Differences and techniques in Vital signs, a comprehensive Tutorial

 

Vital Signs :

* Heart Rate

* Respiratory Rate

* Blood pressure

Body Temperature :

* Tympanic Route

* Axillary Route

* Rectal Route

Heart Rate

In infant & children, it is difficult to palapate pulse in an extremities , so an apical heart rate is preferred .

Preparation :

– Move clothing away from anterior chest .

– Give the infant a pacifier or other

– distraction to get a resting pulse rate .

Equipment : Stethoscope

Procedure:

1. Placed the stethoscope on the anterior chest at the 5th intercostal space in a midclavicular position .

2. Each “ lub-dub ” sound is one beat .

Count the beats for :

* 1 full minute, or

* for 30 seconds X 2

3. While auscultating the heart rate,  note if the rhythm is regular or irregular .

Heart rate Common sites used for children Over 3 years old

image

Normal Heart Rates for children at different ages

image

Respiratory Rate

Note :

Observe the abdomen rather than the chest rise and fall in an infant and young child ( The respirations are diaphragmatic, the abdomen moves more than the chest with breathing ) .

image

  • Abdominal movement in a child will be irrigular .
  • Count for breaths for 1 full minute,
  • or count for 30 seconds x 2

Normal Respiration Rates for children at different ages

image

Blood Pressure

image

Equipments needed for heart pressure

• Various sizes of B.P pressure cuff

• Electronic B . P monitor ( Doppler ultrusonography )

• Sphygmomanometer and stethoscope

Procedure  to measure Heart Pressure

With Doppler ultra sonography:

image

1. Place the cuff around the desired extremity .

2. Activate the equipment according to manufacture’s recommendations .

3. Pressure is recorded as the number over “ D “ .

With Manual sphygnomanometer

image

1. Wrap the cuff snuggly around the desired extremity .

2. Palpate for the pulse & place the stethoscope over the pulse area .

3. Close the air escape valve. Pump the cuff with the bulb until the gauge rises and no beat is auscultated. Continue pumping until the gauage rises another 20 – 30 mm .

4. Slowly release the air through the valve at 2 – 3 mm/sec while watching the falling gauge .

5. Note the number at which the first return of a pulse is heard; this is the systolic pressure .

6. Continue releasing the air to determine the diastolic pressure .

If the child is less than 12 years,

a muffled sound will be heard. Record this as the diastolic pressure .

If the child is older than 12 years,

all sound will disappear at the diastolic pressure .

7. Blood pressure is read as systolic over diastolic pressure .

image

image

Body Temperature

image

1. Tympanic Route :

* Child younger than 1 Year  Pull pinna of ear straight and down ward

* Child Older than 1 Year  Pull pinna of ear  up and back

Preparation :

image

1. Place the infant in a supine position on a flat surface . Stabilize the infant’s head & turn the infant’s head 90 degrees for easy access .

2. Position the child on parent’s or assistant’s lap with head secured .

Equipment and supplies:

Tympanic thermometer with clean disposable probe

Procedure : Child younger than 1 year

1. If using the child’s right ear, hold the thermometer in the right hand . For the child’s left ear, hold thermometer in the left hand .

2. Pull the pinna of the ear straight back and downward . Approach the ear from behind to direct the tip interiorly to make sure the thermometer tip is aimed toward the tympanic membrane.

3. Place the probe in the ear as possible to seal the canal . Turn on the scanner .

4. Leave the probe in the ear according to the manufacture’s recommendation .

5. Remove the probe, and read and record the temperature .

Procedure : Child older than 1 year

image

1.Pull the pinna up and back in children over 3 year or up and downward under that age .

2. Place the probe and continue as described in step 1 for the child younger than 1 year .

3. Read and record the temperature .

Oral Route :  Used for child over 3 Years

image

Preparation :

Assess the cooperation of the child to hold the thermometer in the mouth, under the tongue with the mouth closed .

Equipment :

An electronic nonbreakable is preferred

Procedure

image

1.Place the oral probe or an electronic thermometer ( with protective sheath ) under the tongue & have the child enclose it with the lips .

1.Turn on the scanner & follow the manufacture’s recommendations . It will sound a tone or beep when finished . Remove the probe .

2.Read and record the temperature .

Axillary Route :

image

Used for :

– Newborn

– Seizure prone

– Unconscious

– Immunosupressed

Procedure :

1.The electronic thermometer ( with protective sheath ) is held in place in the axilla, with the child’s arm pressed close to the side .

image

Procedure :

1.Turn on the scanner & follow the manufacture’s recommendations . It will sound a tone or beep when finished . Remove the probe .

2.Read and record the temperature .

Rectal Route

The rectal temperature is one degree higher than the oral temperature .

Preparation:

image

Place the infant or child on a bed or the parent’s lap; turn the older child on the side .

Equipment and supplies :

– Electronic thermometer with sheath

– Water- soluble lubricant

Procedure :

1. Cover the tip of the electronic thermometer protective sheath with a water-soluble lubricant .

2. For infant insert tip of thermometer 0.25 – 0.5 inch into rectum . For Child insert tip of thermometer  ( 1 inch = 2.5 cm ) into rectum

3. Turn on the scanner & follow the manufacture’s recommendations . It will sound a tone or beep when finished . Remove the probe .

4. Read and record the temperature .

Related posts:

Posted in Fundamental Nursing, General, Nursing Care Plans

FaceBook Page

(function(i,s,o,g,r,a,m){i[\'GoogleAnalyticsObject\']=r;i[r]=i[r]||function(){ (i[r].q=i[r].q||[]).push(arguments)},i[r].l=1*new Date();a=s.createElement(o), m=s.getElementsByTagName(o)[0];a.async=1;a.src=g;m.parentNode.insertBefore(a,m) })(window,document,\'script\',\'https://www.google-analytics.com/analytics.js\',\'ga\'); ga(\'create\', \'UA-69237529-7\', \'auto\'); ga(\'send\', \'pageview\');