Vital Signs – Weight/HeightUnit V

I. Identify Vital SignsII. Discuss NAR responsibilityIII. Identify methods and responsibilities when

obtaining height and weightIV. Recognize how Lack of Oxygen Affects Vital

SignsV. Identify effective methods of providing oxygen

to Residents.

Vital Sign Skills Oxygen tubing safety Temperature with a glass thermometer Temperature with an electronic

thermometer Pulse and Respiration Blood Pressure Height and weight measurements

Key Terms

Temperature - Measurement of body heat.

Fever - Elevated temperature; usually a sign of illness.

Pulse - Expansion and contraction of an artery.

Pulse Rate - Measures heart beats; the number of times the heartbeats per minute

Pulse Spots - Areas on body where pulse can be counted ormeasured.

Respirations – The process of breathing; the exchange of gases(oxygen and carbon dioxide) in the lungs.

Blood Pressure – Measurement of the force of the blood againstthe walls of the arteries.

Systolic Pressure - Number at which the first sound is heard orhighest number when the blood pressure ismeasured.

Diastolic Pressure - Number at which the last sound is heard or lowest number when blood pressure ismeasured.

Hypertension - High blood pressure; greater than 140/90.

Hypotension - Low blood pressure; lower than 90/50.

TPR - Abbreviation for temperature, pulse andrespiration.

VS - Abbreviation for vital signs which aretemperature, pulse, respiration and bloodpressure.

I. Describe Vital Signs

A. Define Vital Signs

1. Measurement of the functioning of vital (necessary forlife) organs of the body: heart, lungs and blood vessels.

2. The resident’s condition can be monitored by vitalsigns; temperature, pulse, respiration and bloodpressure.

3. Accuracy is important4. Report immediately to the nurse vital signs which are

high or low compared to the resident’s usual range.5. Vital signs are measured ad rest meaning the resident

has been sitting or lying for at least 15 minutes.

B. Temperature – Measurement of Body Heat

1. Thermometers measure temperature using eitherFahrenheit or Celsius scales, both of which aredivided into units called degrees. Be alert towhich time of thermometer your facility uses.

2. When the temperature is elevated, the resident issaid to have a “fever”.

3. Temperatures can be increased by:a. Infection, illnessb. Dehydration (lack of fluids)c. Physical exercised. Intake of hot liquidse. Extremely warm environmentf. Emotions such as crying

4. Temperatures can be decreased by:a. Shockb. Cold environmentc. Medications

5. Realize “normal temperature” is a range of normal. Eachresident has his/her own true normal. Older persons’ normaltemperature may be slightly lower (97-98 degrees F) thanthe usual normal temperature of 98.6.F or 37 C.

B. Temperature – Measurement of Body Heat (Cont.)

B. Temperature – Measurement of Body Heat (Cont.)

6. List sites where temperatures are measureda. Oral – by mouth

- may be measured with glass, electronic or digital thermometer.

- used when the resident is alert,cooperative.

- glass thermometer has a blue tip onend, a bulb or slender end with mercury.

- should not be taken if resident has justtaken hot or cold liquids (wait 5-10 minutesbefore taking oral temperature).

B. Temperature – Measurement of Body Heat (Cont.)

6. List sites where temperatures are measured (Cont.)

b. Axillary - underarm- Glass thermometers usually used for measurement- Least accurate method- Used only when unable to take oral, rectal or

tympanic- Normal axillary temp is 97.6 degrees F- Indicate with “A” when axillary temp is taken

B. Temperature – Measurement of Body Heat (Cont.)6. List sites where temperatures are measured (Cont.)

c. Rectal – rectum- Glass or electronic thermometer are usually used.- Most accurate method.- Glass thermometer has a red tip on end, a rounded

bulb with mercury.- Normal rectal temp is 99.6 temp degrees F.- Indicate by “R” if temperature was taken rectally.

d. Tympanic – ear- Most commonly used.- Used with all ages and health conditions.- Reads temperature from blood vessels in ear drum.- Fit probe snugly in ear.- Impacted wax in ear canal may result in incorrect

reading.

B. Temperature – Measurement of Body Heat (Cont.)

7. Electronic Thermometers

a. Audible beep usuallyIndicates measurementCompleted.

b. The reading of thetemperature is shown ona digital lighted display.

c. Be alert to Fahrenheit andCelsius scales.

d. Cover probe with disposable plasticsheath or cup.

e. Follow procedure foruse as indicated bymanufacturer or facility policy.

f. Stay with resident.

B. Temperature – Measurement of Body Heat (Cont.)

8. Describe general rules for taking temperature with glassThermometer.a. Do not take oral temperature with glass thermometer

On children under 5 years of age, confused adults,Or those with seizure disorders.

b. Check thermometer for chips, cracks.c. Shake mercury down away from resident or hard

Objects before inserting.d. Lubricate rectal thermometer wiping from colored

end to mercury tip before inserting.e. Cover with disposable plastic film sheath.f. Hold thermometer in place.g. Stay with resident.h. Disinfect according to facility policy.

B. Temperature – Measurement of Body Heat (Cont.)

8. Describe general rules for taking temperature with glass thermometer (Cont.)

i. Describe reading a glass thermometer.- Remove and discard plastic film sheath.- Hold at eye level and locate the mercury column.- Each long line is one degree.- Each shorter line indicates 0.2 (two-tenths) degree.- Read thermometer at line where mercury ends.

9. Temperatures are always recorded as whole numbers anddecimals such as 98.6.

C. Pulse

1. Pulse is the expansion and contraction of an artery (bloodvessel).

2. Pulse rate indicates how fast the heart is beating.3. Pulse rate may be measured at several body sites.

a. Radial (wrist) pulse is most common site.4. Rate of Pulse – number of beats per minute.

a. Rate varies with individuals – depends on age, sex,body size and exercise.

b. Usually pulse rate goes up as temperature increases.c. Normal adult resting rate if 60-80 beats per minute.

- Pulse rates of the elderly are affected by disease conditions and some medications.

C. Pulse

5. List observations when measuring radialpulse.a. Resident should be at rest.b. Arm to be resting on a surface such as a

bed or table.c. Use tips of 2nd and 3rd fingers; never use thumb because

you may feel your own pulse in thumb.d. Press gently, compressing blood vessel between your

fingers and resident’s radial (wrist) bone.e. Note rate – number of beats.f. Under 60 bpm is bradycardia, over 100 bpm is tachycardia

C. Pulse (Cont.)

f. Note rhythm – regularity- normal pulse – smooth, equal time between beats,

equal pressure- irregular – time between beats is not equal- intermittent – period of some normal beats followed

by irregular or skipped beats.g. Note volume – weak, thready, strong.h. Count for 30 seconds if pulse is regular or one minute

if pulse is irregular, or as indicated by your facility orresident’s care plan.

i. Record what pulse would be in one minute(if counting for 30 seconds, double andrecord number).

j. Pulse rates are recorded in whole numbers.

D. Respirations1. Respiration is the body process of breathing which

Supplies the body with oxygen and releases carbonDioxide.

2. Respiration includesa. Inspiration (breathing in)b. Expiration (breathing out)

3. Normal respirationsa. Adults – 16-22 per minute

4. Respirations increase witha. Infection and some chronic diseasesb. Fever (elevated temperature)c. Some heart, lung and blood vessel diseasesd. Emotional upsets, stress, cryinge. Exercise or activity

D. Respirations (Cont.)

5. Respirations decrease witha. Some medications and diseases

6. Guidelines when taking respirationsa. Breathing can be controlled, so resident is not informed

when respirations are counted.b. One inspiration and one expiration of breath is counted

as one respiration.c. Count respirations immediately following the pulse

count, remembering the pulse count as you count the rise and fall of the chest.

d. Keep your fingers in same position on wrist as whencounting pulse in order not to disturb the resident’sbreathing pattern.

D. Respirations (Cont.)

e. Note if respirations are:- regular- shallow- deep- difficult, labored (working or struggling to get a breath)

f. Count respirations for 30 seconds or 1 minute, as indicatedBy your facility or resident’s care plan.

g. Count for one full minute if respirations are irregular.h. Record what respirations would be for one minute (if

counting for one minute (if counting for 30 seconds, doubleand record number).

i. Respirations are recorded in whole numbers.

E. Blood Pressure

1. Blood pressure is the force of blood pushingagainst the walls of the blood vessels.

2. General guidelines when taking blood pressure

a. Equipment should be in good working condition.b. Use cuff of correct size for thickness of upper

arm. (Sphygmomanometer)c. Have gauge at eye level.

d. Resident should be sitting or lying ina relaxed comfortable position, witharm resting on solid surface.

e. Use arm indicated on care plan. If no arm is designated to be used, the left arm should be used. Do not use an arm that:- has an intravenous infusion in it.- has been weakened by a CVA (stroke)

f. Inflate cuff to about 160mm. If sound is heard upon immediate release of air, deflate cuff immediately tozero and reinflate to a higher number.

g. Record accurately as a fraction such as 120/80.

E. Blood Pressure (Cont.)

F. Record Vital Signs

1. List correct way to record.a. Temperature written first.b. Pulse listed second.c. Respirations listed last

T P R98.6 80 20

d. Always indicate when temperature is taken rectally oraxillary by placing “R” or “A(Ax)” behind temperature,if temperature is not followed by a “R” or “A” the nursewill assume the temperature is an oral temp.

99.4R 80 2097.4A 80 20

F. Record Vital Signs

e. Record accurately.f. Follow facility policy regarding recording of vital

signs. You may use a graphic sheet to record this date.

Factors affecting Blood Pressure Age Obesity Exercise/sleep Heart disease, diabetes, heredity Pain Blood loss Time of day

Blood Pressure Hypertension is blood pressure higher then

140/90 Hypotension is blood pressure lower then

90/60 Report promptly any abnormal vital sign

Pain – The fifth Vital sign Pain is regularly and frequently evaluated Pain rating scales are 0-10 with 10 the most

severe Observe resident for pain when moving,

facial expressions, crying, moaning, rigid posture, restless, refusal to eat.

Cultural responses to pain varies.

G. Measuring and Recording Height and Weight

1. Height and weight measurements are notvital signs, but are also part of informationcollected to evaluate a person’s health.

2. Weighing Residents

a. Methods of weighing residents:

- standing scale - bed scale - chair scale - tub chair scale - wheelchair scale - mechanical lift scale

b. Accuracy of weighing resident- check care plan for type of scale, time of day and clothing worn.- Know how scale works.- Weigh wheelchair and additional equipment before or after weight resident and subtract from total weight.- Medications and treatments are often ordered depending on changes in resident’s weight.

G. Measuring and Recording Height and Weight

3. Measuring resident’s height

a. Used in nutritional assessmentb. Usually done one, on admissionc. Standing scale has height indicator, tape measure is

used for residents in bed.d. Record in feet and inches or total inches.

How lack of oxygen affects Vital Signs Signs of Hypoxia

Confusion, restlessness, perspiration, cyanosis

Changes in Vital signs. At first pulse is fast and irregular. As O2 becomes less pulse slows dangerously down. Respirations may be rapid and then slow down to dangerous levels.

NOTIFY NURSE immediately.

Providing O2 to residents The purpose of oxygen therapy is to assist

resident who have difficulty breathing because of illness or emergency

Types of O2 delivery system O2 tank (gas or liquid) Concentrator Wall Unit

Methods of Delivery Nasal Canula – most common. Prongs

placed in nose. Oxygen mask – cuplike device placed over

mouth and nose An oximeter is used to measure the

oxygenation of the patient.

NAR Responsibilities Report any skin irritation caused by tubing Elevate HOB as directed Clean residents mouth and moisten lips Know how to read a flow meter and know

the ordered flow rate. Notify nurse immediately if flow is not

correct or resident having breathing problems.

Home Health AideUnit V

Vital Signs – Weight/Height

I. Discuss Measuring Vital Signs in Client’s Home

A. Review measurements of vital signs.

B. Review activities that change vital sign measurements.

C. Know how to use thermometer and other vital sign measurement equipment available in client’s home.

I. Discuss Measuring Vital Signs in Client’s Home (Cont.)

D. Supervisor will describe and demonstrate measurementof infant vital signs if you are required to complete

themon an infant client.1. Infant vital signs vary according to their size and

development.a. Temperature control in infants and young

childrenis unstable but averages between 99.0o –

99.7oF. May not stabilize at 98.6o until school age.

b. Normal pulse ranges.- Infants: ( Birth to 2 yrs) 120-160

beats/minute- toddler: 2-3yrs) 90-140 beats/min.- preschool (3-5Yrs) : 80-120 beats/minute

Normal pulses School age clients 6-12yrs, 70 -110 bpm Adolescents ( 14 – 20) 60 – 90 bpm

I. Discuss Measuring Vital Signs in Client’s Home (Cont.)c. Normal respiratory rate depends on size and lung

development.

Infants: 30 – 60 per minute or greater.Toddlers: 24-40 per minutePreschool: 22-34 per minute

2. Infant Weights

a. Infants usually double birth weightin six months, triple in a year.

b. Infants and younger children weights need to be accurate as medication dosages are prescribed by weight not age.

C. Infant height will double in the first year.