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Nursing Assistant

Nursing Assistant. Vital Signs. Vital Signs. Temperature Pulse Respiration Blood pressure Oxygen saturation Pain. Vital Signs. Indicators of body function Assess body systems Signify changes taking place in body Observations should also include Skin color & temp Behaviors

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Nursing Assistant

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  1. Nursing Assistant Vital Signs

  2. Vital Signs • Temperature • Pulse • Respiration • Blood pressure • Oxygen saturation • Pain

  3. Vital Signs • Indicators of body function • Assess body systems • Signify changes taking place in body • Observations should also include • Skin color & temp • Behaviors • Statements from resident (subjective)

  4. Temperature • Balance of heat gained & heat lost • Hypothalamus is temp regulation center • Heat produced by • Cellular activity • Infection elevates temp • Brain injury can increase or decrease temp • Food metabolism • Muscle activity • Exercise elevates temp • Hormones • External factors – heat, hot drinks, warm clothing • Internal factors - dehydration

  5. Temperature • Heat lost from body by • Skin • Sweating • Increased blood flow to skin surface • Lungs • Increased resp rate • Elimination • Urine or feces

  6. Temperature • Heat conserved by body through • Reducing perspiration • Decreasing flow of blood to skin • Shivering • Increases muscle activity & produces heat

  7. Temperature Norms • Adult 97 – 99 degrees Fahrenheit • Oral – 98.6 • Rectal – 99.6 • Axillary – 97.6 • Tympanic – 98.6

  8. Temperature procedure • Wear gloves • Shake mercury down below 96 • If smoked or had something to drink, wait 10 min • Insert thermometer, wait…. • Oral – under tongue, 5 minutes • Axillary – in armpit, 10 minutes • Rectal – in rectum, 3 minutes

  9. Contraindications for oral temps • Confused, disoriented • Restless • Unconscious • Coughing, unable to breathe through nose • Seizures • Oral/nasal oxygen • NG

  10. Contraindications for rectal temps • Diarrhea • Fecal impaction • Rectal bleeding • Hemorrhoids • Surgical rectal closure • When doing rectal temps, remember • Lubricant before inserting thermometer • Insert 1 – 1 ½ inches • Hold thermometer in place • NEVER leave resident

  11. Nursing measures • Raise temperature • Increase thermostat in room • Add blankets or clothing • Give hot or warm liquids to drink • Give warm baths or soaks • Lower temperature • Lower thermostat in room • Remove clothing or blankets • Offer cool liquids to drink • Provide cool or tepid bath or sponge

  12. Pulse • Force against the arterial walls that cause them to expand with each heartbeat • Count for one minute • Norm adult pulse is 60 –100 beats/min • < 60 beats/min = bradycardia • > 100 beats/min = tachycardia

  13. Major pulse sites • Carotid – neck • Apical – left chest below nipple (need stethescope) • Brachial – inner aspect of elbow • Radial – thumb side of wrist • Femoral – groin • Popliteal – behind knee • Posterior tibialis – behind inner ankle • Dorsalis pedis – on top of foot

  14. Factors that increase pulse • Exercise • Strong emotions – fear, anger, laughter, excitement • Fever • Pain • Shock • Hemorrhage

  15. Factors that decrease pulse • Sleep/rest • Depression • Drugs – digitalis, morphine • Athletes in good physical condition may have a lower pulse, probably <60 beats/min. This is normal

  16. Qualities of pulse • Rate – number of beats/min • Rhythm – regularity of pulse • Strength – force • Weak or thready • Bounding • Strong

  17. Respiration • Exchange of oxygen & carbon dioxide in lungs • 1 respiration = 1 inhalation + 1 exhalation • Regulated by the medulla • Normal adult rate is 16 – 20 breaths/min • Normal breathing is quiet, effortless, & regular in rhythm

  18. Qualities to observe for Resp • Rate • Rhythm • Depth – shallow, norm, deep • Effort involved to breathe • Discomfort it causes • Position resident adopts • Sounds that accompany it • Color of skin, mucous membranes, nailbeds – check for cyanosis

  19. Abnormal breathing • Labored – struggles to breathe • Orthopnea- can breathe only when sitting or standing • Stertorous – snoring sounds when breathing (partial airway obstruction) • Abdominal – uses abd muscles • Shallow – uses only upper part of lungs • Dyspnea – painful or difficult breathing • Tachypnea – resp rate > 24 per min • Bradypnea – resp rate < 10 per min • Apnea – absence of breathing • Cheyne-Stokes – resp gradually increase in rate & depth & then become shallow & slow

  20. Process of taking TPR • Take temperature first • Pulse second • Respirations last • When taking resp, keep fingers on pulse so that resident does not know you are counting resp • Document all together

  21. Blood pressure • Pressure exerted against walls of blood vessels • Systolic – highest reading • Pressure when heart contracting • Diastolic – lower reading • Pressure when heart is at rest • Hear thumping sounds as blood flows through arteries • Sounds correspond to numbers representing mm Hg on sphygmomanometer • First sound heard is systolic • Last sound heard is diastolic

  22. Blood pressure • Normal adult reading 120/80 • Normal systolic = 100 – 140 • Normal diastolic = 60 – 90 • Abnormal readings • Hypertension – BP > 140/90 • Hypotension – BP < 90/60

  23. Factors increasing BP • Strong emotion • Exercise • Sitting or standing • Excitement • Pain • Decrease of vessel size • Digestion • Improperly placed or sized cuff

  24. Factors decreasing BP • Rest/sleep • Lying down • Depression • Shock • Hemorrhage • Improperly sized cuff

  25. Equipment for BP • Sphygmomanometer • Cuff • Stethescope • Cuff too narrow gives false high • Cuff below heart level will give false high • Cuff too large or improperly placed can give false low

  26. Procedure for BP • Guidelines • Measure BP at brachial artery • Do not use injured arm, arm with IV, or casted • Resident should be at rest • Position arm level with heart • Apply cuff to bare arm NOT over clothing • Use appropriate size cuff • Position sphygmomanometer at eye level

  27. Pain • Ask resident if they have pain • Observe facial expression, movement, respiration • Ask level of pain using facility method (Usually number 0 – 10) • Report c/o pain to licensed nurse

  28. Charting VS • Report norm & abn to licensed nurse • Record on flow sheets, graphic records, & NA notes according to facility • Record in TPR order • Chart rectal temps with “R” • Chart axillary temps with “Ax” • Pulse readings other than radial are noted • If BP in a place other than arm,note location • Write BP on chart as a fraction

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