Measurements
Pre-CNA
SP2-AP2
This presentation will:
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Briefly review the four vital signs
Height and weight
Intake and Output
Measurements
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When working with your
resident, you will
measure:
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Vital signs (VS)
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Height/weight (ht/wt)
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Intake and output (I&O)
Why Do You Take Vital Signs?
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Vital signs show minor changes in the
resident’s condition.
Vital signs show how the resident
responds to treatment.
Vital signs change with fear, exercise,
anxiety, pain and other activities.
Vital Signs
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Vital signs include:
Temperature
Pulse
Respiration
Blood pressure
Report vital signs promptly
when:
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they are above or below normal.
there is a significant change from the
prior reading.
Body Temperature
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The body temperature is the amount of
heat produced by the body.
The temperature is lower in the
morning and higher in afternoon and
evening.
Body temperature is affected by age,
weather, exercise, emotions, stress and
illness.
Sites for Measuring
Temperature
Mouth – oral
 Rectal - anus
 Ear – tympanic
 Axilla - underarm
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Oral Temperature
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Taken in the mouth.
Do not use if a
person has an injury
to his mouth,
difficulty breathing,
or confusion.
Normal Range
97.6-99.6 F
(36.5 C-37.5 C)
Rectal Temperature
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Do not use when the
person has:
diarrhea, a rectal injury
or rectal surgery, heart
disease, or confusion.
Normal Range
98.6-100.6 F
(37.0-38.0 C)
Most accurate route
Tympanic Temperature
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This site has fewer
microbes than other
sites. However, it
should not be used
if there is ear
drainage.
Normal range
97.6-99.6 F
(36.5-37.5 C)
Axillary Temperature
The axilla is the
“armpit”.
 It is the least
accurate site.
 Normal Range
96.6-98.6 F
(35.5-36.5 C)
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Pulse
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Used to monitor the
circulatory system
(heart and blood
vessels)
Pulse Rate
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Measures how fast
the heart is beating
Normal rate=60-100 beats/minute
Tachycardia=“fast heart”
>100 beats/minute
Bradycardia=“slow heart”
<60 beats/minute
Other Pulse Characteristics
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Rhythm
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Regular: same amount of
time between beats
Irregular: NOT the same
amount of time between
beats or skipped
(missed)beats
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Strength
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Strong/bounding:
easy to feel
Weak/thready:
difficult to feel
The Pulse Sites
Taking A Pulse
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These pictures show
radial and brachial
pulse sites.
Radial pulse
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The most common location to check a pulse
On the thumb side of the wrist
Gently press with 2 or 3 fingers.
Do not use your thumb when checking a
pulse
Count for 1 minute
Blood Pressure
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Used to monitor the
circulatory system.
Normal range:
90-120
60-80
Systolic
Diastolic
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Systolic
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Heart is contracting
Higher or top number
First sound you hear
Normal Range:
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90-120mmHg
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Diastolic
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Heart is resting
Lower or bottom
number
Last sound you hear
Normal Range:
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60-80mmHg
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Hypertension
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Hyper=“too much”
Tension=“pressure”
High BP
Systolic >140
Diastolic>90
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Hypotension
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Hypo=“too little”
Tension=“pressure”
Low BP
Systolic<90
Diastolic<60
When do you not use a person’s arm to
measure blood pressure?
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If the arm has an IV, cast or dialysis
access site.
If a woman has had surgery to remove
a breast on that side of her body.
Any injury of surgery to the arm.
What are the parts of the
sphygmomanometer?
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Manometer
Bulb
valve
cuff
Respiration
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Respiration means
breathing air into
(inhalation) and out of
(exhalation) the lungs.
1 respiration= 1
exhalation + 1
inhalation
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People tend to change breathing patterns
when they know someone is counting their
respirations.
Respirations are counted right after taking
the pulse. Keep your fingers on their radial
pulse and observe their chest rising and
falling.
Count for 1 minute.
What to observe when taking
respirations
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Rate: Normal respirations are 12-20
times per minute.
Depth: deep or shallow
Rhythm: regular or irregular
Equality: equal or unequal
Pt. c/o pain or dyspnea
Abnormal noises
Height/Weight
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Baseline height and
weight is measured
when the resident is
admitted to the
nursing home.
Height
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Standing:
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No shoes, have the person
stand straight.
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Lying
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Have person in good alignment
in supine position.
Using a tape measure, measure
from top of head to soles of
feet.
Weight
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The scale should be set at zero.
The resident should be weighed
at the same time of day
wearing as few clothes as
possible.
The morning before breakfast is
the best time.
Make sure the person empties
his/her bladder before
weighing.
This is one method of
monitoring the patient’s fluid
status
Intake and Output (I&O)
Used to monitor fluid
balance and kidney
function
Intake= amount of fluid
entering the body
PO (oral)
Output=amount of fluid
leaving the body
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Urine
Diarrhea
Emesis
Drainage
Sweat (perspiration)
Breathing
(exhalation)
As a NA, you will help record:
Oral Fluid Intake
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water, milk, juice,
coffee, etc.
Foods that melt at
room temperature:
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Ice cream
Jello
Popsicles
You will also record:
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Measurable fluid output:
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Urine
Diarrhea
Emesis
Drainage from tubes
You cannot measure:
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Non-measurable output
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Sweat
Breathing
Wound drainage without a
tube
If a person is incontinent
How many milliliters (ml) in an
ounce?
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1 ounce (oz) = 30 ml (cc)
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