Understanding vital signs, height, and weight measurement skills.
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Understanding vital signs, height, and weight measurement skills.
Unit B Resident Care SkillsEssential Standard NA4.00 Understand nurse aide skills related to the residents’ vital function and movementIndicator 4.01 Understand vital signs, height, and weight skills.
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F Y I - Intentional Repeat
There is intentional repeat of some HSII course content in Nursing Fundamentals.
Repeating course content distributes learning over time and increases long term memory.
Academic and skill competence must be maintained at a very high level for direct resident care.
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Introduction
Indicator 4.01 introduces skills the nurse aide will need to measure and record the resident’s vital signs, height and weight.
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provide information about changes in normal body function and the resident’s response to treatment. 4.01 Nursing Fundamentals 7243 4
Vital Signs
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Often the FIRST sign that there is a problem!
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Vital Signs
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TPR+BP = Vital Signs4.01 Nursing Fundamentals 7243 6
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TPR+BP = Vital Signs
• Reflect the function of three body processes that are essential for life.–Regulation of body temperature–Heart function–Breathing
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TPR+BP = Vital Signs
• Abbreviations:–Temperature – T–Pulse – P–Respirations – R–Blood Pressure – BP–Vital signs - TPR and BP
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TPR+BP = Vital Signs
• Purpose–Measured to detect
any changes in normal body function
–Used to determine response to treatment
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TPR+BP = Vital SignsTemperature
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TPR+BP = Vital SignsTemperature
• Heat production–muscles–glands–oxidation of
food
• Heat loss–respiration–perspiration–excretion
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TPR+BP = Vital SignsTemperature
Balance between heat production and heat loss is body
temperature
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Factors Affecting Temperature• Exercise• Illness• Age• Time of day• Medications
• Infection• Emotions• Hydration• Clothing• Environmental
temperature/air movement
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Equipment - Thermometer
• Instrument used to measure body temperature
• Types–Non-mercury glass
•oral• rectal
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Equipment - Thermometer• Types (continued)
–chemically treated paper – disposable
–plastic – disposable–electronic - probe covered with
disposable shield–tympanic - electronic probe used in
the ear4.01 Nursing Fundamentals 7243 15
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Electronic Thermometers
ElectronicCan be used for oral, rectal, or axillaryBlue probe for oralRed probe for rectal
Disposable probe covers prevent cross-contamination
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Aural/Tympanic Temperature- taken in the ear- measures the thermal infrared energy radiating from the blood vessels in the eardrum- position and ear wax can affect readings-left in until it beeps-temperature is calculated into an equivalent by mode
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Positioning the Patients Ear for Tympanic temperature
• Infants under 1 year– Pull ear pinna straight back
• Infants over 1 year and adults– Pull ear pinna straight back
and down• Positioning the pinna
correctly straightens the auditory canal so the probe will point directly at the tympanic membrane– Pull ear pinna straight back
and down
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Placement of the Oral Thermometer
Put the bulb tip of the thermometer in the “hot pocket” under the tongue.
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Normal Temperature Range For Adults
• Oral - 97.6 - 99.6 F (Fahrenheit) or 36.5 -37.5 C (Celsius)
• Rectal - 98.6 - 100.6 F or 37.0 - 38.1 C
• Axillary - 96.6 - 98.6 F or 36.0 - 37.0 C
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“Tic-Tac-Know”Normal Range For Adult Temperature
FREE SPACE
98.6°F is the FREE SPACE
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“Tic-Tac-Know”Normal Range For Adult Temperature
ORAL 98.6°F
98.6°F is the average oral temperature for adults and it falls in the middle of the
normal range.
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“Tic-Tac-Know”Normal Range For Adult Temperature
ORAL 98.6°F 99.6°F
Add one degree to 98.6°F then place the results in the oral space to the right
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“Tic-Tac-Know”Normal Range For Adult Temperature
ORAL 97.6 98.6 99.6
Subtract one degree from 98.6 then place the results in the oral space to the left
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“Tic-Tac-Know”Normal Range For Adult Temperature
ORAL 97.6° 98.6 99.6
The average adult temperature taken orally is 98.6° F and the
RANGE is 97.6° F to 99.6° F.4.01 Nursing Fundamentals 7243 26
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“Tic-Tac-Know”Normal Range For Adult Temperature
ORAL 97.6°F 98.6°F 99.6°F
RECTAL 99.6°F
Body heat REGISTERS one degree warmer when the temperature is taken RECTALLY ®. Add one degree to
98.6°F then place the results in the space below 98.6°F
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“Tic-Tac-Know”Normal Range For Adult Temperature
ORAL 97.6°F 98.6°F 99.6°F
RECTAL 99.6°F 100.6°F
Add one degree to 99.6°F then place the results in the rectal space to the right.
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“Tic-Tac-Know”Normal Range For Adult Temperature
ORAL 97.6°F 98.6°F 99.6°F
RECTAL 98.6 99.6°F 100.6°F
Subtract one degree from 99.6°F then place the results in the rectal space to the left.
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“Tic-Tac-Know”Normal Range For Adult Temperature
ORAL 97.6°F 98.6°F 99.6°F
RECTAL 98.6 99.6°F 100.6°F
The average adult temperature taken RECTALLY is 99.6° F and the
RANGE is 98.6° F to 100.6° F.
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“Tic-Tac-Know”Normal Range For Adult Temperature
AXILLARY or GROIN 97.6
ORAL 97.6°F 98.6°F 99.6°F
RECTAL 98.6 99.6°F 100.6°F
Body heat REGISTERS one degree COOLER when the temperature is taken AXILLARY (Ax) or in the GROIN. Subtract one degree from
98.6°F then place the results in the space above 98.6°F
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“Tic-Tac-Know”Normal Range For Adult Temperature
AXILLARY or GROIN 97.6°F 98.6
ORAL 97.6°F 98.6°F 99.6°F
RECTAL 98.6 99.6°F 100.6°F
Add one degree to 97.6°F then place the results to the right of 97.6°F
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“Tic-Tac-Know”Normal Range For Adult Temperature
AXILLARY or GROIN 96.7° 97.6°F 98.6
ORAL 97.6°F 98.6°F 99.6°F
RECTAL 98.6 99.6°F 100.6°F
Subtract one degree from 97.6°F then place the results to the left of 97.6°F
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“Tic-Tac-Know”Normal Range For Adult Temperature
AXILLARY or GROIN 96.7° 97.6°F 98.6
ORAL 97.6°F 98.6°F 99.6°F
RECTAL 98.6 99.6°F 100.6°F
YOU MUST RECORD THE LOCATION WHERE THE TEMPERATURE WAS TAKEN IN ORDER TO INTERPRET
NORMAL FROM ABNORMAL !
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“Tic-Tac-Know”Normal Range For Adult Temperature
AXILLARY or GROIN
(Ax) or Groin
<Pic of Groin>
ORAL O If no location is indicated, the oral route is assumed
RECTAL (R)
YOU MUST RECORD THE LOCATION WHERE THE TEMPERATURE WAS TAKEN IN ORDER TO INTERPRET
NORMAL FROM ABNORMAL !
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To Read A Non-mercury Glass Thermometer
• Hold eye level• Locate solid column of liquid in the
glass• Observe lines on scale at upper
side of column of liquid in the glass
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To Read A Non-mercury Glass Thermometer
(continued)• Read at point where liquid ends• If liquid falls between two lines, read it
to closest line– long line represents degree–short line represents 0.2 of a degree
Fahrenheit
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Sites To Take A Temperature • Oral – most common• Rectal – registers one degree
Fahrenheit higher than oral• Axillary – least accurate; registers
one degree Fahrenheit lower than oral
• Tympanic – probe inserted into the ear canal
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Sites To Take A Temperature (continued)
Condition of resident determines which is the best site for measuring body temperature
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Temperature: Safety Precautions• Hold rectal and axillary thermometers
in place • Stay with resident when taking
temperature • Check glass thermometers for chips • Prior to use, shake liquid in glass
down • Shake thermometer away from
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Temperature: Safety Precautions(continued)
• Wipe from “handle” end toward bulb tip of thermometer prior to reading
• Delay taking oral temperature for 10 - 15 minutes if resident has been smoking, eating or drinking hot/cold liquids.
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Temperature Conditions• Hyperthermia
– Increased body temp– Body temp >104ºF– >106 ºF will cause
convulsions and death
• Fever- temp over 101 ºF R- Due to illness or
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Temperature Conditions• Hypothermia
– Body temp below– 96 ºF– due to exposure to
cold temperatures – Depends on core
temperature, age and length of exposure
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SKILL 4.01AOral temperature using a non-mercury
glass thermometer
Training Lab AssignmentEngage in the Skill Acquisition Process for:
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SKILL 4.01BAxillary temperature using a
non-mercury glass thermometer
Training Lab AssignmentEngage in the Skill Acquisition Process for:
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SKILL 4.01CRectal Temperature using a
non-mercury glass thermometer
Training Lab AssignmentEngage in the Skill Acquisition Process for:
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SKILL 4.01DtoMeasure Temperature with
Electronic Thermometer
Training Lab AssignmentEngage in the Skill Acquisition Process for:
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SKILL 4.01EMeasure Temperature with
Tympanic Thermometer
Training Lab AssignmentEngage in the Skill Acquisition Process for:
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TPR+BP = Vital Signs
PULSE
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PULSE
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Measuring the pulse is one way of checking on the circulatory system
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Circulatory System
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Circulatory System
• Circulation is continuous movement of blood throughout body
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Circulatory System(continued)
• Functions of circulatory system–Arteries carry blood with
oxygen and nutrients away from heart and to cells
–Veins carry waste products away from cells and to heart
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Blood
• Adult has 5 to 6 quarts (liters)• Consists of
–water - 90% (plasma)–blood cells–carbon dioxide and oxygen–nutrients, hormones and
enzymes–waste products
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Blood(continued)
• Types of blood cells –Red blood cells - erythrocytes
•carry oxygen from blood to cells –White blood cells - leukocytes
• fight infection –Platelets - thrombocytes
• required for clotting to stop bleeding
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Blood Vessels
• Arteries - carry blood away from heart• Veins – carry blood to heart
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Heart
• Tissue (three layers)–endocardium - smooth,
inner layer–myocardium – thick,
muscular middle layer–pericardium – double-
walled membrane that covers outside of heart
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Heart Chambers• Heart divided into
right and left side• Atria – upper
chambers – receive blood
• Ventricles – lower chambers – pump blood to lungs and body
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Heart Chambers• Four chambers
–right atrium (1) - receives blood from two large veins:•superior vena cava• inferior vena cava
–right ventricle (2) - receives blood from right atrium and pumps it to lungs through pulmonary artery
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Heart Chambers(continued)
• Four chambers– left atrium (3) - receives
oxygenated blood from left and right pulmonary veins
– left ventricle (4) - pumps blood to aorta, which delivers blood to all body parts (except lungs)
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Heart Valves
• Located at entrance and exit of each ventricle
• Four heart valves
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Heartbeat
• Systole - contraction of heart muscle• Diastole - relaxation of heart muscle• Blood pressure – highest and lowest
pressure against walls of blood vessels as heart contracts and relaxes
• Pulse - expansion and contraction of artery
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Common Disorders of the Circulatory System
• Arteriosclerosis - walls of arteries become thick and harden
• Hypertension - high blood pressure • Peripheral vascular disease -
decrease in flow of blood to extremities and brain
• Angina pectoris - chest pain 4.01
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Common Disorders of the Circulatory System
(continued)• Varicose veins - enlarged, twisted
veins usually in legs • Congestive heart failure -
circulatory congestion caused by weak pumping of heart muscle
• Myocardial infarction (MI) - heart attack due to blockage in coronary arteries
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Common Disorders of the Circulatory System
(continued)
• Anemia – low red blood cell counts• Thrombus – blood clot• Phlebitis – inflammation of vein• Atherosclerosis - fatty deposits on
walls of arteries that reduce blood flow
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Changes of the Circulatory System Due To Aging
• Heart muscle less efficient• Blood pumped with less force• Arteries lose elasticity and
become narrow• Blood pressure increases• Blood chemistry less efficient• Capillaries become more fragile4.01
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Observations of the Circulatory System
• Changes in pulse rate and blood pressure
• Changes in skin color• Changes in skin
temperature – coldness
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Observations of the Circulatory System
(continued)
• Complaint of dizziness and headaches
• Complaint of pain in chest and/or indigestion
• Edema in feet and legs• Shortness of breath
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Observations of the Circulatory System
(continued)• Sweating• Blue color to lips and/or nail beds• Complaint of tingling sensations• Memory lapses• Lack of energy• Irregular respirations• Anxiety• Staring and lack of responsiveness4.01
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TPR+BP = Vital SignsPULSE
• Pulse is pressure of blood pushing against wall of artery as heart beats and rests
• Pulse easier to locate in arteries close to skin that can be pressed against bone
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Sites For Taking Pulse• Radial – base of thumb• Temporal – side of
forehead• Carotid – side of neck• Brachial – inner aspect
of elbow• Femoral – inner aspect
of upper thigh
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Sites For Taking Pulse(continued)
• Popliteal - behind knee• Dorsalis pedis – top of
foot • Apical pulse – over apex
of heart–taken with stethoscope– left side of chest
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Factors Affecting Pulse• Age• Sex• Position• Drugs• Illness• Emotions• Activity level • Temperature• Physical training
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Measurement of Pulse
• Normal pulse range/characteristics: 60 -100 beats per minute and regular
• Documenting pulse rate–Noted as number of beats per
minute–Rhythm - regular or irregular–Volume - strong, weak, thready,
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SKILL 4.01FCount and Record
Radial Pulse
Training Lab AssignmentEngage in the Skill Acquisition Process for:
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SKILL 4.01GMeasure and Record
Apical Pulse
Training Lab AssignmentEngage in the Skill Acquisition Process for:
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TPR+BP = Vital SignsRESPIRATIONS
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RESPIRATIONSMeasuring respirations is one way of checking on the respiratory system
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Respiratory System
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The Respiratory System
• Respiration means to breathe in oxygen and breathe out carbon dioxide
• Exchange of oxygen and carbon dioxide necessary for life
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The Respiratory System(continued)
• Process–External respiration - oxygen and
carbon dioxide exchanged between lungs and blood
–Internal respiration - oxygen and carbon dioxide exchanged between blood stream and cells
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The Respiratory SystemStructure
• Oral cavity – mouth• Pharynx – throat• Larynx - voice box• Trachea – windpipe• Bronchi - right and left• Bronchioles - smallest branches of
bronchi• Alveoli - air sacs covered with
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The Respiratory SystemStructure(continued)
• Nose - lined with mucous membrane–air filtered by cilia–mucous membrane
warms and moistens air
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The Respiratory SystemStructure(continued)
• Lungs–right - 3 lobes– left - 2 lobes
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The Respiratory SystemStructure(continued)
• Pleura – membrane that encloses lungs
• Diaphragm - muscle that separates the chest and abdomen–contraction - draws air into lungs–relaxation - forces air out of lungs
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Common Disorders of Respiratory System
• URI – Upper Respiratory Infection - infection of nose, throat, larynx, trachea
• Pneumonia - inflammation or infection of the lungs
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Common Disorders of Respiratory System
(continued)• Emphysema (Chronic Obstructive
Pulmonary Disease – COPD) – alveoli become stretched and stiff preventing adequate exchange of oxygen and carbon dioxide
• Asthma – spasms of bronchial tube walls causing narrowing of air passages usually due to allergies
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Common Disorders of Respiratory System
(continued)• Allergy – reaction to substances that
leads to slight or severe response by body.
• Influenza – highly contagious URI• Pleurisy – inflammation of the pleura
surrounding the lungs
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Common Disorders of Respiratory System
(continued)• Bronchitis - inflammation of the
bronchi• Lung cancer - malignant tumors in
the lungs that destroy tissue
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Changes in Respiratory System Due To Aging
• Lung tissue becomes less elastic• Respiratory muscles weaken• Number of alveoli decrease• Respirations increase• Voice pitched higher and weaker due
to changes in larynx• Chest wall and structures become
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Observations Of Respiratory System• Rate and rhythm of respirations• Respiratory secretions – character• Character of cough• Changes in skin color - pale or bluish
gray• Temperature changes• Difficulty breathing
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Observations Of Respiratory System(continued)
• Color of sputum• Complaint of pain in
chest, back, sides• Shortness of breath• Noisy respirations• Sneezing• Gasping for breath• Anxiety
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Measuring Respirations
• Respiration – process of taking in oxygen and expelling carbon dioxide from lungs and respiratory tract
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Measuring Respirations(continued)
• Age• Activity
level• Position• Drugs
• Sex• Illness• Emotions• Temperature
Factors Affecting Rate
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Measuring Respirations(continued)
• Qualities of normal respirations–12-20 respirations per minute–Quiet–Effortless–Regular
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Measuring Respirations(continued)
• Documenting respiratory rate–Noted as number of inhalations
and exhalations per minute (one inhalation and one exhalation equals one respiration)
–Rhythm – regular or irregular–Character: shallow, deep, labored
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SKILL 4.01HCount and Record
Respiration
Training Lab AssignmentEngage in the Skill Acquisition Process for:
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TPR+BP = Vital SignsBLOOD PRESSURE
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Blood Pressure
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Measuring the pulse is one way of checking on the circulatory system
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Measuring Blood Pressure• Blood pressure is the force of blood
pushing against walls of arteries–Systolic pressure: greatest force
exerted when heart contracting–Diastolic pressure: least force
exerted as heart relaxes
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Factors Influencing Blood Pressure
• Weight• Sleep• Age• Emotions• Sex• Heredity• Viscosity of blood• Illness/Disease
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Blood Pressure: Equipment
• Sphygmomanometer (manual)–cuff - different sizes–pressure control bulb–pressure gauge – marked
with numbers•aneroid•mercury
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Blood Pressure: Equipment(continued)
• Stethoscope–magnifies sound–has diaphragm
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Measuring Blood Pressure
Blood Pressure Systolic (top#)
Diastolic (bottom #)
Normal ≤ 120 <80
Pre Hypertension 120-139 80-89
Hypertension Stage (1) 140-159 90-99
Hypertension Stage (2) ≥160 ≥100
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Guidelines for Blood Pressure Measurements
• Measure on upper arm
• Have correct size cuff
• Identify brachial artery for correct placement of stethoscope
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=
Positioning of stethoscope diaphragm directly over the brachial artery increases ability to hear the systolic and diastolic sounds
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Positioning of stethoscope diaphragm directly over the brachial artery increases ability to hear the systolic and diastolic
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Guidelines for Blood Pressure Measurements
(continued)
• First sound heard – systolic pressure
• Last sound heard or change - diastolic pressure
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Systolic – Start hearing a Sound – Heart Muscle is Squeezing
Diastolic – Don’t hear sound anymore – Heart muscle does not work during diastolic. This number is written down under the systolic number.
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Guidelines for Blood Pressure Measurements
(continued)
• Record - systolic/diastolic• Resident in relaxed
position, sitting or lying down
• Blood pressure usually taken in left arm
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Guidelines for Blood Pressure Measurements
(continued)
Do not measure blood pressure in arm with IV, A-V shunt (dialysis), cast, wound, or sore
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Guidelines for Blood Pressure Measurements
(continued)• Apply cuff to bare
upper arm, not over clothing
• Room quiet so blood pressure can be heard
• Sphygmomanometer must be clearly visible
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Blood Pressure: Reading Gauge
• Large lines are at increments of 10 mmHg
• Shorter lines at 2 mm intervals
• Take reading at closest line
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SKILL 4.01IMeasure Blood Pressure
Manual
Training Lab AssignmentEngage in the Skill Acquisition Process for:
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SKILL 4.01JCombined Vital Signs
Training Lab AssignmentEngage in the Skill Acquisition Process for:
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Measuring
Height and Weight
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The resident’s weight, compared with the height, gives information about his/her nutritional status and changes in the medical condition.
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Measuring Height And Weight
• Baseline measurement obtained on admission and must be accurate.
• Other measurements obtained as ordered.
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Measuring Height And Weight(continued)
• Height measurements–Feet–Inches –Centimeters
• Weight measurements–Pounds–Ounces–Kilograms
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Measuring Height and Weight(continued)
• Reasons for obtaining height and weight–Indicator of nutritional status–Indicator of change in medical
condition–Used by doctor to order medications
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Special Case for Height Measurement
• Residents who are contractured or • Residents who cannot stand• Must be measured using a tape
measure
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Measuring Height and Weight(continued)
–Use same scale each time
–Have resident void, remove shoes and outer clothing
–Weigh at same time each day
• Guidelines for weighing residents
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Measuring Height and Weight(continued)
• Scales–Remain more accurate if moved as
little as possible.–Various types of scales
•bathroom scale•standing scale•scales attached to hydraulic lifts•wheelchair scales•bed scales
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SKILL 4.01KMeasure Height
& Weight
Training Lab AssignmentEngage in the Skill Acquisition Process for:
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Understand vital signs, height, and weight measurement skills.
127
END 4.01
4.01 Nursing Fundamentals 7243