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Understanding Understanding vital vital signs, height,signs, height, and and
Unit BUnit BResident Care SkillsResident Care Skills
Essential Standard NA4.00 Essential Standard NA4.00 Understand nurse aide skills related to the residen ts’ vital function and movementUnderstand nurse aide skills related to the residen ts’ vital function and movement
Indicator 4.01Indicator 4.01Understand vital signs, height, and weight skills. Understand vital signs, height, and weight skills.
signs, height,signs, height, and and
weightweight measurement measurement skills. skills.
4.01 Nursing Fundamentals 7243 1
FF YY II -- Intentional RepeatIntentional Repeat
There is intentional repeat of some HSII There is intentional repeat of some HSII course content in Nursing Fundamentals. course content in Nursing Fundamentals.
Repeating Repeating course content distributes learning course content distributes learning Repeating Repeating course content distributes learning course content distributes learning over time and increases long term memory. over time and increases long term memory.
Academic and Academic and skill skill competence must be competence must be maintained at a maintained at a very high very high level for level for direct direct resident careresident care. .
4.01 Nursing Fundamentals 7243 2
IntroductionIntroduction
Indicator Indicator 4.01 4.01 introduces introduces skills the nurse aide will need skills the nurse aide will need skills the nurse aide will need skills the nurse aide will need to measure and record the to measure and record the resident’s resident’s vital signsvital signs , , heightheightand and weightweight . .
4.01 Nursing Fundamentals 7243 3
provide information provide information about about changeschanges in in normal body function normal body function
Vital Signs Vital Signs
normal body function normal body function and the and the resident’s resident’s response to treatmentresponse to treatment . .
4.01 Nursing Fundamentals 7243 4
Often the Often the FIRST FIRST sign sign that that
Vital Signs Vital Signs
sign sign that that there is a there is a problem!problem!
4.01 Nursing Fundamentals 7243 5
TPR+BP = TPR+BP = Vital SignsVital Signs4.01 Nursing Fundamentals 7243 6
TPR+BP = Vital SignsTPR+BP = Vital Signs
• Reflect the function of three body processes that are essential for life.–Regulation of body temperature–Heart function–Heart function–Breathing
4.01 Nursing Fundamentals 7243 7
TPR+BP = Vital SignsTPR+BP = Vital Signs
• Abbreviations:–Temperature – T–Pulse – P–Pulse – P–Respirations – R–Blood Pressure – BP–Vital signs - TPR and BP
4.01 Nursing Fundamentals 7243 8
TPR+BP = Vital SignsTPR+BP = Vital Signs
• Purpose–Measured to detect
any changes in normal body normal body function
–Used to determine response to treatment
4.01 Nursing Fundamentals 7243 9
TTPR+BP = Vital SignsPR+BP = Vital Signs
TemperatureTemperature
4.01 Nursing Fundamentals 7243 10
TTPR+BP = Vital SignsPR+BP = Vital SignsTemperatureTemperature
• Heat production–muscles–glands
• Heat loss–respiration–perspiration–glands
–oxidation of food
–perspiration–excretion
4.01 Nursing Fundamentals 7243 11
TTPR+BP = Vital SignsPR+BP = Vital SignsTemperatureTemperature
Balance between heat production and heat loss is body
temperaturetemperaturetemperaturetemperature
4.01 Nursing Fundamentals 7243 12
Factors Affecting Temperature
• Exercise• Illness• Age• Time of day
• Infection• Emotions• Hydration• Clothing• Time of day
• Medications• Clothing• Environmental
temperature/air movement
4.01 Nursing Fundamentals 7243 13
Equipment - Thermometer
• Instrument used to measure body temperature
• Types–Non-mercury glass–Non-mercury glass
• oral• rectal
4.01 Nursing Fundamentals 7243 14
Equipment - Thermometer
• Types (continued)–chemically treated paper –
disposable–plastic – disposable–plastic – disposable–electronic - probe covered with
disposable shield–tympanic - electronic probe used in
the ear4.01 Nursing Fundamentals 7243 15
Electronic ThermometersElectronic Thermometers
ElectronicElectronicCan be used for oral, Can be used for oral, rectal, or axillaryrectal, or axillaryBlueBlue probe for oralprobe for oralRedRed probe for rectalprobe for rectalRedRed probe for rectalprobe for rectal
Disposable probe covers Disposable probe covers prevent crossprevent cross--contaminationcontamination
4.01 Nursing Fundamentals 7243 16
Aural/Tympanic TemperatureAural/Tympanic Temperature- taken in the ear
- measures the thermal infrared energy radiating from the blood vessels in the eardrum- position and ear wax - position and ear wax can affect readings-left in until it beeps-temperature is calculated into an equivalent by mode
4.01 Nursing Fundamentals 7243 17
Positioning the Patients Ear for Positioning the Patients Ear for Tympanic temperatureTympanic temperature
• Children under 2– Pull ear pinna down and
back
• Adults and children over 2– Pull ear pinna up and back– Pull ear pinna up and back
• Positioning the pinna correctly straightens the auditory canal so the probe will point directly at the tympanic membrane
4.01 Nursing Fundamentals 7243 18
4.01 Nursing Fundamentals 7243 19
Placement of the Oral Placement of the Oral ThermometerThermometer
Put the bulb tip Put the bulb tip of the of the of the of the thermometer in thermometer in the the “hot “hot pocket” pocket” under under the tongue. the tongue.
4.01 Nursing Fundamentals 7243 20
Normal Temperature Range For Adults
• Oral - 97.6° - 99.6° F (Fahrenheit) or 36.5° -37.5° C (Celsius)
• Rectal - 98.6° - 100.6° F or 37.0° - 38.1° C
• Axillary - 96.6° - 98.6° F or 36.0° - 37.0° C
4.01 Nursing Fundamentals 7243 21
“Tic -Tac-Know”Normal Range For Adult Temperature
FREE SPACE
98.6°F is the FREE SPACE
4.01 Nursing Fundamentals 7243 22
“Tic -Tac-Know”Normal Range For Adult Temperature
ORALORAL 98.6°FORALORAL 98.6°F
98.698.6°°F is the F is the averageaverage oral temperature oral temperature for adults and it falls in the for adults and it falls in the middle of the middle of the
normal range. normal range.
4.01 Nursing Fundamentals 7243 23
“Tic -Tac-Know”Normal Range For Adult Temperature
ORALORAL 98.698.6°°FF 99.699.6°°FFORALORAL 98.698.6°°FF 99.699.6°°FF
Add one degree to 98.6°F then place the results in the oral space to the right
4.01 Nursing Fundamentals 7243 24
“Tic -Tac-Know”Normal Range For Adult Temperature
ORALORAL 97.697.6 98.698.6 99.699.6ORALORAL 97.697.6 98.698.6 99.699.6
Subtract one degree from 98.6 then place the results in the oral space to the left
4.01 Nursing Fundamentals 7243 25
“Tic -Tac-Know”Normal Range For Adult Temperature
ORALORAL 97.697.6°° 98.698.6 99.699.6ORALORAL 97.697.6°° 98.698.6 99.699.6
The The averageaverage adult temperature taken adult temperature taken orally is orally is 98.698.6°°FF and the and the
RANGERANGE is is 97.697.6°°FF to to 99.699.6°°F.F.
4.01 Nursing Fundamentals 7243 26
“Tic -Tac-Know”Normal Range For Adult Temperature
Body heat Body heat REGISTERSREGISTERS one degree one degree warmerwarmer when the when the temperature is taken temperature is taken RECTALLY ®RECTALLY ® . Add one degree to . Add one degree to 98.698.6°°F then place the results in the space below 9 8.6F then place the results in the space below 98.6°°F F
ORALORAL 97.697.6°°FF 98.698.6°°FF 99.699.6°°FF
RECTALRECTAL 99.699.6°°FF
4.01 Nursing Fundamentals 7243 27
“Tic -Tac-Know”Normal Range For Adult Temperature
ORALORAL 97.697.6°°FF 98.698.6°°FF 99.699.6°°FFORALORAL 97.697.6°°FF 98.698.6°°FF 99.699.6°°FF
RECTALRECTAL 99.699.6°°FF 100.6100.6°°FF
Add one degree to 99.6Add one degree to 99.6°°F then place the results in the F then place the results in the rectal space to the right.rectal space to the right.
4.01 Nursing Fundamentals 7243 28
“Tic -Tac-Know”Normal Range For Adult Temperature
ORALORAL 97.697.6°°FF 98.698.6°°FF 99.699.6°°FFORALORAL 97.697.6°°FF 98.698.6°°FF 99.699.6°°FF
RECTALRECTAL 98.698.6 99.699.6°°FF 100.6100.6°°FF
Subtract one degree from 99.6Subtract one degree from 99.6°°F then place the F then place the results in the rectal space to the left.results in the rectal space to the left.
4.01 Nursing Fundamentals 7243 29
“Tic -Tac-Know”Normal Range For Adult Temperature
ORALORAL 97.697.6°°FF 98.698.6°°FF 99.699.6°°FFORALORAL 97.697.6°°FF 98.698.6°°FF 99.699.6°°FF
RECTALRECTAL 98.698.6 99.699.6°°FF 100.6100.6°°FF
The The averageaverage adult temperature taken adult temperature taken RECTALLYRECTALLY is is 99.699.6°°FF and the and the
RANGERANGE is is 98.698.6°°FF to to 100.6100.6°°F.F.
4.01 Nursing Fundamentals 7243 30
“Tic -Tac-Know”Normal Range For Adult Temperature
AXILLARY AXILLARY 97.697.6
Body heat Body heat REGISTERSREGISTERS one degree one degree COOLERCOOLER when the temperature when the temperature is taken is taken AXILLARY (Ax) AXILLARY (Ax) or in the or in the GROIN. GROIN. Subtract one degree from Subtract one degree from
98.698.6°°F then place the results in the space F then place the results in the space aboveabove 98.698.6°°FF
AXILLARY AXILLARY oror GROINGROIN
97.697.6
ORALORAL 97.697.6°°FF 98.698.6°°FF 99.699.6°°FF
RECTALRECTAL 98.698.6 99.699.6°°FF 100.6100.6°°FF
4.01 Nursing Fundamentals 7243 31
“Tic -Tac-Know”Normal Range For Adult Temperature
AXILLARY AXILLARY oror GROINGROIN
97.697.6°°FF 98.698.6
ORALORAL 97.697.6°°FF 98.698.6°°FF 99.699.6°°FF
RECTALRECTAL 98.698.6 99.699.6°°FF 100.6100.6°°FF
Add one degree to 97.6Add one degree to 97.6°°F then place the results to the right F then place the results to the right of 97.6of 97.6°°FF
4.01 Nursing Fundamentals 7243 32
“Tic -Tac-Know”Normal Range For Adult Temperature
AXILLARY AXILLARY oror GROINGROIN
96.796.7°° 97.697.6°°FF 98.698.6
ORALORAL 97.697.6°°FF 98.698.6°°FF 99.699.6°°FF
RECTALRECTAL 98.698.6 99.699.6°°FF 100.6100.6°°FF
Subtract one degree from 97.6Subtract one degree from 97.6°°F then place the res ults to F then place the results to the left of 97.6the left of 97.6°°FF
4.01 Nursing Fundamentals 7243 33
“Tic -Tac-Know”Normal Range For Adult Temperature
AXILLARY AXILLARY oror GROINGROIN
96.796.7°° 97.697.6°°FF 98.698.6
ORALORAL 97.697.6°°FF 98.698.6°°FF 99.699.6°°FFORALORAL 97.697.6°°FF 98.698.6°°FF 99.699.6°°FF
RECTALRECTAL 98.698.6 99.699.6°°FF 100.6100.6°°FF
YOU MUST RECORD THE YOU MUST RECORD THE LOCATION WHERE THE LOCATION WHERE THE TEMPERATURE WAS TAKENTEMPERATURE WAS TAKEN IN ORDER TO INTERPRET IN ORDER TO INTERPRET
NORMAL FROM ABNORMAL !NORMAL FROM ABNORMAL !
4.01 Nursing Fundamentals 7243 34
“Tic -Tac-Know”Normal Range For Adult Temperature
AXILLARY AXILLARY oror GROINGROIN
(Ax) (Ax) or or GroinGroin
<Pic of <Pic of Groin>Groin>
ORALORAL OOIf no locationIf no location is is
indicated, the oral indicated, the oral ORALORAL OO indicated, the oral indicated, the oral route is assumedroute is assumed
RECTALRECTAL (R)(R)
YOU MUST RECORD THE LOCATION WHERE THE YOU MUST RECORD THE LOCATION WHERE THE TEMPERATURE WAS TAKEN IN ORDER TO INTERPRET TEMPERATURE WAS TAKEN IN ORDER TO INTERPRET
NORMAL FROM ABNORMAL !NORMAL FROM ABNORMAL !
4.01 Nursing Fundamentals 7243 35
To Read A Non -mercury Glass Thermometer
• Hold eye level• Locate solid column of liquid in the
glass• Observe lines on scale at upper
side of column of liquid in the glass
4.01 Nursing Fundamentals 7243 36
To Read A Non -mercury Glass Thermometer
(continued)• Read at point where liquid ends• If liquid falls between two lines, read it
to closest lineto closest line–long line represents degree–short line represents 0.2 of a degree
Fahrenheit
4.01 Nursing Fundamentals 7243 37
4.01 Nursing Fundamentals 7243 38
4.01 Nursing Fundamentals 7243 39
Sites To Take A Temperature
• Oral – most common• Rectal – registers one degree
Fahrenheit higher than oral• Axillary – least accurate; registers • Axillary – least accurate; registers
one degree Fahrenheit lower than oral
• Tympanic – probe inserted into the ear canal
4.01 Nursing Fundamentals 7243 40
Sites To Take A Temperature(continued)
Condition of resident determines which is the best site for measuring best site for measuring body temperature
4.01 Nursing Fundamentals 7243 41
Temperature: Safety Precautions
• Hold rectal and axillary thermometers in place
• Stay with resident when taking temperature
• Check glass thermometers for chips• Prior to use, shake liquid in glass
down• Shake thermometer away from
resident and hard objects4.01 Nursing Fundamentals 7243 42
Temperature: Safety Precautions(continued)
• Wipe from “handle” end toward bulb tip of thermometer prior to readingreading
• Delay taking oral temperature for 10 - 15 minutes if resident has been smoking, eating or drinking hot/cold liquids.
4.01 Nursing Fundamentals 7243 43
Temperature ConditionsTemperature Conditions
•• HyperthermiaHyperthermia– Increased body temp– Body temp >104ºF– >106 ºF will cause
convulsions and death
•• FeverFever- temp over 101 ºF R- Due to illness or
injury4.01 Nursing Fundamentals 7243 44
Temperature ConditionsTemperature Conditions
•• HypothermiaHypothermia– Body temp below– 96 ºF– due to exposure to
cold temperatures – Depends on core
temperature, age and length of exposure
4.01 Nursing Fundamentals 7243 45
SKILLSKILL 4.01A4.01A
Training Lab AssignmentTraining Lab AssignmentEngage in the Skill Acquisition Process for:Engage in the Skill Acquisition Process for:
4.01 Nursing Fundamentals 7243 46
SKILLSKILL 4.01A4.01AOral temperature using a nonOral temperature using a non --mercury mercury
glass thermometerglass thermometer
SKILLSKILL 4.01B4.01B
Training Lab AssignmentTraining Lab AssignmentEngage in the Skill Acquisition Process for:Engage in the Skill Acquisition Process for:
4.01 Nursing Fundamentals 7243 47
SKILLSKILL 4.01B4.01BAxillary temperature using a Axillary temperature using a
nonnon --mercury glass thermometermercury glass thermometer
SKILLSKILL 4.01C4.01C
Training Lab AssignmentTraining Lab AssignmentEngage in the Skill Acquisition Process for:Engage in the Skill Acquisition Process for:
4.01 Nursing Fundamentals 7243 48
SKILLSKILL 4.01C4.01CRectal Temperature using a Rectal Temperature using a
nonnon --mercury glass thermometermercury glass thermometer
SKILLSKILL 4.01Dto4.01Dto
Measure Temperature with Measure Temperature with
Training Lab AssignmentTraining Lab AssignmentEngage in the Skill Acquisition Process for:Engage in the Skill Acquisition Process for:
4.01 Nursing Fundamentals 7243 49
Measure Temperature with Measure Temperature with
Electronic ThermometerElectronic Thermometer
SKILLSKILL 4.01E4.01E
Measure Temperature with Measure Temperature with
Training Lab AssignmentTraining Lab AssignmentEngage in the Skill Acquisition Process for:Engage in the Skill Acquisition Process for:
4.01 Nursing Fundamentals 7243 50
Measure Temperature with Measure Temperature with
Tympanic ThermometerTympanic Thermometer
TTPPR+BP = Vital SignsR+BP = Vital Signs
PULSEPULSEPULSEPULSE
4.01 Nursing Fundamentals 7243 51
PULSEPULSEMeasuring the pulse is one way of
checking on the circulatory system
4.01 Nursing Fundamentals 7243 52
Circulatory SystemCirculatory System
4.01 Nursing Fundamentals 7243 53
Circulatory SystemCirculatory System
Circulatory System
• Circulation is continuous movement of blood
Nursing Fundamentals 7243 54
movement of blood throughout body
4.01
Circulatory System(continued)
• Functions of circulatory system–Arteries carry blood with
oxygen and nutrients away from heart and to cells
Nursing Fundamentals 7243 55
from heart and to cells–Veins carry waste products
away from cells and to heart
4.01
Blood
• Adult has 5 to 6 quarts (liters)• Consists of
–water - 90% (plasma)–blood cells
Nursing Fundamentals 7243 56
–blood cells–carbon dioxide and oxygen–nutrients, hormones and
enzymes–waste products
4.01
Blood(continued)
• Types of blood cells–Red blood cells - erythrocytes
• carry oxygen from blood to cells–White blood cells - leukocytes
Nursing Fundamentals 7243 57
–White blood cells - leukocytes• fight infection
–Platelets - thrombocytes• required for clotting to stop bleeding
4.01
Blood Vessels
• Arteries - carry blood away from heart• Veins – carry blood to heart
Nursing Fundamentals 7243 584.01
Heart
• Tissue (three layers)–endocardium - smooth,
inner layer–myocardium – thick,
Nursing Fundamentals 7243 59
–myocardium – thick, muscular middle layer
–pericardium – double-walled membrane that covers outside of heart
4.01
Heart Chambers
• Heart divided into right and left side
• Atria – upper chambers –
Nursing Fundamentals 7243 60
receive blood• Ventricles –
lower chambers – pump blood to lungs and body
4.01
Heart Chambers
• Four chambers–right atrium (1) - receives
blood from two large veins:• superior vena cava
Nursing Fundamentals 7243 61
• superior vena cava• inferior vena cava
–right ventricle (2) - receives blood from right atrium and pumps it to lungs through pulmonary artery
4.01
Heart Chambers(continued)
• Four chambers–left atrium (3) - receives
oxygenated blood from left and right pulmonary veins
Nursing Fundamentals 7243 62
and right pulmonary veins–left ventricle (4) - pumps
blood to aorta, which delivers blood to all body parts (except lungs)
4.01
Heart Valves
• Located at entrance and exit of each ventricle
• Four heart valves
Nursing Fundamentals 7243 634.01
Heartbeat
• Systole - contraction of heart muscle• Diastole - relaxation of heart muscle• Blood pressure – highest and lowest
Nursing Fundamentals 7243 64
• Blood pressure – highest and lowest pressure against walls of blood vessels as heart contracts and relaxes
• Pulse - expansion and contraction of artery
4.01
Common Disorders of the Circulatory System
• Arteriosclerosis - walls of arteries become thick and harden
• Hypertension - high blood pressure
Nursing Fundamentals 7243 65
• Hypertension - high blood pressure• Peripheral vascular disease -
decrease in flow of blood to extremities and brain
• Angina pectoris - chest pain4.01
Common Disorders of the Circulatory System
(continued)
• Varicose veins - enlarged, twisted veins usually in legs
• Congestive heart failure -
Nursing Fundamentals 7243 66
• Congestive heart failure -circulatory congestion caused by weak pumping of heart muscle
• Myocardial infarction (MI) - heart attack due to blockage in coronary arteries
4.01
Common Disorders of the Circulatory System
(continued)
• Anemia – low red blood cell counts• Thrombus – blood clot• Phlebitis – inflammation of vein
Nursing Fundamentals 7243 67
• Phlebitis – inflammation of vein• Atherosclerosis - fatty deposits on
walls of arteries that reduce blood flow
4.01
Changes of the Circulatory System Due To Aging
• Heart muscle less efficient• Blood pumped with less force• Arteries lose elasticity and
Nursing Fundamentals 7243 68
• Arteries lose elasticity and become narrow
• Blood pressure increases• Blood chemistry less efficient• Capillaries become more fragile4.01
Observations of the Circulatory System
• Changes in pulse rate and blood pressure
• Changes in skin color
Nursing Fundamentals 7243 69
• Changes in skin color• Changes in skin
temperature – coldness
4.01
Observations of the Circulatory System
(continued)
• Complaint of dizziness and headaches
• Complaint of pain in chest
Nursing Fundamentals 7243 70
• Complaint of pain in chest and/or indigestion
• Edema in feet and legs• Shortness of breath
4.01
Observations of the Circulatory System
(continued)• Sweating• Blue color to lips and/or nail beds• Complaint of tingling sensations• Memory lapses
Nursing Fundamentals 7243 71
• Memory lapses• Lack of energy• Irregular respirations• Anxiety• Staring and lack of responsiveness4.01
TTPPR+BP = Vital SignsR+BP = Vital SignsPULSEPULSE
• Pulse is pressure of blood pushing against wall of artery as heart beats and restsbeats and rests
• Pulse easier to locate in arteries close to skin that can be pressed against bone
4.01 Nursing Fundamentals 7243 72
Sites For Taking Pulse
• Radial – base of thumb• Temporal – side of
forehead• Carotid – side of neck• Carotid – side of neck• Brachial – inner aspect
of elbow• Femoral – inner aspect
of upper thigh
4.01 Nursing Fundamentals 7243 73
Sites For Taking Pulse(continued)
• Popliteal - behind knee• Dorsalis pedis – top of
foot • Apical pulse – over apex • Apical pulse – over apex
of heart–taken with stethoscope–left side of chest
4.01 Nursing Fundamentals 7243 74
Factors Affecting Pulse
• Age• Sex• Position• Drugs• Illness• Illness• Emotions• Activity level • Temperature• Physical training
4.01 Nursing Fundamentals 7243 75
Measurement of Pulse
• Normal pulse range/characteristics: 60 -100 beats per minute and regular
• Documenting pulse rate–Noted as number of beats per –Noted as number of beats per
minute–Rhythm - regular or irregular–Volume - strong, weak, thready,
bounding
4.01 Nursing Fundamentals 7243 76
SKILLSKILL 4.01F4.01FCount and Record Count and Record
Training Lab AssignmentTraining Lab AssignmentEngage in the Skill Acquisition Process for:Engage in the Skill Acquisition Process for:
4.01 Nursing Fundamentals 7243 77
Count and Record Count and Record Radial PulseRadial Pulse
SKILLSKILL 4.01G4.01G
Measure and Record Measure and Record
Training Lab AssignmentTraining Lab AssignmentEngage in the Skill Acquisition Process for:Engage in the Skill Acquisition Process for:
4.01 Nursing Fundamentals 7243 78
Measure and Record Measure and Record
Apical PulseApical Pulse
TPTPRR+BP = Vital Signs+BP = Vital Signs
RESPIRATIONSRESPIRATIONS
4.01 Nursing Fundamentals 7243 79
RESPIRATIONSRESPIRATIONSMeasuring respirations is one way of Measuring respirations is one way of checking on the checking on the respiratory systemrespiratory system
4.01 Nursing Fundamentals 7243 80
Respiratory SystemRespiratory System
4.01 Nursing Fundamentals 7243 81
Respiratory SystemRespiratory System
The Respiratory System
• Respiration means to breathe in oxygen and breathe out carbon dioxide
• Exchange of oxygen and carbon
Nursing Fundamentals 7243 82
• Exchange of oxygen and carbon dioxide necessary for life
4.01
The Respiratory System(continued)
• Process–External respiration - oxygen and
carbon dioxide exchanged between lungs and blood
Nursing Fundamentals 7243 83
lungs and blood–Internal respiration - oxygen and
carbon dioxide exchanged between blood stream and cells
4.01
The Respiratory SystemStructure
• Oral cavity – mouth• Pharynx – throat• Larynx - voice box• Trachea – windpipe
Nursing Fundamentals 7243 84
• Trachea – windpipe• Bronchi - right and left• Bronchioles - smallest branches of
bronchi• Alveoli - air sacs covered with
capillaries4.01
The Respiratory SystemStructure(continued)
• Nose - lined with mucous membrane–air filtered by cilia
Nursing Fundamentals 7243 85
–air filtered by cilia–mucous membrane
warms and moistens air
4.01
The Respiratory SystemStructure(continued)
• Lungs–right - 3 lobes
Nursing Fundamentals 7243 86
–right - 3 lobes–left - 2 lobes
4.01
The Respiratory SystemStructure(continued)
• Pleura – membrane that encloses lungs
• Diaphragm - muscle that separates
Nursing Fundamentals 7243 87
• Diaphragm - muscle that separates the chest and abdomen–contraction - draws air into lungs–relaxation - forces air out of lungs
4.01
Common Disorders of Respiratory System
• URI – Upper R espiratory I nfection -infection of nose, throat, larynx, trachea
• Pneumonia - inflammation or
Nursing Fundamentals 7243 88
• Pneumonia - inflammation or infection of the lungs
4.01
Common Disorders of Respiratory System
(continued)
• Emphysema (Chronic Obstructive Pulmonary Disease – COPD) –alveoli become stretched and stiff
Nursing Fundamentals 7243 89
alveoli become stretched and stiff preventing adequate exchange of oxygen and carbon dioxide
• Asthma – spasms of bronchial tube walls causing narrowing of air passages usually due to allergies
4.01
Common Disorders of Respiratory System
(continued)
• Allergy – reaction to substances that leads to slight or severe response by body.
Nursing Fundamentals 7243 90
body.• Influenza – highly contagious URI• Pleurisy – inflammation of the pleura
surrounding the lungs
4.01
Common Disorders of Respiratory System
(continued)
• Bronchitis - inflammation of the bronchi
• Lung cancer - malignant tumors in
Nursing Fundamentals 7243 91
• Lung cancer - malignant tumors in the lungs that destroy tissue
4.01
Changes in Respiratory System Due To Aging
• Lung tissue becomes less elastic• Respiratory muscles weaken• Number of alveoli decrease
Nursing Fundamentals 7243 92
• Respirations increase• Voice pitched higher and weaker due
to changes in larynx• Chest wall and structures become
more rigid4.01
Observations Of Respiratory System
• Rate and rhythm of respirations• Respiratory secretions – character• Character of cough• Changes in skin color - pale or bluish
Nursing Fundamentals 7243 93
• Changes in skin color - pale or bluish gray
• Temperature changes• Difficulty breathing
4.01
Observations Of Respiratory System(continued)
• Color of sputum• Complaint of pain in
chest, back, sides• Shortness of breath
Nursing Fundamentals 7243 94
• Shortness of breath• Noisy respirations• Sneezing• Gasping for breath• Anxiety
4.01
Measuring Respirations
• Respiration – process of taking in oxygen and expelling carbon dioxide from lungs dioxide from lungs and respiratory tract
4.01 Nursing Fundamentals 7243 95
Measuring Respirations(continued)
• Age• Activity
• Sex• Illness
Factors Affecting Rate
• Activity level
• Position• Drugs
• Illness• Emotions• Temperature
4.01 Nursing Fundamentals 7243 96
Measuring Respirations(continued)
• Qualities of normal respirations–12-20 respirations per minute–Quiet–Effortless–Effortless–Regular
4.01 Nursing Fundamentals 7243 97
Measuring Respirations(continued)
• Documenting respiratory rate–Noted as number of inhalations
and exhalations per minute (one inhalation and one exhalation inhalation and one exhalation equals one respiration)
–Rhythm – regular or irregular–Character: shallow, deep, labored
4.01 Nursing Fundamentals 7243 98
SKILLSKILL 4.01H4.01HCount and Record Count and Record
Training Lab AssignmentTraining Lab AssignmentEngage in the Skill Acquisition Process for:Engage in the Skill Acquisition Process for:
4.01 Nursing Fundamentals 7243 99
Count and Record Count and Record RespirationRespiration
TPR+TPR+BPBP = Vital Signs= Vital Signs
BLOOD PRESSUREBLOOD PRESSURE
4.01 Nursing Fundamentals 7243 100
Blood PressureBlood PressureMeasuring the pulse is one way of
checking on the circulatory system
4.01 Nursing Fundamentals 7243 101
Measuring Blood Pressure
• Blood pressure is the force of blood pushing against walls of arteries–Systolic pressure: greatest force
exerted when heart contractingexerted when heart contracting–Diastolic pressure: least force
exerted as heart relaxes
4.01 Nursing Fundamentals 7243 102
Factors Influencing Blood Pressure
• Weight• Sleep• Age• Emotions• Emotions• Sex• Heredity• Viscosity of blood• Illness/Disease
4.01 Nursing Fundamentals 7243 103
Blood Pressure: Equipment
• Sphygmomanometer (manual)–cuff - different sizes–pressure control bulb–pressure gauge – marked
with numbers• aneroid• mercury
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Blood Pressure: Equipment(continued)
• Stethoscope–magnifies sound–has diaphragm–has diaphragm
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Measuring Blood Pressure
Blood Pressure Systolic(top#)
Diastolic (bottom #)
NormalNormal ≤ 120≤ 120 <80<80
Pre HypertensionPre Hypertension 120120--139139 8080--8989
Hypertension StageHypertension Stage (1)(1) 140140--159159 9090--9999
Hypertension Stage (2)Hypertension Stage (2) ≥160≥160 ≥100≥100
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Guidelines for Blood Pressure Measurements
• Measure on upper arm
• Have correct size cuff cuff
• Identify brachial artery for correct placement of stethoscope
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=
Positioning of stethoscope Positioning of stethoscope diaphragm diaphragm directly over the brachial artery directly over the brachial artery increases ability to increases ability to hear the systolic and diastolic soundshear the systolic and diastolic sounds
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=
Positioning of Positioning of stethoscope stethoscope diaphragm diaphragm directly directly over the brachial over the brachial artery artery increases increases
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artery artery increases increases ability to hear the ability to hear the systolic and systolic and diastolicdiastolic
Guidelines for Blood Pressure Measurements
(continued)
• First sound heard –systolic pressure
• Last sound heard or • Last sound heard or change - diastolic pressure
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SystolicSystolic –– SStart hearing a tart hearing a SSound ound –– Heart Muscle is Heart Muscle is SSqueezingqueezing
1201208080
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DiastolicDiastolic –– DDon’t hear sound anymore on’t hear sound anymore –– Heart muscle Heart muscle ddoes not oes not work during work during ddiastolic. This number is written iastolic. This number is written ddown under the own under the systolic number.systolic number.
Guidelines for Blood Pressure Measurements
(continued)
• Record - systolic/diastolic• Resident in relaxed
position, sitting or lying down
• Blood pressure usually taken in left arm
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Guidelines for Blood Pressure Measurements
(continued)
Do not measure blood Do not measure blood pressure in arm with IV, pressure in arm with IV, pressure in arm with IV, pressure in arm with IV, AA--V shunt (dialysis), V shunt (dialysis), cast, wound, or sorecast, wound, or sore
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Guidelines for Blood Pressure Measurements
(continued)
• Apply cuff to bare upper arm, not over clothingclothing
• Room quiet so blood pressure can be heard
• Sphygmomanometer must be clearly visible
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Blood Pressure: Reading Gauge
• Large lines are at increments of 10 mmHg
• Shorter lines at • Shorter lines at 2 mm intervals
• Take reading at closest line
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SKILLSKILL 4.01I4.01IMeasure Blood Pressure Measure Blood Pressure
Training Lab AssignmentTraining Lab AssignmentEngage in the Skill Acquisition Process for:Engage in the Skill Acquisition Process for:
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Measure Blood Pressure Measure Blood Pressure ManualManual
SKILLSKILL 4.01J4.01J
Training Lab AssignmentTraining Lab AssignmentEngage in the Skill Acquisition Process for:Engage in the Skill Acquisition Process for:
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SKILLSKILL 4.01J4.01JCombined Vital SignsCombined Vital Signs
Measuring Measuring
Height and WeightHeight and Weight
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Height and WeightHeight and Weight
The resident’s The resident’s weightweight , , compared with the compared with the heightheight , , gives information about gives information about his/her his/her nutritional status nutritional status his/her his/her nutritional status nutritional status and changes in the and changes in the medical medical condition. condition.
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Measuring Height And Weight
• Baseline measurement obtained on admission and must be accurate.
• Other measurements obtained as ordered.
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Measuring Height And Weight(continued)
• Height measurements–Feet–Inches –Centimeters–Centimeters
• Weight measurements–Pounds–Ounces–Kilograms
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Measuring Height and Weight(continued)
• Reasons for obtaining height and weight–Indicator of nutritional status–Indicator of nutritional status–Indicator of change in medical
condition–Used by doctor to order medications
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Special Case for Height Measurement
• Residents who are contractured or • Residents who cannot stand• Must be measured using a tape • Must be measured using a tape
measure
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Measuring Height and Weight(continued)
–Use same scale each time
–Have resident void,
• Guidelines for weighing residents
–Have resident void, remove shoes and outer clothing
–Weigh at same time each day
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Measuring Height and Weight(continued)
• Scales–Remain more accurate if moved as
little as possible.–Various types of scales
• bathroom scale• bathroom scale• standing scale• scales attached to hydraulic lifts• wheelchair scales• bed scales
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SKILLSKILL 4.01K4.01KMeasure HeightMeasure Height
Training Lab AssignmentTraining Lab AssignmentEngage in the Skill Acquisition Process for:Engage in the Skill Acquisition Process for:
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Measure HeightMeasure Height& Weight& Weight
�� ENDEND ��
4.014.01Understand Understand vital signsvital signs , , heightheight , and , and weightweight measurement skills. measurement skills.
127
4.014.01
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