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 • Statements from resident (subjective)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Nursing Assistant