Nursing Assistant
Vital Signs
Vital Signs
Temperature
 Pulse
 Respiration
 Blood pressure
 Oxygen saturation
 Pain
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Vital Signs
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Indicators of body function
– Assess body systems
– Signify changes taking place in body
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Observations should also include
– Skin color & temp
– Behaviors
– Statements from resident (subjective)
Temperature
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Balance of heat gained & heat lost
 Hypothalamus is temp regulation center
 Heat produced by
– Cellular activity
• Infection elevates temp
• Brain injury can increase or decrease temp
– Food metabolism
– Muscle activity
• Exercise elevates temp
– Hormones
– External factors – heat, hot drinks, warm clothing
– Internal factors - dehydration
Temperature
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Heat lost from body by
– Skin
• Sweating
• Increased blood flow to skin surface
– Lungs
• Increased resp rate
– Elimination
• Urine or feces
Temperature
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Heat conserved by body through
– Reducing perspiration
– Decreasing flow of blood to skin
– Shivering
• Increases muscle activity & produces heat
Temperature Norms
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Adult 97 – 99 degrees Fahrenheit
– Oral – 98.6
– Rectal – 99.6
– Axillary – 97.6
– Tympanic – 98.6
Temperature procedure
Wear gloves
 Shake mercury down below 96
 If smoked or had something to drink,
wait 10 min
 Insert thermometer, wait….
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– Oral – under tongue, 5 minutes
– Axillary – in armpit, 10 minutes
– Rectal – in rectum, 3 minutes
Contraindications for oral temps
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Confused, disoriented
Restless
Unconscious
Coughing, unable to breathe through nose
Seizures
Oral/nasal oxygen
NG
Contraindications for rectal
temps
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Diarrhea
Fecal impaction
Rectal bleeding
Hemorrhoids
Surgical rectal closure
When doing rectal temps, remember
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Lubricant before inserting thermometer
Insert 1 – 1 ½ inches
Hold thermometer in place
NEVER leave resident
Nursing measures
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Raise temperature
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Increase thermostat in room
Add blankets or clothing
Give hot or warm liquids to drink
Give warm baths or soaks
Lower temperature
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Lower thermostat in room
Remove clothing or blankets
Offer cool liquids to drink
Provide cool or tepid bath or sponge
Pulse
Force against the arterial walls that
cause them to expand with each
heartbeat
 Count for one minute
 Norm adult pulse is 60 –100 beats/min
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– < 60 beats/min = bradycardia
– > 100 beats/min = tachycardia
Major pulse sites
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Carotid – neck
Apical – left chest below nipple (need
stethescope)
Brachial – inner aspect of elbow
Radial – thumb side of wrist
Femoral – groin
Popliteal – behind knee
Posterior tibialis – behind inner ankle
Dorsalis pedis – on top of foot
Factors that increase pulse
Exercise
 Strong emotions – fear, anger, laughter,
excitement
 Fever
 Pain
 Shock
 Hemorrhage
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Factors that decrease pulse
Sleep/rest
 Depression
 Drugs – digitalis, morphine
 Athletes in good physical condition may
have a lower pulse, probably <60
beats/min. This is normal
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Qualities of pulse
Rate – number of beats/min
 Rhythm – regularity of pulse
 Strength – force
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– Weak or thready
– Bounding
– Strong
Respiration
Exchange of oxygen & carbon dioxide in
lungs
 1 respiration = 1 inhalation + 1
exhalation
 Regulated by the medulla
 Normal adult rate is 16 – 20 breaths/min
 Normal breathing is quiet, effortless, &
regular in rhythm
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Qualities to observe for Resp
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Rate
Rhythm
Depth – shallow, norm, deep
Effort involved to breathe
Discomfort it causes
Position resident adopts
Sounds that accompany it
Color of skin, mucous membranes, nailbeds –
check for cyanosis
Abnormal breathing
Labored – struggles to breathe
 Orthopnea- can breathe only when sitting or standing
 Stertorous – snoring sounds when breathing (partial
airway obstruction)
 Abdominal – uses abd muscles
 Shallow – uses only upper part of lungs
 Dyspnea – painful or difficult breathing
 Tachypnea – resp rate > 24 per min
 Bradypnea – resp rate < 10 per min
 Apnea – absence of breathing
 Cheyne-Stokes – resp gradually increase in rate &
depth & then become shallow & slow
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Process of taking TPR
Take temperature first
 Pulse second
 Respirations last
 When taking resp, keep fingers on pulse
so that resident does not know you are
counting resp
 Document all together
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Blood pressure
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Pressure exerted against walls of blood
vessels
– Systolic – highest reading
• Pressure when heart contracting
– Diastolic – lower reading
• Pressure when heart is at rest
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Hear thumping sounds as blood flows
through arteries
– Sounds correspond to numbers representing mm
Hg on sphygmomanometer
– First sound heard is systolic
– Last sound heard is diastolic
Blood pressure
Normal adult reading 120/80
 Normal systolic = 100 – 140
 Normal diastolic = 60 – 90
 Abnormal readings
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– Hypertension – BP > 140/90
– Hypotension – BP < 90/60
Factors increasing BP
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Strong emotion
Exercise
Sitting or standing
Excitement
Pain
Decrease of vessel size
Digestion
Improperly placed or sized cuff
Factors decreasing BP
Rest/sleep
 Lying down
 Depression
 Shock
 Hemorrhage
 Improperly sized cuff
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Equipment for BP
Sphygmomanometer
 Cuff
 Stethescope
 Cuff too narrow gives false high
 Cuff below heart level will give false
high
 Cuff too large or improperly placed can
give false low
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Procedure for BP
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Guidelines
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Measure BP at brachial artery
Do not use injured arm, arm with IV, or casted
Resident should be at rest
Position arm level with heart
Apply cuff to bare arm NOT over clothing
Use appropriate size cuff
Position sphygmomanometer at eye level
Pain
Ask resident if they have pain
 Observe facial expression, movement,
respiration
 Ask level of pain using facility method
(Usually number 0 – 10)
 Report c/o pain to licensed nurse
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Charting VS
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Report norm & abn to licensed nurse
Record on flow sheets, graphic records, & NA
notes according to facility
Record in TPR order
Chart rectal temps with “R”
Chart axillary temps with “Ax”
Pulse readings other than radial are noted
If BP in a place other than arm,note location
Write BP on chart as a fraction