Textbook for Nursing Assistants
Chapter 16: Vital Signs, Height, and Weight
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Vital Signs/
Height & Weight
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Objective:
• Vital signs are important indicators of health states of the
body.
• Vital signs are defined as various determinations that provide
information about the basic body conditions of the patient.
• By the end of this lesson every student will be able to define all
of the words in this Vital Signs Vocabulary.
• Students will be able to identify the medical equipment
normally used by Health Care professionals in assessing a
patients vital signs
• Students will be able to demonstrate the proper procedures to
take a set of Vital Signs on a partner and accurately
demonstrate that skill to the teacher in under 3 minutes.
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Vital Signs
• What is a vital sign?
– Vital signs are key measurements that
provide essential information about
overall health status
• What do vital signs indicate?
– A change in a vital sign may indicate a
response to illness or injury
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When Are Vital Signs Taken?
• Specified on nursing care plan or doctor’s orders
– Long-term care facility: once daily or weekly,
and as needed
– Hospital: every shift or every few hours, and
as needed
• Within the nursing assistant’s scope of practice
to take vital signs whenever he or she thinks it
is warranted
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Recording and Reporting Vital Signs
• Accuracy is important: many people rely on
these measurements to make decisions
about the person’s care
• Report an abnormal measurement
immediately
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VS Intervals
• Are taken at the beginning of each shift
–
medical /surgical floors- q8h on average
• *** anytime a change in condition is suspected
• PCU Progressive Care Unit- q4h
• *** anytime a change in condition is suspected
• ICU or any other critical care unit- q2h or as needed
• PACU- q5-15 minutes for the first hour- then q30-60
minutes as needed until patient is stable
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Body Temperature
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What Is Body Temperature?
• It is the difference between heat produced
and heat lost by the body
• Body heat is produced as a normal process
of metabolism
• Body temperature is regulated by
thermoregulatory center located in the brain
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Factors Affecting Body Temperature
• Physical or emotional stress
• Environmental temperature
• Time of the day
• Age
• Gender
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Measurement of Body Temperature
• Measured in either degrees Fahrenheit (°F) or degrees
Celsius (°C)
• Measured from
– Mouth: Oral temperature
– Rectum: Rectal temperature
– Armpit: Axillary temperature
– Ear: Aural temperature
– Forehead: Temporal temperature
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Types of Clinical Thermometers
• Glass Thermometer
• Electronic and Digital Thermometer
• Tympanic Thermometer
• Temporal Artery Thermometer
Glass Thermometers
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Normal and Abnormal Findings
• Normal body temperature ranges from
0.5°F to 1°F above or below the range
considered “normal”
• Pyrexia: increased body temperature
– A person with pyrexia is said to be
“febrile”
– The doctor may order an antipyretic
(fever-reducing) drug
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Reading
• Oral ---97.6F-99.6F or 36.5C-37.5C
• Rectal– 98.6F-100.6F or 37-38.1C
• Axillary—96.6-98.6F or 36-37C
• Tympanic—98.6 F or 37.0C
• Temporal –99.6F or 37.5C
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Do not take a rectal temperature on:
• Pt with hemorrhoids, rectal bleeding or a disease
involving the rectum
• Diarrhea
• Has had rectal surgery
• Has certain heart conditions
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Tell the Nurse
• Temp is higher than normal
• Temp is lower than normal
• You are having difficulty reading the patients
temperature
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Pulse
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What Is a Pulse?
• When the heart beats, it sends a wave, or
pulse, of blood through the arteries
• When checking the pulse, we look at the
– Pulse rate
– Pulse rhythm
•Irregular pulse rhythm is called
dysrhythmia
– Pulse amplitude
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Factors Affecting Pulse
• Physical activity (increases the body’s need
for oxygen and nutrients)
• Anger and anxiety, illness, pain, fever, and
excitement
• Certain medications
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Measuring the Pulse
• Radial Pulse: Taken by placing fingers over
the radial artery (inside of wrist)
• Apical Pulse: Taken by listening over the
apex of the heart with a stethoscope
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Apical Pulse
• Should be taken when a patient has a weak or irregular
pulse
• The pulse of choice for infants and with patients with
know heart disease
• Assess the Apical pulse by placing the stethoscope obver
the apex of the heart under the patient clothing
• Listen for ONE full minute
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Pulse
Points
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Pulse Point Assessment Video
• How to assess pulse points
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Normal and Abnormal Findings
• Tachycardia is a rapid heart rate, or a
pulse rate of more than 100 beats per
minute for an adult
• A heart rate that is slower than normal,
that is, a pulse rate of less than 60 beats
per minute is called bradycardia
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Pulse Deficit
• The difference between the apical and radial pulse
• The heart does not pump strong enough to send enough
blood through the arteries with each beat
• Heart beat is heard at the apex but not felt at the wrist
• How to:
– One person takes the apical pulse
– One person takes the radial pulse at the same time
– The difference between the 2 pulse is the pulse
deficit
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Normal Pulse Rates
• Adult
60-100 bpm
• Adolescent
60-100 bpm
• School aged children 5-12
• Preschoolers – 3-5 years old
75-110 bpm
80-120 bpm
• Toddler 1-3 years olds–
80-140 bpm
• Infant birth to 1 year
80-180 bpm
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Tell the Nurse
• Pulse is higher than normal
• Pulse is lower than normal
• Rhythm is irregular
• Pulse is weak or thready
• Difficulty taking the patients pulse
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Respiration
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Process of Respiration
• Respiration is accomplished through ventilation
• Ventilation is
– Inhalation of oxygen
– Exhalation of carbon dioxide
• When measuring respiration, we look at
– Respiratory rate
– Respiratory rhythm
– Depth of respiration
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Factors Affecting Respiration
• Physical activity
• Anxiety, pain, fear
• Fever
• Infections and diseases of the heart and
lungs
• Stroke or head injury
• Medications
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Measuring Respiration
• Respiratory rate determined by watching the
rise and fall of the person’s chest and
counting the number of breaths that occur in
either 30 seconds or 1 minute
• One breath = 1 exhalation and 1 inhalation
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Normal and Abnormal Findings
• Normal respiratory rate: Eupnea
– 16 to 20 times a minute for adult
– Higher for children and infants
• Abnormal respiratory patterns
– Tachypnea – greater than 24 bpm
– Bradypnea – less than 10 bpm
– Dyspnea- difficulty breathing
– Hyperventilation – increased rate & depth
– Hypoventilation- decreased rate & depth
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What to assess? What we look for….
• Respiratory rate= # of times a person breathes in 1
minute
• Respiratory rhythm= regularity with which the person
breathes
• Depth of respirations= quality of each breath- shallow or
deep?
• **** Listen for abnormal sounds*****
– Is the person congested
– Is the person wheezing
– Is the person gurgling
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Respiratory Rate Ranges
• Adult- 12-20/minute
• Adolescent – 15-20/minute
• School- aged – 5-12 years old–15-25/ minute
• Preschooler-3-5 years old—20-34/ minute
• Toddler– 1-3 years old—20-40/ minute
• Infant- birth – 1 year- 30-60/minute
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Measuring RR
• Patients can consciously control their RR
• Respiratory rate should be take right after you assess the
patients pulse rate
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Tell the Nurse
• RR is > 24/ minute
• RR rate is < 10-12/ minute
• RR is irregular
• Breaths are very deep or very shallow
• Patients breathing appears difficult & painful or the
patient reports pain while breathing
• Chest is not equally rising
• RR is noisy with wheezing and or congestion
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Pulse Oximetry
• Pulse oximetry is a procedure used to
measure the oxygen level (or oxygen
saturation) in the blood. It is
considered to be a noninvasive,
painless, general indicator of oxygen
delivery to the peripheral tissues (such
as the finger, earlobe, or nose).
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Pulse Oximetry
• Pulse oximetry technology uses the light absorptive
characteristics of hemoglobin & the pulsating nature of blood
flow in the arteries to aid in determining the oxygenation
status in the body
• There is a color difference between arterial hemoglobin
saturated with oxygen, which is bright red, and venous
hemoglobin without oxygen, which is darker.
• with each heartbeat there is a slight increase in the volume of
blood flowing through the arteries
• Pulse Oximetry measures the maximum amount of oxygen-rich
hemoglobin pulsating through the blood vessels
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Expected Pulse Oximetry Values
• Normal pulse oximeter readings range from 95 to 100
percent, under most circumstances
• Values under 90 percent are considered low
– Hypoxemia
• describes a lower than normal level of oxygen in
your blood.
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Pain Assessment and the PCT
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Pain Assessment
• Pain is subjective
• Pain is also multidimensional, so the clinician must
consider multiple aspects (sensory, affective, cognitive)
of the pain experience.
• the nature of the assessment varies with multiple factors
so no single approach is appropriate for all patients or
settings.
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Pain Assessment
• Onset & duration
• Location
• Quality-what does it feel like?
• Intensity- give a numeric reading
• Alleviating or exacerbating factors
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Common Assessment Tools
• Wong Baker Scale
• Numeric Scales
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Blood Pressure
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What Is Blood Pressure?
• The force that the blood exerts against the arterial
walls
• Two pressure levels
– Systolic pressure
– Diastolic pressure
• The difference between the two is pulse
pressure.
• Measured in millimeters of mercury (mm Hg) and
recorded as a fraction
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Factors Affecting Blood Pressure
• Cardiac output
• Blood volume
• Resistance to blood flow
• Age
• Gender
• Race
• Stress factors
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Measuring Blood Pressure
• Two ways of measuring:
– Manually operated
sphygmomanometer
and a stethoscope
– Automated
sphygmomanometers
Manually operated
sphygmomanometer
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Normal and Abnormal Findings
• Accepted normal ranges for the systolic
pressure are between 100 and 140 mm Hg,
and for the diastolic pressure, between 60
and 90 mm Hg
• Abnormal ranges
– Hypertension
– Hypotension
– Orthostatic hypotension
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Normal BP readings
• Adult 120/80
• Adolescent 102/80
• School aged child 100/62
• Preschooler 95/75
• Toddler 1-3 years of age 90/55
• Infant 0-12 months 73/55
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Tell the Nurse --BP
• BP is higher than normal
• BP is lower than normal
• You have difficulty measuring the patients
BP
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Orthostatic Blood Pressure
aka Postural Hypotension
• Orthostatic hypotension — also called postural
hypotension —
– is a form of low blood pressure that happens when
you stand up from sitting or lying down
– Can make you feel dizzy or lightheaded, and maybe
even faint
– Can lasting a few seconds to a few minutes after
standing
• long-lasting orthostatic hypotension can be a sign
of more-serious problems
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Orthostatic Blood Pressure
Symptoms
• Orthostatic hypotension signs and symptoms include:
• Feeling lightheaded or dizzy after standing up
• Blurry vision
• Weakness
• Fainting (syncope)
• Confusion
• Nausea
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Orthostatic Blood Pressure
Causes:
• Orthostatic or postural hypotension occurs when
something interrupts the body's natural process of
counteracting low blood pressure
• Orthostatic hypotension can be caused by many different
conditions, including:
– Dehydration. Fever, vomiting, not drinking enough
fluids, severe diarrhea and strenuous exercise with
excessive sweating can all lead to dehydration
– Heart problems. Some heart conditions that can
lead to low blood pressure include extremely low
heart rate (bradycardia), heart valve problems, heart
attack and heart failure
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Causes:
– Endocrine problems. Thyroid conditions, adrenal
insufficiency (Addison's disease), low blood sugar
(hypoglycemia) and, in some cases, diabetes can
trigger low blood pressure. Diabetes can also
damage the nerves that help send signals regulating
blood pressure.
– Nervous system disorders. Some nervous system
disorders, such as Parkinson's disease, can disrupt
your body's normal blood pressure regulation
system
– After eating meals. Some people experience low
blood pressure after eating meals (postprandial
hypotension). This condition is more common in
older adults
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Risk Factors
The risk factors for
orthostatic hypotension
include:
• Age. Orthostatic hypotension is common in those who
are age 65 and older. As your body ages, the ability of
special cells (baroreceptors) near your heart and neck
arteries to regulate blood pressure can be slowed
• Medications. People who take certain medications have
a greater risk of orthostatic hypotension. These include
medications used to treat high blood pressure or heart
disease, such as diuretics, alpha blockers, beta blockers,
calcium channel blockers, angiotensin-converting enzyme
(ACE) inhibitors and nitrates.
• Certain diseases. Some heart conditions, such as heart
valve problems, heart attack & failure, certain nervous
system disorders, such as Parkinson's disease
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Risk Factors
Continued:
• Heat exposure. Being in a hot environment can cause
you to sweat leading to dehydration
• Bed rest. If you have to stay in bed a long time
because of an illness, you may become weak. When you
try to stand up, you may experience orthostatic
hypotension.
• Pregnancy. Because your circulatory system expands
rapidly during pregnancy, blood pressure is likely to
drop. This is normal, and blood pressure usually returns
to your pre-pregnancy level after you've given birth.
• Alcohol. Drinking alcohol can increase your risk of
orthostatic hypotension.
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Complications:
• These complications include:
– Falls. Falling down as a result of fainting (syncope)
is a common complication in people with orthostatic
hypotension.
– Stroke. The swings in blood pressure when you
stand and sit as a result of orthostatic hypotension
can be a risk factor for stroke due to the reduced
blood supply to the brain.
– Cardiovascular diseases. Orthostatic hypotension
can be a risk factor for cardiovascular diseases and
complications, such as chest pain, heart failure or
heart rhythm problems
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How do you correctly measure Orthostatic
Blood Pressure:
1. Have the patient lie down for 5 minutes
2. Measure the BP and pulse rate
3. Have the patient stand
4. Repeat blood pressure and pulse rate measurements
after standing 1 and 3 minutes
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Guidelines for Taking a BP
What do you remember???
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Guidelines for taking a Patients BP
• Relax for 5 min
• Have manometer properly calibrated
• Use right cuff size & make sure it fits snug
• Never over clothing
• Never use arm with IV, mastectomy or dialysis shunt
• Never partially deflate and reinflate while taking the
reading
• Room should be QUIET so you can hear the sounds
– Korotkoff sounds
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STOP and Practice
• You are to take the BP of 6 of your classmates using the
manual method
• Then take 6 BP’s using the electronic machines
• Make sure you are using AIDET
• Properly identifying your patients
• IF you have been checked off—
– Read and outline Chapter 19 in your textbook- p.328
• Vital Signs, Height and Weight
• Complete “ What did you learn”?- p. 362
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Contraindications to Oral Temperature
Readings
• Unconscious
• Unable to close mouth
• Unable to breathe through nose
• Will bite or is biting thermometer
• Hx of seizures
• Excessive Coughing or sneezing
• Hx mouth surgery or trauma to mouth
• Receiving O2 by face mask
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What you MUST report__ TELL the RN!!
• Measurement obtained
• SOB or dyspnea
• Temp- higher or lower
• Unequal chest rise & fall
• Pulse- higher or lower
• Noise breathing-wheeze
• Irregular pulse
• High or low BP
• Weak or thready pulse
• Weight loss or gain
• RR <10 or >24 bpm
• Difficulty obtaining
measurements
• Irregular RR
• Deep or shallow
respirations
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Stop & Think
• Case Study 1
• You are assigned to take vital signs on
all the residents in the north hall of
your facility. Mrs. Tito, in room 102,
has a cast on her left arm and an IV
line in her right.
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Stop & Think
• Case Study 2
• You are taking vital signs that are routinely
done once every day for the residents on
your unit. Today, as you take Mr. Hayes
pulse, you notice that it does not feel as
strong as usual, and although his rate is
about what it always is, the rhythm is
irregular.
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Discussion Topics
• You have been delegated to obtain vitals signs for
the new admission in room 222. Your patient is an
82-year-old gentleman admitted with congestive
heart failure. He is receiving oxygen, and is restless
and unable to remain still. He has an IV in his right
arm, and because he is obese, you are not able to
feel his radial pulse.
• What will you do to obtain the most accurate
temperature and pulse for this patient, and why?
• What will you do to obtain the most accurate blood
pressure for this patient?
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Discussion Topics
• Mr. Roberts is a 50-year-old man who was involved in
an auto accident. After being treated for a head injury
in the emergency room, he is admitted to an
observation bed on your unit. You are assigned to care
for him, and are to take his vital signs every 4 hours.
– On admission his vital signs were: temperature
97.6 degrees F, pulse 84, respirations 16, and
blood pressure 140/88
–
When you take his vital signs 4 hours later, you
obtain a temperature of 97.7 degrees F, pulse 90,
respirations 18, and blood pressure 130/80
–
The second time you take his vital signs, you
obtain a temperature of 98 degrees F, a pulse of
110, respirations of 26, and blood pressure 100/60
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Discussion Topics
• What medical terms will you use to describe
the results of your first and second sets of
vital sign measurements?
• Which set of vital signs should be reported to
the nurse immediately, and what factors
may be affecting the vital sign
measurements?
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Height and Weight
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Height and Weight
• A person’s weight
– Provides insight into overall health, and
nutritional status
– Often used to calculate medication dosages
• Frequency for checking
– Height: On admission, and on transfer or
discharge
– Weight: On admission, and at regular
intervals
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Measuring Height and Weight
• Height is measured in feet (’) and inches (”) or in
centimeters (cm). Weight is measured in pounds
(lbs) or kilograms (kg)
• Ways of measurement
– Upright scale
– Chair scale
– Tape measure and sling scale
Upright Scale
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• 1 kg = 2.2 lbs
Conversions
– Kg to lbs you must multiply by 2.2
• 63 kg X 2.2 lb = 138.6 lbs
• 138.6/2.2 = 63 kg
– Lbs to kg you must divide by 2.2
• 1 cm= 0.39 inch
– Cm to inches you must multiply by 0.39
• 161.5 X 0.39= 63 in
– Inches to cm you must divide by 0.39
• 63 inches/ 0.39 cm = 161.5 cm
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End of Presentation
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