1. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Textbook for Nursing Assistants Chapter 16: Vital Signs, Height, and Weight

2. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Vital Signs Height & Weight

3. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins What is a vital sign? –Vital signs are key measurements that provide essential information about overall health status What do vital signs indicate? –A change in a vital sign may indicate a response to illness or injury Vital Signs

4. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Specified on nursing care plan or doctor’s orders –Long-term care facility: once daily or weekly, and as needed –Hospital: every shift or every few hours, and as needed Within the nursing assistant’s scope of practice to take vital signs whenever he or she thinks it is warranted When Are Vital Signs Taken?

5. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Accuracy is important: many people rely on these measurements to make decisions about the person’s care Report an abnormal measurement immediately Recording and Reporting Vital Signs

6. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Body Temperature

7. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins It is the difference between heat produced and heat lost by the body Body heat is produced as a normal process of metabolism Body temperature is regulated by thermoregulatory center located in the brain What Is Body Temperature?

8. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Physical or emotional stress Environmental temperature Time of the day Age Gender Factors Affecting Body Temperature

9. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Measured in either degrees Fahrenheit (°F) or degrees Celsius (°C) Measured from –Mouth: Oral temperature –Rectum: Rectal temperature –Armpit: Axillary temperature –Ear: Aural temperature –Forehead: Temporal temperature Measurement of Body Temperature

10. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Glass Thermometer Electronic and Digital Thermometer Tympanic Thermometer Temporal Artery Thermometer Types of Clinical Thermometers Glass Thermometers

11. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Normal body temperature ranges from 0.5°F to 1°F above or below the range considered “normal” Pyrexia: increased body temperature – A person with pyrexia is said to be “febrile” –The doctor may order an antipyretic (fever-reducing) drug Normal and Abnormal Findings

12. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Pulse

13. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins When the heart beats, it sends a wave, or pulse, of blood through the arteries When checking the pulse, we look at the –Pulse rate –Pulse rhythm Irregular pulse rhythm is called dysrhythmia –Pulse amplitude What Is a Pulse?

14. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Physical activity (increases the body’s need for oxygen and nutrients) Anger and anxiety, illness, pain, fever, and excitement Certain medications Factors Affecting Pulse

15. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Radial Pulse: Taken by placing fingers over the radial artery (inside of wrist) Apical Pulse: Taken by listening over the apex of the heart with a stethoscope Measuring the Pulse

16. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Pulse Points

17. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Tachycardia is a rapid heart rate, or a pulse rate of more than 100 beats per minute for an adult A heart rate that is slower than normal, that is, a pulse rate of less than 60 beats per minute is called bradycardia Normal and Abnormal Findings

18. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Respiration

19. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Respiration is accomplished through ventilation Ventilation is –Inhalation of oxygen –Exhalation of carbon dioxide When measuring respiration, we look at –Respiratory rate –Respiratory rhythm –Depth of respiration Process of Respiration

20. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Physical activity Anxiety, pain, fear Fever Infections and diseases of the heart and lungs Stroke or head injury Medications Factors Affecting Respiration

21. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Respiratory rate determined by watching the rise and fall of the person’s chest and counting the number of breaths that occur in either 30 seconds or 1 minute One breath = 1 exhalation and 1 inhalation Measuring Respiration

22. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Normal respiratory rate: Eupnea –16 to 20 times a minute for adult –Higher for children and infants Abnormal respiratory patterns –Tachypnea – greater than 24 bpm –Bradypnea – less than 10 bpm –Dyspnea- difficulty breathing –Hyperventilation – increased rate & depth –Hypoventilation- decreased rate & depth Normal and Abnormal Findings

23. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Blood Pressure

24. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins The force that the blood exerts against the arterial walls Two pressure levels –Systolic pressure –Diastolic pressure The difference between the two is pulse pressure. Measured in millimeters of mercury (mm Hg) and recorded as a fraction What Is Blood Pressure?

25. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Cardiac output Blood volume Resistance to blood flow Age Gender Race Factors Affecting Blood Pressure

26. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Two ways of measuring: –Manually operated sphygmomanometer and a stethoscope –Automated sphygmomanometers Measuring Blood Pressure Manually operated sphygmomanometer

27. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Accepted normal ranges for the systolic pressure are between 100 and 140 mm Hg, and for the diastolic pressure, between 60 and 90 mm Hg Abnormal ranges –Hypertension –Hypotension –Orthostatic hypotension Normal and Abnormal Findings

28. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Height and Weight

29. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins A person’s weight –Provides insight into overall health, and nutritional status –Often used to calculate medication dosages Frequency for checking –Height: On admission, and on transfer or discharge –Weight: On admission, and at regular intervals Height and Weight

30. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Height is measured in feet (’) and inches (”) or in centimeters (cm). Weight is measured in pounds (lbs) or kilograms (kg) Ways of measurement –Upright scale –Chair scale –Tape measure and sling scale Measuring Height and Weight Upright Scale

31. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins End of Presentation