362 Chapter 16 electronic record. Any irregularities must be reported to the licensed nursing staff. How Is Blood Pressure Measured? Blood pressure is the force of blood pushing against the body’s arterial walls. Measuring blood pressure is important. If a resident has hypotension (blood pressure that is too low), the body may not be getting enough oxygen and nutrients. The opposite of hypotension is hypertension (blood pressure that is too high), which may place too much pressure on the walls of the arteries (Figure 16.20). This pressure can Using a Pulse Oximeter Another way to measure how well oxygen is being used in the body is to determine oxygen saturation (levels) in the blood. A pulse oximeter is commonly used when vital signs are being measured and is also used to measure oxygen effectiveness for a resident receiving oxygen. A pulse oximeter is applied to the finger (or sometimes the earlobe or toe). It uses infrared light that passes through the body tissue of the finger. A pulse oximeter’s digital display will show the amount of oxygen in the blood as a percentage (Figure 16.19). A normal reading is 95 percent to 100 percent oxygen in the blood. A reading below 85 percent is too low a level and is called hypoxia (not enough oxygen in the body). Oxygen saturation in the blood is documented as SpO 2 . Using a pulse oximeter has very few risks. If improperly placed, the pulse oximeter may give an inaccurate reading. If a pulse oximeter is used continuously, pay attention to the skin around and under the device and check for possible irritation. Respirations (rate, regularity, and depth) and pulse oximeter percentages are documented on a form provided by the healthcare facility or in the Counting Respirations (continued) 13. The best time to count respirations is immediately after counting pulse rate. It is best not to tell residents you are counting respirations. When residents know their breathing is being observed, they may change their breathing patterns. Best Practice: Depending on which pulse was taken, keep your fingers on the wrist or keep the stethoscope on the chest while counting respirations. 14. Begin counting respirations when the chest rises. Each rise and fall of the chest counts as one respiration. Note the regularity and depth of respirations, the expansion of the chest, and any pain or difficulty breathing. 15. Note the position of the second hand on your watch and count respirations for one full minute. Some facilities allow nursing assistants to count respirations for 15 seconds and multiply the result by four or count respirations for 30 seconds and multiply the result by two. Follow the facility policy. Counting respirations for one full minute should be done if the respiration is irregular. 16. Let the licensed nursing staff know immediately if the resident complains of pain or difficulty breathing. 17. Document the respiration rate on a pad, on a form, or in the electronic record. 18. If the resident is in bed, check to be sure the bed wheels are locked. Then reposition the resident and lower the bed. 19. Follow the plan of care to determine if the side rails should be raised or lowered. Follow-Up 20. Wash your hands to ensure infection control. 21. Make sure the resident is comfortable and place the call light and personal items within reach. 22. Conduct a safety check before leaving the room. The room should be clean and free from clutter or spills. 23. Wash your hands or use hand sanitizer before leaving the room. Reporting and Documentation 24. Report any specific observations, complications, or unusual responses to the licensed nursing staff. Click and Photo/Shutterstock.com Figure 16.19 The pulse oximeter is placed on the finger and measures oxygen saturation in the blood. Copyright Goodheart-Willcox Co., Inc.