nursing assistant vital signs. temperature pulse respiration blood pressure oxygen saturation pain
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Vital Signs
Indicators of body function– Assess body systems– Signify changes taking place in body
Observations should also include– Skin color & temp– Behaviors– Statements from resident (subjective)
Temperature 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
Heat lost from body by– Skin
• Sweating• Increased blood flow to skin surface
– Lungs• Increased resp rate
– Elimination• Urine or feces
Temperature
Heat conserved by body through– Reducing perspiration– Decreasing flow of blood to skin– Shivering
• Increases muscle activity & produces heat
Temperature Norms
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….
– Oral – under tongue, 5 minutes– Axillary – in armpit, 10 minutes– Rectal – in rectum, 3 minutes
Contraindications for oral temps
Confused, disoriented Restless Unconscious Coughing, unable to breathe through nose Seizures Oral/nasal oxygen NG
Contraindications for rectal temps Diarrhea Fecal impaction Rectal bleeding Hemorrhoids Surgical rectal closure When doing rectal temps, remember
– Lubricant before inserting thermometer– Insert 1 – 1 ½ inches– Hold thermometer in place– NEVER leave resident
Nursing measures
Raise temperature– Increase thermostat in room– Add blankets or clothing– Give hot or warm liquids to drink– Give warm baths or soaks
Lower temperature– 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
– < 60 beats/min = bradycardia– > 100 beats/min = tachycardia
Major pulse sites
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
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
Qualities of pulse
Rate – number of beats/min Rhythm – regularity of pulse Strength – force
– 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
Qualities to observe for Resp
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
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
Blood pressure Pressure exerted against walls of blood vessels
– Systolic – highest reading• Pressure when heart contracting
– Diastolic – lower reading• Pressure when heart is at rest
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
– Hypertension – BP > 140/90– Hypotension – BP < 90/60
Factors increasing BP
Strong emotion Exercise Sitting or standing Excitement Pain Decrease of vessel size Digestion Improperly placed or sized cuff
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
Procedure for BP
Guidelines– 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
Charting VS
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