Pcc cna-2011 unit 12, cna

download Pcc cna-2011 unit 12, cna

of 41

  • date post

    20-Feb-2017
  • Category

    Education

  • view

    152
  • download

    0

Embed Size (px)

Transcript of Pcc cna-2011 unit 12, cna

  • Vital SignsUnit 12

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

    *

  • Vital SignsMeasuring 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.

    *

  • TemperatureIs 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 ThermometersElectronic 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 ThermometersTypes (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 PointsOral-98.6 (F) FahrenheitRange 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)

    *

  • TemperatureVariations 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-OralUsed 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 placePlacementResident safetyTime to register(follow facility procedure)

    *

  • *

  • Checking Body Temperature-Rectal RouteUsed when oral route is unsafe or inaccurateResident is not reliableResident cannot hold mouth closed around thermometerResidents mouth is dry or inflamed

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

    *

  • *

  • Checking Body Temperature- Tympanic (ear) RouteMost accurate route, IF PROPERLY DONE. If technique is not correct, errors in reading will result.Key pointsPreparing thermometer for accurate readingInfection control and disinfectionPlacementTime to register (follow facility policy)

    *

  • *

  • Checking Body Temperature- Axillary RouteUsed when other methods are unsafe or inaccurate. This method can provide less consistent readings than the other routes.Key PointsPreparing thermometer for accurate readingInfection control and disinfectionPlacementResident safetyTime to register (follow facility policy)

    *

  • *

  • Reporting and Recording-TemperatureNotify 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=OTympanic=TRectal=RAxillary=Ax

    *

  • *

  • PulseMeasurement of number of times the heart beats, a basic observation of the functioning of the heart and circulatory system.Normal or average pulse60-100 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 pressureAll 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 minutePulse rate may be increased by such things as exercise, activity, emotional distress, fever.

    *

  • PulseAbnormal 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 PulseRadial PulseKey pointsLocation to palpate

    Wrist thumb sidePlacement of CNAs fingers

    Middle 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

    *

  • *

  • *

  • PulseReporting and recordingReport changes in residents pulse from what is normal for him/herReport pulses 100All 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)

    *

  • RespirationCounting 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.

    *

  • RespirationVariations-all variations in respiratory rate should be reported to the nurse.RateIncreased 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.

    *

  • RespirationCounting respiratory rateKey pointsCounting without residents awareness

    Reporting and recording-Report changes in residents respiratory rate from what is normal for him/her.-Report respiratory rates 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 PressureBlood pressure is the force of blood against artery wallsPressure level depends on:Rate and strength of heart beatEase with which blood flows through the arteriesAmount of blood within the circulatory system

    *

  • Blood PressureSystolic PressureThe force within arteries when the heart contractsThe highest pressure within the arteriesThe top number of BPThe first sound heard when measuring BP.

    Diastolic PressureThe force within arteries when heart relaxes between beatsThe lower number of BPThe level at which pulse sounds change or cease.

    *

  • Blood PressureNormal or average blood pressure for the older adult.Systolic pressure
  • Blood PressureVariationsBlood pressure may increase slightly with age, due to various factors. BP may be temporarily elevated by exercise or emotional distress.Hypertension-High Blood PressureSystolic BP >140, Diastolic BP >90Postural Hypotension (orthostatic hypotension)-elderly persons 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 BPEquipment usedSphygmomanometer (BP cuff) and gaugeStethoscopeTechnique/Key pointsChoosing cuff of appropriate size

    Correct size range indicated on inside of cuffPositioning cuff, gauge and stethoscope

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

    *

  • Measuring BPTechnique/Key points (continued)Positioning stethoscope

    Place diaphragm firmly over brachial artery located little finger side above bend in elbowInterpreting sounds heard

    First sound heard systolicPoint where sound disappears/changes diastolicTime and interval with rechecking

    Wait 30-60 seconds before rechecking

    *

  • *

  • *

  • *

  • Blood PressureReporting and recordingReport to nurse changes in residents BP from what is normal for him/her.Report systolic pressure 190Report diastolic pressure 100Notify nurse if CNA has difficulty hearing or measuring BP.Record and document BP measurement.Write as systolic over diastolic (120/80)

    *

  • HeightFrequency of measurementOn admissionMay be measured annually. Changes such as osteoporosis can decrease the residents height.MethodResident 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.

    *

  • *

  • *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *