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Textbook For Nursing Assistants Chapter 16 Vital Signs, Height and Weight Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 1 Vital Signs Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 2 Vital Signs What is a vital sign? Vital signs are key measurements that provide essential information about overall health status What do vital signs indicate? A change in a vital sign may indicate a response to illness or injury Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 3 When are Vital Signs Taken? Specified on nursing care plan or doctor’s orders Long-term care facility: once daily or weekly, and as needed Hospital: every shift or every few hours, and as needed Within the nursing assistant’s scope of practice to take vital signs whenever he or she thinks it is warranted Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 4 Recording and Reporting Vital Signs Accuracy is important: many people rely on these measurements to make decisions about the person’s care Report an abnormal measurement immediately Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 5 Body Temperature Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 6 What is Body Temperature? It is the difference between heat produced and heat lost by the body Body heat is produced as a normal process of metabolism Body temperature is regulated by thermoregulatory center located in the brain Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 7 Factors Affecting Body Temperature Physical or emotional stress Environmental temperature Time of the day Age Gender Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 8 Measurement of Body Temperature Measured in either degrees Fahrenheit (°F) or degrees Celsius (°C) Measured from Mouth – Oral temperature Rectum – Rectal temperature Armpit – Axillary temperature Ear – Aural temperature Forehead – Temporal temperature Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 9 Types of Clinical Thermometers Glass Thermometer Electronic and Digital Thermometer Tympanic Thermometer Temporal Artery Thermometer Glass Thermometers Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 10 Normal and Abnormal Findings Normal body temperature ranges from 0.5 °F to 1 °F above or below the range considered “normal” Pyrexia: increased body temperature A person with pyrexia is said to be “febrile” The doctor may order an antipyretic (feverreducing) drug Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 11 Pulse Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 12 What is a Pulse? When the heart beats, it sends a wave, or pulse, of blood through the arteries When checking the pulse, we look at the: Pulse rate Pulse rhythm Irregular pulse rhythm is called dysrhythmia Pulse amplitude Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 13 Factors Affecting Pulse Need for oxygen and nutrients Anger and anxiety, illness, pain, fever, and excitement Certain medications Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 14 Measuring the Pulse Radial Pulse: Taken by placing fingers over the radial artery (inside of wrist) Apical Pulse: Taken by listening over the apex of the heart with a stethoscope Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 15 Pulse Points Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 16 Normal and Abnormal Findings Tachycardia is a rapid heart rate, or a pulse rate of more than 100 beats per minute for an adult A heart rate that is slower than normal, that is, a pulse rate of less than 60 beats per minute is called bradycardia Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 17 Respiration Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 18 Process of Respiration Respiration is accomplished through ventilation Ventilation is: Inhalation of oxygen Exhalation of carbon dioxide Respiration indicates: Respiratory rate Respiratory rhythm Depth of respiration Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 19 Factors Affecting Respiration Control center, chemoreceptors Anxiety, pain, fear Fever Infections and diseases of the heart and lungs Stroke or head injury Medications Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 20 Measuring Respiration Respiratory rate determined by watching the rise and fall of the person’s chest and counting the number of breaths that occur in either 30 seconds or 1 minute One breath = 1 exhalation and 1 inhalation Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 21 Normal and Abnormal Findings Normal respiratory rate – Eupnea 16 to 20 times a minute for adult Higher for children and infants Abnormal respiratory patterns Tachypnea Bradypnea Dyspnea Hyperventilation Hypoventilation Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 22 Blood Pressure Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 23 What is Blood Pressure? The force that the blood exerts against the arterial walls Two pressure levels Systolic pressure Diastolic pressure The difference between the two is pulse pressure Measured in millimeters of mercury (mm Hg) and recorded as a fraction Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 24 Factors Affecting Blood Pressure Cardiac output Blood volume Resistance to blood flow Age Gender Race Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 25 Measuring Blood Pressure Two ways of measuring: Manually operated sphygmomanometer and a stethoscope Automated sphygmomanometers Manually operated sphygmomanometer Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 26 Normal and Abnormal Findings Accepted normal ranges for the systolic pressure are between 100 and 140 mm Hg, and for the diastolic pressure, between 60 and 90 mm Hg Abnormal ranges Hypertension Hypotension Orthostatic hypotension Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 27 Height and Weight Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 28 Height and Weight A person’s weight: Provides insight into overall health, and nutritional status Often used to calculate medication dosages Frequency for checking Height - on admission, and on transfer or discharge Weight - at regular intervals Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 29 Measuring Height and Weight Height is measured in feet (‘) and inches (‘’) or in centimeters (cm). Weight is measured in pounds (lbs) or kilograms (kg.) Ways of measurement: Upright scale Chair scale Tape measure and sling scale Upright Scale Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 30 End of Presentation Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Slide 31