1. Define important words in this chapter apical pulse:

1. 1. Define important words in this chapter • apical pulse: • the pulse on the left side of the chest, just below the nipple. • apnea: • the absence of breathing; may be temporary. • BPM: • the abbreviation for “beats per minute.” • brachial pulse: • the pulse inside the elbow; used to measure blood pressure.

2. 1. Define important words in this chapter (con’t) • bradycardia: • a slow heart rate; under 60 beats per minute. • Celsius: • the centigrade temperature scale in which the boiling point of water is 100 degrees and the freezing point of water is 0 degrees. • Cheyne-Stokes respiration: • type of respiration with periods of apnea lasting at least 10 seconds, along with alternating periods of slow, irregular respirations or rapid, shallow respirations. • diastolic: • second measurement of blood pressure; phase when the heart relaxes.

3. 1. Define important words in this chapter (con’t) • dilate: • to widen. • dyspnea: • difficulty breathing. • eupnea: • normal respirations. • expiration: • the process of exhaling air out of the lungs.

4. 1. Define important words in this chapter (con’t) • Fahrenheit: • a temperature scale where the boiling point of water is 212 degrees and the freezing point of water is 32 degrees. • hypertension: • high blood pressure. • hypotension: • low blood pressure. • hypothermia: • a condition in which body temperature drops below the level required for normal functioning; severe sub-normal body temperature.

5. 1. Define important words in this chapter (con’t) • inspiration: • the process of inhaling air into the lungs. • orthopnea: • shortness of breath when lying down that is relieved by sitting up. • orthostatic hypotension: • a sudden drop in blood pressure that occurs when a person stands up; also called postural hypotension. • prehypertension: • a condition in which a person has a systolic measurement of 120–139 mm Hg and a diastolic measurement of 80–89 mm Hg; indicator that the person does not have high blood pressure now but is likely to have it in the future.

6. 1. Define important words in this chapter (con’t) • radial pulse: • the pulse on the inside of the wrist, where the radial artery runs just beneath the skin. • respiration: • the process of inhaling air into the lungs (inspiration) and exhaling air out of the lungs (expiration).. • sphygmomanometer: • a device that measures blood pressure. • stethoscope: • an instrument used to hear sounds in the human body, such as the heartbeat or pulse, breathing sounds, or bowel sounds.

7. 1. Define important words in this chapter (con’t) • systolic: • first measurement of blood pressure; phase when the heart is at work, contracting and pushing blood out of the left ventricle. • tachycardia: • a fast heartbeat, over 100 beats per minute. • tachypnea: • rapid respirations. • thermometer • a device used for measuring the degree of heat or cold.

8. 1. Define important words in this chapter (con’t) • vital signs: • measurements that monitor the function of the vital organs of the body.

9. 2. Discuss the relationship of vital signs to health and well-being • Vital signs consist of body temperature, pulse, respirations, blood pressure, and pain level.

10. 3. Identify factors that affect body temperature Factors that affect body temperature include: • The person’s age • Amount of exercise • The circadian rhythm • Stress • Illnesses • Environment Hypothermia is a condition in which body temperature drops below the level required for normal functioning.

11. 4. List guidelines for taking body temperature Common types of thermometers are: • Mercury-free glass • Digital • Electronic • Disposable • Tympanic • Temporal artery thermometer

12. Measuring and recording oral temperature Equipment: mercury-free glass, digital, or electronic thermometer, gloves, disposable plastic sheath/cover for thermometers, tissues, pen and paper Do not take an oral temperature on a resident who has eaten or drunk fluids within the last 10–20 minutes. Identify yourself by name. Identify the resident. Greet the resident by name.

13. Measuring and recording oral temperature Wash your hands. Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. Encourage resident to assist if possible. Provide for the resident’s privacy with a curtain, screen, or door. Put on gloves.

14. Measuring and recording oral temperature Using a mercury-free glass thermometer: Hold thermometer by stem. Before inserting thermometer in resident’s mouth, shake thermometer down to below the lowest number (at least below 96°F or 35°C). To shake thermometer down, hold it at the end opposite the bulb with the thumb and two fingers.

15. Measuring and recording oral temperature (con’t) With a snapping motion of the wrist, shake the thermometer (Fig. 13-8). Stand away from furniture and walls while doing so. Fig. 13-8. Shake thermometer down to below the lowest number before inserting in a resident’s mouth.

16. Measuring and recording oral temperature Put on disposable sheath, if applicable. Gently insert bulb end of thermometer into resident’s mouth. Place it under tongue and to one side (Fig. 13-9). Resident should breathe through his or her nose. Tell resident to hold thermometer in mouth with lips closed. Assist as necessary. Ask the resident not to bite down or to talk. Fig. 13-9. Insert thermometer under the resident’s tongue and to one side.

17. Measuring and recording oral temperature Leave thermometer in place for at least three minutes. Remove the thermometer. Wipe with tissue from stem to bulb or remove sheath. Dispose of tissue or sheath. Hold thermometer at eye level. Roll thermometer between your thumb and forefinger until the line appears.

18. Measuring and recording oral temperature (con’t) Read temperature. Remember the temperature reading. Clean thermometer according to facility policy. Return it to plastic case or container. Store it away from any heat source.

19. Measuring and recording oral temperature Using a digital thermometer: Put on disposable sheath. Turn on thermometer. Wait until “ready” sign appears. Insert end of digital thermometer into resident’s mouth. Place under tongue and to one side.

20. Measuring and recording oral temperature Leave in place until thermometer blinks or beeps. Remove the thermometer. Read temperature on display screen. Remember the temperature reading. Using a tissue, remove and dispose of sheath.

21. Measuring and recording oral temperature Clean thermometer according to facility policy. Replace thermometer in case. Using an electronic thermometer: Remove probe from base unit. Put on probe cover. Insert the covered probe into resident’s mouth. Place under tongue and to one side.

22. Measuring and recording oral temperature Leave in place until you hear a tone or see a flashing or steady light. Read the temperature on the display screen. Remember the temperature reading. Remove the probe. Press the eject button to discard the cover (Fig. 13-10). Return the probe to the holder. Fig. 13-10. Eject the probe cover after use.

23. Measuring and recording oral temperature Final steps for all methods: Remove privacy measures. Make resident comfortable. Remove and dispose of gloves properly. Leave call light within resident’s reach. Wash your hands. Be courteous and respectful at all times.

24. Measuring and recording oral temperature Report any changes in the resident to the nurse. Document procedure using facility guidelines. Record resident’s name, temperature, date, time, and method used (oral).

25. Measuring and recording rectal temperature Equipment: rectal mercury-free glass, digital or electronic thermometer, lubricant, gloves, tissue, disposable plastic sheath/cover, pen and paper Identify yourself by name. Identify the resident. Greet the resident by name. 2. Wash your hands.

26. Measuring and recording rectal temperature Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. Encourage resident to assist if possible. Provide for the resident’s privacy with a curtain, screen, or door. Practice good body mechanics. Adjust bed to safe working level, usually waist high. Lock bed wheels.

27. Measuring and recording rectal temperature Lower the side rail (if bed has one and if it is not already lowered) on side nearest you. Help the resident to left-lying (Sims’) position (Fig. 13-11). Fold back linens to expose only rectal area. Put on gloves. Fig. 13-11. The resident must be in the left-lying (Sims’) position.

28. Measuring and recording rectal temperature Mercury-free glass thermometer: Hold thermometer by stem. Shake thermometer down to below the lowest number. Put on disposable sheath. Apply small amount of lubricant to sheath. Digital thermometer: Put on disposable sheath. Apply small amount of lubricant to sheath.

29. Measuring and recording rectal temperature Turn on thermometer. Wait until “ready” sign appears. Electronic thermometer: Remove probe from base unit. Put on probe cover. Apply small amount of lubricant to cover.

30. Measuring and recording rectal temperature Separate the buttocks. Gently insert thermometer one inch into rectum (Fig. 13-12). Stop if you meet resistance. Do not force the thermometer in the rectum. Replace sheet over buttocks. Hold onto the thermometer at all times. Fig. 13-12. Gently insert a rectal thermometer one inch into the rectum. Do not force it into the rectum.

31. Measuring and recording rectal temperature Mercury-free glass thermometer: Hold thermometer in place for at least three minutes. Digital thermometer: Hold thermometer in place until thermometer blinks or beeps. Electronic thermometer: Leave in place until you hear a tone or see a flashing or steady light.

32. Measuring and recording rectal temperature Gently remove the thermometer. Wipe with tissue from stem to bulb or remove sheath or cover. Dispose of tissue. Read thermometer as you would for an oral temperature. Remember the temperature reading. Mercury-free glass thermometer: Clean thermometer according to facility policy. Return it to plastic case or container.

33. Measuring and recording rectal temperature Digital thermometer: Discard sheath. Clean thermometer according to facility policy. Return thermometer to storage area. Electronic thermometer: Discard the cover. Return probe to holder. Remove and dispose of gloves properly. Wash your hands.

34. Measuring and recording rectal temperature Make resident comfortable Return bed to low position if raised. Ensure resident’s safety. Return side rails to ordered position. Remove privacy measures. Leave call light within resident’s reach. Wash your hands. Be courteous and respectful at all times.

35. Measuring and recording rectal temperature Report any changes in the resident to the nurse. Document procedure using facility guidelines. Record resident’s name, temperature, date, time, and method used (rectal).

36. Measuring and recording tympanic temperature Equipment: mercury-free glass, digital or electronic thermometer, gloves, tissues, disposable sheath/cover, pen and paper Identify yourself by name. Identify the resident. Greet the resident by name. Wash your hands.

37. Measuring and recording tympanic temperature Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. Provide for the resident’s privacy with a curtain, screen, or door. Put on gloves. Put a disposable sheath over earpiece of the thermometer.

38. Measuring and recording tympanic temperature Position the resident’s head so that the ear is in front of you. Straighten the ear canal by pulling up and back on the outside edge of the ear (Fig. 13-13). Insert the covered probe into the ear canal. Press the button. Fig. 13-13. Straighten the ear canal by pulling up and back on the outside edge of the ear.

39. Measuring and recording tympanic temperature Hold thermometer in place until thermometer blinks or beeps. Read temperature. Remember the temperature reading. (If the reading seems too low, repeat the procedure.) Dispose of sheath. Return thermometer to storage or to the battery charger if thermometer is rechargeable.

40. Measuring and recording tympanic temperature Make resident comfortable. Remove privacy measures. Remove and dispose of gloves properly. Leave call light within resident’s reach. Wash your hands. Be courteous and respectful at all times.

41. Measuring and recording tympanic temperature Report any changes in the resident to the nurse. Document procedure using facility guidelines. Record resident’s name, temperature, date, time, and method used (tympanic).

42. Measuring and recording axillary temperature Equipment: mercury-free glass, digital or electronic thermometer, gloves, tissues, disposable sheath/cover, pen and paper Identify yourself by name. Identify the resident. Greet the resident by name. Wash your hands.

43. Measuring and recording axillary temperature Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. Provide for the resident’s privacy with a curtain, screen, or door. Practice good body mechanics. Adjust bed to safe working level, usually waist high. Lock bed wheels.

44. Measuring and recording axillary temperature Put on gloves. Remove resident’s arm from sleeve of gown. Wipe axillary area with tissues. Mercury-free glass thermometer: Hold thermometer by stem. Shake thermometer down to below the lowest number. Put on disposable sheath, if applicable.

45. Measuring and recording axillary temperature Digital thermometer: Put on disposable sheath. Turn on thermometer. Wait until “ready” sign appears. Electronic thermometer: Remove probe from base unit. Put on probe cover. Place the end of thermometer in center of armpit. Fold resident’s arm over chest.

46. Measuring and recording axillary temperature Mercury-free glass thermometer: Hold thermometer in place, with the arm close against the side, for 10 minutes (Fig. 13-14). Digital thermometer: Hold thermometer in place until thermometer blinks or beeps. Electronic thermometer: Leave in place until you hear a tone or see a flashing or steady light. Fig. 13-14. After inserting the thermometer, fold the resident’s arm over her chest and hold it in place for the required time.

47. Measuring and recording axillary temperature Gently remove the thermometer. Wipe with tissue from stem to bulb or remove sheath or cover. Dispose of tissue. Read thermometer as you would for an oral temperature. Remember the temperature reading.

48. Measuring and recording axillary temperature Mercury-free glass thermometer: Clean thermometer according to facility policy. Return it to container for used thermometers. Digital thermometer: Discard sheath. Clean thermometer according to facility policy. Return thermometer to storage area.

49. Measuring and recording axillary temperature Electronic thermometer: Discard the cover. Return probe to holder. Put resident’s arm back into sleeve of gown. Make resident comfortable. Return bed to low position if raised. Ensure resident’s safety. Return side rails to ordered position. Remove privacy measures.

50. Measuring and recording axillary temperature Remove and dispose of gloves properly. Leave call light within resident’s reach. Wash your hands. Be courteous and respectful at all times.