Part Three
- Vital signs
Definition
These are the indications that the health team members are looking for through a physical examination to infer the basic functions of the body, including temperature, pulse, breathing, and blood pressure.
Spirometry
Definition :
Assessment of respiratory rate and regularity (which is the process of obtaining oxygen by the body through breathing, which is necessary to carry out its activities and get rid of carbon dioxide ).
Causes :
Follow-up of the vital functions of the patient.
Natural rates :
12-20 N / s for an adult and from 24 – 40 N / s for children.
The caretaker :
The nursing team.
Tools :
Time timer.
Steps:
1.Getting to know the patient. (Patient's name and identification bracelet )
2. Explain the procedure to the patient.
3.Prepare the tools.
4.Observance of non-spirometry after muscular exertion.
5.Placing the patient in a comfortable position is preferable half-sitting.
6.Make sure that the patient's chest movement is clear to her.
7.Note The Rise and fall of the patient's chest.
8.Each inhalation and exhalation is counted as one breath and for a full minute.
9.Notice any abnormal signs in breathing.
10.Note The Color of the patient, especially around the lips and fingernails.
11.Recording the respiratory rate in the patient's form.
12.Inform the doctor about any abnormal signs.
Oral temperature measurement
Definition :
Temperature is a number that indicates the state of the body in terms of hot and cold.
Causes :
Follow-up of the vital functions of the patient.
Natural rates :
35.5 - 37.5 degrees Celsius.
The caretaker :
The nursing team.
Tools :
Mercury thermometer-alcohol-gauze swab-time timer.
Steps: :-
1. Getting to know the patient. (Patient's name and identification bracelet )
2. Explain the procedure to the patient.
3. Washing hands.
4. Prepare the tools.
5. Maintain patient privacy.
6. Adjust the thermometer and move it vigorously to bring the Mercury line to 35 degrees (starting point).
7. Clean the thermometer from the mercury part from top to bottom with alcohol.
8. Place the thermometer at the viewing level to make sure it reaches the starting point.
9. Place the mercury part of the thermometer under the tongue for three minutes in the patient's mouth.
10. Extract the thermometer from the patient's mouth.
11. Clean the thermometer from bottom to top with a dry gauze pad.
12. Measurement reading record the thermometer reading with the temperature recording model.
13. Move the thermometer vigorously so that the mercury level decreases.
14. Clean the mercury part thermometer from top to bottom with soapy water, dry and disinfect with alcohol.
15. Place the thermometer in the bowl intended for it.
16. Washing hands.
17. Reassure the patient.
18. Register any emergency signs.
Temperature measurement by armpit
Definition :
Temperature is a number that indicates the state of the body in terms of hot and cold.
Causes :
Follow-up of the vital functions of the patient.
Natural rates :
34.7-37.3 degrees Celsius.
The caretaker :
The nursing team.
Tools :
Mercury thermometer-alcohol-gauze swab-time timer.
Steps:
1. Getting to know the patient. (Patient's name and identification bracelet )
2. Explain the procedure to the patient.
3. Washing hands.
4. Prepare the tools.
5. Maintain patient privacy.
6. Adjust the thermometer and move it vigorously to bring the Mercury line to 35 degrees (starting point).
7. Clean the thermometer from the mercury part from top to bottom with alcohol.
8. Place the thermometer at the viewing level to make sure it reaches the starting point.
9. Place the mercury part with a thermometer under the armpit, taking into account that this place is dry.For (five minutes).
10. Extract the thermometer from the patient's mouth.
11. Clean the thermometer from the bottom up with a dry gauze pad.
12. Measurement reading record the thermometer reading with the temperature recording model. Taking into account (an increase of half a degree when reading the thermometer) and its location.
13. Move the thermometer vigorously so that the mercury level decreases.
14. Clean the mercury part thermometer from top to bottom with soapy water, dry and disinfect with alcohol.
15. Place the thermometer in the bowl intended for it..
16. Hand washing.
17. Reassure the patient.
18. Record any emergency signs.
Measuring the temperature by the anus
Definition :
Temperature is a number that indicates the state of the body in terms of hot and cold.
Causes :
Follow-up of the vital functions of the patient.
Natural rates :
36.6 - 38.0 degrees Celsius.
The caretaker :
The nursing team.
Tools :
Mercury thermometer-alcohol-gauze swab-time timer.
Steps:
1. Getting to know the patient.
* (Patient's name and identification bracelet )
2. Explain the procedure to the patient.
3. Hand washing.
4. Prepare the tools.
5. Maintain patient privacy.
6. Adjust the thermometer and move it vigorously to bring the Mercury line to 35 degrees (starting point).
7. Clean the thermometer from the mercury part from top to bottom with alcohol.
8. Place the thermometer at the viewing level to make sure it reaches the starting point.
9. Gel was placed on the edge of the mercury segment and the thermometer was placed for a minute, taking into account that the patient was on his side.
10. Remove the thermometer and cleans from the bottom to the mercury part with a dry gauze swab.
11. Read the measurement and record the thermometer reading with the temperature recording model.
Taking into account (a half-degree decrease when reading the thermometer).
12. Move the thermometer vigorously so that the mercury level decreases.
13. Clean the mercury part thermometer from top to bottom with soapy water, dry and disinfect with alcohol.
14. Place the thermometer in the bowl intended for it.
15. Hand washing.
16. Reassure the patient.
17. Record any emergency signs.
Note: The anal measurement method is used in children and burn cases.
Pulse measurement
Definition :
The pulse is the wave generated in the arteries as a result of the contraction of the heart. The pulse can be felt by feeling the large arteries in the human body, such as the neck and wrist. (As in the attached picture)
Reasons :
Monitoring the patient's vital functions.
Normal rates:
70-100 N/Q per adult and 80-130 N/Q for children.
The person in charge:
Nursing team.
Tools :
Time timer.
Steps:
1. Getting to know the patient. (Patient's name and identification bracelet)
2. Explain the procedure to the patient.
3. Washing hands.
4. Prepare tools.
5. Choose a comfortable position for the patient.
6. Place the tip of two fingers of the hand (index and middle) on the artery (radial - carotid - femoral)
7. Using the watch with the other hand.
8. Count the pulse for one full minute. The normal pulse rate is 70-100 beats/s in an adult and 80-130 beats/s in children.
9. Recording the pulse using the vital notes form and reporting if the pulse is (fast - slow - strong - weak - irregular).
10. Reassure the patient.
11. Hand washing.
Blood pressure measurement
Definition :
Evaluating the movement of blood circulation by knowing the volume of blood, the blood returning to the heart, the extent of resistance of peripheral blood vessels, and the elasticity of the arteries.
Reasons :
Monitoring the patient's vital functions.
Normal rates:
80/110 mm/Hg.
The person in charge:
Nursing team.
Tools :
Blood pressure device and stethoscope.
Steps:
1. Getting to know the patient. (Patient's name and identification bracelet)
2. Explain the procedure to the patient.
3. Prepare tools.
4. Be careful not to measure pressure after muscular effort.
5. Place the patient in a comfortable position.
6. Maintain patient privacy.
7. Measure blood pressure before and after giving high blood pressure medications.
8. Record your blood pressure measurement directly on the form designated for that purpose.
9. Determine the type of diet (low salt and fat).
10. Note the complications that may occur to the patient (nosebleeds).