Module 10

Vital Signs

normal range for BP

120/80

normal range for pulse

60-100 beats per minute

counting heart rate with radial pulse

• get close to resident, preferably in a seated position next to the resident

• the resident should be in a supine or seated position

• ask the resident to get into a comfortable position and try to move as little as possible

• assist the resident in moving their hand to rest comfortably on the bed/chair

• use index and middle finger to locate pulse and press hard enough to feel it

• count each beat felt for total of 60 seconds; if you lost the pulse stop and restart

• the total number of beats felt is the heart; if abnormal, retake and then report to nurse

• record the results

on their scheduled bath day, per the facility’s routine, during an episodic illness, or when delegated by the nurse

when are vital signs usually taken?

systolic BP

within the artery when the heart contracts and pushes blood through the veins; top number of BP

diastolic BP

within the artery when the heart is at rest or between contractions; bottom number of BP

counting heart rate with apical pulse

• locate apical pulse found under the left breast; provide for privacy

• place cleaned and warm stethoscope over apical pulse

• ask the resident to be still and not speak

• count the pulse for one minute; each “lub-dub” is a heart beat

• complete finishing up steps

5 minutes

how long do you have to wait to retake BP if the resident’s results are out of results or if you’re not confident with the results?

tachypnea

breathing that is too fast, typically shallow; respirations that are greater than 20 breaths per minute

axillary temperature

used for residents with dementia or other cognitive disabilities;

• clean the stem of thermometer with an alcohol wipe and discard the wipe 

• assist resident in removing one arm from their sleeve to easily access the axilla, ask resident to raise their arm and assist if unable, place thermometer tip directly in the center, deepest fold of the axilla, ask the resident to lower their arm

• hold thermometer in place until it beeps, remove from axilla, obtain the temp from the screen

• repeat if out of normal and report to nurse

• record results

tympanic thermometer; due to operator error

what is the least accurate method for checking resident’s temperature?

97.6 - 99.6 F

what is the average temperature of the temporal artery scanner?

hypertension

blood pressure that is too high; any systolic measurement greater than 130 or diastolic measurement lower than 80 mmHg

hypotension

blood pressure that is too low; any measurement lower than 90/60 mmHg

dyspnea

shortness of breath

pulse points

radial pulse, carotid pulse, femoral pulse, brachial pulse, temporal pulse, apical pulse, popliteal pulse

lymphedema

painful swelling of the arm, a possible complication of blood pressure measurement on the arm of the same side of the body as a mastectomy

during feeding or activities; get vital signs once resident is in the room

when are vital signs not given

give ice cold fluids

what to do with pt who is experiencing a fever without using medications

15-20 minutes

how long should you wait after eating or drinking to take a temperature orally?

normal range for respirations

12-20 breaths per minute

stage 1 hypertension

systolic: 130-139

diastolic: 80-89

stage 2 hypertension

systolic: 140 or more

diastolic: 90 or more

hypertensive crisis

systolic: 180 or more

diastolic: 120 or more; alert nurse immediately

hypotension

lower than 90/60 mmHg; weakness, dizziness, lightheadedness, fainting