1. Nursing Assistant
Vital Signs

2. Vital Signs Temperature Pulse Respiration Blood pressure
Oxygen saturation
Pain

3. 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)

4. 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

5. Temperature Heat lost from body by Skin Lungs Elimination Sweating
Increased blood flow to skin surface
Lungs
Increased resp rate
Elimination
Urine or feces

6. Temperature Heat conserved by body through Reducing perspiration
Decreasing flow of blood to skin
Shivering
Increases muscle activity & produces heat

7. Temperature Norms Adult 97 – 99 degrees Fahrenheit Oral – 98.6
Rectal – 99.6
Axillary – 97.6
Tympanic – 98.6

8. 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

9. Contraindications for oral temps
Confused, disoriented
Restless
Unconscious
Coughing, unable to breathe through nose
Seizures
Oral/nasal oxygen NG

10. 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

11. Nursing measures Raise temperature Lower 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

12. 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

13. 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

14. Factors that increase pulse
Exercise
Strong emotions – fear, anger, laughter, excitement
Fever
Pain
Shock
Hemorrhage

15. 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

16. Qualities of pulse Rate – number of beats/min
Rhythm – regularity of pulse
Strength – force
Weak or thready
Bounding
Strong

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. Factors increasing BP Strong emotion Exercise Sitting or standing
Excitement
Pain
Decrease of vessel size
Digestion
Improperly placed or sized cuff

24. Factors decreasing BP Rest/sleep Lying down Depression Shock
Hemorrhage
Improperly sized cuff

25. 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

26. 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

27. 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

28. 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