MNA M osby ’ s Long Term Care Assistant Chapter 31 Vital Signs

Vital Signs Reflect function of body process needed for life: Temperature Pulse Respirations Blood Pressure. TPR and B/P

Amount of heat in the body Lower in amHigher in pm Effected by: Age Weather Exercise Emotions Stress illness Temperature

Sites: Oral Axillary Aural Rectal Temporal Temperature Mouth Arm pit Ear Rectum Forehead

Sites: Oral Normal 97.6 – 99.6 º F Leave in place 2-3 minutes No smoking, eating, drinking for 15 minutes Temperature

Sites: Axillary Normal 96.6 – 98.6 º F Leave 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: Rectal Normal 98.6 – º F Sims position Lubricate with KY Jelly Insert 1 inch Hold in place 2 minutes Temperature RED TIP

Sites: Temporal Artery in forehead Normal 97.6 – 99.6 º F Leave in place according to manufacturers instructions Temperature

So ….Normals Oral AX R Temperature Most accurate: Rectal

Reading a Glass Thermometer. 02 degrees

Using a Glass Thermometer Rinse in cool water Check for breaks, cracks, chips Shake down Use plastic covers Standard precautions

Types of Electric Thermometers

Pulse Beat of the felt at an artery Normal Adult Pulse:

Pulse Sites 1. Temporal 2 & 3. Carotid 4. Brachial 5. Radial 6. Femoral 7. Popliteal 8. Posterior tibial 9. Dorsalis pedis

Terms Taqchycardia Bradycardia Rate Rhythm Force Rate over 100 per minute Rate below 60 per minute Number ex 68 Regular or irregular Strong, 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 Inhalation Exhalation Normal 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 relaxes Systolic - 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

Measuring B/P Pt is sitting or lying down Bare arm Cuff is snug Appropriate size cuff Listen for: 1 st sound - systolic last sound - diastolic

Factors effecting B/P AgeStress Gender female Pain ExerciseWeight RaceDrugs PositionSmoking 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 TPR Temperature 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? minutes

Review Normal respiration rate? 12 – 20 per minute

Review The diastolic pressure is the first sound heard TrueFalse

Review AX TID PRN PO STAT S QD axillary 3 x a day As needed By mouth immediately without Once a day _