing
|
Bronchial
|
Loud, high pitch
|
Trachea
|
Abnormal
Breath Sound
Crackles
|
Dependent lobes
|
Random, sudden reinflation of
alveoli fluids
|
Rhonchi
|
Trachea, bronchi
|
Fluids, mucus
|
Wheezes
|
All lung fields
|
Severely narrowed bronchus
|
Pleural
Friction Rub
|
Lateral lung field
|
Inflamed Pleura
|
Ø
Blood
Pressure (NV 120/80 mm/hg)
ü
This
is the force exerted by the blood against a vessel wall
ü
The
pressure rises with age.
ü
A rest
of 30 minutes is indicated before the blood pressure can be readily assessed
after stressful activity.
ü
Interval
of 30 minutes is needed after smoking or drinking caffeine.
ü
After
menopause, women generally have higher blood pressures than before.
ü
Pressure
is usually lowest early in the morning, when the metabolic rate is lowest,
then
rises throughout the day and peaks in the late afternoon or early evening
Common
Errors in Blood Pressure Assessment
Errors
|
Effect
|
Bladder cuff too narrow
|
Erroneously high
|
Bladder cuff too wide
|
Erroneously low
|
Arm unsupported
|
Erroneously high
|
Insufficient rest before the assessment
|
Erroneously high
|
Repeating assessment too quickly
|
Erroneously high
|
Cuff wrapped too loosely or unevenly
|
Erroneously low
|
Deflating cuff too quickly
|
Erroneously low systolic and high
diastolic reading
|
Deflating cuff too slowly
|
Erroneously high diastolic reading
|
Failure to use the same arm consistently
|
Inconsistent measurements
|
Arm above level of the heart
|
Erroneously low
|
Assessing immediately after a meal or while client smokes
|
Erroneously high
|
Failure to identify auscultatory gap pressure
|
Erroneously low systolic pressure and
erroneously low diastolic
|
