Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Introduction Vital Signs -Temperature, Pulse, Respirations, Blood Pressure Competent, confident, accurate. Medications and treatments may be administered or discontinued depending upon VS. If you are ever in doubt, ask the charge nurse to recheck your reading. VS is the signs of life

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Terms and Definitions Arteriosclerosis – loss of elasticity in the walls of the blood vessels Atherosclerosis – accumulation of fat deposits inside of arteries, making them more narrow Axilla - armpit Body temperature – the amount of heat in the body that is as balance between the amount of heat produced and the amount lost by the body Cheyne-Stokes – a pattern of breathing in which respirations gradually increase in rate and depth and then become shallow and slow; breathing may stop for 10 to 20 seconds Congestive heart failure (CHF) – the inability of the heart to pump an adequate quantity of blood Emphysema – respiratory condition in which the elasticity of the alveoli (See Figure 8.2.) is lost, resulting in difficulty breathing

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Terms and Definitions Heart attack/myocardial infarction (MI) – a blockage or clot occurring in an artery in the heart, resulting in chest pain due to tissue damage Hypertension – high blood pressure Hypotension – low blood pressure Pneumonia – inflammation of the lungs with fluid accumulation in the affected alveoli Pulse – the beat of the heart felt at an artery as a wave of blood passes through the artery Pulse rate – the number of heartbeats or pulses felt in 1 minute Respirations – act of breathing in and out of the lungs (inhalation/exhalation) Orthostatic hypotension – a sudden drop in blood pressure when the resident moves from lying to a sitting or standing position; results in fainting

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Terms and Definitions Tuberculosis – an infection, primarily of the lung, from mycobacterium tuberculosis Vital signs – temperature, pulse, respirations, and blood pressure

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Cardiovascular System U Tube- The Heart Song Vanderhorst

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Pathway of Blood Through The Heart

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Cardiovascular System Organs Heart Blood vessels Blood Functions Carries nutrients and oxygen to cells Removes waste products from cells

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Aging Process **Decreased ability of the heart to act as a pump Pulse rate decreases Decreased ability of the cardiovascular system to respond to position changes (orthostatic hypotension) or increased demand for blood supply Cardiovascular System Narrowing of blood vessels and loss of elasticity in vessel wall, which results in poor circulation and elevated blood pressure (BP) Related health problems Hypertension Heart attack/myocardial infarction Congestive heart failure Need for a pacemaker

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Nursing care Report abnormal pulse or BP to the charge nurse. Cardiovascular System Encourage resident to change positions slowly to avoid a sudden drop in BP, resulting in fainting. A resident with hiccups may have a loose pacemaker wire; report to charge nurse. Report changes in skin color or temperature. Observe for shortness of breath or swelling of legs and feet that could indicate CHF. Immediately report to the charge nurse any complaints of chest pain, left arm or jaw pain, difficulty breathing, perspiration, or change in rate or rhythm of pulse. These may be signs of heart attack. Backache in women may also be a sign of a heart attack. NOTE: Many elderly residents experience “silent” MI. They do not always experience chest pain or other symptoms.

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Respiratory System Figure 8.2 – Respiratory System

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Respiratory System Organs Nose Mouth Epiglottis Pharynx Larynx Trachea Bronchi Lungs Bronchioles Alveoli

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Respiratory System Functions Provides oxygen to cells Removes carbon dioxide from cells Aging process Loss of elasticity in lungs – Lungs do not expand and contract as well. Chest muscle weakness results in shallow breathing and less effective cough. Related health problems Emphysema Pneumonia Lung cancer Tuberculosis

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Respiratory System Nursing care Allow frequent rest periods if resident becomes short of breath with exertion or ADLs. Elevate HOB to make breathing easier at night. Report any changes in resident’s color or respiratory rate to the charge nurse.

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Normal Range for Elderly Adult Average Temperature Time Required for Accurate Reading Oral Temperature °F 96.8°5-8 minutes Rectal Temperature °F 97.8°F3-4 minutes Axillary Temperature °F 95.8°F10-12 minutes Tympanic, or aural (ear) Thermometer Same as oral or rectal, depending on setting used Less than 1 minute Electronic Thermometer Same as oral or rectal, depending on setting used 1 minute of less Pulse50-100NA1 full minute Respirations14-20NA1 full minute

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Conclusion Taking the resident’s TPR contributes to the overall evaluation of his/her condition. It should be done with great accuracy and whenever a change of condition is indicated. Most facilities check the resident’s TPR at least once a month.

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Steps of Procedure for Taking Oral Temperature 1.Gather necessary equipment. 2.Wash your hands. Put on gloves. 3.Identify and greet resident. Identify self. 4.Explain what you are going to do. 5.Provide privacy. 6.Resident should be in sitting/lying down position. 7.Using a glass bulb thermometer a. Rinse thermometer with cool water if it has been soaked in disinfectant solution. b.Check thermometer for breaks or chips. c.Shake down thermometer to 94°F or below; firmly grasp at the stem end and snap your wrist several times.

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Steps of Procedure for Taking Oral Temperature d.Ask resident to open mouth and raise tongue. Place the thermometer bulb under resident’s tongue toward side of mouth. e.While holding bulb under tongue, instruct the resident to hold the thermometer in place by closing his/her lips around the thermometer. Leave in place for at least 5 minutes. f.Grasp the stem end of the thermometer and remove it from the resident’s mouth. Wipe thermometer from the stem toward the bulb end with a tissue. g.Read the thermometer. h.Record the temperature reading on the paper. i.Shake down the thermometer.

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Steps of Procedure for Taking Oral Temperature Using an electronic thermometer a. Make sure the oral probe is plugged into the thermometer. b.Remove the probe from the unit and insert it into a probe cover. c.Ask resident to open mouth and raise tongue; place covered probe at the base of the tongue on either side. d.Ask the resident to lower tongue and close mouth. e.The nurse assistant should hold the probe in the resident’s mouth until the tone is heard or when there is a flashing or steady light. f.Read the temperature reading on the digital display.

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Steps of Procedure for Taking Oral Temperature g.Remove the covered probe from the resident’s mouth and discard the probe cover by pressing the eject button. h.Record the temperature reading on paper. i.Return the probe to the holder. 8.Remove, clean, and store equipment. Disinfect glass thermometer. 9.Remove gloves and dispose in appropriate container. Wash hands. 10.Make the resident comfortable; place call signal within reach. 11.Record observations and report anything unusual to the charge nurse.

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Steps of Procedure for Taking Rectal Temperature 1.Gather necessary equipment. 2.Wash your hands. Put on gloves. 3.Identify and greet resident. Identify self. 4.Explain what you are going to do. 5.Provide privacy. Using a glass thermometer 6.Instruct/assist resident to lie on his/her side with upper leg flexed. 7.Rinse thermometer with cool water if it has been soaked in disinfectant solution. 8.Check thermometer for breaks and chips. 9.Shake down thermometer to 94°F or below; firmly grasp at the stem end and snap your wrist several times.

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Steps of Procedure for Taking Rectal Temperature 10.Put a small amount of lubricant on a tissue and lubricate the bulb end of the thermometer. 11.Raise the upper buttock to expose the anus; insert bulb end of the thermometer 1 inch into rectum. Cover resident. 12.Hold the thermometer in place for 3 to 4 minutes while holding top hip of resident to prevent rolling back. 13.Remove the thermometer. Wipe it clean with tissues from the stem toward the bulb. 14.Place the thermometer on clean toilet tissue; wipe the anal area to remove excess lubricant. 15.Cover the resident.

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Steps of Procedure for Taking Rectal Temperature 16.Read the thermometer and record on paper the temperature reading. 17.Shake down the thermometer. 18.Remove, clean, and store equipment. Disinfect glass thermometer. 19.Remove gloves and dispose in appropriate container. Wash hands. 20.Make the resident comfortable; place call signal within reach. 21.Record observations; report anything unusual to the charge nurse.

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Steps of Procedure for Taking Rectal Temperature Using an electronic thermometer (First repeat steps 1-5.) 22.Make sure the rectal probe is plugged into the thermometer (it is usually red). 23.Instruct/assist resident to lie on his/her side with upper leg flexed. 24.Place a small amount of lubricant on the probe cover. 25.Raise the upper buttock to expose the anus; insert the probe 1 inch into the rectum; cover the resident. 26.The nurse assistant should hold the probe in the resident’s rectum until the tone is heard or when there is a flashing or steady light. 27.Read the temperature reading on the digital display.

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Steps of Procedure for Taking Rectal Temperature 28.Remove the covered probe from the resident’s rectum and discard the probe cover into the trash by pressing the eject button. 29.Cover the resident. 30.Make sure the resident is comfortable; place call signal within reach. 31.Record observations and report anything unusual to the charge nurse.

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Steps of Procedure for Taking Axillary Temperature 1.Gather necessary equipment. 2.Wash your hands. 3.Identify and greet resident. Identify self. 4.Explain what you are going to do. 5.Provide privacy. Using a glass thermometer 6.Rinse thermometer with cool water if it has been soaked in disinfectant solution. 7.Check thermometer for breaks or chips.

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Steps of Procedure for Taking Axillary Temperature 8.Shake down thermometer to 94°F or below; firmly grasp at the stem end and snap your wrist several times. 9.Instruct/assist resident to assume sitting or supine position. 10.Help the resident remove an arm from the sleeve of the gown without exposing the resident. 11.Dry axilla of excessive perspiration with a towel. 12.Place bulb end of thermometer in the center of axilla. 13.Bring the arm across the chest and hold in place to snugly hold the thermometer in place for 10 to 12 minutes. 14.Remove thermometer. Read and record temperature reading.

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Steps of Procedure for Taking Axillary Temperature 17.Wash your hands. 18.Make the resident comfortable; place call signal within reach. 19.Record observations and report anything unusual to the charge nurse. 15.Shake down the thermometer. 16.Remove, clean, and store equipment. Disinfect glass thermometer. Using an electronic thermometer (First repeat steps 1- 5.) 20. Instruct/assist resident to assume sitting or supine position. 21. Help the resident remove an arm from the sleeve of the gown without exposing resident.

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Steps of Procedure for Taking Axillary Temperature 22.Dry axilla of excessive perspiration with a towel. 23.Place the end of the probe in the center of the axilla. 24.Bring the arm across the chest and hold in place snugly until the tone is heard or when there is a flashing or steady light. 25.Read the temperature reading on the digital display. 26.Remove, clean, and store equipment. Disinfect electronic thermometer. 27.Wash your hands. 28.Make the resident comfortable; place call signal within reach. 29.Record observations and report anything unusual to the charge nurse.

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Steps of Procedure for Counting Radial Pulse 1.Gather necessary equipment. 2.Wash your hands. 3.Identify and greet resident. Identify self. 4.Explain what you are going to do. 5.Provide privacy. 6.Resident should be in sitting/supine position. 7.Place fingertips over radial artery and locate pulse. Do not take the pulse with your thumb. 8.Note if the pulse is strong or weak and regular or irregular. 9.Count the pulse for 1 full minute. Recount if unsure of reading.

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Steps of Procedure for Counting Radial Pulse 10.Note any abnormal characteristics of the pulse. 11.Record on paper the pulse reading. 12.Wash your hands. 13.Make the resident comfortable; place call signal within reach. 14.Record observations and report anything unusual to the charge nurse.

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Steps of Procedure for Counting Apical Pulse 1.Gather necessary equipment. 2.Wash your hands. 3.Identify and greet resident. Identify self. 4.Explain what you are going to do. 5.Provide privacy. 6.Resident should be in sitting/supine position. 7.Clean the earpieces and diaphragm with the alcohol wipes. 8.Raise the resident’s gown to expose the nipple area of the left chest. Do not expose more of the chest than necessary. 9.Warm the diaphragm with your hands before placing it on the chest. 10.Place the earpieces in your ears.

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Steps of Procedure for Counting Apical Pulse 11.Locate the apical pulse. The diaphragm should be placed just below the left nipple. 12.Listen carefully. 13.Count the apical pulse for 1 full minute. Note if the pulse is regular or irregular. Remove earpiece from your ear. Record pulse on sheet of paper. 14.Cover resident. 15.Clean earpieces with alcohol wipes. Also clean the diaphragm with alcohol wipes. 16.Return the stethoscope to its proper place. 17.Wash your hands. 18.Make the resident comfortable; place call signal within reach. 19.Record observations and report anything unusual to the charge nurse.

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Steps of Procedure for Counting Respirations 1.Wash your hands. 2.Identify and greet resident. Identify self. 3.Explain what you are going to do. 4.Provide privacy. 5.Resident should be in sitting/supine position. 6.Rest resident’s arm across his/her chest with your fingers on radial pulse for ease in observing rise and fall of chest cavity during respirations. 7.Begin counting respirations when you see the chest rise; count respirations for 1 full minute. Recount if unsure. 8.Note any abnormal characteristics of respirations. 9.Record number of respirations on paper.

Nurse Assistant In a Long-Term Care Facility Unit I: The Nurse Assistant Lesson Plan 8: Temperature, Pulse, and Respirations (TPR) Steps of Procedure for Counting Respirations 10.Wash your hands. 11.Make the resident comfortable; place call signal within reach. 12.Record observations and report anything unusual to the charge nurse.