Vital SignsUnit 12

Taking a Radial Pulse and Counting RespirationsMeasuring Blood PressureMeasuring Weight and Height

Vital Signs

• Measuring vital signs is one means of getting information about body condition. Included in vital signs are – Temperature(T)– Pulse (P)– Respiration (R)– Blood Pressure (BP)Measuring height (ht) is included in this unit

although it is not a vital sign.Weight is covered in Unit 10.

Temperature

• Is a measurement of the amount of heat in the body. The healthy body maintains a balance between heat produced and lost.

• Is created as the body changes food to energy.• Is lost from the body to the environment by

contact, perspiration, breathing and other means.

Types of Thermometers• Electronic thermometer

– Types: Simple digital, probe-style digital, tympanic.– Battery powered, usually rechargeable Chemically treated paper or plastic strips-change color to

register temperature reading .Glass thermometer

-glass tube with measurement markings-easily broken, present potential for injury-Mercury, galinstan or colored alcohol within thermometer shows temperature.

MERCURY-CONTAINING THERMOMETERS NO LONGER USED IN MOST LONG-TERM CARE FACILITIES BECAUSE OF ENVIRONMENTAL HAZARDS WHEN THERMOMETER BREAKS

Types of Thermometers

– Types (shapes): oral, security, rectal.– Oral thermometers are marked with blue

while rectal thermometers are marked with red.

• DO NOT PUT RED TIPPED THERMOMETERS IN MOUTH!!!!!

Normal Range Key Points

• Oral-98.6 ‘ (F) Fahrenheit– Range 97.6-99.6 (F)Rectal-99.6 (F)- Range 98.6-100.6 (F)Axillary-97.6 (F)- Range 96.6-98.6 (F)Tympanic-98.6 (F)- Range 97.6-99.6 (F)

Temperature• Variations from “normal” temperature range

before assuming that the temperature reading is out of acceptable range.– Situations causing higher than normal readings:

eating warm food, time of day, infection or other disease.

– Situations causing lower readings: faulty technique, eating cold food, time of day, dry mouth.

Checking Body Temperature-Oral

• Used in almost all situations, except when contraindicated.

• Key points for glass or digital thermometers.– Preparing thermometer for accurate reading

Must be shook down – Infection control and disinfection

Disposable sheath cover in place– Placement– Resident safety– Time to register(follow facility procedure)

Checking Body Temperature-Rectal Route

• Used when oral route is unsafe or inaccurate– Resident is not reliable– Resident cannot hold mouth closed around

thermometer– Resident’s mouth is dry or inflamedKey points

-Preparing thermometer for accurate reading -Infection Control and disinfection-Placement-Resident safety -Time to register (follow facility procedure)

Checking Body Temperature- Tympanic (ear) Route

• Most accurate route, IF PROPERLY DONE. If technique is not correct, errors in reading will result.

• Key points– Preparing thermometer for accurate reading– Infection control and disinfection– Placement– Time to register (follow facility policy)

Checking Body Temperature- Axillary Route

• Used when other methods are unsafe or inaccurate. This method can provide less consistent readings than the other routes.

• Key Points– Preparing thermometer for accurate reading– Infection control and disinfection– Placement– Resident safety– Time to register (follow facility policy)

Reporting and Recording-Temperature

• Notify nurse immediately if:– Oral temperature below 97 (F) or above 100 (F)– Rectal temperature below 98 (F) or above 101 (F)– Axillary temperature below 96 (F) or above 99 (F)– Tympanic temperature below 97 (F)or above 100(F)Notify nurse if CNA has difficulty obtaining

temperature.Record or document temperature reading, using the

following symbols:Oral=O Tympanic=TRectal=R Axillary=Ax

Pulse

• Measurement of number of times the heart beats, a basic observation of the functioning of the heart and circulatory system.

• “Normal” or average pulse– 60-100 beats per minute. Each person has a

rate that is “normal” for him/her.– Should be regular in rate, rhythm and

strength of force.

Variation in pulse pressure

• All variations in pulse should be reported to the nurse.

• Elder pulses are often irregular.– Abnormal rate can be distinguished by

• Pulse beat of less than 60, counted for one full minute.

• Pulse beat of more than 100, counted for one minute

• Pulse rate may be increased by such things as exercise, activity, emotional distress, fever.

Pulse• Abnormal rhythm can be described as:

– Beats that are not evenly spaced apart such as skipped beats, extra beats or an erratic pattern of beats.

Abnormal strength or force can be described as:-Bounding-pulse cannot be occluded by mild pressure.-Weak and thready -pulse can be occluded by slight pressure. Often has fast rate.

Checking Pulse

Radial PulseKey points

– Location to palpateWrist – thumb side

– Placement of CNA’s fingersMiddle three finger tips using only light pressure

Apical PulseKey points

-Equipment neededStethoscope

-Location to listenLeft side of chest

-Time interval Must count for 1 full minute

Pulse• Reporting and recording

– Report changes in resident’s pulse from what is “normal” for him/her

– Report pulses <60 or >100– All variations in pulse should be reported to

the nurse.– Notify nurse if CNA has difficulty obtaining

pulse.– Record or document pulse measurement.– Identify Apical pulse measurement with (AP)

Respiration• Counting the inspiration and expiration of

air.• “Normal” or average respiratory rate is

14-20 per minute for average adult. Each person has a rate that is “normal” for him/her.

Respiration• Variations-all variations in respiratory rate

should be reported to the nurse.– Rate

• Increased by exercise, fever, lung disease, heart disease, emotional distress.

• Decreased by sleep, inactivity, pain medication.Character and rhythm

-Dyspnea- difficult or labored breathing, extra muscles used for breathing.

-Shallow- small amounts of air exchanged.-Noisy- gurgling, wheezing, or snoring sounds.-Irregular- such as cycles of dyspnea followed by apnea.

Respiration• Counting respiratory rate• Key points

– Counting without residents awareness

Reporting and recording-Report changes in resident’s respiratory rate from what is “normal” for him/her.-Report respiratory rates <14 or >24-All variations in respiratory rate should be reported to the nurse.-Notify nurse if CNA has difficulty counting respiratory rate-Record or document respiratory rate

Blood Pressure

• Blood pressure is the force of blood against artery walls

• Pressure level depends on:– Rate and strength of heart beat– Ease with which blood flows through the

arteries– Amount of blood within the circulatory system

Blood Pressure

Systolic Pressure• The force within arteries

when the heart contracts• The highest pressure

within the arteries• The top number of BP• The first sound heard

when measuring BP.

Diastolic Pressure• The force within arteries

when heart relaxes between beats

• The lower number of BP• The level at which pulse

sounds change or cease.

Blood Pressure

• “Normal” or average blood pressure for the older adult.– Systolic pressure <120, Diastolic<90– Resident previous measurements identify

“normal” or expected BP level for that individual.

Blood Pressure• Variations

– Blood pressure may increase slightly with age, due to various factors. BP may be temporarily elevated by exercise or emotional distress.

– Hypertension-High Blood Pressure• Systolic BP >140, Diastolic BP >90

– Postural Hypotension (orthostatic hypotension)-elderly person’s body is unable to rapidly adjust to maintain normal blood pressure in the head and upper body when the person moves from lying to sitting, or sitting to standing. The person will complain of dizziness or feeling faint.

Measuring BP

• Equipment used– Sphygmomanometer (BP cuff) and gauge– Stethoscope

• Technique/Key points– Choosing cuff of appropriate size Correct size range indicated on inside of cuff– Positioning cuff, gauge and stethoscope

Snug fit about 1 inch above bend in elbow on bare upper arm

Measuring BP

• Technique/Key points (continued)– Positioning stethoscope

Place diaphragm firmly over brachial artery located little finger side above bend in elbow

– Interpreting sounds heardFirst sound heard – systolicPoint where sound disappears/changes – diastolic

– Time and interval with recheckingWait 30-60 seconds before rechecking

Blood Pressure

• Reporting and recording– Report to nurse changes in resident’s BP

from what is “normal” for him/her.– Report systolic pressure <100 or >190– Report diastolic pressure <60 or > 100– Notify nurse if CNA has difficulty hearing or

measuring BP.– Record and document BP measurement.– Write as systolic over diastolic (120/80)

Height• Frequency of measurement

– On admission– May be measured annually. Changes such as osteoporosis

can decrease the resident’s height.• Method

– Resident who is able to stand can be measured using the height bar of the standing balance scale.

– Resident who is unable to stand may be measured in bed. Position resident flat on back.

– Measure from top of head to soles of feet. Nurse will guide CNA in performing in-bed measurement.

• Record or document measurement, using standard or metric measurement, according to facility policy.