2. Vital Signs, Height, and Weight18
Chapter
Vital Signs, Height, and Weight

3. Measuring and Recording Vital Signs
18.1
Section
Measuring and Recording Vital Signs

4. Objectives discuss the purpose and importance of taking vital signs;
identify the normal and abnormal ranges of vital signs;
describe the locations and methods used to take vital signs;
(continued)

5. Objectives list the equipment needed to take vital signs;
describe the importance of using a pulse oximeter; and
explain how to measure and record vital signs accurately and effectively.

6. The Importance of Vital Signs
Help diagnose diseases and determine effective treatments
Process is the same for children and adults, but preferred methods change with age
Guidelines determine normal vital sign ranges
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7. Temperature
Recorded in degrees (°) and measures body heat in either Fahrenheit (F) or Celsius (C)
Changes over course of a day due to dilation and expansion of blood vessels
Regulated by the hypothalamus

8. Temperature Locations
Oral
Rectal
Temporal artery
Axillary
Tympanic
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9. Average Body Temperatures
Average temperature for adults: 98.6°F (37.0°C)
Average rectal approximately 1°F (0.6°C) higher
Average axillary and temporal artery approximately 1°F (0.6°C) lower
May fluctuate during the day due to exertion, how much is consumed, or external temperature
Hypothermia—body temperature below 95°F (35°C)

10. Types of Thermometers Nondigital Digital Disposable oral Tympanic
Temporal artery
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11. Procedure Using an Oral Thermometer—Digital
Read through the procedure for using a digital oral thermometer. With a partner, discuss what you need to assess before you take a resident’s oral temperature to make sure the reading is accurate.

12. Procedure Using a Rectal Thermometer—Digital
Read through the procedure for using a digital rectal thermometer. Then, quiz a partner on the supplies you need to do this procedure.

13. Procedure Using an Axillary Thermometer— Digital
Read through the procedure for using a digital axillary thermometer. Then, explain why measuring axillary temperature should not be your first choice when taking a resident’s temperature.
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14. Procedure Using a Tympanic Thermometer— Digital
Read through the procedure for using a digital tympanic thermometer. This type of thermometer relies on exact placement to get an accurate reading. With a partner, practice how to position the ear when using a tympanic thermometer.

15. Procedure Using a Temporal Artery Thermometer—Digital
Read through the procedure for using a digital temporal artery thermometer. With a partner, discuss why this type of temperature is more accurate than oral temperature. For which age group would this thermometer work best?

16. Pulse
Pressure of blood against walls of arteries when the heart contracts and relaxes
Common locations to measure pulse:
Radial artery—located at the wrist
Apical artery—located at apex of heart; measured with stethoscope
Carotid artery—located near bottom of neck

17. Pulse Rate Measurements
Measured by counting number of beats per minute (bpm) using a watch
Affected by activity, anxiety, excitement, pain, fever, medications, sleep patterns, and diseases or health conditions
Bradycardia—pulse slower than 60 bpm
Tachycardia—pulse faster than 100 bpm
Must also count rhythm between beats

18. Measuring a Radial Pulse Procedure
With a partner, read through the procedure for measuring a radial pulse. Take turns locating the radial pulse on one another and counting the beats per minute.

19. Measuring an Apical Pulse Procedure
Read through the procedure for measuring an apical pulse. Then, answer the following questions:
How should you prepare a stethoscope before taking a resident’s apical pulse?
Where should you place the stethoscope on a resident’s body?

20. Rate of Respiration
Measurement of a resident’s breathing cycle (inhalation followed by exhalation)
Helps determine level of blood oxygenation
To measure, record number of full breaths in one minute
Normal rate is 12–20 breaths per minute, but infants and children breathe faster
(continued)

21. Rate of Respiration When counting respirations, note if breathing is:
Regular or irregular
Deep and rapid (hyperventilation) or slow and shallow (hypoventilation)
Rapid (tachypnea), deep and labored (dyspnea), or unusually slow (bradypnea)
Noisy like snoring (stertorous breathing)
Absent (apnea)

22. Discuss
Why is it best to check a resident’s respiration rate right after pulse while leaving your fingers on the radial artery?

23. Counting Respirations Procedure
Read through the procedure for counting respirations. Next, practice calculating a classmate’s respiration rate. Count for 15 seconds while watching the clock, then multiply the number of respirations by four to get your partner’s respiration rate per minute. Make sure to note the regularity and depth of breaths.

24. Using a Pulse Oximeter
Measures blood oxygenation by showing percentage of oxygen in the blood
Normal amount of oxygen is between 95 and 100 percent
Hypoxia—less than 85 percent oxygen in the blood
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25. Blood Pressure
Force of blood pushing against the body’s arterial walls
Hypotension—low blood pressure; body is not getting enough oxygen
Hypertension—high blood pressure; too much pressure placed on walls of arteries

26. Measuring Blood Pressure
Blood pressure levels:
Systolic—heart muscle contracts and pushes blood through arteries; first beat heard
Diastolic—heart muscle relaxes; last beat heard
Measured in millimeters of mercury (mmHg) and recorded as a fraction

27. Factors Affecting Blood Pressure
Diet, weight, and exercise
Race
Time of day
Position
Drugs, cigarettes, alcohol, or medications
Stress, fear, or pain

28. Taking Blood Pressure
Can be measured electronically or manually using stethoscope and sphygmomanometer
Manual aneroid and electronic
Important to ensure proper size
Avoid using arms with IV catheters, casts, or wounds
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29. Taking a Blood Pressure Procedure
Read through the procedure for taking a blood pressure. Then, with a partner, answer the following questions:
How do you apply the cuff of a sphygmomanometer on a resident’s arm?
What do you think a patient’s blood pressure would be if he or she came to the ER with abdominal pain? Would it be high, low, or normal? Why?

30. Review How do you measure an apical pulse?
What is the normal respiration rate for an adult?
Explain the difference between tachypnea and bradypnea.
List three factors that can affect a resident’s blood pressure.

31. Measuring and Recording Height and Weight
18.2
Section
Measuring and Recording Height and Weight

32. Objectives
describe why height and weight measurements are important to know when providing care; and
demonstrate the skills needed to measure height and weight accurately and effectively for ambulatory, wheelchair-bound, and bedridden residents.

33. Importance of Height and Weight
Allows staff to monitor resident’s health, determine nutritional changes, and prescribe appropriate medications
Height and weight used to calculate ideal body weight (IBW) and body mass index (BMI)
Help doctors plan calorie intake and protein and fluid needs

34. Measuring Height For residents who can walk For bedridden residents
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35. Discuss
Describe the types of equipment you can use to measure the height of a resident.

36. Measuring Weight
Used to calculate medication dosages and indicate certain conditions
Measured using upright balance or digital, sling, or chair scales
Important to factor in items that add weight, such as shoes, casts, catheters, or colostomy bags

37. Procedure Measuring the Height and Weight of Ambulatory Residents
Read through the procedure for measuring the height and weight of an ambulatory resident. Then, discuss with a partner why you should weigh a resident at the same time every day. Why is it essential that you record an accurate weight?

38. Procedure Measuring the Height of Bedridden Residents
Read through the procedure for measuring the height of a bedridden resident. Write down what you can do to ensure the safety of the resident during this procedure.

39. Weighing Bedridden Residents Using a Hydraulic Digital Lift or Sling Bed Scale
Procedure
Read through the procedure for weighing bedridden residents using a hydraulic digital lift or a sling bed scale. Discuss how teamwork plays a role in this type of procedure.
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40. Review Explain the difference between IBW and BMI.
What measurements are used to record a resident’s height?
What measurements are used to record a resident’s weight?
Give examples of items that may affect a resident’s weight on a scale.

41. Practice Question
A pulse of fewer than 60 beats per minute is called A. tachypnea B. bradycardia C. bradypnea D. hypotension

42. Practice Question
Which set of adult vitals should you report immediately to the licensed nursing staff? A. 98.6°F, 64 bpm, 12 breaths per minute, 100/66 mmHg. B. 98.0°F, 78 bpm, 14 breaths per minute, 110/74 mmHg. C °F, 52 bpm, 28 breaths per minute, 168/92 mmHg. D. 98.8°F, 86 bpm, 18 breaths per minute, 98/62 mmHg.

43. Practice Question
Which of the following is false regarding height and weight? A. Additional items like shoes should be considered. B. Tape measures can be used to measure bedridden residents. C. Weight helps doctors determine medication dosages. D. Weight can be measured at different times each day.