VITAL SIGNS

Temperature

1. Oral

- Most accessible and convenient

- Normal value: 37 o C – 98.6 o F

- 2 – 3 minutes

2. Rectal

- Most reliable

- Normal value: 37.7 o C – 99.6 o F

- 3 – 5 minutes

3. Axila

- Less accurate

- Normal value: 36.4 o C – 97.5 o F

- 5 – 10 minutes

4. Tympanic membrane

- Directly reflects core temperature

- Normal value: 37.7 o C – 99.9 o F

- Automatic results

CONVERSION

-       Fahrenheit to Celsius =  (F-32) x 5/9

-       Celsius to Fahrenheit =  (C x 9/5) + 32

PULSE SITE

1. Temporal             6. Femoral

2. Carotid                7. Popliteal

3. Apical                 8. Posterior tibial

4. Brachial               9. Dorsalis pedis

5. Radial

ü  When palpating for pulse use 2 – 3 fingers except when taking the apical pulse use stethoscope

ü  Apical pulse is in the 5th intercostals space

ü  Landmark is the angle of Louie

ü  4th intercostals space left mid clavicular line child apical pulse

ü  When using the stethoscope use the flat part when looking for high pitch sounds like (lung and bowel sounds) and use the bell for vascular or heart sounds

RESPIRATION

- Adult: 12 – 20 c/min

- Newborn – 30 – 60 c/min

ERRORS IN TAKING RESPIRATORY RATE

Patient Factor

ü  Insufficient rest before assessing

ü  Assessing immediately after a meal or while client smokes or has pain

Equipment Factor

ü  Stethoscope fits poorly or hearing impaired

ü  Bladder or cuff too wide

ü  Bladder or cuff too narrow

Errors in technique

ü  Arm unsupported

ü  Arm above heart level and not perpendicular to the body

ü  Cuff wrapped to loosely

ü  Deflating cuff to slowly

ü  Deflating cuff to quick

ü  Failure to identify auscultatory gap

Auscultatory gap

ü  Temporary cessation of sounds after initiation

ü  Gap of 10 – 40 mmHg

ü  Common among hypertensive

ü  Repeating assessment too quickly (wait for 2 – 3 minutes after taking again the bp, and maximum of 3 takes same arm and if still inaudible rest arm for 5 – 15 minutes)

ü  Multiple examiner using different Kortkoff sounds for diastolic readings

ü  Failure to use the same arm consistently Effects

ü  Erroneously high readings

                             False low systolic and false high diastolic

                            - False low reading

                            - False high reading

                            - Erroneously high readings

                            - Erroneously low readings

                            - False high readings

                           - False low diastolic reading

                           - False high diastolic reading

                           - False low systolic bp and diastolic bp

                           - False high systolic blood pressure, false low diastolic blood pressure 

ü  Inaccurate interpretation

ü  Inconsistent measurements

ü  For a client who’s blood pressure is to be taken for the first time, take the blood pressure of both arms

ü  Difference of blood pressure for both arms should only be 10 mm Hg

ü  Use higher value as baseline

PALPATORY SYSTOLIC PRESSURE

ü  Point of pulsation stops with the use of stethoscope

ü  Maximum pressure + 30 mmHg that is you limit when taking the blood pressure

KOROTKOFF SOUNDS

Phases

1. Characterized by a thud, thump and tapping sound

2. Swooshing, whoosing sound

3. Sound decrease in intensity when compared to Korotkoff one

4. Muffling sound

5. Disappearance of sound

      - in adults record Korotkoff 1 and Korotkoff 5 of able to hear Korotkoff 4 record also

      - in children record Korotkoff 1 and Korotkoff 4

HYPERTENSION

Average of 2 or more diastolic reading on at least 2 subsequent visits is 90 mmHg or higher or when an average of 2 or more systolic readings on at least 2 visits is higher than 140 mmHg

	SYSTOLIC	DIASTOLIC
Optimal/ Normal Above Normal Hypertension Grade 1 (Mild) Grade 2 (Moderate)              Grade 3 (Severe)	120 – 129       130 – 139 140 – 159 160 – 179 Greater than 180       Greater than 140Less 80	80 – 84 85 – 89 90 – 99 100 – 109 Greater than 110        Less 90

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Posted in: Fundamentals of Nursing