Vital Signs – Weight/Height

Unit VI. Identify Vital Signs

II. Discuss NAR responsibility

III. Identify methods and responsibilities when

obtaining height and weight

IV. Recognize how Lack of Oxygen Affects Vital

Signs

V. Identify effective methods of providing oxygen

to Residents.

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

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.

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.

TPR - Abbreviation for temperature, pulse and

respiration.

VS - Abbreviation for vital signs which are

temperature, pulse, respiration and blood

pressure.

I. 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.

B. 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

4. 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.

B. Temperature – Measurement of Body Heat (Cont.)

B. Temperature – Measurement of Body Heat (Cont.)

6. 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).

B. Temperature – Measurement of Body Heat (Cont.)

6. 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

B. Temperature – Measurement of Body Heat (Cont.)

6. 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.

d. 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.

B. Temperature – Measurement of Body Heat (Cont.)

7. Electronic Thermometers

a. Audible beep usually

Indicates measurement

Completed.

b. The reading of the

temperature is shown on

a digital lighted display.

c. Be alert to Fahrenheit and

Celsius scales.

d. Cover probe with

disposable plastic

sheath or cup.

e. Follow procedure for

use as indicated by

manufacturer or

facility policy.

f. Stay with resident.

B. Temperature – Measurement of Body Heat (Cont.)

8. Describe general rules for taking temperature with glass

Thermometer.

a. Do not take oral temperature with glass thermometer

On children under 5 years of age, confused adults,

Or those with seizure disorders.

b. Check thermometer for chips, cracks.

c. Shake mercury down away from resident or hard

Objects before inserting.

d. Lubricate rectal thermometer wiping from colored

end to mercury tip before inserting.

e. Cover with disposable plastic film sheath.

f. Hold thermometer in place.

g. Stay with resident.

h. Disinfect according to facility policy.

B. Temperature – Measurement of Body Heat (Cont.)

8. Describe general rules for taking temperature with glass

thermometer (Cont.)

i. 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.

9. Temperatures are always recorded as whole numbers and

decimals such as 98.6.

C. 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.

C. 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

C. Pulse (Cont.)

f. 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.

g. Note volume – weak, thready, strong.

h. 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.

i. 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.

D. Respirations

1. Respiration is the body process of breathing which

Supplies the body with oxygen and releases carbon

Dioxide.

2. Respiration includes

a. Inspiration (breathing in)

b. Expiration (breathing out)

3. Normal respirations

a. Adults – 16-22 per minute

4. 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

D. 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.

D. Respirations (Cont.)

e. Note if respirations are:

- regular

- shallow

- deep

- difficult, labored (working or struggling to get a breath)

f. Count respirations for 30 seconds or 1 minute, as indicated

By your facility or resident’s care plan.

g. Count for one full minute if respirations are irregular.

h. 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.

E. Blood Pressure

1. Blood pressure is the force of blood pushing

against the walls of the blood vessels.

2. General guidelines when taking blood pressure

a. Equipment should be in good working condition.

b. Use cuff of correct size for thickness of upper

arm. (Sphygmomanometer)

c. Have gauge at eye level.

d. Resident should be sitting or lying in

a relaxed comfortable position, with

arm resting on solid surface.

e. 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)

f. 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.

E. Blood Pressure (Cont.)

F. Record Vital Signs

1. List correct way to record.

a. Temperature written first.

b. Pulse listed second.

c. Respirations listed last

T P R

98.6 80 20

d. 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

F. Record Vital Signs

e. Record accurately.

f. Follow facility policy regarding recording of vital

signs. You may use a graphic sheet to record this date.

Factors affecting Blood Pressure

Age

Obesity

Exercise/sleep

Heart disease, diabetes, heredity

Pain

Blood loss

Time of day

Blood Pressure

Hypertension is blood pressure higher then

140/90

Hypotension is blood pressure lower then

90/60

Report promptly any abnormal vital sign

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.

G. Measuring and Recording Height and Weight

1. Height and weight measurements are not

vital signs, but are also part of information

collected to evaluate a person’s health.

2. Weighing Residents

a. Methods of weighing residents:

- standing scale - bed scale

- chair scale - tub chair scale

- wheelchair scale - mechanical lift scale

b. 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.

G. Measuring and Recording Height and Weight

3. Measuring resident’s height

a. Used in nutritional assessment

b. Usually done one, on admission

c. Standing scale has height indicator, tape measure is

used for residents in bed.

d. Record in feet and inches or total inches.

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.

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

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.

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.

Home Health Aide

Unit V

Vital Signs – Weight/Height

I. 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.

I. 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

Normal pulses

School age clients 6-12yrs, 70 -110 bpm

Adolescents ( 14 – 20) 60 – 90 bpm

I. 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

a. Infants usually double birth weight

in six months, triple in a year.

b. 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.