Module AA- Measurement (Vital Signs)

What is the equipment you need to check respiration?

Analog watch and Notepad/assignment sheet and pen

When checking respiration and pulse values what do you need to remember when timing it?

You do it for 60 seconds AND you start and stop on the same number.

Document on the resident’s record if the respirations…

1. Fall between 12-20
2. Regular, quiet, with both sides of chest rising and falling equally.

When do you notify the nurse about respirations?

When respirations are abnormal.

How do you take stealth respirations?

Check respirations right after checking pulse (without moving hand from wrist), so resident does not realize respirations are being counted.

What can you NOT do when checking the pulse of the carotid artery?

Never check pulse rates on both carotid arteries at the same time

What is the apical pulse taken with?

A stethoscope

When checking a radial pulse, what fingers do you use?

The first two or three fingers; NEVER thumb

What is the normal pulse rate for adults?

Between 60-100 beats per minute, regular and strong

When do you notify the nurse about pulse rate?

When it is abnormal.

What are 5 ways blood pressure can change from minute to minute?

1. Activity of resident
2. Lifestyle choices
3. Reaction to stressful events
4. Acute injury or emergency
5. Medications

What genetic factors affect blood pressure?

Age, gender, and race

What is a normal systolic BP value?

90 mm Hg to 119 mm Hg

What is normal diastolic BP value?

60 mm Hg to 79 mm Hg

What value(s) is considered to be an elevated blood pressure?

A systolic value of 120 to 129 mm Hg **AND** diastolic value of below 80 mm Hg

What BP values are considered to be hypertension?

A systolic value of 130 mm Hg or higher **OR** a diastolic value of 80 mm Hg or higher.

What BP values are considered to be hypotension?

A systolic value of 90 mm Hg and lower and/or a diastolic value of 60 mm Hg or lower.

What do you need to check blood pressure?

1. Stethoscope
2. Sphygmomanometer
3. Alcohol wipes
4. Note pad/assignment sheet and pen

How should the stethoscope be worn?

Insert in ears, so that they point forward toward the nose.

Should snugly fit in ears to block out noise.

How do you check if the chest piece of a dual-head stethoscope is active?

1. After inserting ear pieces into ears, tap diaphragm lightly to determine if tap is heard; if tap not heard, rotate chest piece at tubing, and repeat the tap
2. If chest piece has an indicator dot, rotate chest-piece so indicator dot is closed

What should you do before using the stethoscope?

1. Always clean before use, between residents, and after use with an alcohol wipe
2. Warm diaphragm with hand before making contact with resident

How to use the diaphragm?

Apply enough pressure to make a seal against the brachial artery at the crook of the elbow.

If the needle on a manometer lands between two dashes, what do you do?

You round up to the next dash.

How do you determine the values of someone’s blood pressure manually?

The systole value will be when the sound starts, and the diastole value will be when the sound stops.

How to take blood pressure?

1. Choose right size
2. Wrap on upper bare arm
3. Align arrows with brachial artetry, an inch above the elbow
4. Turn air-release valve clockwise to close valve; then squeeze the bulb
5. Inflate cuff to between 160 mm Hg to 180 mm Hg
6. If a beat is heard immediately, deflate the cuff; wait 30-60 seconds; inflate cuff to no more than 200 mm Hg.
7. To deflate cuff and open valve, turn air release valve counterclockwise with the thumb and index finger in a slow and controlled manner, remember thumb goes down, needle goes down.

What should you never do when taking blood pressure?

* Do not take blood pressure on an arm with an IV, dialysis shunt, or other medical device in place
* Avoid taking blood pressure on a side that has been injured or burned, is paralyzed, has a cast or had a mastectomy

How to take an orthostatic blood pressure?

1. BP checked while laying down, record in note pad
2. Have resident sit up, wait two minutes, check BP, record in notepad
3. Have resident stand up, wait 2 minutes, check BP, record in notepad
4. Record and report findings to nurse
5. Throughout process, nurse aide should check to see if resident is feeling weak, dizzy, faint, or seeing spots

How to prevent orthostatic hypotension?

* Increase activity in stages: bed rest then sitting on side of bed (dangling) then walking
* Before standing, while sitting on side of bed (dangling), have resident cough/deep breathe and move legs back-and-forth in circles, 1 to 5 minutes
* Ask resident to report weakness, dizziness, faintness, or seeing spots.
* May need two people if resident has an inability to stand

What can affect body temperature?

Age, illness, stress, environment, exercise, time of day.

What are sites of temperature taking?

Mouth, rectum, armpit, ear, and forehead

When do you not take oral temperature?

1. Is unconscious
2. Recent facial or mouth surgery
3. Recent injury to face
4. Has sores, redness, or mouth pain
5. Is confused or agitated
6. History of seizure
7. Is using oxygen
8. Is a mouth breather
9. Has a feeding tube

What to not take rectal temperature?

* Has Diarrhea
* Has rectal problem
* Has heart disease
* Recent rectal surgery
* Is confused or agitated

What is the baseline and normal range for oral temperature?

* Baseline- 98.6 F
* Normal Range: 97.6-99.6 F

What is the baseline and normal range for rectal temperature?

* Baseline- 99.6 F
* Normal Range- 98.6-100.6 F

What is the baseline and normal range for axillary temperature?

* Baseline- 97.6 F
* Normal range- 96.6-98.6 F

What is the baseline and normal range for tympanic membrane temperature?

* Baseline- 98.6
* Normal Range- 97.6-99.6 F

What is the baseline and normal range for temporal temperature?

* Baseline- 98.6 F
* Normal Range- 97.6-99.6 F

What is a digital thermometer?

* Display results digitally and is quick, within 2-60 seconds, and beeps or flashes when done
* Battery-operated
* Requires a disposable sheath

What is a electronic thermometer?

* Have oral (blue tipped) and rectal (red tipped) probes; for axillary temperature use oral (blue tipped) thermometer
* Displays results digitally and is quick, within 2-60 seconds, and beeps or flashes when done
* Battery-operated and stored in recharging device
* Requires a probe cover

What do you need when using a non-mercury, liquid-filled glass thermometers-equipment?

* Thermometer
* Sheath
* Gloves
* Watch
* Pen
* Notepad
* alcohol wipe
* Water soluble lubricant (rectal temperature only)

How are the thermometers color coded?

Red for rectal. Blue or green for oral.

What are things to remember to when taking temperature with a glass thermometer?

* Takes a long time to register- 3 to 10 minutes based on site
* Held at the stem of the thermometer and read at eye level
* The nurse aide must read the thermometer after it registers the temperature; held at stem; read at eye level