Temperature, pulse, respirations, and blood pressure.
If unsure of your measurements, promplty ask the nurse to take them again. Unless otherwise ordered, take vital signs with the person lying or sitting.
older persons have lower body tempperatures than younger adults. an oral temperature of 98.6 may signal and elevated temperature (fever) in an older person. Rectal temperatures are dangerous for persons with heart disease.
Fahrenheit thermometers have long and short lines. Every other long line is marked in an even degree form 94o to 108o F. The short lines mean 0.2 of a degree.
On a centigrade thermometer, each long line meansw 1 degree. Degrees range form 34o to 42o C. Each short line means 0.1 of a degree. - Hold thermometer at the stem.
The beat of the heart felt at an artery as a wave of blood passes through the artery. It is felt every time the heart beats.
The resting blood pressure is too high. The systolic pressure is 140 mm Hg or higher. Or the diastolic pressure is 90 mm Hg or higher.
The radial pulse is used for routine vital signs. Place the first 2 or 3 fingers of one hand against the radial artery. The radial artery is on the thumb side of the wrist. Count the pulse for 30 seconds. Then multiply the number by 2. This gives the number of beats per minute. If the pulse is irregular, count it for 1 minute.
Count the apical pulse for 1 minute. The heartbeat normally sounds like a lub-dub. Count each lub-dub as 1 beat.
Respiration means breathing air into and out of the lungs. Each respiration involves 1 inhalation and 1 exhalation. The healty adult has 12 to 20 respirations per minute. Count for 30 seconds. Muliply by 2. If abnormal pattern count for 1 minute.
An inflammation of the bronchitis.
The alveoli enlarge and become less breathing in and out. Some air is ttrapped in the alveoli when exhaling.
The airway narrows. Difficulty breathing results. Allergies and emotional stress are common causes.
An infammation and infection of lung tissue.
A bacterial infection in the lungs.
The amount of force exerted against the walls of an artery by the blood.
The period of heart muscle contraction.
Period of heart muscle relaxation.
The amount of force needed to pump blood out of the heart into the arterial circulation. It's the higher pressure.
Reflects the pressure in the arteries when the heart is at rest. It's the lower pressure.
Systolic pressures that remain above 140 mm Hg and diastolic pressures that remain abouve 90 mm Hg.
Systolic pressures below 90 mm Hg and diastolic pressures below 60 mm Hg are reported.
Systolic and diastolic pressures are higher in older persons. A blood pressure of 160/90 mm Hg is normal for many older persons.
Do not take blood pressure on an arm with an IV infusion, a cast, or a dialysis access site. If a person had breast surgery, do not take blood pressure on that side. Avoid taking blood pressure on an injured arm.
Height and weight
They are measured on admission to the center. Some residents are weighed daily, weekly, or monthly. Weight the person at the same time of day. Before breakfast is the best time. Food and fluids add weight.
Intake and Output
All fluids taken by mouth are measured and recorde - water, milk, coffe, tea, juices, soups, and soft drinks. So are foods that melt at room temmperature - Ice cream, sherbet, custard, pudding, gelatin, and popsicles. The nurse measures and records IV fluids and tuve feedings. Output includes urine, vomitus, diarrhea, and wound drainage.
Intake and output are easured in milliliters (ml). Know these amounts:
1 once equals 30 ml
A pint is about 500 ml
A quart is about 1000 ml
A measuring container for fluid.
Graduate. It's used to measure leftover fluids, urine, vomitus, adn drainage from suction.
The urinal, commode, bedpan, or specimen is used for voiding.
Pain is felt suddenly from injury, disease, trauma, or surgery.
ly less than Acute pain. There is tissue damage. Acute pain lasts a short time, usually less than 6 months. It lessens with healing.
Lasts longer than 6 monts. Pain is constant or occurs off and on. There is no longer tissue damage.
Chronic pain. Chronic pain remains long after healing. Arthritis and cancer are common causes.
Pain is felt at the site of tissue damage and in nearby areas. Pain from a heart attack is offten felt in the left chest, left jaw, left shoulder, and left arm.
Pain is felt in a body part that is no longer there.
Phantom pain. A person with an amputated leg may still sense leg pain.
Factors causin pain.
Signs and symptoms of Pain.
Body Responses: Increased pulse, respiraions, and blood pressure, Nausea, Pale skin, Sweating, Vomiting
Behaviors: Changes in speech: slow or rapid; loud or quiet, crying, gasping, groaning, grunting holding the affected body part, irritability, maintaining one position; refusin to move, moaning, quietness, restlessness, rubbing, screaming.
Rectal: 99.6 F (37.5 C);------------------------ 98.6 to 100.6 (37. to 38.1)
Oral: 98.6 F (37 C);------------------------------97.6 to 99.6 (36.5 to 37.5)
Tympanic membrane: 98.6 F (37 C);----------98.6 (37 C)
Axiliary: 97.6 f ( 36.5 C);---------------------- 96.6 to 98.6 (35.9 to 37.0)