Vital Signs Notes Teachers COPY.pdf

Teacher’s Copy Vital Signs, Height and Weight Notes Units 18-21 in Nurse Assistant Book (blue) Body Temperature Unit 18 *Be sure to include all Vocabulary at the beginning of the unit either in the notes or on the back of the sheet. I. Body Tem...

Teacher’s Copy Vital Signs, Height and Weight Notes Units 18-21 in Nurse Assistant Book (blue) Body Temperature Unit 18 *Be sure to include all Vocabulary at the beginning of the unit either in the notes or on the back of the sheet. I. Body Temperature Temperature is the measurement of body heat; it is the balance between heat produced and heat lost; body temperature is: 1. Fairly constant 2. Lower the closer to the body surface it is measured 3. Different in the same person when determined from different body areas 4. Less stable in children 6. Excessive temperature places stress on vital body organs A. Normal Range Average oral temperature range is 96.8 degrees F (36 degrees C) to 100.4 degrees F (38 degrees C) average temperature is 98.6 degrees F (37 degrees C) B. Factors affecting body temperature Temperature is affected by illness, environment, medication, age, infection, times of day taken, exercise, emotions, pregnancy, menstrual cycle, crying, and hydration C. Methods of Measurement Oral is most common Tympanic (ear); takes the least time and is believed to be the most accurate method Rectal registers one degree higher than oral; most accurate of commonly used sites Axillary or groin is least accurate and registers one degree below oral; this method should not be used unless it is impossible to obtain the temperature by other methods Temporal a fast and accurate method quickly becoming popular The patient’s condition determines the best site for taking the temperature D. Types of Thermometers Glass Clinical Thermometer- oral, security and rectal (rectal thermometer is always indicated by a red tip or dot). You must be very careful with Mercury Glass Thermometers, mercury is an extremely toxic element. Electronic Thermometers - must be used with a disposable sheath that fits over a probe, provide quick indication of temperature, requires most precise technique for accuracy Disposable thermometer is used once and then discarded Digital thermometers are handheld and covered with a disposable sheath Tympanic thermometer measures temperature by placing the thermometer into the ear; temperature registers in a few seconds Temporal artery thermometer measures temperature of the skin over the temporal artery, the temporal artery temperate is about.8 degrees higher than the oral temperatures E. Precautions to take when measuring temperature Wait 15 minutes if patients have been smoking, eating or drinking and then take the temperature. F. What to do if you break a mercury thermometer? Follow the facilities policy... wear a mask, gown and gloves, with a dust pan and broom seep up the broken glass and debris, carefully place in a puncture proof container, with an index card consolidate the mercury and place in a sealed plastic bag, wipe the floor with a wet paper towel seal all contents in a container labeled mercury spill debris G. Temperature Control Heat is produced by chemical reactions (metabolism) and muscle contractions. Blood carries the heat to the skin and is lost to sweating, breathing and passing urine and feces. 1. Signs and Symptoms of Heat Exhaustion Temp could be normal, headache, weakness, fatigue, dizziness, loss of appetite, nausea and vomiting, muscle cramps, pale skin, rapid pulse, orthostatic hypotension, cool skin, excessive perspiration, confusion, clumsiness 2. Signs and Symptoms of Heat Stroke Headache, dizziness, weakness, fatigue, skin hot and dry. Untreated= extreme high fever, shortness of breath, slow thread pulse or strong rapid pulse, low BP, absence of perspiration, bizarre behavior, combative, seizures, lethargy, heart abnormalities, death 3. Signs and Symptoms of Hypothermia Lowered core temp below 95∘F, poor coordination, stumbling, slurred speech, irrational, poor judgment, amnesia, hallucinations, cyanosis, edema, dilated pupils, stupor, tremors, fatigue, feeling deep cold, disorientation, visual disturbances. 4. Signs and Symptoms of Infection Elevated temp, rapid pulse and or respirations, sweating, chills, skin hot or cold to touch, skin color changes, skin inflammation, drainage, discharge, other abnormalities. H. Guidelines for 1. Oral Temperature (thermometers) Avoid using an oral thermometer if the patient is:  1.Uncooperative 2. Restless or unconscious 3. Chilled, confused, or coughing 4. Infant or child 5. Unable to breathe through the nose or has had oral surgery 6. Irrational or very weak 7. Receiving oxygen 8. On seizure precautions 9. Has dentures in 2. Rectal Temperatures (thermometers) Never use a rectal thermometer when the patient has: 1. Diarrhea or fecal impaction 2. Exhibited combative behavior 3. Rectal bleeding, hemorrhoids, or has had rectal surgery 4. Another appropriate method can be used Always hold the rectal thermometer in place! 3. Glass Thermometers Guidelines for using a glass thermometer safely: 1. Wear disposable gloves when taking oral and rectal temperatures 2. Check glass thermometers for chips 3. Shake liquid down before use; avoid shaking near hard objects 4. Do not leave the patient alone when a thermometer is in place 5. The thermometer should remain in place for 3 minutes for an oral temperature, 3 to 5 minutes for a rectal temperature, and 10 minutes for an axillary temperature 6. Hold rectal and axillary thermometers in place 7. Lubricate the bulb of the thermometer before inserting it into the rectum 8. After removing the thermometer, wipe it from end to tip with an alcohol sponge or cotton ball before reading it 9. Avoid touching the bulb or disposable sheath that has been in the patient’s mouth or anus 10. Glass thermometers must be disinfected between uses by washing carefully in soapy, cold, running water and rinsed; the thermometer is disinfected with a facility-approved disinfectant solution and rinsed well; check for chips before it is reused 4. Tympanic Temperatures (thermometers) Precise user technique is necessary to ensure an accurate temperature reading; pull the upper ear to insert the thermometer correctly. When the probe is in the ear, rotate the handle like a telephone so the sensor at the tip is flat against the tympanic membrane and not tipped to the side Guidelines for obtaining accurate tympanic temperatures 1. The temperature inside the ear is the most accurate temperature in the body; it is quick and convenient, with a reading obtained in one to three seconds 2. The temperature value is obtained from the tympanic membrane, which is close to the core of the body 3. Although the thermometer is very accurate, the user’s technique must be precise  4. Store the thermometer out of the path of any cold air flow; if it is in a cold area, allow it to warm up before use, or it may read low 5. Make sure the patient is not directly in the path of cold air or being fanned; this cools the ears, causing a low temperature reading 6. If the patient is or has been lying on one ear, use the opposite ear 7. If the patient has a hearing aid, use the opposite ear or remove the aid and wait 15 minutes 8. The tympanic thermometer can be set to oral, core, or rectal mode; oral is usually appropriate 9. The mode is displayed on the readout screen; if this screen says “CAL,” or displays an unfamiliar message, the thermometer is in the unadjusted mode, which is used only for calibration and other bench work 10. Check the thermometer to be sure the lens is clean, with no dirt or debris at the end of the probe tip; apply a disposable probe cover firmly 11. Before inserting the thermometer into an adult or child age 3 and over, pull the pinna of the outer ear up and back to straighten the ear canal; for a child under age 3, pull the pinna down and back 12. Insert the probe tip into the ear as far as possible, then rotate the handle to the correct position in alignment with the jaw 13. Hold the thermometer in place until the display flashes, then removing and discarding the protective cover 5. Axillary Temperatures (thermometers) Least accurate, only use when no other method is possible, hold the glass thermometer in place for 10 minutes I. When to report a temperature Outside of the normal range or below or above the residents baseline. J. Math – Converting Fahrenheit Scale to Celsius Scale Convert 37°C to Fahrenheit. K. 37°C x 9/5 + 32 = 98.6°F 37°C x 9 + 32 = 98.6°F 5 Convert 98.6°F to Celsius. L. (98.6°F - 32) x 5/9 = 37°C (98.6°F - 32) x 5 = 37°C 9 Unit 19 Nurse Assisting Book II. Pulse A. The pulse is the pressure of the blood felt against the wall of an artery as the heart alternately contracts and relaxes B. Pulse is more easily felt in arteries that come fairly close to the skin and can be gently pressed against a bone C. Pulse is the same in all arteries throughout the body D. The pulse is a good indication of how the cardiovascular system is meeting the body’s needs A. Normal Range 60-90 bpm Average pulse rates: men – 60-70 bpm, women – 65-80 bpm, Children over 7 – 75-100, preschoolers – 80-110 and infants – 120-160 B. Methods of Measurement Palpation or feeling for it over the pulse points Auscultation or listening to it over the apex of the heart with a stethoscope Electronic measurements – electronic blood pressure cuff or pulse ox machine C. Apical Radial Pulse A comparison between the apical and radial pulse. They are usually the same but may differ if the heart is too weak to send enough blood into the circulatory system. Resulting in little to no pulse being palpated over the radial artery but a detectable apical pulse, the difference is called the pulse deficit. D. Vocabulary 1. Rate – the number a of beats per minute 2. Rhythm - regularity 3. Volume – the intensity or fullness of the beats 4. Bradycardia – unusually slow pulse below 60 bmp 5. Tachycardia – unusually fast pulse above 100 bpm 6. Arrythmia – irregularity in the beating of the heart E. Factors affecting pulse 1. Illness, emotion, and age 2. Exercise, elevated temperature, and sex 3. Position, physical training, and lowered temperature 4. Drugs F. When to report a pulse 1. Pulse rates over 90 2. Pulse rates under 60 3. Irregularities in character 4. over or under baseline III. Respirations A. Main function of respiration is to supply the body cells with oxygen and eliminate excess carbon dioxide B. Two parts to respiration: 1. Inspiration—breathing in 2. Expiration—breathing out A. Normal Range 16-20 breaths per minute B. Methods of Measurement After counting the pulse, leave your hand on the persons wrist, then start counting to rise and fall of their chest, one cycle is a rise and fall or inspiration and expiration Respirations are also checked for: 1. Rate—number of respirations per minute 2. Rhythm—regularity 3. Symmetry—air entry into each lung 4. Volume—depth of respiration 5. Character—checked for regularity, irregularity, shallowness, depth, and difficulty C. Vocabulary 1. Apnea – a period of no respirations 2. Dyspnea – difficult or labored breathing 3. Tachypnea – rapid, shallow breathing 4. Cheyne-Stokes – a period of dyspnea followed by periods of apnea 5. Cyanosis – lack of oxygen causing the person’s skin to become bluish or dusky color 6. Rales – aka crackles, moist respirations caused by fluid buildup or mucous in the lungs 7. Stertorous- snoring like respirations 8. Wheezing- difficulty breathing accompanied by a whistling sound due to narrowed bronchioles 9. Inspiration – or inhalation 10. Expiration – or exhalation D. Factors affecting respiration 1. Illness, emotions, elevated temperature 2. Age, sex, exercise, position, and certain drugs  E. When to report a respiration When the rate or character is outside of the persons baseline or it is below 16 or above 20 bmp Unit 20 Nurse Assistant Book IV. Blood Pressure A. Blood pressure is the measure of the force of blood against the walls of the arteries B. Blood pressure depends on: 1.Volume—amount of blood in the circulatory system 2. Force of the heartbeat 3. Condition of the arteries 4. Distance from the heart C. The blood pressure is measured 1. Systolic pressure—the highest point, or the first regular sound you hear 2. Diastolic pressure—the lowest point, or the change of last sound heard 3. Pulse pressure—the difference between systolic and diastolic D. Blood pressure readings are recorded as an improper fraction, i.e., systolic/diastolic or 120/80 A. Normal Range 60/90-139/89 B. Blood Pressure is elevated by Gender, exercise, eating, use of stimulants, emotional stress, disease, hereditary, pain, obesity, age, blood vessel condition, some medications C. Blood Pressure is lowered by Fasting, rest, use of depressants, weight loos, emotions, hemorrhage, dehydrations, some medications, diuretics, age, sleep, weight, emotions, gender, viscosity of blood, conditions of blood vessles D. Methods of Measurement A. Sphygmomanometer is a blood pressure apparatus and consists of: 1. A cuff 2. Two tubes 3. A pressure gauge B. The stethoscope magnifies sounds and consists of: 1. A bell or diaphragm 2. Tubing, which carries the sounds to the listener 3. Earpieces that direct the sounds into the listener’s ears E. Guidelines to prepare to measure Blood Pressure Never take blood pressure using an arm that is the site of an intravenous infusion, paralyzed, injured, burned, fractured, the site of an A-V shunt, or if edema is present  2. Clean the earpieces of the stethoscope; clean the bell of the stethoscope with a different alcohol sponge before using it 3. Make sure the bell of the stethoscope is open before placing it on the patient’s arm 4. Check the mercury manometer to make sure the column moves rapidly; if it moves too slowly it may be oxidized 5. Check the needle on the aneroid manometer to make sure it is set at zero; if the needle is not on zero, report to the nurse 6. Turn off the radio and television before taking blood pressure F. When not to use an arm in measuring Blood Pressure DO not use an arm that has an IV, dialysis access, paralyzed, injured or had edema present G. What would cause an inaccurate Blood Pressure Causes of inaccurate blood pressure readings are: 1. Using the wrong size cuff 2. Improperly wrapping the cuff 3. Incorrectly positioning the arm 4. Not using the same arm for all readings 5. Not having the gauge at eye level 6. Deflating the cuff too slowly 7. Mistaking an auscultatory gap (sound fadeout for 10–15 mm Hg, which then begins again) as the diastolic pressure H. Vocabulary 1. Systole – heart contracting 2. Dialstole – heart relaxing or refilling with blood 3. Pulse Pressure – the difference between the systolic and diastolic pressures, on average it should be 40mmHg or 30-50mmHg 4. Pre-hypertention – a condition that means the person is likely to develop hypertension 120/80 5. Hypertension – high blood pressure over 140/90 over 2-3 separate readings 6. Hypotension – low blood pressure, below 90/60 7. Orthostatic Hypotension – this condition occurs when blood pressure drops suddenly when position changes from sitting to standing causing the person to feel light headed and dizzy 8. Sphygmomanometer – a cuff, 2 tube and a pressure gauge used to measure blood pressure 9. Stethoscope – a bell, diaphragm and tube that carry a sound to the listener through earpieces 10. Auscultatory Gap – sounds fading out for 10-15 mmHg but then returning  I. Factors affecting blood pressure Blood pressure is elevated by: 1. Sex of patient (males slightly higher) 2. Exercise 3. Eating 4. Stimulants 5. Emotional stress 6. Disease conditions 7. Hereditary factors 8. Pain 9. Obesity 10. Age 11. Condition of the blood vessels 12. Some drugs D. Blood pressure is lowered by: 1. Fasting 2. Rest 3. Depressants 4. Weight loss 5. Emotions, such as grief 6. Abnormal conditions such as hemorrhage or shock 7. Some drugs J. When to report a blood pressure 1. Inability to hear the patient’s blood pressure 2. Blood pressure higher or lower than previous reading 3. A site other than the brachial artery was used to obtain the blood pressure 4. Over or above the normal range K. List Precautions associated with use of the sphygmomanometer Do not use equipment with cracks in the tubing, only inflate to 30mmhg over the estimated systolic, read at eye level, ensure the needle is at zero before inflating the cuff Unit 21 Nurse Assisting Book V. Height and Weight A. Weight is an indicator of a patient’s condition B. A baseline measurement of height and weight is generally obtained on admission C. Weights are measured frequently when patients are given diuretics to increase their urine output D. Measurements of height and weight must always be accurate E. Weight may be recorded in pounds or kilograms, and height may be recorded in inches or centimeters  A. Baseline It is very important to know what the person’s weight and height was before you measured it, this is used as a means to determine if the weight is high or low and if other actions are required B. Methods of Measurement 1. Height Upright scale Measure in bed 2. Weight The upright scale is used for ambulatory patients In-bed scales may be used for patients who must remain in bed Chair scales may be used for weighing patients in wheelchairs Bed scale/ Mechanical lift with a scale attached C. Guidelines for obtaining an accurate height and weight Guidelines for obtaining accurate weight and height measurements 1. Always balance the scale before using it 2. Ask the patient to empty the bladder 3. If the patient is wearing an incontinent brief, make sure it is dry before weighing 4. If the patient has an indwelling catheter, make sure the bag is empty before weighing 5. Weigh the patient at the same time of day each time 6. Ask the patient to wear the same type of clothing each time 7. Use the same method of weighing the patient and same scale each time 8. If the patient has a cast, has recently had a cast removed, or has new onset edema, consult the nurse about possible weight discrepancies 9. Height is measured with the ruler on the upright scale or a tape measure when the patient is in bed D. When to report a height or weight When above or below their baseline. E. Math 1. Converting pounds (lbs) to kilograms (kg) 2.2 pounds (lbs) = 1 kilogram (kg) 130 lbs = how many kg? 130 lbs/2.2 = 59 kg