348 Objectives To achieve the objectives for this section, you must successfully discuss the purpose and importance of taking vital signs identify the normal and abnormal ranges of vital signs describe the locations and methods used to take vital signs list the equipment needed to take vital signs describe the importance of using a pulse oximeter and explain how to measure and document vital signs accurately and effectively. Key Terms Learn these key terms to better understand the information presented in the section. apical pulse apnea aural axillary temperature bradycardia bradypnea carotid pulse Celsius (C) diastolic blood pressure dyspnea Fahrenheit (F) hyperventilation hypotension hypoventilation hypoxia probe radial pulse stertorous breathing stethoscope systolic blood pressure tachycardia tachypnea temporal arteries tympanic temperature Questions to Consider When was the last time someone measured your body’s vital signs of temperature, pulse, respirations, and blood pressure? Did you know why your vital signs were being taken and why they were important? For example, were you sick? Were your vital signs measured for a physical exam? What was it like to have your vital signs measured? Why Are Vital Signs Important? Taking the vital signs of body temperature, pulse, respirations, and blood pressure are important skills for a holistic nursing assistant to learn. Vital signs can help doctors diagnose specific diseases, determine treatments and medications, and evaluate the effectiveness of treatments and medications. For example, a high body temperature can be a signal that a resident has an infection. If temperature starts to lower once treatment begins, this typically means the body is fighting the infection and the resident is getting better. Vital signs are usually taken in a doctor’s office during an exam, during admission to a healthcare facility, or once a day in long-term care facilities (more frequently when necessary). For each vital sign, well-established guidelines help nursing assistants determine whether the measurements are in a normal range. Facility guidelines impact how vital signs are documented. Some facilities use paper forms for all residents on a shift and then transfer the measurements to each resident’s chart or EMR. Other facilities use a specific form for each resident or enter vital signs into a resident’s electronic record immediately. How Is Temperature Measured and Recorded? When you take a resident’s temperature, you are measuring body heat, including how much body heat is produced and lost. Temperature is recorded in degrees (°) and is measured using either the Fahrenheit or the Celsius scale. The Fahrenheit (F) scale is used mostly in the United States, while the Celsius (C), or centigrade, scale is used in other parts of the world (Figure 16.1). Locations for Taking Temperature Temperature can be taken using several different body locations using a thermometer: Oral temperature: taken under the tongue, or sublingually. This is the most common method of taking a temperature. Ask the resident to close his or her mouth completely while breathing through the nose. Wait at least 15 minutes after a resident has eaten, had something to drink, or smoked before using an oral thermometer. Oral temperature is not appropriate for residents who are receiving oxygen, who are coughing or sneezing, who are agitated or comatose, who have had mouth surgery, who may bite the thermometer, or who cannot follow instructions due to cognitive impairment. Measuring and Recording Vital Signs 16.1 section catshila/Shutterstock.com Figure 16.1 In the Fahrenheit (°F) scale, water freezes at 32° and boils at 212°. In the Celsius (°C) scale, water freezes at and boils at 100°. Copyright Goodheart-Willcox Co., Inc.
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