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