module 7 and 10 Flashcards
the metric system
Referred to as the International System of Units
* Based on base units such as meters and grams
* Uses prefixes and a decimal system
* Used in healthcare in the US
Weight
Measured in pounds or kilograms
* 1 kilogram = 2.2 pounds
Weight using a bed scale
if resident cannot stand or sit up to use wheelchair scale you can use a bed scale
ask resident not to move and zero it out
back away from the bed
how can weight be obtained?
Upright scale
* Wheelchair scale
* Bed scale
* Mechanical lift
Weight using a mechanical lift
cannot stand or sit up to use wheelchair scale and if bed has no scale use a mechanical lift
Traditional lift:400 lbs or less
Bariatric lift: > 400 lbs
butt/heels are no loner touching bed, zero scale out, pt does not move, do not touch pt while recording weight
Length (height)
Most often documented using feet and inches (imperial system)
* Can use an upright scale with height rod or a stadiometer
* May need to be obtained while resident is in bed
Measuring using smaller units
Most often documented using metric system
* Examples: pressure injuries, lacerations, bruises
What is the base volume measurement in the metric system?
Liter and 1 ounce = 30 ml= 30 cc
Fluid intake
calculated during meals and snacks
any liquid should be recorded
All calculations in centimeter or milliliter
intake is never calculated in ounces
Military time
Used for documentation and
communication purposes
* Helps eliminate errors
* Based on a 24-hour cycle
* Examples:
* 2:00 am = 0200
* 2:00 pm = 1400
* 4:30 am = 0430
* 4:30 pm = 1630
LTC and hospital vital
LTC: once every week
hospital: every 2 hours
vital signs
Upon admission as a baseline
* Typically on resident’s bath day
* At least once per shift during hospital stay
* Once per shift for 72 hours after a fall, or per facility protocol
* During illness
* As directed by the nurse
Vital signs- Infection control
Clean equipment with alcohol after use
* Use probe covers
* Keep a set of vital sign equipment in isolation rooms
* When isolation precautions are no longer needed, remove equipment from
room and disinfect completely
* Always perform hand hygiene before and after each resident contact
Temperature: ensurinh
When taken orally, ensure resident is not chewing gum and has not had anything to eat or drink for last 15−20 minutes
* When using temporal artery scanner, remove hat and wait about a minute
before taking temp; do not swipe resident’s bangs
When taking pulse what do ask resident to do?
Ask resident to remain still
Before taking resp what should you do?
Do not tell patient you are doing this
ask for permission before doing so
Blood pressure: facts
Do not take on same arm of mastectomy: can cause lymphedema
Do not do on the same arm as an IV
Relaxed state
No feet crossed
Be still and do not talk
be able to place 1 finger and it is overlapped
either roll up sleeve or remove arm from sleeve
Normal vital ranges
Temp: 97.6-99.6
pulse: 60 to 100 beats per minute
respirations: 12-20 breaths per minute
blood pressure 120/80
oral temp
probe is placed under the tongue. Most often a digital model is used
Axillary
Probe is placed under the resident’s arm, in the center and deepest fold of axilla.
Preferable for residents with dementia or cognitive disabilities
Tympanic- ear
Probe is placed into ear canal. Invasive and can be uncomfortable.
Least accurate method due to user error or buildup of cerumen
Temporal Artery Scanner
Less invasive and most accurate as rectal thermometer. Professional and
home models available; follow manufacturer’s directions
Rectal
Most invasive and accurate. can cause ham
non-contact infrared thermeter (NICT)
least invasive since there is no contact with resident. Reduces risk of cross-contamination. Follow manufacturer’s directions
Pulse
(producer)
- have resident sitting
Use the index and middle fingers to find the resident’s radial pulse - Radial pulse is found in the natural groove of the wrist, on the thumb side
- Heartbeat is counted for 60 seconds
- Apical pulse is obtained by using a stethoscope
respiration (measurement)
Counted by observing the rise and fall of the resident’s chest or abdomen
* 1 rise and 1 fall = 1 breath
if resident coughs wait until their done
BP measurment
place cuff around upper arm and line up with brachial artery
* Cuff is inflated to apply pressure to arm and then slowly released
* Manual cuff requires use of stethoscope to listen for first and last heartbeats
* Wrist cuffs are available and convenient but often the least accurate
Extra step bP
if you hear the pluse right away deflate the valuve and let the residetn arm rest for 1 to 2 minutes, reinflates the cuff 30 mmHG higher than pluse left
Korotkoff sound
heart rate heard via stethoscope while taking BP
what to do when you know their usual BP
inflate and add 20 mmHG to average measurement
Temp- factd
too low: hairs rise for a thermal blanket
too high: produce sweat
Affecting factors: environment, smoking, exercise, stress
Body temperature is a balance between amount of heat produced and amount
lost by the body.
* Thermometers measure temperature.
* Fahrenheit (F) and centigrade (C) scales are used
pulse- facts
expansion of artery with every beat of heart
affecting factors: fitness level, chronic illness, age, stress
The pulse is the beat of the heart felt at an artery as a wave of blood passes
through the artery.
* Carotid pulse is taken during CPR and other emergencies.
* The apical pulse is felt over the heart.
* This pulse is taken with a stethoscope.
Respiration: facts
Respiration means breathing air into (inhalation) and out of (exhalation) the lungs.
* Oxygen enters the lungs during inhalation.
* Carbon dioxide leaves the lungs during exhalation.
* The chest rises during inhalation.
* The chest falls during exhalation.
affecting factors: age, exercise, medication, pain, and emotions
Systolic and diastolic
and their ranges
systolic pressure—the pressure in the arteries when the heart contracts
* Diastolic pressure—the pressure in the arteries when the heart is at rest
* Systolic pressure— 90 mm Hg or higher but lower than 120 mm Hg
* Diastolic pressure— 60 mm Hg or higher but lower than 80 mm H
hyper/hypotension: ranges
Hypertension—when the systolic blood pressure is 140 mm Hg or higher
(hyper) or the diastolic blood pressure is 90 mm Hg or higher
* Report any systolic measurement at or above 120 mm Hg.
* Report any diastolic pressure at or above 80 mm Hg.
* Hypotension—when systolic blood pressure is below (hypo) 90 mm Hg or the
diastolic blood pressure is below 60 mm Hg
* Report a systolic pressure below 90 mm Hg.
* Report a diastolic pressure below 60 mm Hg
brady/tachycardia
Bradycardia: a low heart rate; can mean heart is not working properly or
there is a medication problem
* Tachycardia: a high heart rate; can indicate atrial fibrillation, medication
problem, stimulant use, pain, anxiety, or cardiac disease
Brady/tachypnea
Bradypnea: slow breathing; usually caused by medication, narcotic drugs, or alcohol
* Tachypnea: fast, shallow breathing; often caused by respiratory infection or
disease, an imbalance of resident’s pH, pain, or fever
BP ranges
Hypertension:
* Stage 1: 130–139/80–89
* Stage 2: higher than 140/90
* can result in heart attack, stroke, kidney disease or failure, or congestive heart failure
* Hypotension:
* lower than 90/60
* can result in falls and injurie
After taking vital
- Document in the patient chart
- Update nurse if results do not follow resident’s trending normal values
- Orally report any vital signs that are outside of normal limits or do not follow
the resident’s normal value trend
If unsure about vitals
if unsure about any vitals let resident rest arm for 5 minutes than repeat
what it the vital signs order?
1: temp, 2: pulse 3: respiration 4: blood pressure
Brady/tachycardia ranges
brady: less 60
Tachy: more than 100
Oral
Axillary
Rectal
Tympanic
Temporal Artery
RANGES
O: 98.6
A: 97.6
R: 99.6
T:97.6
TA: 99.6
What is a sphygmomaneter and what types are there?
It is a cuff measuring device
- electronic type
-wrist cuff
-aneroid types
- mercury type
