CNA Chapter 33
When taking an axillary temperature, the axilla must be
dry
ID
identification
mm Hg
millimeters of mercury
Body temperature is lower in the
morning
When taking a blood pressure with an aneroid manometer, you place the stethoscope diaphragm
over the brachial artery at the inner aspect of the elbow
The nurse may mark an X where the _______ _______ is found
pedal pulse
Which site is commonly used to check the pulse?
radial pulse
the apical pulse rate is never less than the
radial pulse rate
Trachycardia
rapid heart rate over 100 beats per minute
Vital signs are taken when the person takes drugs that affect the ______ or ______ systems
respiratory or circulatory
When taking blood pressure the person should be in a _______ or _______ position. Sometimes, the doctor orders blood pressure in the ______ position
sitting or lying standing
To read a glass thermometer you should hold it at the
stem and bring it to eye level to read it
A forceful pulse is described as
strong, full, or bounding
Vital signs
temperature, pulse, respirations, and blood pressure; oximetry and pain are included in some agencies
Pulse Sites
temporal, carotid, apical, brachial, radial, femoral, popliteal, posterior tibial, pedal
Blood pressure
the amount of force exerted against the walls of an artery by the blood
body temperature
the amount of heat in the body that is a balance between the amount of heat produced and the amount lost by the body
pulse
the beat of the heart felt at an artery as a wave of blood passes through the artery
An electronic thermometer is inserted into the rectum
1/2 inch
Let the person rest for ____________________ before taking the blood pressure.
10 to 20 minutes
A healthy adult has _______ ______ ______ respirations per minute
12 to 20
respirations are counted for
30 seconds or 1 minute if they are irregular
The adult pulse rate is between
60-100 beats per minute
An apical pulse of 72 is recorded as
72Ap
You counted 40 heartbeats in 30 seconds. What is the person's pulse rate?
80 beats per minute
Axillary Body Temp Range
96.6 - 98.6 degrees F
Oral Body Temp Range
97.6 - 99. 6 degrees F
Axillary Body Temp Baseline
97.6 degrees F
Oral Body Temp Baseline
98.6
Rectal Body Temp
98.6 - 100. 6 degrees F
Tympanic Membrane Body Temp Baseline
98.6 degrees F
If you take a rectal temperature, the normal range of the temperature would be
98.6F to 100.6F
Factors affecting blood pressure
Age Biological sex Family history Blood volume Stress Pain Exercise Weight Race Diet Drugs Position Smoking Alcohol Certain health problems
Tympanic Membrane (Ear) temperatures are not taken if the person has:
An ear disorder Ear drainage
stethoscope
An instrument used to listen to the sounds produced by the heart, lungs, and other body organs
Types of Sphygmomanometers
Aneroid Type - manual types with round dial and a needle that points to the numbers Electronic Type - shows the systolic and diastolic pressure and the pulse rate Wrist Manometer - measure BP at wrist
C
Centigrade
If you are preparing to take an oral temperature, ask the person not to
Eat, drink, smoke, or chew gum for at least 15 to 20 minutes
For a 1-year old child with an ear infection, which equipment would you use to ensure safety and to get the most accurate temperature?
Electronic probe with a red stem
The nurse tells you that the person's pulse was thready on the previous shift. What is the nurse describing about the pulse?
Force
An apical-radial pulse is taken by
Having one staff member take the apical pulse and a second staff member take the radial pulse at the same time.
Glass Thermometer
Hollow glass tube filled with a substance that expands (rises) when heated. When cooled the substance moves back down the tube. Measurement Site: Oral Rectal Axillary
When counting respirations, the best way is to
Keep your fingers over the pulse site while counting respirations
Disposable Oral Thermometer
Measure temperatures using small chemical dots that change colors when heated Measurement Site: Oral
Hg
Mercury
Sites for measuring temperature are the
Oral Rectal Axillary Tympanic membrane Temporal artery
A pedal pulse is found
Over a foot bone
If you are taking vital signs on a person with dementia, it may be better if
Pulse and respirations are done; temperature and blood pressure are done later
When you take a pulse, what observations should be reported and recorded?
Pulse site Pulse rate Pulse deficit (for apical-radial pulse) If pulse is irregular or regular Pulse force
Which site has the highest normal rang in temperature?
Rectal
one respiration is counted for each
Rise and fall of the chest
Report blood pressure that have these readings.
Systolic over 120 mm Hg Systolic below 90 mm Hg Diastolic over 80 mm Hg Diastolic below 60 mm Hg
When listening to blood pressure, the first sound you hear is ______ ______ and the point where the sound disappears is the _______ _______
Systolic pressure Diastolic pressure
A pulse rate 120 beats per minute would be considered
Tachycardia
apical-radial pulse
Taking the apical and radial pulses at the same time
What observations should be reported and recorded when counting respirations?
The respiratory rate Equality and depth of respiration If respirations are regular or irregular Pain or difficulty breathing Respiratory noises Abnormal respiratory pattern
When taking a temperature for persons who are confused and resist care, the best choice would be to
Use a tympanic or temporal artery thermometer
What should you do if a person asks about their vital sign measurement?
You can tell the person the measurements if center policy allows
Standard Electronic Thermometer
battery-operated The probe is inserted at the measurement site Measurement Sites: Oral Rectal Axillary
The blood pressure may be higher in older persons because
blood pressure increases with age
respiration
breathing air into and out of the lungs
You will find out the size of blood pressure cuff needed
by asking the nurse
Which site is used to take a pulse during cardiopulmonary resuscitation (CPR)
cartoid
Doppler
diagnostic instrument that sends an ultrasonic beam into the body Used to find a pulse in pedal pulses
pulse deficit
difference between apical and radial pulse
fever
elevated body temperature
Tympanic membrane and temporal artery thermometers are used for confused persons because they are
fast and comfortable
Febrile
feverish
The apical pulse is taken
for a full minute
Rectal temperatures are not taken if the person:
has diarrhea has a rectal disorder or injury has heart disease had rectal surgery is confused or agitated
hypertension
high blood pressure
IV
intravenous
Oral temperatures are not taken if the person:
is under four or five unconscious had surgery/injury to face, neck, nose, mouth receiving oxygen breathes through mouth has naso-gastric tube delirious, restless, confused, disoriented is paralyzed on one side of the body has a sore mouth has a convulsive seizure disorder
When getting ready to take blood pressure, position the person's arm
level with the heart
hypotension
low blood pressure
If you are taking the temperature of an older person you would expect the temperature to be
lower than the normal range
When you take a rectal temperature, you ___________________ the tip of the thermometer or the end of the covered probe before inserting it into the rectum
lubricate
Unless otherwise ordered, take vital signs when the person is
lying or sitting
Pulse Oximetry
measure the oxygen level in the blood
mm
millimeter
Bradycardia
slow heart rate (less than 60 bpm)
Digital Thermometer
small and battery operated Measurement Site: Oral Rectal Axillary
When taking a tympanic membrane temperature on an adult, pull up and back on the ear to
straighten the ear canal
TPR
temperature, pulse, respiration
systolic pressure
the amount of force it takes to pump blood out of the heart into the arterial circulation
sphygomometer
the cuff and measuring device used to measure blood pressure
pulse rate
the number of heartbeats or pulses felt in 1 minute
systole
the period of heart muscle contraction; the heart is pumping blood
diastole
the period when the heart is at rest
The blood pressure may not be taken in the left arm if
the person has a dialysis access site in the left arm
diastolic pressure
the pressure in the arteries when the heart is at rest
You may count the radial pulse from 30 seconds and multiply by 2 if
the pulse is regular
When taking the radial pulse, place
two fingers on the thumb side of the wrist
When taking an oral temperature, place the tip of the thermometer
under the tongue
A hard to feel pulse is described as
weak, thready, or feeble
Persons in nursing centers usually have vital signs measured
weekly
When using a stethoscope, you can help to prevent infection by
wiping the ear pieces and diaphragm with antiseptic wipes before and after use
Do not take BP on an arm:
with an IV with an arm cast with a dialysis access site on the side of breast surgery that is injured
Afebrile
without fever
Do not use your thumb to take a pulse because
you may mistake the pulse in your thumb for the person's pulse
When taking an apical-radial pulse, each lub-dub sound is counted as
1 beat
Each respiration involves
1 inhalation and 1 exhalation
If a pulse is irregular, count the pulse for
1 minute
thermometer
a device used to measure temperature
Blood pressure is controlled by
- The force of heart contractions - The amount of blood pumped with each heartbeat - How easily the blood flows through the vessels
apical pulses are taken on persons who
- have a heart disease - have irregular heart rhythms - are taking drugs that affect the heart
The blood pressure cuff is inflated ________ beyond the point where you last felt the radial pulse.
30 mm Hg
Rectal Body Temp Baseline
99.6 degrees F
Temporal Artery Body Temp Baseline
99.6 degrees F
When vital signs are taken, report to the nurse at once if
A vital sign is changed from a prior measurement An abnormal vital sign
Vital signs are measured:
After any fall Complains of pain Fever Dizziness Before, after, and during surgery During physical exams When drugs affect the respiratory or circulatory system when the person is admitted to a health care agency when the person's condition requires
Temporal Artery Thermometer
Battery operated Measurement Site: Temporal Artery (forehead)
Tympanic Membrane Thermometer
Battery operated Measurement Site: Tympanic Membrane (Ear)
Pulse ranges by age
Birth to 1 year: 80-190 2 years: 80-160 6 years: 75-120 10 years: 70-110 12 years and older: 60-100
When using an electronic thermometer, what does the color of the probe mean?
Blue - Oral and axillary thermometer Red - rectal thermometers
F
Fahrenheit
Factors affecting vital signs
activity age anger anxiety drugs eating exercise fear biological sex illness, noise pain sleep, smoking stress weather weight
Which site has the lowest baseline temperature?
axillary
Do not use axillary site right after
bathing
BP
blood pressure