Measurements

Pre-CNASP2-AP2

This presentation will: Briefly review the four vital signs Height and weight Intake and Output

Measurements When working with

your resident, you will measure:

Vital signs (VS)

Height/weight (ht/wt)

Intake and output (I&O)

Why Do You Take Vital Signs? Vital signs show minor changes in

the resident’s condition. Vital signs show how the resident

responds to treatment. Vital signs change with fear,

exercise, anxiety, pain and other activities.

Vital Signs

Vital signs include:TemperaturePulseRespirationBlood pressure

Report vital signs promptly when: they are above or below normal.

there is a significant change from the prior reading.

Body Temperature The body temperature is the

amount of heat produced by the body.

The temperature is lower in the morning and higher in afternoon and evening.

Body temperature is affected by age, weather, exercise, emotions, stress and illness.

Sites for Measuring Temperature

Mouth – oral Rectal - anus Ear – tympanic Axilla - underarm

Oral Temperature Taken in the mouth. Do not use if a

person has an injury to his mouth, difficulty breathing, or confusion.

Normal Range97.6-99.6 F

(36.5 C-37.5 C)

Rectal Temperature Do not use when the

person has: diarrhea, a rectal

injury or rectal surgery, heart disease, or confusion.

Normal Range98.6-100.6 F

(37.0-38.0 C) Most accurate route

Tympanic Temperature This site has fewer

microbes than other sites. However, it should not be used if there is ear drainage.

Normal range 97.6-99.6 F (36.5-37.5 C)

Axillary Temperature The axilla is the

“armpit”. It is the least

accurate site. Normal Range 96.6-98.6 F (35.5-36.5 C)

Pulse Used to monitor

the circulatory system (heart and blood vessels)

Pulse Rate Measures how fast the heart is beating

Normal rate=60-100 beats/minute

Tachycardia=“fast heart”>100 beats/minute

Bradycardia=“slow heart” <60 beats/minute

Other Pulse Characteristics

Rhythm Regular: same amount

of time between beats

Irregular: NOT the same amount of time between beats or skipped (missed)beats

Strength Strong/

bounding: easy to feel

Weak/thready: difficult to feel

The Pulse Sites

Taking A Pulse These pictures

show radial and brachial pulse sites.

Radial pulse The most common location to check a

pulse On the thumb side of the wrist Gently press with 2 or 3 fingers. Do not use your thumb when checking a

pulse Count for 1 minute

Blood Pressure Used to monitor

the circulatory system.

Normal range:90-12060-80

SystolicDiastolic

Systolic Heart is contracting Higher or top number First sound you hear Normal Range:

90-120mmHg

Diastolic Heart is resting Lower or bottom

number Last sound you hear Normal Range:

60-80mmHg

Hypertension Hyper=“too much”

Tension=“pressure” High BP Systolic >140 Diastolic>90

Hypotension Hypo=“too little” Tension=“pressur

e” Low BP Systolic<90 Diastolic<60

When do you not use a person’s arm to measure blood pressure?

If the arm has an IV, cast or dialysis access site.

If a woman has had surgery to remove a breast on that side of her body.

Any injury of surgery to the arm.

What are the parts of the sphygmomanometer?

Manometer Bulb valve cuff

Respiration Respiration means

breathing air into (inhalation) and out of (exhalation) the lungs.

1 respiration= 1 exhalation + 1 inhalation

People tend to change breathing patterns when they know someone is counting their respirations.

Respirations are counted right after taking the pulse. Keep your fingers on their radial pulse and observe their chest rising and falling.

Count for 1 minute.

What to observe when taking respirations Rate: Normal respirations are 12-

20 times per minute. Depth: deep or shallow Rhythm: regular or irregular Equality: equal or unequal Pt. c/o pain or dyspnea Abnormal noises

Height/Weight Baseline height and

weight is measured when the resident is admitted to the nursing home.

Height Standing:

No shoes, have the person

stand straight. Lying

Have person in good alignment in supine position.

Using a tape measure, measure from top of head to soles of feet.

Weight• The scale should be set at

zero.• The resident should be

weighed at the same time of day wearing as few clothes as possible.

• The morning before breakfast is the best time.

• Make sure the person empties his/her bladder before weighing.

• This is one method of monitoring the patient’s fluid status

Intake and Output (I&O)

Used to monitor fluid balance and kidney function

Intake= amount of fluid entering the

body

PO (oral)

Output=amount of fluid leaving the body Urine Diarrhea Emesis Drainage Sweat

(perspiration) Breathing

(exhalation)

As a NA, you will help record:

Oral Fluid Intake water, milk, juice,

coffee, etc. Foods that melt at

room temperature: Ice cream Jello Popsicles

You will also record:

Measurable fluid output: Urine Diarrhea Emesis Drainage from tubes

You cannot measure: Non-measurable output

Sweat Breathing Wound drainage without

a tube If a person is incontinent

How many milliliters (ml) in an ounce? 1 ounce (oz) = 30 ml (cc)

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