observation and recording
DESCRIPTION
OBSERVATION AND RECORDING. OBSERVATION AND RECORDING. - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/1.jpg)
OBSERVATION AND RECORDING
![Page 2: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/2.jpg)
OBSERVATION AND RECORDING The most important practical lesson that can
be given to nurses is to teach them what to observe-how to observe-what symptoms indicate improvement –what the reverse- which are of importance –which are of none-which are the evidence of neglect – and of what kind of neglect. All these are what ought to make part, and an essential part , of the training of every nurse. (Florence Nightingale 1860/1969)
![Page 3: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/3.jpg)
OBSERVATION AND RECORDING One of the most valuable qualities of a nurse is
that he/she must be observant. Observations is one of the many tools used in gathering data for planning nursing care for patients.
Observation is gathering data by using one or more of the five senses (sight, hearing, touch, smell and taste ) with an understanding of what has been detected. Without an understanding/ interpretation of what has been observed, the act of observation is useless.
![Page 4: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/4.jpg)
OBSERVATION AND RECORDING What are some of the observations you make
about a friend that gives you some information about him/her?
It is a highly developed skill that uses knowledge from the physical and social science as its basis. Thus when a nurse must have a sound understanding of normal behaviour , she will then be able to recognize an abnormal one.
nurses work with other health team members and also run shifts. (list some members of the team)
![Page 5: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/5.jpg)
OBSERVATION AND RECORDING For this reason, it is paramount that observations
made on patients are accurately communicated from the nurse who made the observation to other members of staff. On account of this, observations made are written for keeping as records.
records are written documents of events or proceedings. Health records are formal, legal and confidential documents that should be accessible only to the members of the health team involved in the patient’s care to use and deliver effective health care to the patient.
![Page 6: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/6.jpg)
OBSERVATION AND RECORDING Records from observations should be
Factual – state exactly what has been observed and devoid of words like “ it appears , it seems, as if …” ; record exactly what was observed.
Complete – contain the important facts that should be known for effective planning. E.g. the correct unit of measurement (mg, g, ml, Fahrenheit (oF), oC ) medication orders-dose, frequency and duration of administration, review dates, types of surgery, etc.
![Page 7: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/7.jpg)
OBSERVATION AND RECORDING Accurate – use the right instrument,
gadgets, procedures and observe the precautions necessary to get correct results. Records should be free from mistakes and other errors as much as possible.
Relevant/ Appropriate – record only information that has a bearing on the issue at stake. The nurse should use his/her knowledge and discretions to sieve relevant information from the irrelevant ones
![Page 8: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/8.jpg)
OBSERVATION AND RECORDING Current – observations should be recorded
immediately with date and time as delay in recording can lead to omissions resulting in denial of the needed care to the client or commissions that may be detrimental. Recording observations instantly keeps it current and up to date.
Organized–chronological recording of observations make the records meaningful and also makes interpretation easier.
![Page 9: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/9.jpg)
OBSERVATION AND RECORDING Confidential – the records of the patient should be
made accessible only to health care team members who need it to care for him/her.
Standard – records from observations should contain only standard and acceptable format and terminologies to avoid misinterpretation.
Why should we keep record of observations? For effective communication among members of
the health team for continuity of care.
![Page 10: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/10.jpg)
OBSERVATION AND RECORDING To avoid duplication of effort. For research purposes To serve as a legal document For auditing and peer review of health
institutions For education purposes.
What do we observe in our patients/clients?
![Page 11: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/11.jpg)
OBSERVATION AND RECORDING Vital signs Level of consciousness Amount of fluids input and output Blood sugar level Appearance of the client Activity level of the client Mental state of the patient Nutritional status of the client Facial expression Gestures Effects of medications Etc.
![Page 12: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/12.jpg)
OBSERVATION AND RECORDING Though the senses are used in
observation, there are pieces of instruments that aid in the procedure E.g.
The thermometer The sphygmomanometer Stethoscope The glucometer
find the rest for our next meeting
![Page 13: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/13.jpg)
observation and recording of vital signs
Vital signs are physiological data that enables health care workers to monitor the functioning of the body. The vital signs –temperature, pulse, respiration and blood pressure – reflect changes in body function that otherwise might not be observed.
since vital signs also known as cardinal signs reflect changes in body functions, they should not be monitored as a matter of routine but a thoughtful reflective scientific assessment.
![Page 14: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/14.jpg)
observation and recording of vital signs
When Should Vitals Signs be Checked? During admission to establish a baseline for
comparison with later readings
When there is a sudden change in a client/ patient’s condition or patient reports symptoms e.g. fainting, palpitation, dizziness etc.
As a routine matter of routine in a health facility
Before and after surgery/invasive procedures e.g. blood transfusion, delivery, etc.
![Page 15: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/15.jpg)
observation and recording of vital signs
Before and after administration of medications that can affect the cardiovascular and or the respiratory system
According to nursing or medical order for provision of individualized care.
before and after nursing interventions that could affect the vital signs e.g. ambulating a patient who had been on bed rest for long.
When client reports some symptoms
![Page 16: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/16.jpg)
observation and recording of vital signs
Factors influencing vital signs1. Age2. Sex3. Race4. Geographical location/environment5. Lifestyle6. Disease conditions (thyrotoxicosis)7. Medication e.g. Paracetamol
![Page 17: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/17.jpg)
VITAL SIGNS
Vital signs consist of : Temperature Pulse Respiration Blood pressureIn some institutions assessment of the level
of ; Oxygen saturation Pain level Consciousness level, are added.
![Page 18: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/18.jpg)
VITAL SIGNS
Vital signs are checked to monitor the functions of the body. They reflect changes in function that otherwise might not be observed.
Vital signs must be looked at in total not individually/singly or as different entities to achieve the above
![Page 19: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/19.jpg)
VITAL SIGNS
Temperature: It is the degree of hotness or coldness measured against a standard scale. It reflects the balance between heat production and heat loss.
The standard scales commonly used are: the centigrade/degrees Celsius (OC) the Fahrenheit scale (OF)
Temperature checked in one scale can be converted into the other
![Page 20: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/20.jpg)
VITAL SIGNS
To convert temperature checked in centigrade (OC) to Fahrenheit (OF), OF = ( OC x 9/5) + 32 OC = (OF - 32) x 5/9
Two (2) kinds of body temperature are:
The core body temperature and The surface body temperature.
![Page 21: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/21.jpg)
VITAL SIGNS
Core temperature refers to the temperature of the deep tissues of the body as in the abdominal cavity, thoracic cavity, the cranium etc. It is relatively constant
Surface temperature is the temperature of the skin, the subcutaneous tissue and fat; it rises and fall in response to the environment.
![Page 22: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/22.jpg)
VITAL SIGNS
Factors influencing vital signs1. Age2. Sex3. Race4. Geographical location/environment5. activity6. Disease conditions (thyrotoxicosis)7. Medication
![Page 23: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/23.jpg)
VITAL SIGNS ALTERATIONS IN BODY TEMPERATURE The normal body temperature is a range
between 36.2 OC – 37.2 OC. There are basically two main alterations in
body in body temperatures: Hyperthermia; Temperatures above the
normal range (pyrexia/fever) Hypothermia; Temperatures below the
normal range Temperatures below or above the normal
range needs interventions to restore it.
![Page 24: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/24.jpg)
VITAL SIGNS
Readings may be: 1. Sub normal <36.2°C 2. Normal 36.2°C - 37.2°C 3. Pyrexia > 37.6°C - Mild (low) pyrexia 37.6 °C- 38.3ºC
- Moderate pyrexia 38.4°C - 39.4°C - High pyrexia 39.5°C - 40.0°C
- Hyperpyrexia > 40°C
![Page 25: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/25.jpg)
VITAL SIGNS
Checking and recording of Temperature This refers to the use of instruments to
estimate the degree of hotness or coldness of the body.
Thermometers are used to check temperature.
There are many types of thermometers; the one used for checking body temperature is the clinical thermometer
![Page 26: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/26.jpg)
OBSERVATION AND RECORDING OF VITAL SIGNS
Electronic thermometers
Mercury in glass thermometers
Chemical dot disposable thermometers
Electronic Chemical
![Page 27: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/27.jpg)
VITAL SIGNS
Infrared thermometer (electronic)
Mercury in glass thermometer (chemical)
![Page 28: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/28.jpg)
VITAL SIGNS
Skin thermometer (chemical)
Digital thermometer
![Page 29: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/29.jpg)
VITAL SIGNSSites for Checking Surface Temperature
Mouth Axilla groin Rectum Ear Skin (forehead)NB: rectal temperature is 0.5°C higher than
oral; axillary and tympanic temperatures are 0.5°C lower than oral temperatures
![Page 30: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/30.jpg)
VITAL SIGNSChecking and Recording of Temperature
Requirements; A clinical thermometer A gallipot containing clean cotton wool swabs A receiver for used swabs A gallipot containing clean water for rinsing the
thermometer (mercury in glass) Lubricant (for rectal thermometer) Temperature chart and pens (usually red and blue) A watch with second hand
![Page 31: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/31.jpg)
VITAL SIGNSThe Procedure of Taking Temperature in
the Axilla (steps using mercury in glass thermometer)
Explain procedure to the patient Provide privacy Take temperature tray to the patient’s side Make patient comfortable in a position that
can enable you work (either sitting or lying) Take the thermometer, dry with cotton wool
swab from the bulb towards the stem
![Page 32: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/32.jpg)
VITAL SIGNS Shake mercury thermometer till mercury
falls below 35 OC. Raise arm of client away from torso, inspect
for lesion and if none, dry axilla by cleaning with dry cotton and discard swab.
Insert the thermometer in the axilla and lower the arm making sure the bulb is in between the skin folds (of the axilla) and place arm across patient’s chest.
leave the thermometer in situ for three (3) minutes or as indicated on it.
![Page 33: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/33.jpg)
VITAL SIGNS Remove the thermometer and wipe from the
stem towards the bulb and check reading, holding the thermometer at an eye level
Record reading on the temperature chart, document in nurses’ note and report any abnormality to the in - charge
Thank patient and make him/her comfortable. Discard the tray Wash and dry hands Report any abnormality in the reading
appropriately.
![Page 34: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/34.jpg)
VITAL SIGNSNB: Patient must be still to prevent dislodging and breaking
of the thermometer. Site must be dry before the insertion of the thermometer The skin surfaces must completely surround the bulb of
the thermometer.
Some Contraindications for Taking Temperature in the Axilla
Boil in the axilla Fracture of the bones of the arm Wound (burns, ulcers etc.) in the axilla
![Page 35: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/35.jpg)
VITAL SIGNSThe Procedure for Taking Oral
Temperature (Steps using electronic thermometer)
Explain procedure to the patient Provide privacy Take temperature tray to the patient’s side Make patient comfortable in a position that
can enable you work (either sitting or lying) Take the thermometer, dry with cotton wool
swab from the bulb towards the stem (mercury in glass thermometer) OR
![Page 36: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/36.jpg)
VITAL SIGNS Remove the thermometer
from the container/charging unit and assemble if necessary (electronic)
Ask client to open his/her mouth; insert the thermometer gently with the probe placed in the posterior sublingual pocket lateral to the centre of the lower jaw
Ask client to hold the thermometer in place with closed lips
![Page 37: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/37.jpg)
VITAL SIGNS Leave the thermometer in situ for 3 minutes or until a
signal (beep) indicates completion and reading appears on the digital display
Remove thermometer and wipe from stem towards the bulb with a swab/discard the probe used is disposable or ***
Check the reading Record the reading on the temperature chart, indicate site
e.g. ‘OT’ Return the thermometer into it’s container/charging system Leave patient comfortable. Discard tray. Wash and dry hands Report any deviations
![Page 38: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/38.jpg)
VITAL SIGNSSome Contraindications for Taking Temperature
in the mouth Difficulty in breathing Patient who fits/convulse frequently Patients with nose packs When there is disease or surgery done in the mouth Unconscious patient Psychiatric patients.
NB: unless electronic thermometers with disposable probe are used, patients must have individual thermometers.
![Page 39: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/39.jpg)
VITAL SIGNSThe Procedure for Taking Rectal
Temperature (Steps using electronic thermometer)
Explain procedure to the patient Provide privacy Take temperature tray to the patient’s side Make patient comfortable in the Sim’s
position with upper leg flexed and expose the anal region/area.
Donn disposable gloves
![Page 40: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/40.jpg)
VITAL SIGNS Lubricate the probe of the electronic thermometer
from bulb upwards covering about 2.5cm. With non-dominant hand part patient’s buttocks to
expose the anus; let him breath slowly and relax. Insert the bulb of the rectal thermometer gently in
the direction of the umbilicus (to 3.5cm from bulb) if no resistance is met; otherwise stop the procedure.
Hold the thermometer in situ until a signal (beep) indicates completion and reading appears on the digital display
dispose off the probe used
![Page 41: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/41.jpg)
VITAL SIGNS Record the reading on the temperature
chart, indicate site e.g. ‘RT’ Return the thermometer into it’s
container/charging system Wipe the client’s anal region and discard
the tissue Leave patient comfortable. Discard tray. Wash and dry hands Report any deviations
![Page 42: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/42.jpg)
VITAL SIGNSSome Contraindications for Taking
Temperature in the rectum Diarrhoea Disease condition of the rectum e.g
haemorrhoides Rectal surgeryRectal prolapse
NB: please read and make note on taking temperature at the rest of the sites not discussed.
![Page 43: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/43.jpg)
VITAL SIGNS
PYREXIA/FEVER/HYPERTHERMIA Body temperature above the normal range
is termed pyrexia/hyperthermia/fever. A person who has fever is said to be febrile; otherwise, he is afebrile.
A very high fever of above 40OC is termed hyperpyrexia. A person is said to be spiking temperature or fever when his temperature rises rapidly from normal range to above normal then to normal within few hours.
![Page 44: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/44.jpg)
TYPES OF PYREXIAConstant- continuous elevation of temperature
which does not vary more than 1.1 °C in a day.Remittent – there are variations of more than 1.1
°C in a day but the lowest temperature does not reach normal temperature
Intermittent / hectic/ swinging- it varies from normal to subnormal to moderate or hyper pyrexia with 1-3days, there is a variation of more than 1.1 ° C between the highest and the lowest temperature and the lowest being normal or below normal . E.g. In malaria and T.B
![Page 45: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/45.jpg)
Irregular- does not fall into any clear group, it shows some characteristics of all the groups.
Inverse- highest temperature is recorded in the morning and lowest in the evening
![Page 46: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/46.jpg)
VITAL SIGNS
When nursing a client with fever, interventions should be designed to support the body’s physiologic processes, provide comfort and prevent complications.
To achieve this the patient’s vital signs should be monitored closely.
![Page 47: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/47.jpg)
VITAL SIGNS
Fever may run through the 3 stages:1. Onset/Cold/Chill Phase that is
characterized by Shivering Increased pulse rate Increased respiratory rate Cold skin with “goose-flesh” Complaints of feeling cold
![Page 48: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/48.jpg)
VITAL SIGNS
Management-nursing measure during this phase is to aimed at helping the client to reduce heat loss:
Check and record vital signs Provide extra warmth (with extra
clothing, give warm drinks; switch off fan/ac etc and close nearby
louvers, windows, doors etc
![Page 49: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/49.jpg)
VITAL SIGNS
2. Course/Hot/Plateau Phase is marked with Complaint of feeling hot Warm and dry skin Increased pulse and respiration Increased thirst Loss of appetite Drowsiness mild to moderate dehydration
![Page 50: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/50.jpg)
VITAL SIGNS
Flushed skin Restlessness, Delirium and confusion may occur Convulsion may occur especially in
children Malaise, weakness and aching of the muscles
![Page 51: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/51.jpg)
VITAL SIGNS
Management is aimed at helping the body to reduce the temperature to normal.
Monitor vital signs Remove excess blankets and extra clothing Tepid sponge patient Allow for good ventilation by opening nearby
windows, doors, louvers, switch on fans/ACs Give antipyretics (drugs that reduce
temperature
![Page 52: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/52.jpg)
VITAL SIGNS
Give cold, nourishing and refreshing fluids frequently
Provide mouth care as there may be dry mouth with coated tongue; this is to keep the mucous membranes moist and boost appetite
Reduce physical activity to reduce heat production.
![Page 53: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/53.jpg)
VITAL SIGNS
3. Termination/Flush/Fever Abatement Phase
Flushed and warm skin Sweating There may be dehydration
![Page 54: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/54.jpg)
VITAL SIGNS
Management as the body works towards reducing its core temperature, nursing activities should also aim at increasing heat loss.
Tepid sponge or Help have a refreshing shower if possible Change wet clothing Encourage more fluids to replace fluid
lost
![Page 55: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/55.jpg)
VITAL SIGNS
Hypothermia –this occurs when the body temperature is below the lower limit of the normal temperature range.
It may result from excessive heat loss from the body Inadequate heat production to counteract
heat loss Impaired function of the thermoregulatory
centre in the hypothalamus
![Page 56: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/56.jpg)
VITAL SIGNS
This may manifest as: Decreased body temperature below the
normal range Severe shivering Pale and cold skin low blood pressure decreased urinary output Drowsiness and disorientation Poor muscle coordination
![Page 57: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/57.jpg)
VITAL SIGNS
Management should be geared towards providing adequate warmth for the body.
Provide warm environment-close nearby windows/louvers/doors etc., switch off fans, ACs etc.
Provide additional clothing and remove wet clothes if any
Give warm drinks
![Page 58: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/58.jpg)
VITAL SIGNS-THE PULSE The pulse is the pressure wave due expansion
and constriction of the arteries during the cardiac cycle. It is the palpable bounding felt in the arteries as a pulsation when the heart contracts and ejects blood into the aorta.
In a healthy person, the pulse reflects the heart beat. The pulse at the periphery is called the peripheral pulse while the apical pulse is that which is located at the apex of the heart.
![Page 59: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/59.jpg)
VITAL SIGNSWhy should the pulse be checked? To assess the adequacy of blood flow to
an area To assess the rate, rhythm, volume and
tension of the pulse which reflect a health problem/disease state.
![Page 60: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/60.jpg)
VITAL SIGNS Sites for Assessing Pulse: Pulse can
be felt wherever a superficial artery runs over a bone
Site Assessment criteriaTemporal- over the temporal bone, superior and lateral to the eye
Used mainly in children and when the radial pulse is inaccessible
Carotid –bilateral; under the lower jaw in the neck along the medial edge of the stenocleido-mastoid muscle
used in infants, during shock, cardiac arrest and when other pulses are not palpable and to assess cranial circulation
Apical –left midclavicular line at the 4th- 5th intercostal space
Used to auscultate heart sounds and assess apical radial deficit
![Page 61: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/61.jpg)
VITAL SIGNSSite Assessment criteriaBrachial –at the anti-cubital fossa between grooves of biceps and triceps
Used to aucultate heart sounds and assess apical radial deficit
Radial-inner aspect of forearm on the thumb side of the wrist
Used mostly and routinely in adults to assess character of peripheral pulse
Ulna-outer aspect of forearm on finger side of the wrist
To assess circulation to ulnar side of hand.
femoral- groin, below inguinal ligaments, midpoint between symphysis pubis and the anterior superior iliac spine
to assess circulation to the legs and during cardiac arrest
Popliteal-behind the knee, at center in the popliteal fossa
To assess circulation to legs and to aucultate blood pressure
![Page 62: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/62.jpg)
VITAL SIGNSSite Assessment criteria
Posterior tibia- inner aspect of the ankle between Achilles tendon and tibia below the medial malleolus
To assess circulation to the feet
Pedal/Dorsalis pedis- over the instep, midpoint on an imaginary line from middle of ankle to interdigital space between the big and the 2nd toes
To assess circulation to the feet
NB-The radial pulse is the most commonly used as it is easily assessed with little disturbance to the patient
![Page 63: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/63.jpg)
VITAL SIGNS
Radial pulse
Pulse over the Temporal regions
Brachial pulse
![Page 64: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/64.jpg)
VITAL SIGNS
Popliteal pulse
Femoral pulse
![Page 65: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/65.jpg)
VITAL SIGNS
![Page 66: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/66.jpg)
VITAL SIGNSCharacteristics of Pulse
Rhythm –refers to the pattern of the beat, the interval between the beats; thus the regularity of the pulse. It describes how evenly the heart is beating
Volume-describes the strength; the amplitude of force exerted by the ejected blood against the arterial wall with each contraction.
![Page 67: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/67.jpg)
VITAL SIGNS Rate – obtained by counting the
number of pulsing sensation in one (1) minute. For a normal adult, the pulse rate ranges 60-100 beats per minute. (Tachycardia, bradycardia)
Tension- the “feel” of the arterial wall. If the walls are tensile, they should be felt as straight pliant and soft under the fingers; not as gritty, twisted or irregular.
![Page 68: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/68.jpg)
VITAL SIGNSFactors that influence pulse Age, Exercise Temperature Sex Drugs Emotional stress Pain Some disease conditions
![Page 69: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/69.jpg)
VITAL SIGNS When checking the pulse: The patient should be made to assume a
comfortable position Instruct patient to be still for the duration of
checking the pulse. Patients who have undertaken vigorous activity
should rest at least 30 min. before their pulse is taken.
Never check pulse using the thumb because there is pulsation in the thumb itself which can be mistaken for the patient`s pulse
![Page 70: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/70.jpg)
VITAL SIGNSAssessing the Radial Pulse Assemble the requirements for the procedure-
watch with a second hand and stethoscope if needed.
Explain procedure to patient and gain consent Provide privacy where necessary Wash and dry hands Select the pulse point (using the radial pulse) Assist client into a comfortable position with
the palm facing downwards
![Page 71: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/71.jpg)
Palpate the pulse with two or three middle fingers and count for 1minute noting the rhythm, volume and tension
Document findings Make patient comfortable and thank him Wash and dry hands
What is pulse deficit?
![Page 72: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/72.jpg)
VITAL SIGNS-RESPIRATION Respiration is a process by which there is
gaseous exchange between the atmosphere and the cells of the body; there is intake of oxygen and output of carbon dioxide.
There are two types of respiration: Internal respiration External respiration
![Page 73: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/73.jpg)
VITAL SIGNS External Respiration – This is the
interchange of oxygen and carbon dioxide in the alveoli of lungs and the pulmonary blood.
Internal Respiration – it takes place throughout the body. Internal respiration is the interchange of oxygen and carbon dioxide between the systemically circulating blood and the cells of the body tissues
![Page 74: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/74.jpg)
VITAL SIGNS Inhalation or inspiration is the intake of air
into the lungs, exhalation or expiration is the breathing out of gases from the lung into the atmosphere. Ventilation is another name for the movement of air into or out of the lungs.
Two types of breathing are usually observed; Costal/Thoracic Breathing – occurs when
the intercostal muscle (chiefly) and other accessory muscles are used to move the chest upward and outward.
![Page 75: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/75.jpg)
VITAL SIGNS Diaphragmatic/Abdominal Breathing
– this involves chiefly the contraction and the relaxation of the diaphragm observed as the movement o the abdomen. It is normally observable in children below seven years.
Normal breathing is automatic, slightly observable, effortless, regular, quiet (silent), and comfortable; neither too deep nor too shallow.
![Page 76: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/76.jpg)
VITAL SIGNSCharacteristics of Respirations 1. Rate – One inspiration and expiration is
counted as one breath. Respiration is recorded in breaths per minute or cycles per minute. Respiratory rate varies for the different age groups.
Find the normal rate for children and adults. It can also be affected by exercise, medication,
pyrexia, anxiety and altitude. Eupnoea refers to respiration that is easy with
normal rate of breath per minute that are age specific.
![Page 77: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/77.jpg)
VITAL SIGNSBradypnoea is the respiratory rate that is lower than
the normal range. Tachypnoea is the respiratory rate higher than the normal range while apnoea is the absence of breathing.
2. Depth- the depth of a person’s respiration can be established by observing the movement of the chest. It is described as either normal, deep or shallow. Usually for an adult, about 500ml of air is inhaled and exhaled. With deep respiration, a larger volume of air is breathed in and out and this demands a full expansion of the lungs. In shallow respiration, only small volume of air exchange takes place.
![Page 78: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/78.jpg)
VITAL SIGNS Hypoventilation is characterized by
shallow, slow respiration while hyperventilation is deep and rapid.
3. Rhythm – it is the regularity of both inspiration and expiration. It may be regular or irregular. Normal respiration is regular and even in rhythm.
![Page 79: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/79.jpg)
VITAL SIGNS 4. Character of Respiration refers to
those aspects of breathing which are different from the normal effortless breathing; thus the amount of effort required to breath, the sound associated with breathing and the skin colour of the patient. Orthopnoa is extreme difficulty in breathing unless sitting upright. Dyspnoea refers to difficulty in breathing with or without pain.
![Page 80: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/80.jpg)
VITAL SIGNSFactors that influence respiration Age, Exercise Temperature Drugs Emotional stress Pain Some disease conditions e.g. asthma
![Page 81: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/81.jpg)
VITAL SIGNSAssessing RespirationAssemble the requirements-watch with a second
hand, gloves if necessary Explain procedure to the patient Wash and dry hands Assist him/her to assume a comfortable positions Observe/palpate and count the respiratory rate;
place a hand against the client’s chest to feel the chest movements with breathing or place the client’s arm across the chest and observe the chest movements while supposedly taking the radial pulse.
![Page 82: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/82.jpg)
VITAL SIGNS Count the respiratory rate for 60
seconds; observing the depth, rhythm, noise or effort associated with the respiration.
Document observations (rate in breaths per minute-bpm or cycles per minute-cpm)
Make patient comfortable and thank him/her.
Assignment: find the normal respiratory rate for children and adults
![Page 83: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/83.jpg)
VITAL SIGNS-BLOOD PRESSURE
Blood Pressure is the measure of the pressure of the blood as it pulsates through the arteries. Because the blood moves in waves, there are two blood pressure measurements
Systolic Pressure- the pressure of the blood as a result of contractions of the ventricles; it is the pressure at the height of blood wave.
Diastolic Pressure- the pressure when the ventricles are at rest; it is the pressure lowest pressure and is present at all times within the arteries
![Page 84: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/84.jpg)
VITAL SIGNS
Pulse pressure is the difference between the diastolic and the systolic pressures
Depending on the client’s condition, and the resources available, blood pressure may be measured by either direct or indirect technique.
In the direct measurement of blood pressure, an intravenous catheter with an electronic sensor is inserted into an artery and the artery-transmitted pressure on an electronic display is read. It is an invasive procedure.
![Page 85: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/85.jpg)
VITAL SIGNS The indirect method- less expensive,
convenient and easier to use- is the most used; it requires the use of the sphygmomanometer and the stethoscope.
The sphygmomanometer is a device that is used to check blood pressure. It has cuff-an inflatable rubber bag (bladder) which is covered with a cloth. The bladder has two tubes; one serves as an attachment for the bulb with a valve which used to inflate and deflate the cuff. The other tube is attached to the manometer/pressure gauge
![Page 86: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/86.jpg)
VITAL SIGNS Two types of manometers (manual) are
commonly used The aneroid manometer is a calibrated dial
with a needle –like pointer that indicates the readings
The mercury manometer is a mercury filled calibrated cylinder; reading is done by looking at the meniscus at the eye level.
The electronic blood pressure apparatus eliminates the need for stethoscope as it measure and record readings on its monitor
![Page 87: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/87.jpg)
TYPES OF SPHYGMOMANOMETERS
Mercury sphygmomanometer Aneroid manometer
![Page 88: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/88.jpg)
VITAL SIGNS Dial of the aneroid manometer Bulb with valve
![Page 89: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/89.jpg)
VITAL SIGNS Electronic Sphygmomanometer
![Page 90: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/90.jpg)
VITAL SIGNSThe stethoscope is used to auscultate the
blood pressure sounds. It has an earpiece that is inserted into the ears and the chest piece made of the diaphragm and the bell.
Two noninvasive indirect methods of measuring blood pressure are
auscultatory and the Palpatory methods
![Page 91: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/91.jpg)
VITAL SIGNSSites for Checking the Blood PressureThe commonest site for blood pressure is the
upper arm over the brachial artery. However it is contraindicated in
injury or trauma to the arm, Cast or bulky bandage on the limb Surgical removal of the axilla as in breast
cancer Intravenous infusion on the arm etc. In case of the above, the popliteal artery behind
the knee on the thigh is use.
![Page 92: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/92.jpg)
VITAL SIGNSFactors that Affect Blood Pressure
Age Sex Exercise Stress drugs/medications Disease state race
![Page 93: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/93.jpg)
VITAL SIGNSProcedure for Checking Blood
PressureNB- for accuracy, the following precautions
should be considered Choose a cuff size that is the bigger the
client’s arm circumference, wider and longer cuff should be.
The arm should be stretched out with palm up; both arm and manometer should be at the level of the heart (below or above the level of the heart, BP is higher or lower respectively)
![Page 94: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/94.jpg)
VITAL SIGNS During inflation of the cuff, compress
until manometer register 30mmHg above diminished pulse point to ensure that cuff is inflated to a pressure greater than the client’s systolic pressure.
The same arm should be used consistently
Checking blood pressure immediately after meals, vigorous exercise or smoking gives inaccurate results
![Page 95: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/95.jpg)
VITAL SIGNSSteps in Checking Blood Pressure Assemble the needed items – stethoscope,
sphygmomanometer, alcohol swabs, gloves if needed, chart, pen and straight edge
Explain procedure to patient and gain consent
Assist patient into the desired position that is both comfortable and convenient for checking the BP accurately
Wash and dry hands; send equipment to the client’s side
![Page 96: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/96.jpg)
VITAL SIGNS Move clothing away to expose the upper
extremity of the arm, Position the arm at the heart level and extend
arm with palm turned upwards Locate the brachial artery in the anticubital
space Apply a totally deflated cuff smoothly over arm
about 2.5cm above the anticubital space with the center of the cuff over the brachial artery
In case of mercury manometer, it should be placed vertically at heart level
![Page 97: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/97.jpg)
VITALS SIGNS Palpate the radial artery, turn valve clockwise to
close and compress bulb to inflate cuff to 30mmHg above the point where palpated pulse disappears
Insert earpiece into the ears and let diaphragm hang loosely
Relocate the brachial pulse with the non-dominant hand and place the bell or diaphragm directly on it but not in contact with the cuff
With the dominant hand, slowly release valve (deflating cuff) and letting the mercury fall at 2-3mmHg per second
![Page 98: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/98.jpg)
Checking the blood pressure
![Page 99: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/99.jpg)
VITAL SIGNS Listen for the Korotkoff’s sound while
noting the manometer reading – a faint tapping sound which appears and increase in intensity is the systolic reading and the abrupt distinctive muffled sounds indicate the diastolic pressure.
After the above sounds are heard, completely and rapidly deflate the cuff
Remove the cuff and completely wait for at least 2 minutes before taking the another reading.
![Page 100: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/100.jpg)
VITAL SIGNS Inform the client of the findings and
record ( the result in millimeters of mercury-mmHg)
Make client comfortable and replace displaced clothing
Dispose equipment appropriately Wash and dry hands, document and
report any abnormality to the in-charge.
![Page 101: OBSERVATION AND RECORDING](https://reader036.vdocuments.mx/reader036/viewer/2022062501/568166f9550346895ddb5a1f/html5/thumbnails/101.jpg)
VITAL SIGNS
QUESTIONS OR COMMENTS?