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