13
Vital Signs
1. Define important words in this chapter
apical pulse
the pulse on the left side of the chest, just below the nipple.
apnea
the absence of breathing.
BPM
the medical abbreviation for “beats per minute.”
brachial pulse
the pulse inside the elbow; about 1 to 1½ inches above the
elbow.
13
Vital Signs
1. Define important words in this chapter
bradycardia
a slow heart rate—under 60 beats per minute.
Celsius
the centigrade temperature scale in which the boiling point of
water is 100 degrees and the freezing point of water is 0
degrees.
Cheyne-Stokes respiration
type of respiration with periods of apnea lasting at least 10
seconds, along with alternating periods of slow, irregular
respirations and rapid, shallow respirations.
13
Vital Signs
1. Define important words in this chapter
diastolic
second measurement of blood pressure; phase when the heart
relaxes.
dilate
to widen.
dyspnea
difficulty breathing.
eupnea
normal respirations.
13
Vital Signs
1. Define important words in this chapter
expiration
the process of exhaling air out of the lungs.
Fahrenheit
a temperature scale in which the boiling point of water is 212
degrees and the freezing point of water is 32 degrees.
hypertension
high blood pressure, measuring 140/90 or higher.
hypotension
low blood pressure, measuring 100/60 or lower.
13
Vital Signs
1. Define important words in this chapter
hypothermia
a condition in which body temperature drops below the level
required for normal functioning; severe sub-normal body
temperature.
inspiration
the process of inhaling air into the lungs.
orthopnea
shortness of breath when lying down that is relieved by sitting
up.
orthostatic hypotension
a sudden drop in blood pressure that occurs when a person
stands or sits up; also called postural hypotension.
13
Vital Signs
1. Define important words in this chapter
prehypertension
a condition in which a person has a systolic measurement of
120–139 mm Hg and a diastolic measurement of 80–89 mm
Hg; indicator that the person is likely to have high blood
pressure in the future, even though he or she does not have it
now.
radial pulse
the pulse on the inside of the wrist, where the radial artery
runs just beneath the skin.
respiration
the process of inhaling air into the lungs (inspiration) and
exhaling air out of the lungs (expiration).
13
Vital Signs
1. Define important words in this chapter
sphygmomanometer
a device that measures blood pressure.
stethoscope
an instrument used to hear sounds in the human body, such as
the heartbeat or pulse, breathing sounds, or bowel sounds.
systolic
first measurement of blood pressure; phase when the heart is
at work, contracting and pushing blood out of the left ventricle.
tachycardia
a fast heartbeat—over 100 beats per minute.
13
Vital Signs
1. Define important words in this chapter
tachypnea
rapid respirations—over 20 breaths per minute.
thermometer
a device used for measuring the degree of heat or cold.
vital signs
measurements (body temperature, pulse, respirations, blood
pressure, and pain level) that monitor the function of the vital
organs of the body.
13
Vital Signs
2. Discuss the relationship of vital signs to health and well-being
Define the following term:
vital signs
measurements (body temperature, pulse, respirations, blood
pressure, and pain level) that monitor the function of the vital
organs of the body.
13
Vital Signs
2. Discuss the relationship of vital signs to health and well-being
Know that vital signs consist of the following:
• Taking temperature
• Counting pulse
• Counting rate of respirations
• Taking blood pressure
• Observing and reporting pain level
13
Vital Signs
2. Discuss the relationship of vital signs to health and well-being
REMEMBER:
A change in vital signs is often the first indication that someone
is ill.
13 Vital Signs
Transparency 13-1: Ranges for Adult Vital Signs
Temp. Site
Oral
Rectal
Axillary
Fahrenheit
97.6° - 99.6°
98.6° - 100.6°
96.6°- 98.6°
Celsius
36.5° - 37.5°
37.0° - 38.1°
36.0° - 37.0°
Normal Pulse Rate: 60-100 beats per minute
Normal Respiratory Rate: 12-20 respirations per minute
Blood Pressure
Normal
Systolic: 100-119
Diastolic: 60-79
Low
Below 100/60
Prehypertensive
Systolic: 120-139
Diastolic: 80-89
High
140/90 or above
13
Vital Signs
3. Identify factors that affect body temperature
Remember that these factors affect body temperature:
• Age
• Amount of exercise
• Circadian rhythm
• Stress
• Illness
• Environment
13
Vital Signs
3. Identify factors that affect body temperature
Define the following term:
hypothermia
a condition in which body temperature drops below the level
required for normal functioning; severe sub-normal body
temperature.
13
Vital Signs
3. Identify factors that affect body temperature
Know the signs of hypothermia:
• Shivering
• Numbness
• Quick and shallow breathing
• Slow movements
• Mild confusion
• Changes in mental status
• Pale and cyanotic skin
13
Vital Signs
4. List guidelines for taking body temperature
Define the following terms:
thermometer
a device used for measuring the degree of heat or cold.
Fahrenheit
a temperature scale in which the boiling point of water is 212
degrees and the freezing point of water is 32 degrees.
Celsius
the centigrade temperature scale in which the boiling point of
water is 100 degrees and the freezing point of water is 0
degrees.
13
Vital Signs
4. List guidelines for taking body temperature
Know the four main sites for measuring temperature:
• Mouth
• Rectum
• Armpit
• Ear
13
Vital Signs
4. List guidelines for taking body temperature
Remember these points about different types of thermometers:
• Mercury-free thermometers can be used to take an oral,
rectal, or axillary temperature.
• Mercury-free thermometers are usually green for oral
thermometers and red for rectal.
• Digital thermometers are commonly used for oral, rectal, and
axillary temps. They register temperature within two to 60
seconds.
• Digital thermometers require a sheath to cover the probe.
• Electronic thermometers are commonly used for oral, rectal,
and axillary temps. They register temperature within two to
60 seconds.
13
Vital Signs
4. List guidelines for taking body temperature
Different types of thermometers (cont’d.):
• Electronic thermometers require a probe cover that must be
discarded after a single use.
• Disposable thermometers can be used to take oral or axillary
temps.
• Disposable thermometers are used once and disposed of.
They do not require a disposable sheath.
• Tympanic thermometers are fast and accurate.
• Temporal artery thermometers are moved across the forehead
and are non-invasive.
13
Vital Signs
4. List guidelines for taking body temperature
Do not take an oral temperature on a person who
• Is unconscious
• Is using oxygen
• Is confused or disoriented
• Is paralyzed from stroke
• Has facial trauma
• Is likely to have a seizure
• Has a nasogastric or orogastric tube (Chapter 26)
• Is younger than six years old
• Has sores, redness, swelling, or pain in the mouth
• Has an injury to the face or neck
Measuring and recording oral temperature
Equipment: clean mercuryfree, digital, or electronic
thermometer, gloves,
disposable sheath/cover for
thermometer, tissues, pen
and paper
Do not take an oral
temperature on a resident
who has smoked, eaten or
drunk fluids, chewed gum, or
exercised within the last
10–20 minutes.
1.
Identify yourself by
name. Identify the
resident. Greet the
resident by name.
2.
Wash your hands.
Measuring and recording oral temperature
3.
Explain procedure to
resident. Speak clearly,
slowly, and directly.
Maintain face-to-face
contact whenever
possible.
4.
Provide for the resident’s
privacy with a curtain,
screen, or door.
5.
Put on gloves.
Measuring and recording oral temperature
6.
Mercury-free
thermometer: Hold
thermometer by stem.
Before inserting
thermometer in resident’s
mouth, shake
thermometer down to
below the lowest number
(at least below 96°F or
35°C). To shake
thermometer down, hold
it at the end opposite the
bulb with the thumb and
two fingers. With a
snapping motion of the
wrist, shake the
thermometer. Stand away
from furniture and walls
while doing so.
Measuring and recording oral temperature
Digital thermometer: Put
on disposable sheath.
Turn on thermometer.
Wait until “ready” sign
appears.
Electronic thermometer:
Remove probe from base
unit. Put on probe cover.
7.
Mercury-free
thermometer: Put on
disposable sheath, if
applicable. Gently insert
bulb end of thermometer
into resident’s mouth.
Place it under tongue
and to one side.
Resident should breathe
through his or her nose.
Measuring and recording oral temperature
Digital thermometer:
Insert end of digital
thermometer into
resident’s mouth. Place
under tongue and to one
side.
Electronic thermometer:
Insert the covered probe
into resident’s mouth.
Place under tongue and to
one side.
Measuring and recording oral temperature
8.
Mercury-free
thermometer: Tell
resident to hold
thermometer in mouth
with lips closed. Assist as
necessary. Ask the
resident not to bite down
or to talk. Leave
thermometer in place for
at least three minutes.
Measuring and recording oral temperature
Digital thermometer:
Leave in place until
thermometer blinks or
beeps.
Electronic thermometer:
Leave in place until you
hear a tone or see a
flashing or steady light.
Measuring and recording oral temperature
9.
Mercury-free
thermometer: Remove
the thermometer. Wipe
with tissue from stem to
bulb or remove sheath.
Dispose of tissue or
sheath. Hold
thermometer at eye
level. Rotate until line
appears, rolling the
thermometer between
your thumb and
forefinger. Read
temperature. Remember
the temperature reading.
Measuring and recording oral temperature
Digital thermometer:
Remove the
thermometer. Read
temperature on display
screen. Remember the
temperature reading.
Electronic thermometer:
Read the temperature on
the display screen.
Remember the
temperature reading.
Remove the probe.
10. Mercury-free
thermometer: Clean
thermometer according
to facility policy. Return
it to plastic case or
container.
Measuring and recording oral temperature
Digital thermometer:
Using a tissue, remove
and discard sheath.
Clean thermometer
according to facility
policy. Replace
thermometer in case.
Electronic thermometer:
Press the eject button to
discard the cover.
Return the probe to the
holder.
11. Remove and discard
gloves. Wash your
hands.
12. Make resident
comfortable. Remove
privacy measures.
Measuring and recording oral temperature
13. Leave call light within
resident’s reach.
14. Wash your hands.
15. Be courteous and
respectful at all times.
16. Report any changes in
the resident to the
nurse. Document
procedure using facility
guidelines. Record the
resident’s name,
temperature, date, time
and method used (oral).
13
Vital Signs
4. List guidelines for taking body temperature
Remember these points about taking rectal temperature:
• Rectal temperatures are most accurate.
• You must explain what you will do before starting.
• Be reassuring.
• You must hold onto the thermometer at all times.
• Gloves must be worn.
• Thermometer must be lubricated for this
procedure.
• The privacy of the resident is important.
• Thermometer must be held the entire time it is in the rectum.
13
Vital Signs
4. List guidelines for taking body temperature
Remember this point about tympanic temperatures:
• The tip will only go into the ear 1/4 to 1/2 inch.
Remember these points about axillary temperatures:
• Axillary temperatures are not as accurate as other sites.
• Axillary area must be clean and dry.
Measuring and recording rectal temperature
Equipment: clean rectal
mercury-free, digital or
electronic thermometer,
lubricant, gloves, tissue,
disposable sheath/cover, pen
and paper
1.
Identify yourself by
name. Identify the
resident. Greet the
resident by name.
2.
Wash your hands.
3.
Explain procedure to
resident. Speak clearly,
slowly, and directly.
Maintain face-to-face
contact whenever
possible. Remind resident
that the procedure will
take only a few minutes.
Measuring and recording rectal temperature
4.
Provide for the resident’s
privacy with a curtain,
screen, or door.
5.
Adjust bed to safe
working level, usually
waist high. Lock bed
wheels.
6.
Help the resident to leftlying (Sims’) position.
7.
Fold back linens to
expose only rectal area.
8.
Put on gloves.
Measuring and recording rectal temperature
9.
Mercury-free
thermometer: Hold
thermometer by stem.
Shake thermometer down to
below the lowest number.
Put on disposable sheath.
Digital thermometer: Put
on disposable sheath. Turn
on thermometer. Wait until
“ready” sign appears.
Electronic thermometer:
Remove probe from base
unit. Put on probe cover.
10. Apply a small amount of
lubricant to tip of bulb or
probe cover (or apply prelubricated cover).
Measuring and recording rectal temperature
11. Separate the buttocks.
Gently insert
thermometer one-half to
one inch into rectum.
Stop if you meet
resistance. Do not force
the thermometer into
the rectum.
12. Replace sheet over
buttocks while holding
on to the thermometer.
Hold onto the
thermometer at all
times.
Measuring and recording rectal temperature
13. Mercury-free
thermometer: Hold
thermometer in place for at
least three minutes.
Digital thermometer:
Hold thermometer in place
until thermometer blinks or
beeps.
Electronic thermometer:
Leave in place until you
hear a tone or see a
flashing or steady light.
14. Gently remove the
thermometer. Wipe with
tissue from stem to bulb or
remove sheath or cover.
Dispose of tissue or
sheath.
Measuring and recording rectal temperature
15. Read thermometer at eye
level as you would for an
oral temperature. Remember
the temperature reading.
16. Mercury-free
thermometer: Clean
thermometer according to
facility policy. Return it to
plastic case or container.
Digital thermometer:
Clean thermometer
according to facility policy.
Replace thermometer in
case.
Electronic thermometer:
Press the eject button to
discard the cover. Return the
probe to the holder.
Measuring and recording rectal temperature
17. Remove and discard
gloves.
18. Wash your hands.
19. Make resident
comfortable.
20. Return bed to lowest
position. Remove privacy
measures.
21. Leave call light within
resident’s reach.
22. Wash your hands.
Measuring and recording rectal temperature
23. Be courteous and
respectful at all times.
24. Report any changes in
the resident to the
nurse. Document
procedure using facility
guidelines. Immediately
record the resident’s
name, temperature,
date, time and method
used (rectal).
Measuring and recording tympanic temperature
Equipment: tympanic
thermometer, gloves,
disposable sheath/cover, pen
and paper
1.
Identify yourself by
name. Identify the
resident. Greet the
resident by name.
2.
Wash your hands.
3.
Explain procedure to
resident. Speak clearly,
slowly, and directly.
Maintain face-to-face
contact whenever
possible.
Measuring and recording tympanic temperature
4.
Provide for the resident’s
privacy with a curtain,
screen, or door.
5.
Put on gloves.
6.
Put a disposable sheath
over earpiece of the
thermometer.
7.
Position the resident’s
head so that the ear is in
front of you. Straighten
the ear canal by gently
pulling up and back on
the outside edge of the
ear. Insert the covered
probe into the ear canal.
Press the button.
Measuring and recording tympanic temperature
8.
Hold thermometer in
place until thermometer
blinks or beeps.
9.
Read temperature.
Remember the
temperature reading.
10. Dispose of sheath.
Return thermometer to
storage or to the battery
charger if thermometer
is rechargeable.
11. Remove and discard
gloves. Wash your
hands.
12. Make resident
comfortable. Remove
privacy measures.
Measuring and recording tympanic temperature
13. Leave call light within
resident’s reach.
14. Wash your hands.
15. Be courteous and
respectful at all times.
16. Report any changes in
the resident to the
nurse. Document
procedure using facility
guidelines. Immediately
record resident’s name,
temperature, date, time,
and method used
(tympanic).
Measuring and recording axillary temperature
Equipment: clean mercuryfree, digital or electronic
thermometer, gloves, tissues,
disposable sheath/cover, pen
and paper
1.
Identify yourself by
name. Identify the
resident. Greet the
resident by name.
2.
Wash your hands.
3.
Explain procedure to
resident. Speak clearly,
slowly, and directly.
Maintain face-to-face
contact whenever
possible.
Measuring and recording axillary temperature
4.
Provide for the resident’s
privacy with a curtain,
screen, or door.
5.
Adjust bed to safe
working level, usually
waist high. Lock bed
wheels.
6.
Put on gloves.
7.
Remove resident’s arm
from sleeve of gown.
Wipe axillary area with
tissues.
Measuring and recording axillary temperature
8.
Mercury-free
thermometer: Hold
thermometer by stem.
Shake thermometer
down to below the
lowest number. Put on
disposable sheath, if
applicable.
Digital thermometer: Put
on disposable sheath.
Turn on thermometer.
Wait until “ready” sign
appears.
Electronic thermometer:
Remove probe from base
unit. Put on probe cover.
Measuring and recording axillary temperature
9.
Position thermometer
(bulb end for mercuryfree) in center of the
armpit. Fold resident’s
arm over chest.
10. Mercury-free
thermometer: Hold
thermometer in place,
with the arm close against
the side, for eight to ten
minutes.
Digital thermometer: Hold
thermometer in place until
thermometer blinks or
beeps.
Electronic thermometer:
Leave in place until you
hear a tone or see a
flashing or steady light.
Measuring and recording axillary temperature
11. Mercury-free thermometer:
Gently remove the
thermometer. Wipe with
tissue from stem to bulb or
remove sheath. Dispose of
tissue or sheath. Read
temperature. Remember the
temperature reading.
Digital thermometer:
Remove the thermometer.
Read temperature on
display screen. Remember
the temperature reading.
Electronic thermometer:
Read the temperature on
the display screen.
Remember the temperature
reading. Remove the probe.
Measuring and recording axillary temperature
12. Mercury-free
thermometer: Clean
thermometer according
to facility policy. Return
it to plastic case or
container.
Digital thermometer:
Using a tissue, remove
and dispose of sheath.
Clean thermometer
according to facility
policy. Replace the
thermometer in case.
Electronic thermometer:
Press the eject button to
discard the cover.
Return the probe to the
holder.
Measuring and recording axillary temperature
13. Remove and discard
gloves. Wash your
hands.
14. Put resident’s arm back
into sleeve of gown.
Make resident
comfortable.
15. Return bed to lowest
position. Remove privacy
measures.
16. Leave call light within
resident’s reach.
17. Wash your hands.
Measuring and recording axillary temperature
18. Be courteous and
respectful at all times.
19. Report any changes in
the resident to the
nurse. Document
procedure using facility
guidelines. Immediately
record the resident’s
name, temperature,
date, time and method
used (axillary).
13 Vital Signs
Handout 13-1: Thermometer Worksheet
Write the temperature reading to the nearest tenth degree underneath each of the examples below.
1. Reading:
_________________
2. Reading:
_________________
3. Reading:
_________________
4. Reading:
_________________
5. Reading:
_________________
13 Vital Signs
Handout 13-1: Thermometer Worksheet (cont’d.)
Write the temperature reading to the nearest tenth degree underneath each of the examples below.
6. Reading:
_________________
7. Reading:
_________________
8. Reading:
_________________
9. Reading:
_________________
10. Reading: _________________
13
Vital Signs
5. Explain pulse and respirations
Define the following terms:
BPM
the medical abbreviation for “beats per minute.”
tachycardia
a fast heartbeat—over 100 beats per minute.
bradycardia
a slow heart rate—under 60 beats per minute.
dilate
to widen.
13
Vital Signs
5. Explain pulse and respirations
Define the following terms:
respiration
the process of inhaling air into the lungs (inspiration) and
exhaling air out of the lungs (expiration).
inspiration
the process of inhaling air into the lungs.
expiration
the process of exhaling air out of the lungs.
13
Vital Signs
5. Explain pulse and respirations
Remember that these factors affect pulse rate:
• Age
• Sex
• Exercise
• Stress
• Hemorrhage
• Medications
• Fever and illness
13
Vital Signs
5. Explain pulse and respirations
Define the following terms:
apnea
the absence of breathing.
dyspnea
difficulty breathing.
eupnea
normal respirations.
orthopnea
shortness of breath when lying down that is relieved by sitting
up.
13
Vital Signs
5. Explain pulse and respirations
Define the following terms:
tachypnea
rapid respirations—over 20 breaths per minute.
Cheyne-Stokes respiration
type of respiration with periods of apnea lasting at least 10
seconds, along with alternating periods of slow, irregular
respirations and rapid, shallow respirations.
13
Vital Signs
6. List guidelines for taking pulse and respirations
Define the following terms:
radial pulse
the pulse on the inside of the wrist, where the radial artery
runs just beneath the skin.
stethoscope
an instrument used to hear sounds in the human body, such as
the heartbeat or pulse, breathing sounds, or bowel sounds.
13
Vital Signs
6. List guidelines for taking pulse and respirations
Remember these points about pulse rate:
• Pulse is the number of heartbeats per minute. Normal rate is
60-100 beats per minute for adults.
• Observe for the overall pattern of the pulse and the quality or
type of the pulse.
13
Vital Signs
6. List guidelines for taking pulse and respirations
Remember these points about respirations:
• Do the counting immediately after taking the pulse.
• Do not let the resident know you are counting breaths.
• Normal rate is 12-20 breaths per minute.
• Observe for the overall pattern of the respirations and the
quality or type of breathing.
Measuring and recording radial pulse and counting and recording respirations
Equipment: watch with
second hand, pen and paper
1.
Identify yourself by
name. Identify the
resident. Greet the
resident by name.
2.
Wash your hands.
3.
Explain procedure to
resident. Speak clearly,
slowly, and directly.
Maintain face-to-face
contact whenever
possible.
4.
Provide for the resident’s
privacy with a curtain,
screen, or door.
Measuring and recording radial pulse and counting and recording respirations
5.
Place the fingertips of
your index finger and
middle finger on the
thumb side of resident’s
wrist to locate radial
pulse. Do not use your
thumb.
6.
Count beats for one full
minute.
7.
Keep your fingertips on
the resident’s wrist.
Count respirations for
one full minute. Observe
for the pattern and
character of the
resident’s breathing.
Normal breathing is
smooth and quiet.
Measuring and recording radial pulse and counting and recording respirations
8.
Remove privacy
measures. Make resident
comfortable.
9.
Leave call light within
resident’s reach.
10. Wash your hands.
11. Be courteous and
respectful at all times.
12. Report any changes in
the resident to the
nurse. Document
procedure using facility
guidelines. Record pulse
rate, date, time and
method used (radial).
Record the respiratory
rate and the pattern or
character of breathing.
13
Vital Signs
6. List guidelines for taking pulse and respirations
Define the following term:
apical pulse
the pulse on the left side of the chest, just below the nipple.
13
Vital Signs
6. List guidelines for taking pulse and respirations
When checking a resident’s pulse, observe for the following:
• The pulse rate (the number of beats in one minute—normal
range is 60 to 100 beats per minute)
• The overall pattern of the pulse: is the pulse regular or
irregular?
• The quality or type of pulse: is the pulse strong or weak?
13
Vital Signs
6. List guidelines for taking pulse and respirations
REMEMBER:
The apical pulse is normally about the same as the radial
pulse.
13
Vital Signs
6. List guidelines for taking pulse and respirations
When counting respirations, observe for the following:
• The respiratory rate (the number of times the resident
breathes in one minute—normal range is 12 to 20)
• The overall pattern of respirations: is breathing regular or
irregular?
• The quality or type of breathing: is shortness of breath or
difficulty breathing (dyspnea) noted? Does the resident have
noisy breathing? Normal breathing is quiet. Is the breathing
deep or shallow?
Measuring and recording apical pulse
Equipment: stethoscope,
watch with second hand,
alcohol wipes, pen and paper
1.
Identify yourself by
name. Identify the
resident. Greet the
resident by name.
2.
Wash your hands.
3.
Explain procedure to
resident. Speak clearly,
slowly, and directly.
Maintain face-to-face
contact whenever
possible.
Measuring and recording apical pulse
4.
Provide for the resident’s
privacy with a curtain,
screen, or door.
5.
Before using
stethoscope, wipe
diaphragm and earpieces
with alcohol wipes.
6.
Fit the earpieces of the
stethoscope snugly in
your ears. Place the flat
metal diaphragm on the
left side of the chest,
just below the nipple.
Listen for the heartbeat.
Measuring and recording apical pulse
7.
Use the second hand of
your watch. Count beats
for one full minute. Each
“lub dub” you hear is
counted as one beat. A
normal heartbeat is
rhythmical. Leave the
stethoscope in place to
count respirations.
8.
Clean earpieces and
diaphragm of
stethoscope with alcohol
wipes. Store
stethoscope.
9.
Make resident
comfortable. Remove
privacy measures.
Measuring and recording apical pulse
10. Leave call light within
resident’s reach.
11. Wash your hands.
12. Be courteous and
respectful at all times.
13. Report any changes in
the resident to the
nurse. Document
procedure using facility
guidelines. Record pulse
rate, date, time, and
method used (apical).
Note any differences in
the rhythm.
13
Vital Signs
6. List guidelines for taking pulse and respirations
The pulse deficit is the difference between an apical pulse and
another pulse.
For example, if the apical pulse is 80 beats in one minute, and
the radial pulse is 68 beats in one minute, the pulse deficit is 12
(80 - 68 = 12).
Measuring and recording apical-radial pulse
Equipment: stethoscope,
watch with second hand,
alcohol wipes, pen and paper
Find a co-worker to assist
you.
1.
Identify yourself by
name. Identify the
resident. Greet the
resident by name.
2.
Wash your hands.
3.
Explain procedure to
resident. Speak clearly,
slowly, and directly.
Maintain face-to-face
contact whenever
possible.
Measuring and recording apical-radial pulse
4.
Provide for the resident’s
privacy with a curtain,
screen, or door.
5.
Before using
stethoscope, wipe
diaphragm and earpieces
with alcohol wipes.
6.
Fit the earpieces of the
stethoscope snugly in
your ears. Place the flat
metal diaphragm on the
left side of the chest,
just below the nipple.
Listen for the heartbeat.
Measuring and recording apical-radial pulse
7.
Your co-worker should
place her fingertips on
the thumb side of
resident’s wrist to locate
the radial pulse.
8.
After both pulses have
been located, look at the
second hand of your
watch. When the second
hand reaches the “12” or
“6,” say, “Start,” and
both people will count
beats for one full minute.
Say, “Stop” after one
minute.
9.
Clean earpieces and
diaphragm of
stethoscope with alcohol
wipes. Store stethoscope.
Measuring and recording apical-radial pulse
10. Make resident
comfortable. Remove
privacy measures.
11. Leave call light within
resident’s reach.
12. Wash your hands.
13. Be courteous and
respectful at all times.
Measuring and recording apical-radial pulse
14. Report any changes in
the resident to the
nurse. Document
procedure using facility
guidelines. Record both
pulse rates, date, time,
and method used
(apical-radial). Record
pulse deficit if the pulse
rates are not the same
(subtract radial pulse
measurement from
apical pulse to get pulse
deficit). Note any
differences in the
rhythm.
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Vital Signs
7. Identify factors that affect blood pressure
Define the following terms:
systolic
first measurement of blood pressure; phase when the heart is
at work, contracting and pushing blood out of the left ventricle.
diastolic
second measurement of blood pressure; phase when the heart
relaxes.
hypertension
high blood pressure, measuring 140/90 or higher.
hypotension
low blood pressure, measuring 100/60 or lower.
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Vital Signs
7. Identify factors that affect blood pressure
Define the following terms:
orthostatic hypotension
a sudden drop in blood pressure that occurs when a person
stands or sits up; also called postural hypotension.
prehypertension
a condition in which a person has a systolic measurement of
120–139 mm Hg and a diastolic measurement of 80–89 mm
Hg; indicator that the person is likely to have high blood
pressure in the future, even though he or she does not have it
now.
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Vital Signs
7. Identify factors that affect blood pressure
Remember that these factors affect blood pressure:
• Age
• Exercise
• Stress
• Race
• Heredity
• Obesity/unhealthy diet
• Alcohol
• Tobacco products
• Time of day
• Illness
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Vital Signs
8. List guidelines for taking blood pressure
Define the following terms:
sphygmomanometer
a device that measures blood pressure.
brachial pulse
the pulse inside the elbow; about 1 to 1½ inches above the
elbow.
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Vital Signs
8. List guidelines for taking blood pressure
There are different types of sphygmomanometers:
• Aneroid
This device has a round gauge that is portable or is attached
to the wall. It may also hook onto clothing.
13
Vital Signs
8. List guidelines for taking blood pressure
Different types of sphygmomanometers (cont’d.):
• Electronic
This device automatically inflates and deflates to measure
blood pressure. The readings are displayed digitally. The use
of a stethoscope is not required with electronic
sphygmomanometers. Ask for instructions on use if you have
not been trained to use this equipment.
13
Vital Signs
8. List guidelines for taking blood pressure
Different types of sphygmomanometers (cont’d.):
• Non-invasive blood pressure monitoring (NIBP).
These monitoring devices measure blood pressure faster than
other methods. They may also measure other vital signs, as
well as perform other measurements. You will receive training
for these devices if they are used at your facility. Follow
facility policy on the use of these machines.
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Vital Signs
8. List guidelines for taking blood pressure
Remember these points about blood pressure:
• Brachial pulse is used.
The brachial pulse is used to take a blood pressure reading.
This is the pulse inside of the elbow, about one to one and a
half inches above the elbow
• The cuff must first be completely deflated.
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Vital Signs
8. List guidelines for taking blood pressure
Do not to take blood pressure when these situations exist:
• An intravenous line (IV) is present.
• An amputation has been performed.
• The cuff does not fit the arm properly.
• The arm has a cast.
• Burns or injuries are present.
• The arm is being used for dialysis.
• The arm or side has had recent trauma.
• The arm or side is paralyzed due to stroke.
• The side has had a mastectomy (or any breast surgery).
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Vital Signs
8. List guidelines for taking blood pressure
Remember these additional points about blood pressure:
• Observe for normal readings and the quality or type of
sounds.
• One-step method does not include getting an estimated
systolic before beginning. Two-step method does require
getting an estimated systolic.
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Vital Signs
8. List guidelines for taking blood pressure
REMEMBER:
Taking accurate blood pressure takes practice. It is not always
easy to perfect the skill of hearing the first and last sounds of the
blood pressure. You may have to do the procedure over and over
again and have others check your results for correctness.
13 Vital Signs
Handout 13-2: Blood Pressure Worksheet
Record the blood pressure shown on the appropriate line and answer the question below
1.
___________________________
Is this reading within normal range?
___________________________
2.
___________________________
Is this reading within normal range?
___________________________
13 Vital Signs
Handout 13-2: Blood Pressure Worksheet (cont’d.)
Record the blood pressure shown on the appropriate line and answer the question below
3.
___________________________
Is this reading within normal range?
___________________________
4.
___________________________
Is this reading within normal range?
___________________________
Measuring and recording blood pressure (one-step method)
Equipment:
sphygmomanometer,
stethoscope, watch with
second hand, alcohol wipes,
pen and paper
1.
Identify yourself by
name. Identify the
resident. Greet the
resident by name.
2.
Wash your hands.
3.
Explain procedure to
resident. Speak clearly,
slowly, and directly.
Maintain face-to-face
contact whenever
possible.
Measuring and recording blood pressure (one-step method)
4.
Provide for the resident’s
privacy with a curtain,
screen, or door.
5.
Ask the resident to roll
up his or her sleeve,
approximately five
inches above the elbow.
Do not measure blood
pressure over clothing.
6.
Position resident’s arm
with palm up. The arm
should be level with the
heart.
Measuring and recording blood pressure (one-step method)
7.
With the valve open,
squeeze the cuff. Make
sure it is completely
deflated.
8.
Place blood pressure cuff
snugly on resident’s
upper arm. The center of
the cuff with
sensor/arrow is placed
over the brachial artery
(1-1½ inches above the
elbow toward inside of
elbow).
9.
Before using the
stethoscope, wipe
diaphragm and earpieces
with alcohol wipes.
Measuring and recording blood pressure (one-step method)
10. Locate brachial pulse
with fingertips.
11. Place diaphragm of the
stethoscope over
brachial artery.
12. Place earpieces of the
stethoscope in ears.
13. Close the valve
(clockwise) until it stops.
Do not over-tighten it.
14. Inflate cuff to 30 mm Hg
above the point at which
the pulse is last heard or
felt.
Measuring and recording blood pressure (one-step method)
15. Open the valve slightly
with thumb and index
finger. Deflate cuff
slowly.
16. Watch gauge. Listen for
sound of pulse.
17. Remember the reading
at which the first clear
pulse sound is heard.
This is the systolic
pressure.
18. Continue listening for a
change or muffling of
pulse sound. The point
of a change or the point
the sound disappears is
the diastolic pressure.
Remember this reading.
Measuring and recording blood pressure (one-step method)
19. Open the valve. Deflate
cuff completely. Remove
cuff.
20. Wipe diaphragm and
earpieces of the
stethoscope with alcohol.
Store equipment.
21. Make resident
comfortable. Remove
privacy measures.
22. Leave call light within
resident’s reach.
23. Wash your hands.
24. Be courteous and
respectful at all times.
Measuring and recording blood pressure (one-step method)
25. Report any changes in
the resident to the
nurse. Document
procedure using facility
guidelines. Record both
the systolic and diastolic
pressures. Write the
numbers like a fraction,
with the systolic reading
on top and the diastolic
reading on the bottom
(for example: 120/80).
Note which arm was
used. Write “RA” for
right arm and “LA” for
left arm.
Measuring and recording blood pressure (two-step method)
Equipment:
sphygmomanometer,
stethoscope, watch with
second hand, alcohol wipes,
pen and paper
1.
Identify yourself by
name. Identify the
resident. Greet the
resident by name.
2.
Wash your hands.
3.
Explain procedure to
resident. Speak clearly,
slowly, and directly.
Maintain face-to-face
contact whenever
possible.
Measuring and recording blood pressure (two-step method)
4.
Provide for the resident’s
privacy with a curtain,
screen, or door.
5.
Ask the resident to roll
up his or her sleeve,
approximately five
inches above the elbow.
Do not measure blood
pressure over clothing.
6.
Position resident’s arm
with palm up. The arm
should be level with the
heart.
7.
With the valve open,
squeeze the cuff. Make
sure it is completely
deflated.
Measuring and recording blood pressure (two-step method)
8.
Place blood pressure cuff
snugly on resident’s
upper arm. The center of
the cuff with
sensor/arrow is placed
over the brachial artery
(1-1½ inches above the
elbow toward inside of
elbow).
9.
Locate the radial (wrist)
pulse with fingertips.
10. Close the valve
(clockwise) until it stops.
Inflate cuff slowly,
watching gauge.
Measuring and recording blood pressure (two-step method)
11.Stop inflating when you
can no longer feel the
pulse. Note the reading.
The number is an estimate
of the systolic pressure.
12.Open the valve. Deflate
cuff completely.
13.Write down estimated
systolic reading.
14.Before using the
stethoscope, wipe
diaphragm and earpieces
of stethoscope with alcohol
wipes.
Measuring and recording blood pressure (two-step method)
15.Locate brachial pulse with
fingertips.
16.Place diaphragm of the
stethoscope over brachial
artery.
17.Place earpieces of the
stethoscope in ears.
18.Close the valve
(clockwise) until it stops.
Do not over-tighten it.
Measuring and recording blood pressure (two-step method)
19. Inflate cuff to 30 mm Hg
above your estimated
systolic pressure.
20. Open the valve slightly
with thumb and index
finger. Deflate cuff
slowly.
21. Watch gauge. Listen for
sound of pulse.
22. Remember the reading
at which the first clear
pulse sound is heard.
This is the systolic
pressure.
Measuring and recording blood pressure (two-step method)
23. Continue listening for a
change or muffling of pulse
sound. The point of a
change or the point the
sound disappears is the
diastolic pressure.
Remember this reading.
24. Open the valve. Deflate
cuff completely. Remove
cuff.
25. Wipe diaphragm and
earpieces of the
stethoscope with alcohol.
Store equipment.
26. Make resident comfortable.
Remove privacy measures.
27. Leave call light within
resident’s reach.
Measuring and recording blood pressure (two-step method)
28. Wash your hands.
29. Be courteous and
respectful at all times.
30. Report any changes in
the resident to the nurse.
Document procedure
using facility guidelines.
Record both the systolic
and diastolic pressures.
Write the numbers like a
fraction, with the systolic
reading on top and the
diastolic reading on the
bottom (for example:
120/80). Note which arm
was used. Write “RA” for
right arm and “LA” for
left arm.
13
Vital Signs
9. Describe guidelines for pain management
Remember these points about pain:
• It is as important to monitor as vital signs.
• It is uncomfortable and an individual experience.
• Take complaints of pain seriously.
• Ask questions to get accurate information.
13
Vital Signs
9. Describe guidelines for pain management
Know the signs and symptoms of pain to observe and report:
• Increased pulse, respirations, and blood pressure
• Sweating
• Nausea and vomiting
• Tightening the jaw
• Squeezing eyes shut
• Holding or guarding a body part
• Frowning
• Grinding teeth
• Increased restlessness
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Vital Signs
9. Describe guidelines for pain management
Signs and symptoms of pain (cont’d.):
• Agitation or tension
• Change in behavior
• Crying
• Sighing
• Groaning
• Breathing heavily
• Difficulty moving or walking
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Vital Signs
9. Describe guidelines for pain management
Remember to take these measures to reduce pain:
• Report complaints of pain or unrelieved pain promptly to the
nurse.
• Check on the resident often and ask if the pain has been
relieved.
• Offer back rubs frequently.
• Assist in frequent changes of position. Be careful when
moving, lifting, or transferring a resident in pain. Make sure to
have enough help to transfer a resident in pain.
• Offer warm baths or showers.
• Encourage slow, deep breaths if the resident has difficulty
breathing.
• Always be patient, caring, gentle, and empathetic.
13
Vital Signs
Exam
Multiple Choice. Choose the correct answer.
1. Which of the following is considered a vital sign?
(A) Body temperature
(B) Orientation
(C) Telemetry
(D) Glycemic index
2. If a nursing assistant is unable to obtain a proper reading of a resident’s vital
signs, she should:
(A) Guess
(B) Use the previous reading from the same resident
(C) Tell the nurse
(D) Leave the space blank and move on to the next resident or procedure
13
Vital Signs
Exam (cont’d.)
3. Common symptoms of a fever include:
(A) Muscle aches
(B) Sleepiness
(C) Slow movements
(D) Nausea
4. If a nursing assistant suspects that a resident has a fever, he should:
(A) Give the resident medication
(B) Take the resident’s temperature
(C) Ask the resident how she is feeling
(D) Measure the resident’s pulse rate
13
Vital Signs
Exam (cont’d.)
5. Which of the following is the normal temperature range for the oral method?
(A) 97.6 - 99.6 degrees F
(B) 96.6 - 98.6 degrees F
(C) 93.6 - 97.9 degrees F
(D) 98.6 - 100.6 degrees F
6. Which method of taking temperature is the most common?
(A) Oral
(B) Rectal
(C) Tympanic
(D) Axillary
13
Vital Signs
Exam (cont’d.)
7. Which of the following is another word for “armpit?”
(A) Tympanic
(B) Rectum
(C) Axillary
(D) Temporal
8. Which method of taking temperature is considered to be the most accurate?
(A) Oral
(B) Rectal
(C) Tympanic
(D) Axillary
13
Vital Signs
Exam (cont’d.)
9. An oral thermometer is usually color-coded:
(A) Green or blue
(B) Red or orange
(C) Black or white
(D) White or gray
10. Under which of the following conditions should a nursing assistant not take an
oral temperature on a person?
(A) The person has influenza.
(B) The person almost certainly has a fever.
(C) The person is over six years old.
(D) The person is confused or disoriented.
13
Vital Signs
Exam (cont’d.)
11. Why do many facilities discourage the use of mercury thermometers?
(A) Mercury thermometers are more expensive.
(B) Mercury thermometers are less accurate.
(C) Mercury is a dangerous, toxic substance.
(D) Mercury thermometers are harder to read.
12. Which of the following statements is true of taking rectal temperatures?
(A) The nursing assistant should not explain the procedure before beginning so
the resident will not feel anxious.
(B) Rectal thermometers should be inserted two inches into the rectum.
(C) The nursing assistant must hold on to the thermometer at all times while
taking a rectal temperature.
(D) To obtain an accurate temperature, the resident should move around during
the procedure.
13
Vital Signs
Exam (cont’d.)
13. How far into the ear should a tympanic thermometer be inserted?
(A) ¼ to ½ inch
(B) ½ to 1 inch
(C) 1 to 1 ½ inches
(D) 1 ½ to 2 inches
14. The normal pulse rate for adults is:
(A) 25 to 50 BPM
(B) 60 to 100 BPM
(C) 100 to 150 BPM
(D) 150 to 175 BPM
13
Vital Signs
Exam (cont’d.)
15. The most common site to take the pulse is the:
(A) Radial pulse
(B) Brachial pulse
(C) Carotid pulse
(D) Pedal pulse
16. The normal respiration rate for adults is:
(A) 18-30 breaths per minute
(B) 15-25 breaths per minute
(C) 12-20 breaths per minute
(D) 8-10 breaths per minute
13
Vital Signs
Exam (cont’d.)
17. Difficulty breathing is called:
(A) Eupnea
(B) Apnea
(C) Tachypnea
(D) Dyspnea
18. Why is respiration rate usually counted directly after taking the pulse rate,
while the fingers are still on the wrist?
(A) It is less work for the nursing assistant to count respirations right after taking
the pulse.
(B) People may breathe more quickly if they know they are being observed.
(C) The chest will not rise and fall if the rate is not counted immediately.
(D) It does not matter when respirations are counted.
13
Vital Signs
Exam (cont’d.)
19. The difference between the apical and radial pulse is called:
(A) Pulse rate
(B) Cheyne-Stokes
(C) Pulse deficit
(D) BPM
20. The _____ blood pressure is the top number in a blood pressure reading,
while the _____ is the bottom number.
(A) Radial, apical
(B) Apical, radial
(C) Diastolic, systolic
(D) Systolic, diastolic
13
Vital Signs
Exam (cont’d.)
21. Which of the following blood pressure readings falls within the normal range?
(A) 119/75
(B) 135/90
(C) 91/70
(D) 140/80
22. Hypertension is:
(A) High fever
(B) High blood pressure
(C) High pulse rate
(D) Low blood pressure
13
Vital Signs
Exam (cont’d.)
23. Blood pressure is measured using a:
(A) Thermometer
(B) Watch
(C) Finger
(D) Sphygmomanometer
24. Prehypertension means:
(A) A person’s blood pressure is too high
(B) A person’s blood pressure is too low
(C) A person does not have low blood pressure now but is likely to have it in the
future
(D) A person does not have high blood pressure now but is likely to have it in the
future
13
Vital Signs
Exam (cont’d.)
25. Both the _____ and _____ pulses are used in taking blood pressure.
(A) Radial and apical
(B) Apical and brachial
(C) Radial and brachial
(D) Brachial and femoral
26. Which of the following is an example of a correct way to write a blood
pressure reading?
(A) 120/75
(B) 120+75
(C) 120-75
(D) 120*75
13
Vital Signs
Exam (cont’d.)
27. Which of the following statements is true of pain?
(A) Everyone experiences pain in the same way.
(B) Everyone will express freely when they are in pain.
(C) Pain is a different experience for each person.
(D) Pain levels do not need to be monitored.
28. Which of the following can help reduce pain?
(A) Pounding the resident on the back
(B) Jumping jacks
(C) Squeezing the body part hard
(D) Change of position