علایم حیاتی Vital Signs

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COOTEDTGS 

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٩0208 ری مني خا وميه دحا صا قات ددجدملا" مر بونج وه اور ‎july‏ ها یکافی (906)) و60۵6 2۵00۵6 9696600۵ ا0) 

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QOBOMPOEMOE سس سس ۳ ایا سس ٩0208 5 عیمم!۲) ۹۹ 

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VITAL SIGNS INCLUDE: TEMPERATURE PULSE RESPIRATIONS BLOOD PRESSURE VITAL SIGNS MUST BE MEASURED, REPORTED, AND RECORDED ACCURATELY IF YOU ARE NOT SURE OF A MEASUREMENT, RECHECK IT 

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VITAL SIGNS ARE TAKEN: OWHEN A PERSON IS ADMITTED TO A HEALTH CARE FACILITY ' SEVERAL TIMES A DAY FOR HOSPITALIZED PATIENTS ۲ BEFORE AND AFTER SURGERY ‘ AFTER SOME NURSING PROCEDURES ‘ BEFORE MEDICATIONS ARE GIVEN THAT AFFECT THE RESPIRATORY OR CIRCULATORY SYSTEM ‘ WHENEVER THE PERSON COMPLAINS OF PAIN, SHORTNESS OF BREATH, RAPID HEART RATE, OR NOT FEELING WELL ‘ WITH THE PERSON AT REST IN A LYING OR SITTING POSITION 

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Factors That Affect Vital Signs 2 WOEES 5 CHOMOOG - GOBER, EEGR, BOXIETY, CHAD 5 EXEROIEE GOO COMOTDY همه و ۲ 0 BD EOOAROOOEOT - OGOMLER 2 COO GOO FLO KTOKE 2 MeMCHeMOoS MOE OF OBY ~ |W ME DOROUE, | 10 TLE GENEROOCHIEOCOWE 2 @owe 8 CLOVE 10 ODE O1POL GIGO OL COOGE © CLBOGE 10 PLE OTWERG 

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REPORT THE VITAL SIGNS TO THE NURSE IF: 0 ANY VITAL SIGN IS CHANGED FROM A PREVIOUS MEASUREMENT 0 VITAL SIGNS ARE ABOVE THE NORMAL RANGE 0 VITAL SIGNS ARE BELOW THE NORMAL RANGE 

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REPORTING AND RECORDING VITAL SIGNS *٠ DOOY GGEOC1IES HOOE TEODP CBOPROG OR PPR BOOKE * RECORD OVPBL CIGD DEBGOREDEDNG GG GOOD BG 0۵841 * CORRY € GOBLL DOPEBOOK 10 VOOR POCKET GO YOO COO RECORD TPHED OG YOO TOKE MLED * ABBREVIATIONS * PEOPERGTORE — “1٠١ * ۳0,۵6 - * RECPIRGMODG - * GLOOM PREGGORE - 0 

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TEMPERATURE MEASUREMENT SITES + MLO DOOM — OROL 0 PALO RCOTOOD — KOOTOL 5 PALE OXWLO (ODOGRORO) = OXALLORY ۰ ۳۳۷۵ 00۸-0 © D8 OOO OLGO WHOS MLO PEOPOROL GAPE - POROWVOOO + MOOT PEHPEROPORGS ORE POKCO OROLLY + REOPOL PEODPEROTORES ORE PUG OOGP ۵ * OXALORY PEOPEROPORGS OK PLB LEGGT O 

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BOOY TEODPEROTORG ‎by the boy‏ بسا ما له لسلسم متا مها وله جما روا - سوت مقر تسا ‏راجت گنت ‎by Renew‏ له ملس تسا ‎ght by adh‏ از اقزایش متاپولیسم سلولی اسمت. ‎proven):‏ اه امسم) سا مسر ‏مرس - ‎ 

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تب عم ۵۱ ۱۳۱۸۳ * TEMPERATURE—the measurement of heat in the body ° FEVER— the measurement of heat in the body that is above normal for the individual 

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CODY TEDPEROTORE poker bk paces Dreckeos 6 - 5 سس مم6 - 6 ساسا ‎Perspective‏ Obi reckeoy Aernkacher تست ام مسب | واه همطل وق ‎Cheers‏ Pereyra 96*0 Oored 98 -99,9°0 prema | ok Pever ٩0-90 و 56*0 اد بلاج مها ان سس 

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TYPES OF THERMOMETERS GLASS THERMOMETER A SMALL HOLLOW GLASS TUBE THAT CONTAINS MERCURY OR A MERCURY-FREE SUBSTANCE IN A BULB AT ONE END.WHEN HEATED THE MERCURY RISES IN THE TUBE ‎Oral thermometer‏ یرت ‎ ‎ ‎ ‎ ‎Pear - shaped tip 

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TYPES OF THERMOMETERS 

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DIGITAL THERMOMETER USE A DISPOSABLE SHEATH DISPOSABLE ORAL THERMOMETER Sta ie 

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TYMPANIC THERMOMETER © MEASURES THE TEMPERATURE IN THE TYMPANIC MEMBRANE (EARDRUM) O 3 SECONDS INFANTS - PULL THE EAR STRAIGHT BACK ADULTS AND CHILDREN OVER ONE YEAR - PULL THE EAR UP AND BACK ma 0 

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TAKING AN ORAL TEMPERATURE GLASS THERMOMETER 0 RINSE WITH COLD WATER ~ CHECK THE THERMOMETER FOR BREAKS, AND CHIPS. ©SHAKE DOWN THE THERMOMETER SO THE MERCURY IS BELOW THE LINES AND NUMBERS PLACE A DISPOSABLE COVER ON THE THERMOMETER PLACE THE THERMOMETER UNDER THE PERSON’S TONGUE LEAVE THE THERMOMETER IN PLACE FOR 2 - 3 MINUTES. | IF THE PERSON HAS BEEN EATING, DRINKING, OR 

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READING A THERMOMETER <————— Stem Bulb 98.6 94.2 94.4 ‎Mercury Column‏ وم جه ودف جيه ‎S533 8883‏ ‎94 96 ۱ 98 100 102 

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ORAL TEMPERATURE * Accessible * Dependable * Accurate * Convenient 

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GUIDELINES FOR TAKING AN ORAL TEMPERATURE DO NOT TAKE AN ORAL TEMPERATURE ON: 1 AN INFANT OR YOUNG CHILD ( UNDER AGE 6) ° AN UNCONSCIOUS PATIENT A PATIENT THAT HAS HAD ORAL SURGERY OR AN INJURY TO THE FACE, NECK, NOSE, OR MOUTH | A PERSON RECEIVING OXYGEN 0 A PATIENT WITH A NASOGASTRIC TUBE IN PLACE ۲ ۸ PATIENT WHO IS CONFUSED OR RESTLESS A PATIENT WHO IS PARALYZED ON ONE SIDE OF THE BODY | HAS A HISTORY OF SEIZURES UA PATIENT WHO BREATHES THROUGH THE MOUTH 

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TAKING A RECTAL TEMPERATURE | LUBRICATE THE THERMOMETER BEFORE INSERTING INTO THE RECTUM PLACE THE PERSON IN A SIDE-LYING POSITION « INSERT THE THERMOMETER 1 INCH INTO THE RECTUM " HOLD THE THERMOMETER IN PLACE FOR 2 MINUTES | REMOVE THE DISPOSABLE COVER AND READ THE THERMOMETER 

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RECTAL TEMPERATURE * Oost retiable * DOGT ket 

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GUIDELINES FOR TAKING A RECTAL TEMPERATURE DO NOT TAKE A RECTAL TEMPERATURE ON: ‘A PERSON WHO HAS HAD RECTAL SURGERY OR RECTAL INJURY IF THE PERSON HAS DIARRHEA | IF THE PERSON IS CONFUSED OR AGITATED | IF THE PERSON HAS HEART DISEASE ( STIMULATES THE VAGUS NERVE WHICH SLOWS THE HEART RATE ) 

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AXILLARY TEMPERATURE * Gate a ۰ ‏نیم‎ ۱ ۱ co) * neh cer a 

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TYMPANIC TEMPERATURE Non-invasive Safe Accurate Disadvantages... — Excessive cerumen — Improper technique 

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(XAILLBRY PEDPEROTORE AIDPORTOON POAIDNA "۱,۶۶ ۳/۵۵۵ CB ‏ت ی‎ PREC OP xX PERGPIROMOD Oot ‏لاس لس‎ Por دمجا روا کت حور Osed wheo casat yet ort ۳ ۳۵ Leave ta place 10 ‏مه‎ Placement for axillary temperature assessment. * ‏رارا/()‎ OOGT 

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ORAL TEMPERATURES * Wait 15-30 minutes after eating, drinking, chewing gum or smoking If mouth breather-do not take orally Leave in place 2-4 minutes with glass thermometer 

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PYOROOIC 122 be sucvel sic (مصلسی) عى ود ‎wheo ot‏ وان back ‎oP ear dow & bark‏ مر ‎0 readies wil te ۶ Dust drevt probe taward TO ‎* Polo testeucticcs * Keep phrged ia ood oot ‎۰ ‏رامج()‎ prePerned wethod * dats —pull pier oP ear up & ‎۰ ‏لا‎ veder Op/o-pull 

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RECTOL TEDPEROTODREG * DOG ‏چیه‎ * OOGT kok ‏تسوا‎ ‎iu place Rectal tharmometer insertion, ‏عمجاو دحوو وكا‎ while rectal ict 

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NURSING DIAGNOSIS Hyperthermia> 100.4F Hypothermia <96.8F Risk for altered body temperature Ineffective Thermoregulation 

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ا ۹ fppticom 

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Pulse * Pulse- is the palpable bounding of the blood noted at various points on the body. It is an indicator of circulator 

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Pulse Sites Radial Ulnar Femoral Popliteal Posterior Tibial * Temporal * Carotid * Apical * Brachial * Dorsalsis Pedis (Pedal) * Radial and Weal are most on pulse 

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Temporal 2 ‏م‎ Carotid ۸ Brachial Artery Radial ۸ Femoral Artery Popliteal Artery Popliteal Artery {Behind the Knea) (Behind the Knee) Dorsalis Pedis Arery (Pedal Pulse) 

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PULSE RANGES RANGE 90400 60-400 (CO vr ‏زاجعا‎ ‎xthteti) 490-0 400-90 (usries wi aye) AGE ELOERLY (8G+) 06 00 0000 O-CF ۵ 0 4 020001 -0 06 0 

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Feel over BONY area DO NOT use thumb Use 2-3 fingers DO NOT squeeze Count 30 seconds if regular x 2 Note Rate, Rhythm, Quality If irregular, count for 1 full minute or take apical pulse for 1 minute. 

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٠ ۳60۱۱۲۵۶ 2 ۵5 ٠ 1 nurse counts apical heart rate ٠ 1 nurse counts radial pulse * BOTH count during the same 60 seconds * 1nurse acts as timekeeper for both nurses 

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COUNTING A PULSE WE USUALLY COUNT A PULSE FOR 30 SECONDS AND MULTIPLY THE NUMBER TIMES 2 TO GET THE PULSE RATE FOR 1 MINUTE WE NOTE THE RHYTHM (PATTERN) OF THE HEART BEAT - IF THE HEART BEAT IS IRREGULAR WE COUNT THE PULSE FOR A FULL MINUTE WE ALSO OBSERVE THE FORCE (STRENGTH) OF THE HEARTBEAT. DOES THE PULSE FEEL : STRONG FULL BOUNDING ‎eee: es Berea jae‏ ا ‎ 

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“ MOST COMMON SITE USED FOR TAKING A PULSE ° CAN BE TAKEN WITHOUT RADIAL PULSE PERSON Ll 0 PLACE THE FIRST TWO OR THREE FINGERS OF ONE HAND AGAINST THE RADIAL ARTERY \ THE RADIAL ARTERY IS ON THE THUMB SIDE OF THE WRIST ۳ {DO NOT USE YOURTHUMBTO |= TAKE A PERSON’S PULSE / 1 USE GENTLE PRESSURE yf vy “ COUNT THE PULSE FOR 30 ۳ SECONDS AND MULTIPLY BY TWO 

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ALWAYS CLEAN THE EARPIECES OF THE STETHOSCOPE WITH ALCOHOL BEFORE AND AFTER USE WARM THE DIAPHRAGM IN YOUR HAND BEFORE PLACING IT ON THE PERSON HOLD THE DIAPHRAGM IN PLACE OVER THE ARTERY DO NOT LET THE TUBING STRIKE AGAINST ANYTHING WHILE THE eRe ‏و‎ ee eee aa 

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APICAL PULSE TAKEN WITH A STETHOSCOPE | COUNTED BY PLACING THE STETHOSCOPE OVER THE HEART | COUNTED FOR ONE FULL MINUTE | THE HEART BEAT NORMALLY SOUNDS LIKE A LUB-DUB. EACH LUB-DUB IS COUNTED AS ONE HEARTBEAT. ' DO NOT COUNT THE LUB AS ONE HEARTBEAT AND THE DUB AS ANOTHER. | THE APICAL PULSE IS TAKEN ON rR PATIENTS WHO HAVE HEART DISEASE , AN IRREGULAR PULSE RATE, OR TAKE MEDICATIONS THAT CAN AFFECT THE HEART. 

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APICAL ۰ RADIAL PULSE _ THE APICAL AND RADIAL PULSE RATES SHOULD BE EQUAL SOMETIMES THE HEART BEAT IS NOT STRONG ENOUGH TO CREATE A PULSE IN THE RADIAL ARTERY THIS WOULD CAUSE THE RADIAL PULSE TO BE LESS THAN THE APICAL PULSE ONE PERSON COUNTS THE APICAL WHILE THE OTHER PERSON COUNTS THE RADIAL THE DIFFERENCE IN PULSES IS CALLED THE PULSE DEFICIT 

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NORMAL ADULT PULSE RATE IS - 60 TO 100 BEATS PER MIN. TACHYCARDIA - HEART RATE OVER 100 BRADYCARDIA - HEART RATE BELOW 60 REPORT ABNORMAL HEART RATES TO THE NURSE IMMEDIATELY Age Pulse Rates per Minute Birth to 4 weeks 80-180 4 weeks to 1 year 80-160. 1 to 2 years 80-130 2 to 6 years 80-120 6 to 12 years 70-110 12 years and older 60-100 

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ABNORMAL RESPIRATIONS TACHYPNEA - RESPIRATORY RATE OVER 20 BRADYPNEA - RESPIRATORY RATE BELOW 12 DYSPNEA - SHORTNESS OF BREATH - DIFFICULTY IN BREATHING APNEA - NO BREATHING HYPERVENTILATION - FAST AND DEEP RESPIRATIONS HYPOVENTILATION - SLOW AND SHALLOW RESPIRATIONS 

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Variations of Pulse Rates = = Abnormally elevated pulse rate. (above 100 beats/ min) = = Abnormally slow pulse rate (less than 60 beats / min) 

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Respirations Mechanism the body uses to exchange gases between the atmosphere, blood, and the cells. Involves three processes: Ventilation Diffusion Perfusion 

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PROCEGGE OP REGPIROMOD * EXPEROOL ۵ — oboled air eaters hua, of devi Oc posses over t7 ‏كدج تطلعوصاط‎ تا حول جوا مت هن وه وب اه لجه ون - ‎ood ore exkoled‏ امسله * IWDTEROGL REGPIROMOD — O8 canted tn bloodstreun crosses over ty body cele - 00© ‏لج‎ her wastes Prow body vels ves over to ‏ولا سا‎ 

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NORMAL RESPIRATION RANGE 0 ۹006 ELDERLY (65+) 12-20 AVERAGE ADULT 12-0 NEWBORN 30-60 0-24 HOURS INFANT 30-50 1 MONTH - 6 Months CHILDREN (varies with age) 

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ABNORMAL RESPIRATIONS *٠ TACHYPNEA - RESPIRATORY RATE OVER 20 * BRADYPNEA - RESPIRATORY RATE BELOW 12 ٠ DYSPNEA - SHORTNESS OF BREATH - DIFFICULTY IN BREATHING ٠ APNEA - NO BREATHING * HYPERVENTILATION - FAST AND DEEP RESPIRATIONS * HYPOVENTILATION - SLOW AND SHALLOW RESPIRATIONS fppticom 

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BLOOD PRESSURE THE MEASUREMENT OF THE AMOUNT OF FORCE THE BLOOD EXERTS AGAINST THE ARTERY WALLS | SYSTOLIC PRESSURE - PRESSURE EXERTED WHEN THE HEART MUSCLE IS CONTRACTING © DIASTOLIC PRESSURE - PRESSURE EXERTED WHEN THE HEART MUSCLE IS RELAXING BETWEEN BEATS BLOOD PRESSURE IS RECORDED AS A FRACTION WITH THE SYSTOLIC PRESSURE ON TOP AND THE DIASTOLIC PRESSURE ON THE BOTTOM SYSTOLIC SYSTOLIC /DIASTOLIC DIASTOLIC 120/80 BP IS MEASURED IN MM (MILLIMETERS) OF HG (MERCURY) 

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EQUIPMENT FOR BP 

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“DOPPLER” OR ELECTRONIC BP READINGS 

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ALTERNATIVE SITES 

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MEASURING BP 

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MEASURING BLOOD PRESSURE * Cuff must be appropriate size not loose stethoscope under cuff ( place cuff 1-2 inches above elbow) systolic and diastolic numbers * Cuff should be snug, * Do not put * Make mental note of 

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NORMAL BLOOD PRESSURE AVERAGE ADULT SYSTOLIC RANGE - 100 TO 140 AVERAGE ADULT DIASTOLIC RANGE - 60 TO 90 ABNORMAL BLOOD PRESSURE HYPERTENSION - MEASUREMENTS ABOVE THE NORMAL SYSTOLIC OR DIASTOLIC PRESSURES HYPOTENSION - MEASUREMENTS BELOW THE NORMAL SYSTOLIC OR DIASTOLIC PRESSURES 

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FACTORS THAT AFFECT BLOOD PRESSURE AGE - BLOOD PRESSURE INCREASES AS A PERSON GROWS OLDER. GENDER - WOMEN USUALLY HAVE LOWER BLOOD PRESSURE THAN MEN, BLOOD VOLUME - SEVERE BLEEDING LOWERS THE BLOOD PRESSURE STRESS - HEART RATE AND BLOOD PRESSURE INCREASE AS PART OF THE BODY'S RESPONSE TO STRESS N - INCREASES BLOOD PRESSURE - INCREASES HEART RATE AND BLOOD PRESSURE WEIGHT - BLOOD PRESSURE IS HIGHER IN OVERWEIGHT PERSONS ~ BLACK PERSONS GENERALLY HAVE HIGHER BLOOD PRESSURE THAN WHITE PERSONS DO A HIGH-SODIUM DIET INCREASES THE FLUID VOLUME IN THE BODY WHICH INCREASES BLOOD PRESSURE, - CAN BE TAKEN TO RAISE OR LOWER BLOOD PRESSURE POSITION - BLOOD PRESSURE IS LOWER WHEN LYING DOWN 

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TYPES OF BLOOD PRESSURE CUFFS THE PROPER NAME FOR A BLOOD PRESSURE CUFF IS SPHYGMOMANOMETER MERCURY ANEROID 

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USING BLOOD PRESSURE EQUIPMENT 

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ASSESSMENT OF BP IN BOTH ARMS Heart disease 1% time BP 5-10 mm Hg difference-use reading that is highest Difference of 10mm Hg should be reported 

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HOW and WHY BP TAKEN BY PALPATION * HOW-apply cuff over brachial artery Pump up to 20-30 points above last systolic reading Feel with 2 fingers for systolic pressure; will not feel diastolic pressure WHY- unable to hear weak BPs 

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GUIDELINES FOR MEASURING BLOOD PRESSURE © DO NOT TAKE A BLOOD PRESSURE ON AN ARM WITH AN IV, A CAST, ORA DIALYSIS SHUNT. | DO NOT TAKE A BLOOD PRESSURE ON THE SIDE THAT A PERSON HAS HAD BREAST SURGERY ON. MEASURE BLOOD PRESSURE WITH THE PERSON SITTING OR LYING. APPLY THE CUFF TO THE BARE UPPER ARM. DO NOT APPLY THE CUFF OVER CLOTHING. MAKE SURE THE CUFF IS SNUG. USE A LARGE CUFF IF NECESSARY. MAKE SURE THE ROOM IS QUIET. IF YOU DO NOT HEAR THE BLOOD PRESSURE, WAIT 30 TO 60 SECONDS AND TRY AGAIN. IF YOU STILL CAN NOT HEAR IT OR ARE UNSURE OF YOUR READINGS, HAVE THE NURSE CHECK YOUR MEASUREMENTS. 

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TLOOK YOO !