1. define important words in this chapter apical pulse:

13Vital Signs

1. Define important words in this chapterapical pulse:

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

apnea: the absence of breathing; may be temporary.

BPM: the abbreviation for “beats per minute.”

brachial pulse: the pulse inside the elbow; used to measure blood pressure.

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1. Define important words in this chapter (con’t)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 or rapid, shallow respirations.

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

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1. Define important words in this chapter (con’t)dilate:

to widen.

dyspnea: difficulty breathing.

eupnea: normal respirations.

expiration: the process of exhaling air out of the lungs.

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1. Define important words in this chapter (con’t)Fahrenheit:

a temperature scale where the boiling point of water is 212 degrees and the freezing point of water is 32 degrees.

hypertension: high blood pressure.

hypotension: low blood pressure.

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

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1. Define important words in this chapter (con’t)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 up; also called postural hypotension.

prehypertension: a 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 does not have high blood pressure now but is likely to have it in the future.

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1. Define important words in this chapter (con’t)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). .

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.

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1. Define important words in this chapter (con’t)systolic:

first 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.

tachypnea: rapid respirations.

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

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1. Define important words in this chapter (con’t)vital signs:

measurements that monitor the function of the vital organs of the body.

13Vital Signs

2. Discuss the relationship of vital signs to health and well-being

• Vital signs consist of body temperature, pulse, respirations, blood pressure, and pain level.

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3. Identify factors that affect body temperature

Factors that affect body temperature include:

• The person’s age• Amount of exercise• The circadian rhythm• Stress• Illnesses• Environment

Hypothermia is a condition in which body temperature drops below the level required for normal functioning.

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4. List guidelines for taking body temperature

Common types of thermometers are:

• Mercury-free glass• Digital• Electronic• Disposable• Tympanic• Temporal artery thermometer

Measuring and recording oral temperature

Equipment: mercury-free glass, digital, or electronic thermometer, gloves, disposable plastic sheath/cover for thermometers, tissues, pen and paper

Do not take an oral temperature on a resident who has eaten or drunk fluids 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. Encourage resident to assist if possible.

4. Provide for the resident’s privacy with a curtain, screen, or door.

5. Put on gloves.


Using a mercury-free glass thermometer:

6. Hold thermometer by stem.

7. 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.


(con’t) With a snapping motion of the wrist, shake the thermometer (Fig. 13-8). Stand away from furniture and walls while doing so.

Fig. 13-8. Shake thermometer down to below the lowest number before inserting in a resident’s mouth.


8. Put on disposable sheath, if applicable. Gently insert bulb end of thermometer into resident’s mouth. Place it under tongue and to one side (Fig. 13-9). Resident should breathe through his or her nose.

9. Tell resident to hold thermometer in mouth with lips closed. Assist as necessary. Ask the resident not to bite down or to talk.

Fig. 13-9. Insert thermometer under the resident’s tongue and to one side.


10. Leave thermometer in place for at least three minutes.

11. Remove the thermometer. Wipe with tissue from stem to bulb or remove sheath. Dispose of tissue or sheath.

12. Hold thermometer at eye level. Roll thermometer between your thumb and forefinger until the line appears.


(con’t) Read temperature. Remember the temperature reading.

13. Clean thermometer according to facility policy. Return it to plastic case or container. Store it away from any heat source.


Using a digital thermometer:

6. Put on disposable sheath.

7. Turn on thermometer. Wait until “ready” sign appears.

8. Insert end of digital thermometer into resident’s mouth. Place under tongue and to one side.


9. Leave in place until thermometer blinks or beeps.

10. Remove the thermometer.

11. Read temperature on display screen. Remember the temperature reading.

12. Using a tissue, remove and dispose of sheath.


13. Clean thermometer according to facility policy. Replace thermometer in case.

Using an electronic thermometer:

6. Remove probe from base unit.

7. Put on probe cover.

8. Insert the covered probe into resident’s mouth. Place under tongue and to one side.


9. Leave in place until you hear a tone or see a flashing or steady light.

10. Read the temperature on the display screen. Remember the temperature reading.

11. Remove the probe.

12. Press the eject button to discard the cover (Fig. 13-10).

13. Return the probe to the holder.

Fig. 13-10. Eject the probe cover after use.


Final steps for all methods:

14. Remove privacy measures. Make resident comfortable.

15. Remove and dispose of gloves properly.

16. Leave call light within resident’s reach.

17. Wash your hands.

18. Be courteous and respectful at all times.


19. Report any changes in the resident to the nurse. Document procedure using facility guidelines. Record resident’s name, temperature, date, time, and method used (oral).

Measuring and recording rectal temperature

Equipment: rectal mercury-free glass, digital or electronic thermometer, lubricant, gloves, tissue, disposable plastic sheath/cover, pen and paper


2. 2. Wash your hands.




5. Practice good body mechanics. Adjust bed to safe working level, usually waist high. Lock bed wheels.


6. Lower the side rail (if bed has one and if it is not already lowered) on side nearest you.

7. Help the resident to left-lying (Sims’) position (Fig. 13-11).

8. Fold back linens to expose only rectal area.

9. Put on gloves.Fig. 13-11. The resident must be in the left-lying (Sims’) position.


10. Mercury-free glass thermometer: Hold thermometer by stem. Shake thermometer down to below the lowest number.

Put on disposable sheath. Apply small amount of lubricant to sheath.

Digital thermometer: Put on disposable sheath. Apply small amount of lubricant to sheath.


Turn on thermometer. Wait until “ready” sign appears.

Electronic thermometer: Remove probe from base unit. Put on probe cover. Apply small amount of lubricant to cover.


11. Separate the buttocks. Gently insert thermometer one inch into rectum (Fig. 13-12). Stop if you meet resistance. Do not force the thermometer in the rectum.

12. Replace sheet over buttocks. Hold onto the thermometer at all times.

Fig. 13-12. Gently insert a rectal thermometer one inch into the rectum. Do not force it into the rectum.


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

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

Electronic thermometer: Leave in place until you hear a tone or see a flashing or steady light.


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

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

16. Mercury-free glass thermometer: Clean thermometer according to facility policy. Return it to plastic case or container.


Digital thermometer: Discard sheath. Clean thermometer according to facility policy. Return thermometer to storage area.

Electronic thermometer: Discard the cover. Return probe to holder.

17. Remove and dispose of gloves properly. Wash your hands.


18. Make resident comfortable

19. Return bed to low position if raised. Ensure resident’s safety. Return side rails to ordered position. Remove privacy measures.





23. Report any changes in the resident to the nurse. Document procedure using facility guidelines. Record resident’s name, temperature, date, time, and method used (rectal).

Measuring and recording tympanic temperature

Equipment: mercury-free glass, digital or electronic thermometer, gloves, tissues, 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.


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 pulling up and back on the outside edge of the ear (Fig. 13-13). Insert the covered probe into the ear canal. Press the button.

Fig. 13-13. Straighten the ear canal by pulling up and back on the outside edge of the ear.


8. Hold thermometer in place until thermometer blinks or beeps.

9. Read temperature. Remember the temperature reading. (If the reading seems too low, repeat the procedure.)

10. Dispose of sheath. Return thermometer to storage or to the battery charger if thermometer is rechargeable.


11. Make resident comfortable.

12. Remove privacy measures.






17. Report any changes in the resident to the nurse. Document procedure using facility guidelines. Record resident’s name, temperature, date, time, and method used (tympanic).

Measuring and recording axillary temperature

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


2. Wash your hands.


6. Put on gloves.

7. Remove resident’s arm from sleeve of gown. Wipe axillary area with tissues.

8. Mercury-free glass thermometer: Hold thermometer by stem. Shake thermometer down to below the lowest number.

Put on disposable sheath, if applicable.


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.

9. Place the end of thermometer in center of armpit. Fold resident’s arm over chest.


10. Mercury-free glass thermometer: Hold thermometer in place, with the arm close against the side, for 10 minutes (Fig. 13-14).

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

Electronic thermometer: Leave in place until you hear a tone or see a flashing or steady light.

Fig. 13-14. After inserting the thermometer, fold the resident’s arm over her chest and hold it in place for the required time.


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

12. Read thermometer as you would for an oral temperature. Remember the temperature reading.


13. Mercury-free glass thermometer: Clean thermometer according to facility policy. Return it to container for used thermometers.

Digital thermometer: Discard sheath. Clean thermometer according to facility policy. Return thermometer to storage area.


Electronic thermometer: Discard the cover. Return probe to holder.

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



20. Report any changes in the resident to the nurse. Document procedure using facility guidelines. Record resident’s name, temperature, date, time, and method used (axillary).

13Vital Signs

5. Explain pulse and respirations

The pulse count is the number of times the heart beats per minute.

Different types of respiration are:

• Apnea

• Dyspnea

• Eupnea

• Orthopnea

• Tachypnea

• Cheyne-Stokes respiration

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6. List guidelines for taking pulse and respirations

• The radial pulse is the most common site for counting pulse beats and is found on the inside of the wrist, on the thumb-side of the body.

• The apical pulse is heard by listening directly over the heart with a stethoscope.

Measuring and recording radial pulse and counting and recording respirations

Equipment: watch with second hand, pen and paper


2. Wash your hands.




5. Place fingertips on thumb side of resident’s wrist to locate pulse (Fig. 13-18).

6. Count beats for one full minute.

Fig. 13-18. Take the radial pulse by placing fingertips on the thumb side of the wrist.


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.

Measuring and recording apical pulse

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


2. Wash your hands.





6. 6. Lower the side rail (if bed has one and if it is not already lowered) on side nearest you.


7. Before using stethoscope, wipe diaphragm and earpieces with alcohol wipes.

8. 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.


9. Use the second hand of your watch. Count beats for one full minute. Each “lubdub” that you hear is counted as one beat. A normal heartbeat is rhythmic (Fig. 13-19). Leave the stethoscope in place to count respirations.

10. Clean earpieces and diaphragm of stethoscope with alcohol wipes. Store stethoscope.

Fig. 13-19. Count the heartbeats for one full minute to measure the apical pulse.



16. 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.

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.


6. Lower the side rail (if bed has one and if it is not already lowered) on side nearest you.


8. 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.


9. Your co-worker should place her fingertips on the thumb side of resident’s wrist to locate the radial pulse.

10. 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 (Fig. 13-20).

Fig. 13-20. Use the second hand on your watch to count the beats for one full minute.


11. Clean earpieces and diaphragm of stethoscope with alcohol wipes. Store stethoscope.




17. 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

• The top number in a blood pressure reading is called the systolic blood pressure.

• The bottom number is the diastolic blood pressure.

• When blood pressure is too high, it is called hypertension.

• When blood pressure is too low, it is called hypotension.

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8. List guidelines for taking blood pressure

Types of sphygmomanometers:

• Aneroid sphygmomanometer

• Electronic sphygmomanometer

• Non-invasive blood pressure monitoring (NIBP)

Measuring and recording blood pressure (one-step method)

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


2. Wash your hands.


5. Position resident’s arm with palm up. The arm should be level with the heart. Roll up long sleeves approximately five inches above the elbow.

6. With the valve open, squeeze the cuff. Make sure it is completely deflated.


7. Place blood pressure cuff snugly on resident’s upper arm. The center of the cuff is placed over the brachial artery (1-1½ inches above the elbow toward inside of elbow) (Fig. 13-24).


9. Locate brachial pulse with fingertips.

Fig. 13-24. Place the center of the cuff over the brachial artery.


10. Place diaphragm of stethoscope over brachial artery.

11. Place earpieces of stethoscope in ears.

12. Close the valve (clockwise) until it stops. Do not over-tighten it (Fig. 13-25)

13. Inflate cuff to 30 mm Hg above the point at which the pulse is last heard.

Fig. 13-25. Close the valve by turning it clockwise until it stops.


14. Open the valve slightly with thumb and index finger. Deflate cuff slowly.

15. Watch gauge. Listen for sound of pulse.

16. Remember the reading at which the first clear pulse sound is heard. This is the systolic pressure.


17. 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.

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


19. Wipe diaphragm and earpieces of stethoscope with alcohol. Store equipment.

20. Make resident comfortable. Remove privacy measures.





24. Report any changes in the resident to the nurse. Document procedure using facility guidelines. Record both the systolic and diastolic pressures.

Measuring and recording blood pressure (two-step method)

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


2. Wash your hands.


5. Position resident’s arm with palm up. The arm should be level with the heart. Roll up long sleeves approximately five inches above the elbow.

6. With the valve open, squeeze the cuff. Make sure it is completely deflated.


7. Place blood pressure cuff snugly on resident’s upper arm. The center of the cuff is placed over the brachial artery (1-1½ inches above the elbow toward inside of elbow).

8. Locate the radial (wrist) pulse with fingertips.

9. Close the valve (clockwise) until it stops. Inflate cuff slowly, watching gauge.


10. Stop inflating when you can no longer feel the pulse. Note the reading. The number is an estimate of the systolic pressure.

11. Open the valve. Deflate cuff completely.

12. Write down estimated systolic reading.


13. Before using stethoscope, wipe diaphragm and earpieces of stethoscope with alcohol wipes.

14. Locate brachial pulse with fingertips.


15. Place diaphragm of stethoscope over brachial artery.

16. Place earpieces of stethoscope in ears.

17. Close the valve (clockwise) until it stops. Do not over-tighten it (Fig. 13-26).

Fig. 13-26. Close the valve but do not over-tighten it. Tight valves are too hard to release.


18. Inflate cuff to 30 mm Hg above your estimated systolic pressure.

19. Open the valve slightly with thumb and index finger. Deflate cuff slowly.

20. Watch gauge. Listen for sound of pulse.

21. Remember the reading at which the first clear pulse sound is heard. This is the systolic pressure.


22. 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.

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


24. Wipe diaphragm and earpieces of stethoscope with alcohol. Store equipment.

25. Make resident comfortable. Remove privacy measures.





29. Report any changes in the resident to the nurse. Document procedure using facility guidelines. Record systolic and diastolic pressures.

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9. Describe guidelines for pain management

Signs of pain:

• Sweating

• Nausea

• Vomiting

• Tightening of the jaw

• Holding a body part tightly

• Frowning

• Grinding teeth, etc.

1. define important words in this chapter apical pulse:

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