4.01 ppt height weight measurements

1. Understanding Understanding vital vital
signs, height,signs, height, and and
weightweight measurement measurement
skills. skills.
Unit BUnit B
Resident Care SkillsResident Care Skills
Essential Standard NA4.00 Essential Standard NA4.00
Understand nurse aide skills related to the residents’ vital function and movementUnderstand nurse aide skills related to the residents’ vital function and movement
Indicator 4.01Indicator 4.01
Understand vital signs, height, and weight skills. Understand vital signs, height, and weight skills.
4.01 Nursing Fundamentals 7243 1

2. FF YY II - - Intentional RepeatIntentional Repeat
There is intentional repeat of some HSII There is intentional repeat of some HSII
course content in Nursing Fundamentals. course content in Nursing Fundamentals.
Repeating course content distributes learning Repeating course content distributes learning
over time and increases long term memory. over time and increases long term memory.
Academic and skill competence must be Academic and skill competence must be
maintained at a maintained at a very high level for direct very high level for direct
resident careresident care. .
4.01 Nursing Fundamentals 7243 2

3. IntroductionIntroduction
Indicator Indicator 4.01 4.01 introduces introduces
skills the nurse aide will need skills the nurse aide will need
to measure and record the to measure and record the
resident’s resident’s vital signsvital signs, , heightheight
and and weightweight. .
4.01 Nursing Fundamentals 7243 3

4. provide information provide information
about about changeschanges in in
normal body function normal body function
and the and the resident’s resident’s
response to treatmentresponse to treatment. .
4.01 Nursing Fundamentals 7243 4
Vital Signs Vital Signs

5. Often the Often the
FIRST FIRST
sign sign that that
there is a there is a
problem!problem!
4.01 Nursing Fundamentals 7243 5
Vital Signs Vital Signs

6. TPR+BP = TPR+BP = Vital SignsVital Signs
4.01 Nursing Fundamentals 7243 6

7. TPR+BP = Vital SignsTPR+BP = Vital Signs
•Reflect the function of three body
processes that are essential for life.
–Regulation of body temperature
–Heart function
–Breathing
4.01 Nursing Fundamentals 7243 7

8. TPR+BP = Vital SignsTPR+BP = Vital Signs
•Abbreviations:
–Temperature – T
–Pulse – P
–Respirations – R
–Blood Pressure – BP
–Vital signs - TPR and BP
4.01 Nursing Fundamentals 7243 8

9. TPR+BP = Vital SignsTPR+BP = Vital Signs
•Purpose
–Measured to detect
any changes in
normal body
function
–Used to determine
response to
treatment
4.01 Nursing Fundamentals 7243 9

10. TTPR+BP = Vital SignsPR+BP = Vital Signs
TemperatureTemperature
4.01 Nursing Fundamentals 7243 10

11. TTPR+BP = Vital SignsPR+BP = Vital Signs
TemperatureTemperature
•Heat production
–muscles
–glands
–oxidation of
food
•Heat loss
–respiration
–perspiration
–excretion
4.01 Nursing Fundamentals 7243 11

12. TTPR+BP = Vital SignsPR+BP = Vital Signs
TemperatureTemperature
Balance between heat
production and heat loss is body
temperaturetemperature
4.01 Nursing Fundamentals 7243 12

13. Factors Affecting Temperature
•Exercise
•Illness
•Age
•Time of day
•Medications
•Infection
•Emotions
•Hydration
•Clothing
•Environmental
temperature/air
movement
4.01 Nursing Fundamentals 7243 13

14. Equipment - Thermometer
•Instrument used to measure body
temperature
•Types
–Non-mercury glass
•oral
•rectal
4.01 Nursing Fundamentals 7243 14

15. Equipment - Thermometer
•Types (continued)
–chemically treated paper –
disposable
–plastic – disposable
–electronic - probe covered with
disposable shield
–tympanic - electronic probe used in
the ear
4.01 Nursing Fundamentals 7243 15

16. Electronic ThermometersElectronic Thermometers
ElectronicElectronic
Can be used for oral, Can be used for oral,
rectal, or axillaryrectal, or axillary
BlueBlue probe for oral probe for oral
RedRed probe for rectal probe for rectal
Disposable probe covers Disposable probe covers
prevent cross-prevent cross-
contaminationcontamination
4.01 Nursing Fundamentals 7243 16

17. Aural/Tympanic TemperatureAural/Tympanic Temperature
- taken in the ear
- measures the thermal
infrared energy
radiating from the blood
vessels in the eardrum
- position and ear wax
can affect readings
-left in until it beeps
-temperature is
calculated into an
equivalent by mode
4.01 Nursing Fundamentals 7243 17

18. Positioning the Patients Ear for Positioning the Patients Ear for
Tympanic temperatureTympanic temperature
•Infants under 1 year
–Pull ear pinna straight back
•Infants over 1 year and
adults
–Pull ear pinna straight back
and down
•Positioning the pinna
correctly straightens the
auditory canal so the probe
will point directly at the
tympanic membrane
–Pull ear pinna straight back
and down
4.01 Nursing Fundamentals 7243 18

19. 4.01 Nursing Fundamentals 7243 19

20. Placement of the Oral Placement of the Oral
ThermometerThermometer
Put the bulb tip Put the bulb tip
of the of the
thermometer in thermometer in
the the “hot “hot
pocket” pocket” under under
the tongue. the tongue.
4.01 Nursing Fundamentals 7243 20

21. Normal Temperature Range For Adults
•Oral - 97.6° - 99.6° F
(Fahrenheit) or 36.5°
-37.5° C (Celsius)
•Rectal - 98.6° - 100.6° F
or 37.0° - 38.1° C
•Axillary - 96.6° - 98.6° F
or 36.0° - 37.0° C
4.01 Nursing Fundamentals 7243 21

22. “Tic-Tac-Know”
Normal Range For Adult Temperature
FREE
SPACE
98.6°F is the FREE SPACE
4.01 Nursing Fundamentals 7243 22

23. “Tic-Tac-Know”
Normal Range For Adult Temperature
ORALORAL 98.6°F
98.6°F is the 98.6°F is the averageaverage oral temperature oral temperature
for adults and it falls in the for adults and it falls in the middle of the middle of the
normal range. normal range.
4.01 Nursing Fundamentals 7243 23

24. “Tic-Tac-Know”
Normal Range For Adult Temperature
ORALORAL 98.6°F98.6°F
99.6°F99.6°F
Add one degree to 98.6°F then place the
results in the oral space to the right
4.01 Nursing Fundamentals 7243 24

25. “Tic-Tac-Know”
Normal Range For Adult Temperature
ORALORAL 97.697.698.698.6
99.699.6
Subtract one degree from 98.6 then place
the results in the oral space to the left
4.01 Nursing Fundamentals 7243 25

26. “Tic-Tac-Know”
Normal Range For Adult Temperature
ORALORAL 97.6°97.6°98.698.6
99.699.6
The The averageaverage adult temperature taken adult temperature taken
orally is orally is 98.6° F98.6° F and the and the
RANGERANGE is is 97.6° F97.6° F to to 99.6° F.99.6° F.
4.01 Nursing Fundamentals 7243 26

27. “Tic-Tac-Know”
Normal Range For Adult Temperature
ORALORAL 97.6°F97.6°F
98.6°F98.6°F99.6°F99.6°F
RECTALRECTAL 99.6°F99.6°F
Body heat Body heat REGISTERSREGISTERS one degree one degree warmerwarmer when the when the
temperature is taken temperature is taken RECTALLY ®RECTALLY ®. Add one degree . Add one degree
to 98.6°F then place the results in the space below to 98.6°F then place the results in the space below
98.6°F98.6°F
4.01 Nursing Fundamentals 7243 27

28. “Tic-Tac-Know”
Normal Range For Adult Temperature
ORALORAL 97.6°F97.6°F
98.6°F98.6°F99.6°F99.6°F
RECTARECTA
LL
99.6°F99.6°F100.6°F100.6°F
Add one degree to 99.6°F then place the results in the Add one degree to 99.6°F then place the results in the
rectal space to the right.rectal space to the right.
4.01 Nursing Fundamentals 7243 28

29. “Tic-Tac-Know”
Normal Range For Adult Temperature
ORALORAL 97.6°F97.6°F
98.6°F98.6°F99.6°F99.6°F
RECTARECTA
LL
98.698.699.6°F99.6°F100.6°F100.6°F
Subtract one degree from 99.6°F then place the Subtract one degree from 99.6°F then place the
results in the rectal space to the left.results in the rectal space to the left.
4.01 Nursing Fundamentals 7243 29

30. “Tic-Tac-Know”
Normal Range For Adult Temperature
ORALORAL 97.6°F97.6°F
98.6°F98.6°F99.6°F99.6°F
RECTARECTA
LL
98.698.699.6°F99.6°F100.6°F100.6°F
The The averageaverage adult temperature taken adult temperature taken RECTALLYRECTALLY is is
99.6° F99.6° F and the and the
RANGERANGE is is 98.6° F98.6° F to to 100.6° F.100.6° F.
4.01 Nursing Fundamentals 7243 30

31. “Tic-Tac-Know”
Normal Range For Adult Temperature
AXILLARY AXILLARY
or GROINor GROIN
97.697.6
ORALORAL 97.6°F97.6°F
98.6°F98.6°F99.6°F99.6°F
RECTALRECTAL 98.698.699.6°F99.6°F100.6°F100.6°F
Body heat Body heat REGISTERSREGISTERS one degree one degree COOLERCOOLER when the temperature when the temperature
is taken is taken AXILLARY (Ax) AXILLARY (Ax) or in the or in the GROIN. GROIN. Subtract one degree from Subtract one degree from
98.6°F then place the results in the space 98.6°F then place the results in the space aboveabove 98.6°F 98.6°F
4.01 Nursing Fundamentals 7243 31

32. “Tic-Tac-Know”
Normal Range For Adult Temperature
AXILLARY AXILLARY
or GROINor GROIN
97.6°F97.6°F98.698.6
ORALORAL 97.6°F97.6°F
98.6°F98.6°F99.6°F99.6°F
RECTALRECTAL 98.698.699.6°F99.6°F100.6°F100.6°F
Add one degree to 97.6°F then place the results to the right Add one degree to 97.6°F then place the results to the right
of 97.6°Fof 97.6°F
4.01 Nursing Fundamentals 7243 32

33. “Tic-Tac-Know”
Normal Range For Adult Temperature
AXILLARY AXILLARY
or GROINor GROIN
96.6°96.6°
97.6°F97.6°F98.698.6
ORALORAL 97.6°F97.6°F
98.6°F98.6°F99.6°F99.6°F
RECTALRECTAL 98.698.699.6°F99.6°F100.6°F100.6°F
Subtract one degree from 97.6°F then place the results to Subtract one degree from 97.6°F then place the results to
the left of 97.6°Fthe left of 97.6°F
4.01 Nursing Fundamentals 7243 33

34. “Tic-Tac-Know”
Normal Range For Adult Temperature
AXILLARY AXILLARY
or GROINor GROIN
96.6°96.6°
97.6°F97.6°F98.698.6
ORALORAL 97.6°F97.6°F
98.6°F98.6°F99.6°F99.6°F
RECTALRECTAL 98.698.699.6°F99.6°F100.6°F100.6°F
YOU MUST RECORD THE YOU MUST RECORD THE LOCATION WHERE THE LOCATION WHERE THE
TEMPERATURE WAS TAKENTEMPERATURE WAS TAKEN IN ORDER TO INTERPRET IN ORDER TO INTERPRET
NORMAL FROM ABNORMAL !NORMAL FROM ABNORMAL !
4.01 Nursing Fundamentals 7243 34

35. “Tic-Tac-Know”
Normal Range For Adult Temperature
AXILLARY AXILLARY
or GROINor GROIN
(Ax) (Ax) or or
GroinGroin
<Pic of <Pic of
Groin>Groin>
ORALORAL OO
If no location is If no location is
indicated, the oral indicated, the oral
route is assumedroute is assumed
RECTALRECTAL (R)(R)
YOU MUST RECORD THE LOCATION WHERE THE YOU MUST RECORD THE LOCATION WHERE THE
TEMPERATURE WAS TAKEN IN ORDER TO INTERPRET TEMPERATURE WAS TAKEN IN ORDER TO INTERPRET
NORMAL FROM ABNORMAL !NORMAL FROM ABNORMAL !
4.01 Nursing Fundamentals 7243 35

36. To Read A Non-mercury Glass
Thermometer
•Hold eye level
•Locate solid column of liquid in the
glass
•Observe lines on scale at upper
side of column of liquid in the glass
4.01 Nursing Fundamentals 7243 36

37. To Read A Non-mercury Glass
Thermometer
(continued)
•Read at point where liquid ends
•If liquid falls between two lines, read it
to closest line
–long line represents degree
–short line represents 0.2 of a degree
Fahrenheit
4.01 Nursing Fundamentals 7243 37

38. 4.01 Nursing Fundamentals 7243 38

39. 4.01 Nursing Fundamentals 7243 39

40. Sites To Take A Temperature
•Oral – most common
•Rectal – registers one degree
Fahrenheit higher than oral
•Axillary – least accurate; registers
one degree Fahrenheit lower than
oral
•Tympanic – probe inserted into the
ear canal
4.01 Nursing Fundamentals 7243 40

41. Sites To Take A Temperature
(continued)
Condition of resident
determines which is the
best site for measuring
body temperature
4.01 Nursing Fundamentals 7243 41

42. Temperature: Safety Precautions
•Hold rectal and axillary thermometers
in place
•Stay with resident when taking
temperature
•Check glass thermometers for chips
•Prior to use, shake liquid in glass
down
•Shake thermometer away from
resident and hard objects
4.01 Nursing Fundamentals 7243 42

43. Temperature: Safety Precautions
(continued)
•Wipe from “handle” end
toward bulb tip of
thermometer prior to
reading
•Delay taking oral
temperature for 10 - 15
minutes if resident has
been smoking, eating or
drinking hot/cold liquids.
4.01 Nursing Fundamentals 7243 43

44. Temperature ConditionsTemperature Conditions
•HyperthermiaHyperthermia
–Increased body temp
–Body temp >104ºF
–>106 ºF will cause
convulsions and
death
•FeverFever
-temp over 101 ºF R
-Due to illness or
injury
4.01 Nursing Fundamentals 7243 44

45. Temperature ConditionsTemperature Conditions
•HypothermiaHypothermia
–Body temp below
– 96 ºF
–due to exposure to
cold temperatures
–Depends on core
temperature, age
and length of
exposure
4.01 Nursing Fundamentals 7243 45

46. 4.01 Nursing Fundamentals 7243 46
SKILLSKILL 4.01A4.01A
Oral temperature using a non-mercury Oral temperature using a non-mercury
glass thermometerglass thermometer
Training Lab AssignmentTraining Lab Assignment
Engage in the Skill Acquisition Process for:Engage in the Skill Acquisition Process for:

47. 4.01 Nursing Fundamentals 7243 47
SKILLSKILL 4.01B4.01B
Axillary temperature using a Axillary temperature using a
non-mercury glass thermometernon-mercury glass thermometer
Training Lab AssignmentTraining Lab Assignment
Engage in the Skill Acquisition Process for:Engage in the Skill Acquisition Process for:

48. 4.01 Nursing Fundamentals 7243 48
SKILLSKILL 4.01C4.01C
Rectal Temperature using a Rectal Temperature using a
non-mercury glass thermometernon-mercury glass thermometer
Training Lab AssignmentTraining Lab Assignment
Engage in the Skill Acquisition Process for:Engage in the Skill Acquisition Process for:

49. 4.01 Nursing Fundamentals 7243 49
SKILLSKILL 4.01Dto4.01Dto
Measure Temperature with Measure Temperature with
Electronic ThermometerElectronic Thermometer
Training Lab AssignmentTraining Lab Assignment
Engage in the Skill Acquisition Process for:Engage in the Skill Acquisition Process for:

50. 4.01 Nursing Fundamentals 7243 50
SKILLSKILL 4.01E4.01E
Measure Temperature with Measure Temperature with
Tympanic ThermometerTympanic Thermometer
Training Lab AssignmentTraining Lab Assignment
Engage in the Skill Acquisition Process for:Engage in the Skill Acquisition Process for:

51. TTPPR+BP = Vital SignsR+BP = Vital Signs
PULSEPULSE
4.01 Nursing Fundamentals 7243 51

52. PULSEPULSE
4.01 Nursing Fundamentals 7243 52
Measuring the pulse is one way of
checking on the circulatory system

53. 4.01 Nursing Fundamentals 7243 53

Circulatory SystemCirculatory System

54. Nursing Fundamentals 7243 54
Circulatory System
•Circulation is
continuous
movement of blood
throughout body
4.01

55. Nursing Fundamentals 7243 55
Circulatory System
(continued)
•Functions of circulatory system
–Arteries carry blood with
oxygen and nutrients away
from heart and to cells
–Veins carry waste products
away from cells and to heart
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56. Nursing Fundamentals 7243 56
Blood
•Adult has 5 to 6 quarts (liters)
•Consists of
–water - 90% (plasma)
–blood cells
–carbon dioxide and oxygen
–nutrients, hormones and
enzymes
–waste products
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57. Nursing Fundamentals 7243 57
Blood
(continued)
•Types of blood cells
–Red blood cells - erythrocytes
•carry oxygen from blood to cells
–White blood cells - leukocytes
•fight infection
–Platelets - thrombocytes
•required for clotting to stop
bleeding
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58. Nursing Fundamentals 7243 58
Blood Vessels
•Arteries - carry blood away from heart
•Veins – carry blood to heart
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59. Nursing Fundamentals 7243 59
Heart
•Tissue (three layers)
–endocardium - smooth,
inner layer
–myocardium – thick,
muscular middle layer
–pericardium – double-
walled membrane that
covers outside of heart
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60. Nursing Fundamentals 7243 60
Heart Chambers
•Heart divided into
right and left side
•Atria – upper
chambers –
receive blood
•Ventricles –
lower chambers
– pump blood to
lungs and body
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61. Nursing Fundamentals 7243 61
Heart Chambers
•Four chambers
–right atrium (1) - receives
blood from two large veins:
•superior vena cava
•inferior vena cava
–right ventricle (2) - receives blood
from right atrium and pumps it to
lungs through pulmonary artery
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62. Nursing Fundamentals 7243 62
Heart Chambers
(continued)
•Four chambers
–left atrium (3) - receives
oxygenated blood from left
and right pulmonary veins
–left ventricle (4) - pumps
blood to aorta, which
delivers blood to all body
parts (except lungs)
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63. Nursing Fundamentals 7243 63
Heart Valves
•Located at entrance and exit of each
ventricle
•Four heart valves
4.01

64. Nursing Fundamentals 7243 64
Heartbeat
•Systole - contraction of heart muscle
•Diastole - relaxation of heart muscle
•Blood pressure – highest and lowest
pressure against walls of blood
vessels as heart contracts and
relaxes
•Pulse - expansion and contraction of
artery
4.01

65. Nursing Fundamentals 7243 65
Common Disorders of the
Circulatory System
•Arteriosclerosis - walls of arteries
become thick and harden
•Hypertension - high blood pressure
•Peripheral vascular disease -
decrease in flow of blood to
extremities and brain
•Angina pectoris - chest pain
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66. Nursing Fundamentals 7243 66
Common Disorders of the
Circulatory System
(continued)
•Varicose veins - enlarged, twisted
veins usually in legs
•Congestive heart failure -
circulatory congestion caused by
weak pumping of heart muscle
•Myocardial infarction (MI) - heart
attack due to blockage in coronary
arteries
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67. Nursing Fundamentals 7243 67
Common Disorders of the
Circulatory System
(continued)
•Anemia – low red blood cell counts
•Thrombus – blood clot
•Phlebitis – inflammation of vein
•Atherosclerosis - fatty deposits on
walls of arteries that reduce blood
flow
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68. Nursing Fundamentals 7243 68
Changes of the Circulatory System
Due To Aging
•Heart muscle less efficient
•Blood pumped with less force
•Arteries lose elasticity and
become narrow
•Blood pressure increases
•Blood chemistry less efficient
•Capillaries become more fragile
4.01

69. Nursing Fundamentals 7243 69
Observations of the Circulatory
System
•Changes in pulse rate and
blood pressure
•Changes in skin color
•Changes in skin
temperature – coldness
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70. Nursing Fundamentals 7243 70
Observations of the Circulatory
System
(continued)
•Complaint of dizziness and
headaches
•Complaint of pain in chest
and/or indigestion
•Edema in feet and legs
•Shortness of breath
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71. Nursing Fundamentals 7243 71
Observations of the Circulatory
System
(continued)
•Sweating
•Blue color to lips and/or nail beds
•Complaint of tingling sensations
•Memory lapses
•Lack of energy
•Irregular respirations
•Anxiety
•Staring and lack of responsiveness
4.01

72. TTPPR+BP = Vital SignsR+BP = Vital Signs
PULSEPULSE
•Pulse is pressure of
blood pushing against
wall of artery as heart
beats and rests
•Pulse easier to locate
in arteries close to
skin that can be
pressed against bone
4.01 Nursing Fundamentals 7243 72

73. Sites For Taking Pulse
•Radial – base of thumb
•Temporal – side of
forehead
•Carotid – side of neck
•Brachial – inner aspect
of elbow
•Femoral – inner aspect
of upper thigh
4.01 Nursing Fundamentals 7243 73

74. Sites For Taking Pulse
(continued)
•Popliteal - behind knee
•Dorsalis pedis – top of
foot
•Apical pulse – over apex
of heart
–taken with stethoscope
–left side of chest
4.01 Nursing Fundamentals 7243 74

75. Factors Affecting Pulse
•Age
•Sex
•Position
•Drugs
•Illness
•Emotions
•Activity level
•Temperature
•Physical training
4.01 Nursing Fundamentals 7243 75

76. Measurement of Pulse
•Normal pulse range/characteristics:
60 -100 beats per minute and regular
•Documenting pulse rate
–Noted as number of beats per
minute
–Rhythm - regular or irregular
–Volume - strong, weak, thready,
bounding
4.01 Nursing Fundamentals 7243 76

77. 4.01 Nursing Fundamentals 7243 77
SKILLSKILL 4.01F4.01F
Count and Record Count and Record
Radial PulseRadial Pulse
Training Lab AssignmentTraining Lab Assignment
Engage in the Skill Acquisition Process for:Engage in the Skill Acquisition Process for:

78. 4.01 Nursing Fundamentals 7243 78
SKILLSKILL 4.01G4.01G
Measure and Record Measure and Record
Apical PulseApical Pulse
Training Lab AssignmentTraining Lab Assignment
Engage in the Skill Acquisition Process for:Engage in the Skill Acquisition Process for:

79. TPTPRR+BP = Vital Signs+BP = Vital Signs
RESPIRATIONSRESPIRATIONS
4.01 Nursing Fundamentals 7243 79

80. RESPIRATIONSRESPIRATIONS
Measuring respirations is one way of Measuring respirations is one way of
checking on the checking on the respiratory systemrespiratory system
4.01 Nursing Fundamentals 7243 80

81. 4.01 Nursing Fundamentals 7243 81

Respiratory SystemRespiratory System

82. Nursing Fundamentals 7243 82
The Respiratory System
•Respiration means to breathe in
oxygen and breathe out carbon
dioxide
•Exchange of oxygen and carbon
dioxide necessary for life
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83. Nursing Fundamentals 7243 83
The Respiratory System
(continued)
•Process
–External respiration - oxygen and
carbon dioxide exchanged between
lungs and blood
–Internal respiration - oxygen and
carbon dioxide exchanged between
blood stream and cells
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84. Nursing Fundamentals 7243 84
The Respiratory System
Structure
•Oral cavity – mouth
•Pharynx – throat
•Larynx - voice box
•Trachea – windpipe
•Bronchi - right and left
•Bronchioles - smallest branches of
bronchi
•Alveoli - air sacs covered with
capillaries
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85. Nursing Fundamentals 7243 85
The Respiratory System
Structure
(continued)
•Nose - lined with mucous
membrane
–air filtered by cilia
–mucous membrane
warms and moistens air
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86. Nursing Fundamentals 7243 86
The Respiratory System
Structure
(continued)
•Lungs
–right - 3 lobes
–left - 2 lobes
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87. Nursing Fundamentals 7243 87
The Respiratory System
Structure
(continued)
•Pleura – membrane that encloses
lungs
•Diaphragm - muscle that separates
the chest and abdomen
–contraction - draws air into lungs
–relaxation - forces air out of lungs
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88. Nursing Fundamentals 7243 88
Common Disorders of Respiratory
System
•URI – Upper Respiratory Infection -
infection of nose, throat, larynx,
trachea
•Pneumonia - inflammation or
infection of the lungs
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89. Nursing Fundamentals 7243 89
Common Disorders of Respiratory
System
(continued)
•Emphysema (Chronic Obstructive
Pulmonary Disease – COPD) –
alveoli become stretched and stiff
preventing adequate exchange of
oxygen and carbon dioxide
•Asthma – spasms of bronchial tube
walls causing narrowing of air
passages usually due to allergies
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90. Nursing Fundamentals 7243 90
Common Disorders of Respiratory
System
(continued)
•Allergy – reaction to substances that
leads to slight or severe response by
body.
•Influenza – highly contagious URI
•Pleurisy – inflammation of the pleura
surrounding the lungs
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91. Nursing Fundamentals 7243 91
Common Disorders of Respiratory
System
(continued)
•Bronchitis - inflammation of the
bronchi
•Lung cancer - malignant tumors in
the lungs that destroy tissue
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92. Nursing Fundamentals 7243 92
Changes in Respiratory System
Due To Aging
•Lung tissue becomes less elastic
•Respiratory muscles weaken
•Number of alveoli decrease
•Respirations increase
•Voice pitched higher and weaker due
to changes in larynx
•Chest wall and structures become
more rigid
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93. Nursing Fundamentals 7243 93
Observations Of Respiratory System
•Rate and rhythm of respirations
•Respiratory secretions – character
•Character of cough
•Changes in skin color - pale or bluish
gray
•Temperature changes
•Difficulty breathing
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94. Nursing Fundamentals 7243 94
Observations Of Respiratory System
(continued)
•Color of sputum
•Complaint of pain in
chest, back, sides
•Shortness of breath
•Noisy respirations
•Sneezing
•Gasping for breath
•Anxiety
4.01

95. Measuring Respirations
•Respiration – process
of taking in oxygen
and expelling carbon
dioxide from lungs
and respiratory tract
4.01 Nursing Fundamentals 7243 95

96. Measuring Respirations
(continued)
•Age
•Activity
level
•Position
•Drugs
• Sex
• Illness
• Emotions
• Temperature
Factors Affecting Rate
4.01 Nursing Fundamentals 7243 96

97. Measuring Respirations
(continued)
•Qualities of normal respirations
–12-20 respirations per minute
–Quiet
–Effortless
–Regular
4.01 Nursing Fundamentals 7243 97

98. Measuring Respirations
(continued)
•Documenting respiratory rate
–Noted as number of inhalations
and exhalations per minute (one
inhalation and one exhalation
equals one respiration)
–Rhythm – regular or irregular
–Character: shallow, deep, labored
4.01 Nursing Fundamentals 7243 98

99. 4.01 Nursing Fundamentals 7243 99
SKILLSKILL 4.01H4.01H
Count and Record Count and Record
RespirationRespiration
Training Lab AssignmentTraining Lab Assignment
Engage in the Skill Acquisition Process for:Engage in the Skill Acquisition Process for:

100. TPR+TPR+BPBP = Vital Signs = Vital Signs
BLOOD PRESSUREBLOOD PRESSURE
4.01 Nursing Fundamentals 7243 100

101. Blood PressureBlood Pressure
4.01 Nursing Fundamentals 7243 101
Measuring the pulse is one way of
checking on the circulatory system

102. Measuring Blood Pressure
•Blood pressure is the force of blood
pushing against walls of arteries
–Systolic pressure: greatest force
exerted when heart contracting
–Diastolic pressure: least force
exerted as heart relaxes
4.01 Nursing Fundamentals 7243 102

103. Factors Influencing Blood Pressure
•Weight
•Sleep
•Age
•Emotions
•Sex
•Heredity
•Viscosity of blood
•Illness/Disease
4.01 Nursing Fundamentals 7243 103

104. Blood Pressure: Equipment
•Sphygmomanometer (manual)
–cuff - different sizes
–pressure control bulb
–pressure gauge – marked
with numbers
•aneroid
•mercury
4.01 Nursing Fundamentals 7243 104

105. Blood Pressure: Equipment
(continued)
•Stethoscope
–magnifies sound
–has diaphragm
4.01 Nursing Fundamentals 7243 105

106. Measuring Blood Pressure
Blood Pressure Systolic
(top#)
Diastolic
(bottom #)
NormalNormal ≤ ≤ 120120 <80<80
Pre HypertensionPre Hypertension 120-139120-139 80-8980-89
Hypertension Stage (1)Hypertension Stage (1) 140-159140-159 90-9990-99
Hypertension Stage (2)Hypertension Stage (2) ≥≥160160 ≥≥100100
4.01 Nursing Fundamentals 7243 106

107. Guidelines for Blood Pressure
Measurements
•Measure on upper
arm
•Have correct size
cuff
•Identify brachial
artery for correct
placement of
stethoscope
4.01 Nursing Fundamentals 7243 107

108. 4.01 Nursing Fundamentals 7243 108
=
Positioning of stethoscope Positioning of stethoscope
diaphragm diaphragm
directly over the brachial artery directly over the brachial artery increases ability to increases ability to
hear the systolic and diastolic soundshear the systolic and diastolic sounds

109. 4.01 Nursing Fundamentals 7243 109
Positioning of Positioning of
stethoscope stethoscope
diaphragm diaphragm directly directly
over the brachial over the brachial
artery artery increases increases
ability to hear the ability to hear the
systolic and systolic and
diastolicdiastolic

110. Guidelines for Blood Pressure
Measurements
(continued)
•First sound heard –
systolic pressure
•Last sound heard or
change - diastolic
pressure
4.01 Nursing Fundamentals 7243 110

111. 4.01 Nursing Fundamentals 7243 111
SystolicSystolic – – SStart hearing a tart hearing a SSound – Heart Muscle is ound – Heart Muscle is SSqueezingqueezing
DiastolicDiastolic – – DDon’t hear sound anymore – Heart muscle on’t hear sound anymore – Heart muscle ddoes not oes not
work during work during ddiastolic. This number is written iastolic. This number is written ddown under the own under the
systolic number.systolic number.
120120
8080

112. Guidelines for Blood Pressure
Measurements
(continued)
•Record - systolic/diastolic
•Resident in relaxed
position, sitting or lying
down
•Blood pressure usually
taken in left arm
4.01 Nursing Fundamentals 7243 112

113. Guidelines for Blood Pressure
Measurements
(continued)
Do not measure blood Do not measure blood
pressure in arm with IV, pressure in arm with IV,
A-V shunt (dialysis), A-V shunt (dialysis),
cast, wound, or sorecast, wound, or sore
4.01 Nursing Fundamentals 7243 113

114. Guidelines for Blood Pressure
Measurements
(continued)
•Apply cuff to bare
upper arm, not over
clothing
•Room quiet so blood
pressure can be heard
•Sphygmomanometer
must be clearly visible
4.01 Nursing Fundamentals 7243 114

115. Blood Pressure: Reading Gauge
•Large lines are
at increments of
10 mmHg
•Shorter lines at
2 mm intervals
•Take reading at
closest line
4.01 Nursing Fundamentals 7243 115

116. 4.01 Nursing Fundamentals 7243 116
SKILLSKILL 4.01I4.01I
Measure Blood Pressure Measure Blood Pressure
ManualManual
Training Lab AssignmentTraining Lab Assignment
Engage in the Skill Acquisition Process for:Engage in the Skill Acquisition Process for:

117. 4.01 Nursing Fundamentals 7243 117
SKILLSKILL 4.01J4.01J
Combined Vital SignsCombined Vital Signs
Training Lab AssignmentTraining Lab Assignment
Engage in the Skill Acquisition Process for:Engage in the Skill Acquisition Process for:

118. 4.01 Nursing Fundamentals 7243 118

Measuring Measuring
Height and WeightHeight and Weight

119. The resident’s The resident’s weightweight, ,
compared with the compared with the heightheight, ,
gives information about gives information about
his/her his/her nutritional status nutritional status
and changes in the and changes in the medical medical
condition. condition.
4.01 Nursing Fundamentals 7243 119

120. Measuring Height And Weight
•Baseline measurement
obtained on admission
and must be accurate.
•Other measurements
obtained as ordered.
4.01 Nursing Fundamentals 7243 120

121. Measuring Height And Weight
(continued)
•Height measurements
–Feet
–Inches
–Centimeters
•Weight measurements
–Pounds
–Ounces
–Kilograms
4.01 Nursing Fundamentals 7243 121

122. Measuring Height and Weight
(continued)
•Reasons for obtaining height and
weight
–Indicator of nutritional status
–Indicator of change in medical
condition
–Used by doctor to order medications
4.01 Nursing Fundamentals 7243 122

123. Special Case for Height
Measurement
•Residents who are contractured or
•Residents who cannot stand
•Must be measured using a tape
measure
4.01 Nursing Fundamentals 7243 123

124. Measuring Height and Weight
(continued)
–Use same scale
each time
–Have resident void,
remove shoes and
outer clothing
–Weigh at same time
each day
•Guidelines for weighing residents
4.01 Nursing Fundamentals 7243 124

125. Measuring Height and Weight
(continued)
•Scales
–Remain more accurate if moved as
little as possible.
–Various types of scales
•bathroom scale
•standing scale
•scales attached to hydraulic lifts
•wheelchair scales
•bed scales
4.01 Nursing Fundamentals 7243 125

126. 4.01 Nursing Fundamentals 7243 126
SKILLSKILL 4.01K4.01K
Measure HeightMeasure Height
& Weight& Weight
Training Lab AssignmentTraining Lab Assignment
Engage in the Skill Acquisition Process for:Engage in the Skill Acquisition Process for:

127. Understand Understand vital signsvital signs, , heightheight, and , and
weightweight measurement skills. measurement skills.
127
 ENDEND 
4.014.01
4.01 Nursing Fundamentals 7243