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

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1. Define important words in this chapter

apical pulsethe pulse on the left side of the chest, just below the nipple.

apneathe 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.

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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.

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diastolic second measurement of blood pressure; phase when the heart relaxes.

dilate to widen.

dyspnea difficulty breathing.

eupneanormal respirations.

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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.

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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.

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prehypertensiona 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).

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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.

systolicfirst 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.

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tachypnea rapid respirations—over 20 breaths per minute.

thermometera device used for measuring the degree of heat or cold.

vital signsmeasurements (body temperature, pulse, respirations, blood pressure, and pain level) that monitor the function of the vital organs of the body.

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2. Discuss the relationship of vital signs to health and well-beingDefine the following term:vital signsmeasurements (body temperature, pulse, respirations, blood pressure, and pain level) that monitor the function of the vital organs of the body.

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2. Discuss the relationship of vital signs to health and well-beingKnow that vital signs consist of the following:• Taking temperature• Counting pulse• Counting rate of respirations• Taking blood pressure• Observing and reporting pain level

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2. Discuss the relationship of vital signs to health and well-beingREMEMBER:A change in vital signs is often the first indication that someone is ill.

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Transparency 13-1: Ranges for Adult Vital Signs

Temp. Site Fahrenheit CelsiusOral 97.6° - 99.6° 36.5° - 37.5°Rectal 98.6° - 100.6° 37.0° - 38.1°

Axillary 96.6°- 98.6° 36.0° - 37.0° Normal Pulse Rate: 60-100 beats per minuteNormal Respiratory Rate: 12-20 respirations per minuteBlood PressureNormalSystolic: 100-119Diastolic: 60-79

LowBelow 100/60

PrehypertensiveSystolic: 120-139Diastolic: 80-89

High140/90 or above

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3. Identify factors that affect body temperature

Remember that these factors affect body temperature:• Age• Amount of exercise• Circadian rhythm• Stress• Illness• Environment

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Define the following term:hypothermia a condition in which body temperature drops below the level required for normal functioning; severe sub-normal body temperature.

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Know the signs of hypothermia:• Shivering• Numbness• Quick and shallow breathing• Slow movements• Mild confusion• Changes in mental status• Pale and cyanotic skin

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4. List guidelines for taking body temperature

Define the following terms:thermometera 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.

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Know the four main sites for measuring temperature:• Mouth• Rectum• Armpit• Ear

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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.

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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.

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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 mercury-free, 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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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).

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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.

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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


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.



5. Adjust bed to safe working level, usually waist high. Lock bed wheels.

6. Help the resident to left-lying (Sims’) position.

7. Fold back linens to expose only rectal area.

8. Put on gloves.


9. Mercury-free thermometer: Hold thermometer by stem. Shake thermometer down to below the lowest number. Put on disposable sheath.



10. Apply a small amount of lubricant to tip of bulb or probe cover (or apply pre-lubricated cover).


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.


13. Mercury-free thermometer: Hold thermometer in place for at least three minutes.

Digital thermometer: Hold thermometer in place until thermometer blinks or beeps.


14. Gently remove the thermometer. Wipe with tissue from stem to bulb or remove sheath or cover. Dispose of tissue or sheath.


15. Read thermometer at eye level as you would for an oral temperature. Remember the temperature reading.


Digital thermometer: Clean thermometer according to facility policy. Replace thermometer in case.



17. Remove and discard gloves.


19. Make resident comfortable.

20. Return bed to lowest position. Remove privacy measures.





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


2. Wash your hands.




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.


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.







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 mercury-free, digital or electronic thermometer, gloves, tissues, disposable sheath/cover, pen and paper


2. Wash your hands.




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.


8. Mercury-free thermometer: Hold thermometer by stem. Shake thermometer down to below the lowest number. Put on disposable sheath, if applicable.




9. Position thermometer (bulb end for mercury-free) 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.



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.



Digital thermometer: Using a tissue, remove and dispose of sheath. Clean thermometer according to facility policy. Replace the thermometer in case.




14. Put resident’s arm back into sleeve of gown. Make resident comfortable.

15. Return bed to lowest position. Remove privacy measures.





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).

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Handout 13-1: Thermometer Worksheet

1. Reading: _________________

2. Reading: _________________

3. Reading: _________________

4. Reading: _________________

5. Reading: _________________

Write the temperature reading to the nearest tenth degree underneath each of the examples below.

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Handout 13-1: Thermometer Worksheet (cont’d.)

6. Reading: _________________

7. Reading: _________________

8. Reading: _________________

9. Reading: _________________

10. Reading: _________________

Write the temperature reading to the nearest tenth degree underneath each of the examples below.

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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.

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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.

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Remember that these factors affect pulse rate:• Age• Sex• Exercise• Stress• Hemorrhage• Medications• Fever and illness

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Define the following terms:apneathe absence of breathing.

dyspnea difficulty breathing.

eupneanormal respirations.

orthopnea shortness of breath when lying down that is relieved by sitting up.

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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.

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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.

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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.

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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


2. Wash your hands.




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.


8. Remove privacy measures. Make resident comfortable.




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.

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Define the following term:apical pulsethe pulse on the left side of the chest, just below the nipple.

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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?

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REMEMBER:The apical pulse is normally about the same as the radial pulse.

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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


2. Wash your hands.




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.


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.






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.

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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.


2. Wash your hands.




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.


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.







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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7. Identify factors that affect blood pressure

Define the following terms:systolicfirst 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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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.

prehypertensiona 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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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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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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There are different types of sphygmomanometers:• AneroidThis device has a round gauge that is portable or is attached to the wall. It may also hook onto clothing.

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Different types of sphygmomanometers (cont’d.):• ElectronicThis 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.

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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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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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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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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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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.

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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. ___________________________


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Handout 13-2: Blood Pressure Worksheet (cont’d.)

Record the blood pressure shown on the appropriate line and answer the question below

3. ___________________________


4. ___________________________


Measuring and recording blood pressure (one-step method)

Equipment: sphygmomanometer, stethoscope, watch with second hand, alcohol wipes, pen and paper


2. Wash your hands.




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.

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.


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.


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.


19. Open the valve. Deflate cuff completely. Remove cuff.

20. Wipe diaphragm and earpieces of the stethoscope with alcohol. Store equipment.






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


2. Wash your hands.




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.


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.


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.


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.


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.


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.






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.

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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.

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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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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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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.

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ExamMultiple 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

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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

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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

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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

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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.

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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.

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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

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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

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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.

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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

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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

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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

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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

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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

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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