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definition of nursing vital signs
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| nursing vital signs |
The definition of nursing vital signs importance of certain parameters in medical practice is such that they cannot be overestimated. Accurate measurement of their values is so vital to the management of the patient that they are called Vital Signs.
The following parameters make up the nursing vital signs
The importance of certain parameters in medical practice is such that they cannot be overestimated.
- Temperature
- Respiration
- Pulse
- Blood Pressure
TEMPERATURE
The temperature is a state of hotness or coldness of a body. The instrument used to measure temperature is called a Thermometer. This instrument functions on the principle that substances expand on heating and contract on cooling that work together with most nursing vital signs
MERCURY: This is the material commonly used in thermometers due to its numerous advantages. some of these advantages include:
(A) High boiling and low freezing pointer.
(B) It is opaque and its level can be easily read in a transparent glass tube.
(C) It is a good conductor of heat and rapidly reaches the temperature of any substance under test.
THE SCALES OF THE THERMOMETER: is most commonly used are the no centigrade and the Fahrenheit scales. Another scale called the Reaumur is no longer used in our environment. Here too theу centigrade scale is most popular and generally, the world is going centigrade. It should be noted that the upper and lower points of these scales correspond to the normal atmospheric pressure.
The temperature of the human being remains almost constant. However, a slight variation of about 0.5C may occur in the day. The highest temperature occurs between 5 8 p.m8p.m and the lowest between 2 and 6 a.m. The average body temperature is 36.9°C or 98.4°F
- Subnormal Temperature = 35 to 36.2°C
- Normal Temperature = 36.3 to 36.9°C
- Pyrexia = 37.2 C to 40°C
- Hyperpyrexia = over 40°C
Example of nursing vital signs: 50°C = (50 x 9/5)+32 = 122°The nurse must learners how to convert from one scale to another as she does not know where work can carry here To convert from centigradeFahrenheitheit multiple by 9/5 and are To convert fFahrenheitheit to centigrade subtract 32 an multiple by 5/9. Example: 212° F = (212-32)5/9 = 180 x 5/9 = 10 C. The details of how the constant figures were arrived at are Some thermometers are not commonly used especially in plate hospitals but which the nurse need know given in this book about. These are the bath Thermometer used to measure the temperature of the water the patient will batLotionotio
Thermometer to measure the temperature of Lotions before applying them .o patients; Wall Thermometer to measure the atmospheric temperature of the hospital. But by far the commonest and most popular Thermometer in use in the hospital is the Clinica Thermometer
THE CLINICAL THERMOMETER: it differs from the others in that it is self 1 registering. There is a kink at the bore of the tube just above the Bulb. Mercury that has passed above the kink cannot return to the bulb unless the thermometer is shaken. The common sites where the temperature of the body can be taken care of:
- (1) Axilla
- (2) Groin
- (3) Mouth
- (4) Rectum
The nursing vital signs temperature is considered the most accurate. It is higher than that of the month by about 0.25 C. That of the mouth is higher than that of the axilla and groin by about the same margin.
HOW TO MEASURE THE TEMPERATURE:-
1. Remove the thermometer from its container and check to ensure there is no crack. Wipe the thermometer with a spirit wall and then with a try swab.
2. See that the mercury is in the bulb; if not shake the thermometer
3. Explain the procedure to the patient.
4. Place the thermometer in position and leave it there for one-three minutes. The nurse must be with the patient
5. Remove the thermometer, read and record the content temperature, note that the patient does not move unnecessarily to break the thermometer. and place the thermometer into its container.
7. Report any abnormal temperature to the sister if the doctor is not.
PULSE
This is the wave of distension and elongation felt in an artery wall Hd It is due to the contraction of the left ventricle forcing blood into the aorta. ģently against a bone. The pulsation of an artery is felt at any point where it can be pressed In taking the pulse of a patient it is necessary to note the following
characteristics:
- The rate at which the heart is beating is calculated per minute and may be too high or too low.
- Rhythm
- OW (c) Volume or strength
- Tension on the vessel.
The rhythm denotes the regularity at which the heart is beating. ore Some beats may be irregular. The volume is associated with the strength of the wave felt at the hand. It may be small, no, normal, or bounding The vessel norm feels feel soft under the finger. It should not feel hard tortuous
In reporting, pulse, therefore, all the above parameters are mentioned Beef The tension however is not normally restored io except where the vessel is tortFor example, the pulse is 80 beats per minute, regular the and of good volume.
The pulse is influenced by age, sex, position, and the temperature of the body. The pulse rate is more in children than adults, in females than males, in motion than at rest, and when the body temperature is high than when it is normal.
The peripheral arteries where the pulse can be taken are:
3. Facial artery
5. Carotid artery.
Temporal artery
4. Femoral artery.
6. Dorsalis pedis.
The hospital sister or your Doctor will show you the position of these arteries.
HOW TO TAKE THE PULSE OF A PATIENT
1. Explain the procedure to the patient.
2. Place the first three fingers of the hand on the radial artery Beforecounting the rate it is necessary to note the rhythm, volume, and state of the artery. Count the rate for one minute.
3. Record the rate.
ABNORMAL PULSE RATE
1. Tachycardia: Increase in heart rate above 100 beats per minute. This is normally seen in high-grade fevers, anemia, thyrotoxicosis, and some heart diseases.
2. Bradycardia: Abnormally low heart rate of about 30 to 40 beats per minute. It is seen in stock states, head injury, and liver diseases.
3. Irregular Pulse: This is when the interval between the beats are uneven
4. Extra Systole: Besides the pulse being irregular there is, in addition, extra beats:
3. RESPIRATION
Respiration is the taking in oxygen and expulsion of carbon dioxide from the lung. The taking in of oxygen is called the inspiration and the Expulsion of carbon dioxide is expiration. These actions are controlled by the respiratory center in the medulla oblongata. As respiration is taking place, the chest wall steadily rises and falls. This movement corresponds with the rate of respiration and that is what the nurse must count and record as a nursing vital signs
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| nursing vital signs |
Normally, respiration should be regular, quiet, rhythmical, and neither be too deep nor too shallow. Check any degree of discomfort. The normal respiratory rate of an adult is between 14 and 18 per minute. It is influenced by age, sex, and position.
Naturally, the rate is higher in children and in females. It is also increased inactivity, excitement, and where there is sudden chilling in the body. The rate decreases at rest, sleep, and when one is tired or hungry. Infant: 30 to 35 per minute. One year: 24 to 30 per minute. Two to five years: 20 to 25 per minute. Adult 14 to 18 per minute.
Abnormal Respiration
1. Stridor:- Harsh whistling sound due to an obstruction in the airway.
2. Wheeze:-Result from air passing through fluid in the air passage.
3 whoop:- Long drawn-out noisy inspiration occurring after a paroxysm of coughing in whooping cough.
4. Grunting:- occur at the end of expiration and it is common in pneumonia.
5. Dyspnea:- Difficulty in breathing.
6. Orthopnoea:- Difficultly breathing when the patient is lying down.
BLOOD PRESSURE
The normal blood pressure as defined by the World Health Organization (WHO) is 160/90 mm Hg. Although the value has been S reduced to 140/90 mm Hg above which the person is said to beer hypertensive. The upper value is called the s/stolic blood pressure while the lower value is the diastolic blood pressure. The difference in theге value of both pressures is called Pulse Pressure and this is usually high in the elderly.
Blood pressure is affected by age; sex; mood, exercise; diet; stress; obesity, and smoking. When the blood pressure is high it is referred to as hypertension and when it is low it is called hype, tension. Both have their attendant dangerous sequels. Hypertension causes Persistent headache, blurring of vision, and stroke if untreated. Hypotension can cause weakness; easy fatiguability and collapse.
What is a sphygmomanometer?
The instrument used in measuring blood pressure is called a sphygmomanometer. It has an inflatable cuff, a rubber tubing that is connected with mercury, or an aneroid manometer.
HOW TO MEASURE BLOOD PRESSURE:-
1. Wrap the inflatable cuff around the upper arm.
2. Ensure that the rubber tubing lies on the medial aspect of the upper arm over the brachial artery.
3. Part of the nursing vital signs is to use one hand to palpate the radial artery and the other hand to inflate the cuff until the pulsation of the artery stops. Note this point as it corresponds to the systolic blood pressure. Deflate the cuff completely
4. Inflate the cuff a second time until it is just all over the level where the pulsation of the radial artery stopped before.
5. Place the diaphragm of a stethoscope on the brachial artery around the cubital fossa and deflate the cuff slowly.
The point of return of the pulsation corresponds to the systolic blood pressure. As the pressure falls further the sound becomes louder and then suddenly it becomes muffled. The point at which it muffled is the diastolic pressure. The sound as the pressure falls is called Korotkov.
SOUND.
For those who are already used to taking blood pressure, all the above steps are not necessary. All they need do is to place the diaphragm, some use the bell of the stethoscope, on the brachial artery around the cubital fossa. Inflate the cuff until the artery stops
pulsating; then note the point and inflate a little higher than that point. Deflate the cuff slowly. The point of return of the sound is taken as the systolic blood pressure. The point at which the sound muffles is the diastolic blood pressure.
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