Vital signs презентация

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These measurements indicate if the circulatory, pulmonary, neurological, and endocrine body systems are

functioning normally.
Because of their importance as indicators of the body’s physiological status and response to physical, environmental, and psychological stressors, they are referred to as vital signs.
Vital signs reveal sudden changes in a patient’s condition, as well as changes that occur progressively over time.
Any difference between a patient’s normal baseline measurement and present vital
signs may indicate the need for nursing therapies and necessary medical interventions.
You will frequently perform assessment of a patient’s level of comfort and pain with vital sign measurements.

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1 A nurse caring for a patient is responsible for measuring vital
signs. Nurses

analyze vital signs to interpret their significance
and make decisions about appropriate interventions.
2 Equipment must be clean, functional, properly calibrated,
and appropriate for the patient’s size, age, condition, and
characteristics.
3 A nurse knows a patient’s usual range of vital signs. His or her
usual values may differ from the acceptable range for that age
or physical state. They serve as a baseline for comparison with
later findings; thus you detect changes in condition over time.
4 A nurse knows a patient’s medical history, therapies, and prescribed
medications. Some illnesses or treatments cause predictable
vital sign changes. Most medications affect at least one of
the vital signs.

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5 Control or minimize environmental factors that affect vital
signs. For example, assessing the

patient’s temperature in a
warm, humid room may yield a value that is not a true indicator
of the patient’s condition.
6 Use an organized, systematic (step-by-step) approach when
taking vital signs ensures accuracy of findings.
7 Based on the patient’s condition, collaborate with the health
care provider to decide the minimum frequency of vital sign
assessment for each patient. Following surgery or treatment
intervention, measure vital signs more frequently to detect complications.
In a clinic or outpatient setting take vital signs before the health care provider examines the patient and after any invasive procedures. As a patient’s physical condition worsens, it is important to monitor the vital signs as often as every 5 to
15 minutes.
You are responsible for judging whether more frequent assessments are necessary.

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Its main job is to pump blood to different body parts so that

oxygen and other vital nutrients will be transported to cells, tissues, organs, and other body systems.
Normally, a heartbeat has two sounds: “lub” and “dub”. A lub sound is created when the upper chambers of your heart contract to squeeze the blood down to your ventricles.
This, in turn, causes the lower chambers of your heart to contract pushing blood upward into the aorta (largest artery), resulting in a dub sound.
The blood from each contraction of your heart creates a bulge in the artery. This bulge is the pulse you feel.

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The pulse can be felt anywhere an artery close to your skin such

as:
Your wrist (radial)
Inner part of your elbow (brachial)
Side of your throat (carotid)
Temple (temporal)
Groin (femoral)
Back of your knee (popliteal)
Inner part of your ankle joint (posterior tibial)
Foot (dorsalis pedis)
Your pulse rate is exactly equal to your heartbeat because the contractions that your heart creates increase the pressure within your arteries that lead to a palpable pulse. Therefore, checking for your pulse rate is a direct measure of your heart rate.

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For trained athletes and people who are physically active, a heart rate lower

than 60 beats per minute is normal. If you have low activity levels and your heart rate is abnormally low, this may indicate an underlying problem.
The same goes for a resting heart rate above normal.

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In order to palpate for a radial pulse, follow these steps:
1. Turn your

one hand over so that your palm is facing upwards. Use your non-dominant hand.
2. Use your free hand to place your point and middle finger gently below your wrist about an inch along from the base of the thumb. Never use your thumb to check for a pulse because it has its own pulse that you may feel, resulting in an inaccurate result.
3. Adjust your point and middle finger until you feel a strong pulse. Do not put too much pressure on your radial artery as it can impede blood flow.
4. Using a watch or a digital timer, count your pulse for one minute. Another way to do this is to count the number of beats for 15 seconds and then multiply it by 4 to get your total beats in a minute. However, this method is not recommended for people with underlying heart disease because the pattern of their pulses might be different (there might be an additional pulse in the first 15 seconds and it can fade in the next 15 seconds). Therefore, counting the pulse for a full minute is recommended in people with heart disease.

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In adults, the normal respiratory rate range from 10 to 20 breaths per

minute while it can go as high as 30 to 60 breaths per minute in younger children.

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If one hundred hemoglobin molecules are only carrying 200 oxygen molecules, then the

oxygen saturation is only 50%.

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In healthy adults and children, normal oxygen saturation ranges from 95% to 100%.

For people with abnormally low oxygen saturation levels, additional oxygen may be administered via nasal cannula or facemask.
Oxygen saturation levels are dependent upon several factors such as the following:
Ability of hemoglobin to carry oxygen molecules.
Gas exchange in the lungs.
Oxygen availability.
The concentration of hemoglobin in red blood cells.

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For instance, the blood pressure reading is 120/80 mmHg. 120 is the systolic

reading while 80 is the diastolic reading. The ideal blood pressure for healthy adults is 120/80 mmHg.
Like all other vital signs, the blood pressure reading can be affected by activity levels, stress, diet, medications, and underlying medical conditions.

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The following are the steps in measuring blood pressure:
1. Remove air out of

the bulb of the sphygmomanometer by turning it counter-clockwise while pressing the cuff.
2. Place the cuff about 1 inch above the elbow of the person. Make sure to wrap about two-thirds of the cuff to fit the entire arm. Never place the cuff in a weak arm, wound, or an arteriovenous fistula.
3. Place the gauge of the sphygmomanometer near you so that it is at your eye level.
4. Get the stethoscope and put on the earpieces.
5. Place the flat part of the stethoscope (called diaphragm) at the brachial artery and listen for the pulse.
6. Turn the valve on the bulb of the sphygmomanometer clockwise until it will turn no further. If you hear a hissing sound, this indicates air leak or the valve is loose.
7. Inflate the cuff rapidly by squeezing the bulb repeatedly.
8. Deflate the cuff slowly by turning the valve on the bulb counter-clockwise. Let the needle on the gauge move at about a rate of 2 mm or one marking per second.
9. Listen to the 2 sounds during cuff deflation. The first sound is a clear and loud tapping sound – this is the systolic blood pressure. The second sound is the last tapping sound and is usually weak – this is the diastolic blood pressure. Check the number markings on the gauge of the sphygmomanometer as you hear these sounds and remember them.
10. Turn the valve on the bulb of the sphygmomanometer counter-clockwise all the way to expel all the air from the cuff.
11. Remove the cuff and record the blood pressure.

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The average body temperature is 36.5 to 37.5 degrees Celsius or 98.6 degrees

Fahrenheit. Certain factors such as environment, physical activity, and disease can affect normal body temperature.
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