MNAMosby’s Long Term Care Assistant Chapter 31Vital Signs

Vital Signs

Reflect function of body process needed for life:

TemperaturePulseRespirationsBlood Pressure.

TPR and B/P

Amount of heat in the bodyLower in am Higher in pmEffected by:AgeWeatherExerciseEmotionsStress illness

Temperature

Sites:Oral

Axillary

Aural

RectalTemporal

Temperature

Mouth

Arm pit

Ear

Rectum

Forehead

Sites:

OralNormal 97.6 – 99.6 º FLeave in place 2-3 minutesNo smoking, eating, drinking for 15 minutes

Temperature

Sites:

Axillary

Normal 96.6 – 98.6 º FLeave in place

5-10minutes

Dry the arm pit first

Temperature

Sites:Aural (tympanic)

Adult - Pull the ear up and back

Child – pull the ear down and back

Temperature

Normal 97.6 – 99.6 º F

Leave in place according to manufacturers instructions

Sites:RectalNormal 98.6 – 100.6 º F

Sims positionLubricate with KY JellyInsert 1 inchHold in place 2 minutes

Temperature

RED TIP

Sites:TemporalArtery in foreheadNormal 97.6 – 99.6 º F

Leave in place according to manufacturers instructions

Temperature

So….Normals

Oral

AX

R

Temperature

98.697.6 99.6

97.696.6 98.6

99.698.6 100.6

Most accurate:

Rectal

Reading a Glass Thermometer

.02 degrees

94.8

98.8

97102.4

104.4

106.6

Using a Glass Thermometer

Rinse in cool waterCheck for breaks,

cracks, chipsShake downUse plastic coversStandard precautions

Types of Electric Thermometers

Pulse

Beat of the

felt at an artery

Normal Adult Pulse: 60 - 100

Pulse Sites1. Temporal

2 & 3. Carotid

4. Brachial

5. Radial

6. Femoral

7. Popliteal

8. Posterior tibial

9. Dorsalis pedis

Terms

Taqchycardia

Bradycardia

RateRhythmForce

Rate over 100 per minute

Rate below 60 per minute

Number ex 68Regular or irregularStrong, weak, thready

Taking a Pulse

Use radial

Count for 30 seconds and X 2

Taking an Apical Pulse

Use a stethoscope

Listen at the apex

Count for 1 full minute

Using a Stethoscope

Instrument used to listen to sounds

Clean earpieces with antiseptic

Bend of tips point forward when placed in ears

Tap diaphragm gently

If no sound turn chest piece at tubing

Respirations

InhalationExhalation

Normal - 12 -20 per minute

Breath in Breath out

Count for 30 seconds X 2

Count when pt is at rest

and unaware that you are

counting

Blood Pressure

Amount of force against walls of artery when beats and when

relaxesSystolic - heart contraction

Diastolic – heart relaxation

120/60

Blood Pressure

Key terms:

Stethoscope – used to listen

Aneroid - dial

Sphygmomanometer – B/P cuff

B/P

Diaphragm – flat surface at end of stethoscope

Brachial – arm

Hypertension - ↑ B/P

Hypotension – ↓ B/P

Normal Adult Blood Pressure

100 - 140

60 - 90

Measuring B/P

Pt is sitting or lying downBare armCuff is snugAppropriate size cuffListen for: 1st sound - systolic last sound - diastolic

Factors effecting B/P

Age Stress

Gender female Pain

Exercise Weight

Race Drugs

Position Smoking

Alcohol

↑↑

↑↑

↑

↑

Review

Amount of force exerted on walls of artery by blood is ?

A.pulse

B.respiration

C.temperature

D.Blood pressure

Review

Heart rate less then 60 beats per minute?

bradycardia

TPRTemperature pulse respiration

Review

The beat of the heart is felt at

A.A vein

B.An artery

C.A capillary

D.A joint

Review

Used to measure B/P?

sphygmomanometer

Used to listen to body sounds?

stethoscope

Review

Rectal thermometer is color coded?

RED

Most common site for taking a pulse?

Radial

Review

How long after smoking before taking an oral temp?

10 - 15 minutes

Review

Normal respiration rate?

12 – 20 per minute

Review

The diastolic pressure is the first sound heard

True False

Review

AX

TID

PRN

PO

STAT

S

QD

axillary3 x a dayAs neededBy mouthimmediatelywithout

Once a day

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