Vital Signs – Weight/Height Unit V

1. Vital Signs – Weight/Height Unit V • Identify Vital Signs • Discuss NAR responsibility • Identify methods and responsibilities when obtaining height and weight • Recognize how Lack of Oxygen Affects Vital Signs • Identify effective methods of providing oxygen to Residents.

2. Vital Sign Skills • Oxygen tubing safety • Temperature with a glass thermometer • Temperature with an electronic thermometer • Pulse and Respiration • Blood Pressure • Height and weight measurements

3. Key Terms Temperature - Measurement of body heat. Fever - Elevated temperature; usually a sign of illness. Pulse - Expansion and contraction of an artery. Pulse Rate - Measures heart beats; the number of times the heart beats per minute Pulse Spots - Areas on body where pulse can be counted or measured. Respirations – The process of breathing; the exchange of gases (oxygen and carbon dioxide) in the lungs.

4. Blood Pressure – Measurement of the force of the blood against the walls of the arteries. Systolic Pressure - Number at which the first sound is heard or highest number when the blood pressure is measured. Diastolic Pressure - Number at which the last sound is heard or lowest number when blood pressure is measured. Hypertension - High blood pressure; greater than 140/90. Hypotension - Low blood pressure; lower than 90/50.

5. TPR - Abbreviation for temperature, pulse and respiration. VS - Abbreviation for vital signs which are temperature, pulse, respiration and blood pressure.

6. Describe Vital Signs • A. Define Vital Signs • 1. Measurement of the functioning of vital (necessary for • life) organs of the body: heart, lungs and blood vessels. • 2. The resident’s condition can be monitored by vital • signs; temperature, pulse, respiration and blood • pressure. • 3. Accuracy is important • 4. Report immediately to the nurse vital signs which are • high or low compared to the resident’s usual range. • 5. Vital signs are measured ad rest meaning the resident • has been sitting or lying for at least 15 minutes.

7. Temperature – Measurement of Body Heat • 1. Thermometers measure temperature using either • Fahrenheit or Celsius scales, both of which are • divided into units called degrees. Be alert to • which time of thermometer your facility uses. • 2. When the temperature is elevated, the resident is • said to have a “fever”. • 3. Temperatures can be increased by: • a. Infection, illness • b. Dehydration (lack of fluids) • c. Physical exercise • d. Intake of hot liquids • e. Extremely warm environment • f. Emotions such as crying

8. Temperature – Measurement of Body Heat (Cont.) • Temperatures can be decreased by: • a. Shock • b. Cold environment • c. Medications • 5. Realize “normal temperature” is a range of normal. Each • resident has his/her own true normal. Older persons’ normal • temperature may be slightly lower (97-98 degrees F) than • the usual normal temperature of 98.6.F or 37 C.

9. Temperature – Measurement of Body Heat (Cont.) • List sites where temperatures are measured • a. Oral – by mouth • - may be measured with glass, • electronic or digital thermometer. • - used when the resident is alert, • cooperative. • - glass thermometer has a blue tip on • end, a bulb or slender end with mercury. • - should not be taken if resident has just • taken hot or cold liquids (wait 5-10 minutes • before taking oral temperature).

10. Temperature – Measurement of Body Heat (Cont.) • List sites where temperatures are measured (Cont.) • b. Axillary - underarm • - Glass thermometers usually used for measurement • - Least accurate method • - Used only when unable to take oral, rectal or • tympanic • - Normal axillary temp is 97.6 degrees F • - Indicate with “A” when axillary temp is taken

11. Temperature – Measurement of Body Heat (Cont.) • List sites where temperatures are measured (Cont.) • c. Rectal – rectum • - Glass or electronic thermometer are usually used. • - Most accurate method. • - Glass thermometer has a red tip on end, a rounded • bulb with mercury. • - Normal rectal temp is 99.6 temp degrees F. • - Indicate by “R” if temperature was taken rectally. • Tympanic – ear • - Most commonly used. • - Used with all ages and health conditions. • - Reads temperature from blood vessels in ear drum. • - Fit probe snugly in ear. • - Impacted wax in ear canal may result in incorrect • reading.

12. Temperature – Measurement of Body Heat (Cont.) 7. Electronic Thermometers • Cover probe with • disposable plastic • sheath or cup. • Follow procedure for • use as indicated by • manufacturer or • facility policy. • Stay with resident. • Audible beep usually • Indicates measurement • Completed. • The reading of the • temperature is shown on • a digital lighted display. • Be alert to Fahrenheit and • Celsius scales.

13. Temperature – Measurement of Body Heat (Cont.) • Describe general rules for taking temperature with glass • Thermometer. • Do not take oral temperature with glass thermometer • On children under 5 years of age, confused adults, • Or those with seizure disorders. • Check thermometer for chips, cracks. • Shake mercury down away from resident or hard • Objects before inserting. • Lubricate rectal thermometer wiping from colored • end to mercury tip before inserting. • e. Cover with disposable plastic film sheath. • Hold thermometer in place. • Stay with resident. • h. Disinfect according to facility policy.

14. Temperature – Measurement of Body Heat (Cont.) • Describe general rules for taking temperature with glass thermometer (Cont.) • Describe reading a glass thermometer. • - Remove and discard plastic film sheath. • - Hold at eye level and locate the mercury column. • - Each long line is one degree. • - Each shorter line indicates 0.2 (two-tenths) degree. • - Read thermometer at line where mercury ends. • Temperatures are always recorded as whole numbers and • decimals such as 98.6.

15. Pulse • 1. Pulse is the expansion and contraction of an artery (blood • vessel). • 2. Pulse rate indicates how fast the heart is beating. • 3. Pulse rate may be measured at several body sites. • a. Radial (wrist) pulse is most common site. • 4. Rate of Pulse – number of beats per minute. • a. Rate varies with individuals – depends on age, sex, • body size and exercise. • b. Usually pulse rate goes up as temperature increases. • c. Normal adult resting rate if 60-80 beats per minute. • - Pulse rates of the elderly are affected by disease • conditions and some medications.

16. Pulse 5. List observations when measuring radial pulse. a. Resident should be at rest. b. Arm to be resting on a surface such as a bed or table. c. Use tips of 2nd and 3rd fingers; never use thumb because you may feel your own pulse in thumb. d. Press gently, compressing blood vessel between your fingers and resident’s radial (wrist) bone. e. Note rate – number of beats. f. Under 60 bpm is bradycardia, over 100 bpm is tachycardia

17. Pulse (Cont.) • Note rhythm – regularity • - normal pulse – smooth, equal time between beats, • equal pressure • - irregular – time between beats is not equal • - intermittent – period of some normal beats followed • by irregular or skipped beats. • Note volume – weak, thready, strong. • Count for 30 seconds if pulse is regular or one minute • if pulse is irregular, or as indicated by your facility or • resident’s care plan. • Record what pulse would be in one minute • (if counting for 30 seconds, double and • record number). • j. Pulse rates are recorded in whole numbers.

18. D. Respirations • Respiration is the body process of breathing which • Supplies the body with oxygen and releases carbon • Dioxide. • Respiration includes • Inspiration (breathing in) • Expiration (breathing out) • Normal respirations • a. Adults – 16-22 per minute • Respirations increase with • a. Infection and some chronic diseases • b. Fever (elevated temperature) • c. Some heart, lung and blood vessel diseases • d. Emotional upsets, stress, crying • e. Exercise or activity

19. Respirations (Cont.) • 5. Respirations decrease with • a. Some medications and diseases • 6. Guidelines when taking respirations • a. Breathing can be controlled, so resident is not informed • when respirations are counted. • b. One inspiration and one expiration of breath is counted • as one respiration. • c. Count respirations immediately following the pulse • count, remembering the pulse count as you count the • rise and fall of the chest. • d. Keep your fingers in same position on wrist as when • counting pulse in order not to disturb the resident’s • breathing pattern.

20. Respirations (Cont.) • Note if respirations are: • - regular • - shallow • - deep • - difficult, labored (working or struggling to get a breath) • Count respirations for 30 seconds or 1 minute, as indicated • By your facility or resident’s care plan. • Count for one full minute if respirations are irregular. • Record what respirations would be for one minute (if • counting for one minute (if counting for 30 seconds, double • and record number). • i. Respirations are recorded in whole numbers.

21. E. Blood Pressure • Blood pressure is the force of blood pushing • against the walls of the blood vessels. 2. General guidelines when taking blood pressure • Equipment should be in good working condition. • Use cuff of correct size for thickness of upper • arm. (Sphygmomanometer) • c. Have gauge at eye level. • Resident should be sitting or lying in • a relaxed comfortable position, with • arm resting on solid surface.

22. E. Blood Pressure (Cont.) • Use arm indicated on care plan. If no arm is designated to be used, the left arm should be used. Do not use an arm that: • - has an intravenous infusion in it. • - has been weakened by a CVA (stroke) • Inflate cuff to about 160mm. If sound is heard upon immediate release of air, deflate cuff immediately to • zero and reinflate to a higher number. • g. Record accurately as a fraction such as 120/80.

23. F. Record Vital Signs • List correct way to record. • a. Temperature written first. • b. Pulse listed second. • c. Respirations listed last • T P R • 98.6 80 20 • Always indicate when • temperature is taken rectally or • axillary by placing “R” or “A(Ax)” behind temperature, • if temperature is not followed by a “R” or “A” the nurse • will assume the temperature is an oral temp. • 99.4R 80 20 • 97.4A 80 20

24. F.Record Vital Signs • Record accurately. • Follow facility policy regarding recording of vital • signs. You may use a graphic sheet to record this date.

25. Factors affecting Blood Pressure • Age • Obesity • Exercise/sleep • Heart disease, diabetes, heredity • Pain • Blood loss • Time of day

26. Blood Pressure • Hypertension is blood pressure higher then 140/90 • Hypotension is blood pressure lower then 90/60 • Report promptly any abnormal vital sign

27. Pain – The fifth Vital sign • Pain is regularly and frequently evaluated • Pain rating scales are 0-10 with 10 the most severe • Observe resident for pain when moving, facial expressions, crying, moaning, rigid posture, restless, refusal to eat. • Cultural responses to pain varies.

28. G. Measuring and Recording Height and Weight • Height and weight measurements are not • vital signs, but are also part of information • collected to evaluate a person’s health. • Weighing Residents • Methods of weighing residents: • - standing scale - bed scale • - chair scale - tub chair scale • - wheelchair scale - mechanical lift scale

29. G. Measuring and Recording Height and Weight • Accuracy of weighing resident • - check care plan for type of scale, time of day and • clothing worn. • - Know how scale works. • - Weigh wheelchair and additional equipment before or after weight resident and subtract from total weight. • - Medications and treatments are often ordered depending on changes in resident’s weight. 3. Measuring resident’s height • Used in nutritional assessment • Usually done one, on admission • Standing scale has height indicator, tape measure is • used for residents in bed. • d. Record in feet and inches or total inches.

30. How lack of oxygen affects Vital Signs • Signs of Hypoxia • Confusion, restlessness, perspiration, cyanosis • Changes in Vital signs. At first pulse is fast and irregular. As O2 becomes less pulse slows dangerously down. Respirations may be rapid and then slow down to dangerous levels. • NOTIFY NURSE immediately.

31. Providing O2 to residents • The purpose of oxygen therapy is to assist resident who have difficulty breathing because of illness or emergency • Types of O2 delivery system • O2 tank (gas or liquid) • Concentrator • Wall Unit

32. Methods of Delivery • Nasal Canula – most common. Prongs placed in nose. • Oxygen mask – cuplike device placed over mouth and nose • An oximeter is used to measure the oxygenation of the patient.

33. NAR Responsibilities • Report any skin irritation caused by tubing • Elevate HOB as directed • Clean residents mouth and moisten lips • Know how to read a flow meter and know the ordered flow rate. • Notify nurse immediately if flow is not correct or resident having breathing problems.

34. Home Health Aide Unit V Vital Signs – Weight/Height

35. Discuss Measuring Vital Signs in Client’s Home • A. Review measurements of vital signs. • B. Review activities that change vital sign measurements. • C. Know how to use thermometer and other vital sign • measurement equipment available in client’s home.

36. Discuss Measuring Vital Signs in Client’s Home (Cont.) • D. Supervisor will describe and demonstrate measurement • of infant vital signs if you are required to complete them • on an infant client. • 1. Infant vital signs vary according to their size and • development. • a. Temperature control in infants and young children • is unstable but averages between 99.0o – 99.7oF. • May not stabilize at 98.6o until school age. • b. Normal pulse ranges. • - Infants: ( Birth to 2 yrs) 120-160 beats/minute • - toddler: 2-3yrs) 90-140 beats/min. • - preschool (3-5Yrs) : 80-120 beats/minute

37. Normal pulses • School age clients 6-12yrs, 70 -110 bpm • Adolescents ( 14 – 20) 60 – 90 bpm

38. Discuss Measuring Vital Signs in Client’s Home (Cont.) • c. Normal respiratory rate depends on size and lung • development. Infants: 30 – 60 per minute or greater. Toddlers: 24-40 per minute Preschool: 22-34 per minute 2. Infant Weights • Infants usually double birth weight • in six months, triple in a year. • Infants and younger children weights • need to be accurate as medication dosages are • prescribed by weight not age. • C. Infant height will double in the first year.