VITAL
SIGNS:
Body
temperature (T), Pulse (P), Respiration ® and Blood Pressure (BP) are the basic
signs of Life. Vital Signs are the assessment of physiological, Psychological
health of a client. The Vital signs is also called as “Cardinal
Signs”. If we say simply, TPR
BP is the vital signs. We can assess a client diagnosis with the help of TPR
BP.
Let us see what T P R & BP are
·
Body Temperature: Body Temperature is defined as the degree or
heat maintained by
the body or it is the balance between heat
produced and the heat lost in the body.
Instrument
used to check body Temperature- Clinical thermometer
Normal
Body temperature - 37˚C or 98.6˚F
Temperature can check from Oral(Mouth),Axilla and Rectum.
·
Pulse:
It is defined as the alternate expansion and recoil of an artery as the
wave of blood is
forced through it
during the contraction of the left ventricle.
Instrument used to check
Pulse- Index and Middle fingers of Hand
Normal Pulse – 70 to 80 beats /minute
·
Respiration : It is a process of taking oxygen and Giving
out carbon dioxide
Instrument used to check respiration- palms or by eyes
Normal Body temperature – 16-20 breaths /min
·
Blood pressure : It is the force exerted by the blood against
the walls of the blood vessels as the
blood flows through them. There are 2 types of blood pressure. Systolic and
Diastolic pressure. Systolic pressure is the highest degree of pressure exerted by the blood against the walls of the
blood vessels during the ventricular systole
when the ventricle is forcing the blood
into the Aorta. Normal systolic pressure in adult is 120 mm of Hg.
Diastolic pressure is the lowest pressure
that occurs when the heart is in its resting period just before the contraction
of the left ventricle. Normal diastolic pressure is 80mm of Hg.
Instrument used to check blood pressure -
Sphygmomanometer
Normal Blood pressure – 120/80 mm of Hg
Let us see how to check Vital signs (TPR
BP)
Instructions before doing Vital
Signs procedure
1. Do hand washing neatly with soap.
2. Conform that the thermometers are
properly disinfected
3. Give an explanation of procedure to the
patients.
4. Tell the patients what to do and what do
not
5. Instruct the client not to bite on the
thermometer while doing Oral temperature procedure.
6. Never leave the patient alone with a
thermometer in position.
7. Never hold the thermometer by touching
the bulb.
8. Lubricate the bulb of the rectal
thermometer before placing thermometer into the rectum.
9. Do not count the pulse if the patient is
nervous or immediately after exercise.
10. Never make the patient conscious that you are counting the
respiration.
11. Never use thumb for counting the pulse
because there is a pulse in the thumb.
Articles needed for taking TPR
:
Articles
|
Quantity
|
Purpose
|
Tray
|
1
|
To keep articles
|
thermometer
|
2-3
|
To check the temperature
|
Disinfectant bottle
|
2-3
|
To keep the thermometer
|
Jar with clean water
|
1
|
To rinse the thermometer
|
A
bowl with cotton swab
|
1
|
To wipe the thermometer
|
Kidney tray or paper bag
|
1
|
To discard the waste swabs
|
Wrist watch with sec needle
|
1
|
To check the time of procedure
|
 |
| parts of thermometer |
Procedure of taking temperature
from mouth (oral temperature
- Do a
hand washing first to prevent the cross
infections
·
Take
thermometer from disinfectant bottle
·
Rinse
it in water to clean the disinfectant lotion
·
Take
a cotton swab and wipe the thermometer from the bulb to stem of the
thermometer.
·
Check
the mercury level and shake it to minimum level.
·
Place
the thermometer under the tongue of the patient and note the time. 2 minute is
enough for checking oral temperature.
·
Check
the pulse for first minute and respiration for 2nd minute. For
checking pulse, place the client’s hand over his chest with the wrist extended
and palm downwards. Place the finger tips over the pulse point. Count the pulse
beat for one minute.
·
Keep
your hand is on same position. So that you can check the respiration easily.
Count the rise and fall of chest without the knowledge of the client. Count the
respiration for 1 minute.
·
Remove
the thermometer .wipe the thermometer with a cotton swab from stem to bulb.
·
Read
the level of mercury. Note it in a paper.
·
Keep
the thermometer in disinfectant bottle
·
Wash
hands and keep the soiled articles in place to clean them.
Procedure for
Axillary temperature
·
Keep
the thermometer in dry axilla
·
The
procedures are same. But the main difference is in oral temperature 2 minute is
enough for checking the temperature. But in axillary 5 minutes is necessary.
Procedure for
Rectal temperature
·
Keep
the thermometer in rectum .
·
The
procedures are same. But the main difference is in oral temperature 2 minute is
enough for checking the temperature. But in rectal temperature 5 minutes is
necessary. Use any lubricant for lubricating the thermometer for inserting the
thermometer to rectum.
