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Measurements
Pre-CNASP2-AP2
This presentation will: Briefly review the four vital signs Height and weight Intake and Output
Measurements When working with
your resident, you will measure:
Vital signs (VS)
Height/weight (ht/wt)
Intake and output (I&O)
Why Do You Take Vital Signs? 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
Vital signs include:TemperaturePulseRespirationBlood pressure
Report vital signs promptly when: they are above or below normal.
there is a significant change from the prior reading.
Body Temperature 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
Oral Temperature Taken in the mouth. Do not use if a
person has an injury to his mouth, difficulty breathing, or confusion.
Normal Range97.6-99.6 F
(36.5 C-37.5 C)
Rectal Temperature Do not use when the
person has: diarrhea, a rectal
injury or rectal surgery, heart disease, or confusion.
Normal Range98.6-100.6 F
(37.0-38.0 C) Most accurate route
Tympanic Temperature 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)
Pulse Used to monitor
the circulatory system (heart and blood vessels)
Pulse Rate 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
Rhythm Regular: same amount
of time between beats
Irregular: NOT the same amount of time between beats or skipped (missed)beats
Strength Strong/
bounding: easy to feel
Weak/thready: difficult to feel
The Pulse Sites
Taking A Pulse These pictures
show radial and brachial pulse sites.
Radial pulse 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 Used to monitor
the circulatory system.
Normal range:90-12060-80
SystolicDiastolic
Systolic Heart is contracting Higher or top number First sound you hear Normal Range:
90-120mmHg
Diastolic Heart is resting Lower or bottom
number Last sound you hear Normal Range:
60-80mmHg
Hypertension Hyper=“too much”
Tension=“pressure” High BP Systolic >140 Diastolic>90
Hypotension Hypo=“too little” Tension=“pressur
e” Low BP Systolic<90 Diastolic<60
When do you not use a person’s arm to measure blood pressure?
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?
Manometer Bulb valve cuff
Respiration Respiration means
breathing air into (inhalation) and out of (exhalation) the lungs.
1 respiration= 1 exhalation + 1 inhalation
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 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 Baseline height and
weight is measured when the resident is admitted to the nursing home.
Height Standing:
No shoes, have the person
stand straight. Lying
Have person in good alignment in supine position.
Using a tape measure, measure from top of head to soles of feet.
Weight• 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 Urine Diarrhea Emesis Drainage Sweat
(perspiration) Breathing
(exhalation)
As a NA, you will help record:
Oral Fluid Intake water, milk, juice,
coffee, etc. Foods that melt at
room temperature: Ice cream Jello Popsicles
You will also record:
Measurable fluid output: Urine Diarrhea Emesis Drainage from tubes
You cannot measure: Non-measurable output
Sweat Breathing Wound drainage without
a tube If a person is incontinent
How many milliliters (ml) in an ounce? 1 ounce (oz) = 30 ml (cc)
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