Chapter Eight

1

• 1. Define important words in this chapter
• apical pulse
• the pulse on the left side of the chest, just
  below the nipple.
• apnea
• the absence of breathing may be temporary.
• BPM
• the abbreviation for beats per minute.
• brachial pulse
• the pulse inside the elbow used to measure blood
  pressure.

2

• 1. Define important words in this chapter (cont)
• bradycardia
• a slow heart rate under 60 beats per minute.
• Celsius
• the centigrade temperature scale in which the
  boiling point of water is 100 degrees and the
  freezing point of water is 0 degrees.
• Cheyne-Stokes respiration
• type of respiration with periods of apnea lasting
  at least 10 seconds, along with alternating
  periods of slow, irregular respirations or rapid,
  shallow respirations.
• diastolic
• second measurement of blood pressure phase when
  the heart relaxes.

3

• 1. Define important words in this chapter (cont)
• dilate
• to widen.
• dyspnea
• difficulty breathing.
• eupnea
• normal respirations.
• expiration
• the process of exhaling air out of the lungs.

4

• 1. Define important words in this chapter (cont)
• Fahrenheit
• a temperature scale where the boiling point of
  water is 212 degrees and the freezing point of
  water is 32 degrees.
• hypertension
• high blood pressure.
• hypotension
• low blood pressure.
• hypothermia
• a condition in which body temperature drops below
  the level required for normal functioning severe
  sub-normal body temperature.

5

• 1. Define important words in this chapter (cont)
• inspiration
• the process of inhaling air into the lungs.
• orthopnea
• shortness of breath when lying down that is
  relieved by sitting up.
• orthostatic hypotension
• a sudden drop in blood pressure that occurs when
  a person stands up also called postural
  hypotension.
• prehypertension
• a condition in which a person has a systolic
  measurement of 120139 mm Hg and a diastolic
  measurement of 8089 mm Hg indicator that the
  person does not have high blood pressure now but
  is likely to have it in the future.

6

• 1. Define important words in this chapter (cont)
• radial pulse
• the pulse on the inside of the wrist, where the
  radial artery runs just beneath the skin.
• respiration
• the process of inhaling air into the lungs
  (inspiration) and exhaling air out of the lungs
  (expiration). .
• sphygmomanometer
• a device that measures blood pressure.
• stethoscope
• an instrument used to hear sounds in the human
  body, such as the heartbeat or pulse, breathing
  sounds, or bowel sounds.

7

• 1. Define important words in this chapter (cont)
• systolic
• first measurement of blood pressure phase when
  the heart is at work, contracting and pushing
  blood out of the left ventricle.
• tachycardia
• a fast heartbeat, over 100 beats per minute.
• tachypnea
• rapid respirations.
• thermometer
• a device used for measuring the degree of heat or
  cold.

8

• 1. Define important words in this chapter (cont)
• vital signs
• measurements that monitor the function of the
  vital organs of the body.

9

• 2. Discuss the relationship of vital signs to
  health and well-being
• Vital signs consist of body temperature, pulse,
  respirations, blood pressure, and pain level.

10

• 3. Identify factors that affect body temperature
• Factors that affect body temperature include
• The persons age
• Amount of exercise
• The circadian rhythm
• Stress
• Illnesses
• Environment
• Hypothermia is a condition in which body
  temperature drops below the level required for
  normal functioning.

11

• 4. List guidelines for taking body temperature
• Common types of thermometers are
• Mercury-free glass
• Digital
• Electronic
• Disposable
• Tympanic
• Temporal artery thermometer

12
Measuring and recording oral temperature

• Equipment mercury-free glass, digital, or
  electronic thermometer, gloves, disposable
  plastic sheath/cover for thermometers, tissues,
  pen and paper
• Do not take an oral temperature on a resident who
  has eaten or drunk fluids within the last 1020
  minutes.
• Identify yourself by name. Identify the resident.
  Greet the resident by name.

13
Measuring and recording oral temperature

1. Wash your hands.
2. Explain procedure to resident. Speak clearly,
   slowly, and directly. Maintain face-to-face
   contact whenever possible. Encourage resident to
   assist if possible.
3. Provide for the residents privacy with a
   curtain, screen, or door.
4. Put on gloves.

14
Measuring and recording oral temperature

• Using a mercury-free glass thermometer
• Hold thermometer by stem.
• Before inserting thermometer in residents mouth,
  shake thermometer down to below the lowest number
  (at least below 96F or 35C). To shake
  thermometer down, hold it at the end opposite the
  bulb with the thumb and two fingers.

15
Measuring and recording oral temperature

• (cont) With a snapping motion of the wrist,
  shake the thermometer (Fig. 13-8). Stand away
  from furniture and walls while doing so.

Fig. 13-8. Shake thermometer down to below the
lowest number before inserting in a residents
mouth.
16
Measuring and recording oral temperature

1. Put on disposable sheath, if applicable. Gently
   insert bulb end of thermometer into residents
   mouth. Place it under tongue and to one side
   (Fig. 13-9). Resident should breathe through his
   or her nose.
2. Tell resident to hold thermometer in mouth with
   lips closed. Assist as necessary. Ask the
   resident not to bite down or to talk.

Fig. 13-9. Insert thermometer under the
residents tongue and to one side.
17
Measuring and recording oral temperature

• Leave thermometer in place for at least three
  minutes.
• Remove the thermometer. Wipe with tissue from
  stem to bulb or remove sheath. Dispose of tissue
  or sheath.
• Hold thermometer at eye level. Roll thermometer
  between your thumb and forefinger until the line
  appears.

18
Measuring and recording oral temperature

• (cont) Read temperature. Remember the
  temperature reading.
• Clean thermometer according to facility policy.
  Return it to plastic case or container. Store it
  away from any heat source.

19
Measuring and recording oral temperature

• Using a digital thermometer
• Put on disposable sheath.
• Turn on thermometer. Wait until ready sign
  appears.
• Insert end of digital thermometer into residents
  mouth. Place under tongue and to one side.

20
Measuring and recording oral temperature

1. Leave in place until thermometer blinks or beeps.
2. Remove the thermometer.
3. Read temperature on display screen. Remember the
   temperature reading.
4. Using a tissue, remove and dispose of sheath.

21
Measuring and recording oral temperature

• Clean thermometer according to facility policy.
  Replace thermometer in case.
• Using an electronic thermometer
• Remove probe from base unit.
• Put on probe cover.
• Insert the covered probe into residents mouth.
  Place under tongue and to one side.

22
Measuring and recording oral temperature

1. Leave in place until you hear a tone or see a
   flashing or steady light.
2. Read the temperature on the display screen.
   Remember the temperature reading.
3. Remove the probe.
4. Press the eject button to discard the cover
   (Fig. 13-10).
5. Return the probe to the holder.

Fig. 13-10. Eject the probe cover after use.
23
Measuring and recording oral temperature

• Final steps for all methods
• Remove privacy measures. Make resident
  comfortable.
• Remove and dispose of gloves properly.
• Leave call light within residents reach.
• Wash your hands.
• Be courteous and respectful at all times.

24
Measuring and recording oral temperature

1. Report any changes in the resident to the nurse.
   Document procedure using facility guidelines.
   Record residents name, temperature, date, time,
   and method used (oral).

25
Measuring and recording rectal temperature

• Equipment rectal mercury-free glass, digital or
  electronic thermometer, lubricant, gloves,
  tissue, disposable plastic sheath/cover, pen and
  paper
• Identify yourself by name. Identify the resident.
  Greet the resident by name.
• 2. Wash your hands.

26
Measuring and recording rectal temperature

1. Explain procedure to resident. Speak clearly,
   slowly, and directly. Maintain face-to-face
   contact whenever possible. Encourage resident to
   assist if possible.
2. Provide for the residents privacy with a
   curtain, screen, or door.
3. Practice good body mechanics. Adjust bed to safe
   working level, usually waist high. Lock bed
   wheels.

27
Measuring and recording rectal temperature

1. Lower the side rail (if bed has one and if it is
   not already lowered) on side nearest you.
2. Help the resident to left-lying (Sims) position
   (Fig. 13-11).
3. Fold back linens to expose only rectal area.
4. Put on gloves.

Fig. 13-11. The resident must be in the
left-lying (Sims) position.
28
Measuring and recording rectal temperature

• Mercury-free glass thermometer Hold thermometer
  by stem. Shake thermometer down to below the
  lowest number.
• Put on disposable sheath. Apply small amount of
  lubricant to sheath.
• Digital thermometer Put on disposable sheath.
  Apply small amount of lubricant to sheath.

29
Measuring and recording rectal temperature

• Turn on thermometer. Wait until ready sign
  appears.
• Electronic thermometer Remove probe from base
  unit. Put on probe cover. Apply small amount of
  lubricant to cover.

30
Measuring and recording rectal temperature

• Separate the buttocks. Gently insert thermometer
  one inch into rectum (Fig. 13-12). Stop if you
  meet resistance. Do not force the thermometer in
  the rectum.
• Replace sheet over buttocks. Hold onto the
  thermometer at all times.

Fig. 13-12. Gently insert a rectal thermometer
one inch into the rectum. Do not force it into
the rectum.
31
Measuring and recording rectal temperature

• Mercury-free glass thermometer Hold thermometer
  in place for at least three minutes.
• Digital thermometer Hold thermometer in place
  until thermometer blinks or beeps.
• Electronic thermometer Leave in place until you
  hear a tone or see a flashing or steady light.

32
Measuring and recording rectal temperature

1. Gently remove the thermometer. Wipe with tissue
   from stem to bulb or remove sheath or cover.
   Dispose of tissue.
2. Read thermometer as you would for an oral
   temperature. Remember the temperature reading.
3. Mercury-free glass thermometer Clean thermometer
   according to facility policy. Return it to
   plastic case or container.

33
Measuring and recording rectal temperature

• Digital thermometer Discard sheath. Clean
  thermometer according to facility policy. Return
  thermometer to storage area.
• Electronic thermometer Discard the cover.
  Return probe to holder.
• Remove and dispose of gloves properly. Wash your
  hands.

34
Measuring and recording rectal temperature

1. Make resident comfortable
2. Return bed to low position if raised. Ensure
   residents safety. Return side rails to ordered
   position. Remove privacy measures.
3. Leave call light within residents reach.
4. Wash your hands.
5. Be courteous and respectful at all times.

35
Measuring and recording rectal temperature

1. Report any changes in the resident to the nurse.
   Document procedure using facility guidelines.
   Record residents name, temperature, date, time,
   and method used (rectal).

36
Measuring and recording tympanic temperature

• Equipment mercury-free glass, digital or
  electronic thermometer, gloves, tissues,
  disposable sheath/cover, pen and paper
• Identify yourself by name. Identify the resident.
  Greet the resident by name.
• Wash your hands.

37
Measuring and recording tympanic temperature

• Explain procedure to resident. Speak clearly,
  slowly, and directly. Maintain face-to-face
  contact whenever possible.
• Provide for the residents privacy with a
  curtain, screen, or door.
• Put on gloves.
• Put a disposable sheath over earpiece of the
  thermometer.

38
Measuring and recording tympanic temperature

1. Position the residents head so that the ear is
   in front of you. Straighten the ear canal by
   pulling up and back on the outside edge of the
   ear (Fig. 13-13). Insert the covered probe into
   the ear canal. Press the button.

Fig. 13-13. Straighten the ear canal by pulling
up and back on the outside edge of the ear.
39
Measuring and recording tympanic temperature

1. Hold thermometer in place until thermometer
   blinks or beeps.
2. Read temperature. Remember the temperature
   reading. (If the reading seems too low, repeat
   the procedure.)
3. Dispose of sheath. Return thermometer to storage
   or to the battery charger if thermometer is
   rechargeable.

40
Measuring and recording tympanic temperature

1. Make resident comfortable.
2. Remove privacy measures.
3. Remove and dispose of gloves properly.
4. Leave call light within residents reach.
5. Wash your hands.
6. Be courteous and respectful at all times.

41
Measuring and recording tympanic temperature

1. Report any changes in the resident to the nurse.
   Document procedure using facility guidelines.
   Record residents name, temperature, date, time,
   and method used (tympanic).

42
Measuring and recording axillary temperature

• Equipment mercury-free glass, digital or
  electronic thermometer, gloves, tissues,
  disposable sheath/cover, pen and paper
• Identify yourself by name. Identify the resident.
  Greet the resident by name.
• Wash your hands.

43
Measuring and recording axillary temperature

1. Explain procedure to resident. Speak clearly,
   slowly, and directly. Maintain face-to-face
   contact whenever possible.
2. Provide for the residents privacy with a
   curtain, screen, or door.
3. Practice good body mechanics. Adjust bed to safe
   working level, usually waist high. Lock bed
   wheels.

44
Measuring and recording axillary temperature

• Put on gloves.
• Remove residents arm from sleeve of gown. Wipe
  axillary area with tissues.
• Mercury-free glass thermometer Hold thermometer
  by stem. Shake thermometer down to below the
  lowest number.
• Put on disposable sheath, if applicable.

45
Measuring and recording axillary temperature

• Digital thermometer Put on disposable sheath.
  Turn on thermometer. Wait until ready sign
  appears.
• Electronic thermometer Remove probe from base
  unit. Put on probe cover.
• Place the end of thermometer in center of armpit.
  Fold residents arm over chest.

46
Measuring and recording axillary temperature

• Mercury-free glass thermometer Hold thermometer
  in place, with the arm close against the side,
  for 10 minutes (Fig. 13-14).
• Digital thermometer Hold thermometer in place
  until thermometer blinks or beeps.
• Electronic thermometer Leave in place until you
  hear a tone or see a flashing or steady light.

Fig. 13-14. After inserting the thermometer, fold
the residents arm over her chest and hold it in
place for the required time.
47
Measuring and recording axillary temperature

• Gently remove the thermometer. Wipe with tissue
  from stem to bulb or remove sheath or cover.
  Dispose of tissue.
• Read thermometer as you would for an oral
  temperature. Remember the temperature reading.

48
Measuring and recording axillary temperature

• Mercury-free glass thermometer Clean thermometer
  according to facility policy. Return it to
  container for used thermometers.
• Digital thermometer Discard sheath. Clean
  thermometer according to facility policy. Return
  thermometer to storage area.

49
Measuring and recording axillary temperature

• Electronic thermometer Discard the cover.
  Return probe to holder.
• Put residents arm back into sleeve of gown. Make
  resident comfortable.
• Return bed to low position if raised. Ensure
  residents safety. Return side rails to ordered
  position. Remove privacy measures.

50
Measuring and recording axillary temperature

• Remove and dispose of gloves properly.
• Leave call light within residents reach.
• Wash your hands.
• Be courteous and respectful at all times.

51
Measuring and recording axillary temperature

• Report any changes in the resident to the nurse.
  Document procedure using facility guidelines.
  Record residents name, temperature, date, time,
  and method used (axillary).

52

• 5. Explain pulse and respirations
• The pulse count is the number of times the heart
  beats per minute.
• Different types of respiration are
• Apnea
• Dyspnea
• Eupnea
• Orthopnea
• Tachypnea
• Cheyne-Stokes respiration

53

• 6. List guidelines for taking pulse and
  respirations
• The radial pulse is the most common site for
  counting pulse beats and is found on the inside
  of the wrist, on the thumb-side of the body.
• The apical pulse is heard by listening directly
  over the heart with a stethoscope.

54
Measuring and recording radial pulse and counting
and recording respirations

• Equipment watch with second hand, pen and paper
• Identify yourself by name. Identify the resident.
  Greet the resident by name.
• Wash your hands.
• Explain procedure to resident. Speak clearly,
  slowly, and directly. Maintain face-to-face
  contact whenever possible. Encourage resident to
  assist if possible.

55
Measuring and recording radial pulse and counting
and recording respirations

1. Provide for the residents privacy with a
   curtain, screen, or door.
2. Place fingertips on thumb side of residents
   wrist to locate pulse (Fig. 13-18).
3. Count beats for one full minute.

Fig. 13-18. Take the radial pulse by placing
fingertips on the thumb side of the wrist.
56
Measuring and recording radial pulse and counting
and recording respirations

• Keep your fingertips on the residents wrist.
  Count respirations for one full minute. Observe
  for the pattern and character of the residents
  breathing. Normal breathing is smooth and quiet.
• Remove privacy measures. Make resident
  comfortable.
• Leave call light within residents reach.

57
Measuring and recording radial pulse and counting
and recording respirations

1. Wash your hands.
2. Be courteous and respectful at all times.
3. Report any changes in the resident to the nurse.
   Document procedure using facility guidelines.
   Record pulse rate, date, time and method used
   (radial). Record the respiratory rate and the
   pattern or character of breathing.

58
Measuring and recording apical pulse

• Equipment stethoscope, watch with second hand,
  alcohol wipes, pen and paper
• Identify yourself by name. Identify the resident.
  Greet the resident by name.
• Wash your hands.
• Explain procedure to resident. Speak clearly,
  slowly, and directly. Maintain face-to-face
  contact whenever possible.

59
Measuring and recording apical pulse

1. Provide for the residents privacy with a
   curtain, screen, or door.
2. Practice good body mechanics. Adjust bed to safe
   working level, usually waist high. Lock bed
   wheels.
3. 6. Lower the side rail (if bed has one and if it
   is not already lowered) on side nearest you.

60
Measuring and recording apical pulse

1. Before using stethoscope, wipe diaphragm and
   earpieces with alcohol wipes.
2. Fit the earpieces of the stethoscope snugly in
   your ears. Place the flat metal diaphragm on the
   left side of the chest, just below the nipple.
   Listen for the heartbeat.

61
Measuring and recording apical pulse

1. Use the second hand of your watch. Count beats
   for one full minute. Each lubdub that you hear
   is counted as one beat. A normal heartbeat is
   rhythmic (Fig. 13-19). Leave the stethoscope in
   place to count respirations.
2. Clean earpieces and diaphragm of stethoscope with
   alcohol wipes. Store stethoscope.

Fig. 13-19. Count the heartbeats for one full
minute to measure the apical pulse.
62
Measuring and recording apical pulse

1. Make resident comfortable.
2. Return bed to low position if raised. Ensure
   residents safety. Return side rails to ordered
   position. Remove privacy measures.
3. Leave call light within residents reach.
4. Wash your hands.

63
Measuring and recording apical pulse

1. Be courteous and respectful at all times.
2. Report any changes in the resident to the nurse.
   Document procedure using facility guidelines.
   Record pulse rate, date, time, and method used
   (apical). Note any differences in the rhythm.

64
Measuring and recording apical-radial pulse

• Equipment stethoscope, watch with second hand,
  alcohol wipes, pen and paper
• Find a co-worker to assist you.
• Identify yourself by name. Identify the resident.
  Greet the resident by name.
• Wash your hands.

65
Measuring and recording apical-radial pulse

1. Explain procedure to resident. Speak clearly,
   slowly, and directly. Maintain face-to-face
   contact whenever possible. Encourage resident to
   assist if possible.
2. Provide for the residents privacy with a
   curtain, screen, or door.
3. Practice good body mechanics. Adjust bed to safe
   working level, usually waist high. Lock bed
   wheels.

66
Measuring and recording apical-radial pulse

1. Lower the side rail (if bed has one and if it is
   not already lowered) on side nearest you.
2. Before using stethoscope, wipe diaphragm and
   earpieces with alcohol wipes.
3. Fit the earpieces of the stethoscope snugly in
   your ears. Place the flat metal diaphragm on the
   left side of the chest, just below the nipple.
   Listen for the heartbeat.

67
Measuring and recording apical-radial pulse

1. Your co-worker should place her fingertips on the
   thumb side of residents wrist to locate the
   radial pulse.
2. After both pulses have been located, look at the
   second hand of your watch. When the second hand
   reaches the 12 or 6, say, Start, and both
   people will count beats for one full minute. Say,
   Stop after one minute (Fig. 13-20).

Fig. 13-20. Use the second hand on your watch to
count the beats for one full minute.
68
Measuring and recording apical-radial pulse

1. Clean earpieces and diaphragm of stethoscope with
   alcohol wipes. Store stethoscope.
2. Make resident comfortable.
3. Return bed to low position if raised. Ensure
   residents safety. Return side rails to ordered
   position. Remove privacy measures.

69
Measuring and recording apical-radial pulse

1. Leave call light within residents reach.
2. Wash your hands.
3. Be courteous and respectful at all times.

70
Measuring and recording apical-radial pulse

1. Report any changes in the resident to the nurse.
   Document procedure using facility guidelines.
   Record both pulse rates, date, time, and method
   used (apical-radial). Record pulse deficit if the
   pulse rates are not the same (subtract radial
   pulse measurement from apical pulse to get pulse
   deficit). Note any differences in the rhythm.

71

• 7. Identify factors that affect blood pressure
• The top number in a blood pressure reading is
  called the systolic blood pressure.
• The bottom number is the diastolic blood
  pressure.
• When blood pressure is too high, it is called
  hypertension.
• When blood pressure is too low, it is called
  hypotension.

72

• 8. List guidelines for taking blood pressure
• Types of sphygmomanometers
• Aneroid sphygmomanometer
• Electronic sphygmomanometer
• Non-invasive blood pressure monitoring (NIBP)

73
Measuring and recording blood pressure (one-step
method)

• Equipment sphygmomanometer and blood pressure
  cuff, stethoscope, watch with second hand,
  alcohol wipes, pen and paper
• Identify yourself by name. Identify the resident.
  Greet the resident by name.
• Wash your hands.

74
Measuring and recording blood pressure (one-step
method)

• Explain procedure to resident. Speak clearly,
  slowly, and directly. Maintain face-to-face
  contact whenever possible. Encourage resident to
  assist if possible.
• Provide for the residents privacy with a
  curtain, screen, or door.

75
Measuring and recording blood pressure (one-step
method)

1. Position residents arm with palm up. The arm
   should be level with the heart. Roll up long
   sleeves approximately five inches above the
   elbow.
2. With the valve open, squeeze the cuff. Make sure
   it is completely deflated.

76
Measuring and recording blood pressure (one-step
method)

1. Place blood pressure cuff snugly on residents
   upper arm. The center of the cuff is placed over
   the brachial artery (1-1½ inches above the elbow
   toward inside of elbow) (Fig. 13-24).
2. Before using stethoscope, wipe diaphragm and
   earpieces with alcohol wipes.
3. Locate brachial pulse with fingertips.

Fig. 13-24. Place the center of the cuff over the
brachial artery.
77
Measuring and recording blood pressure (one-step
method)

1. Place diaphragm of stethoscope over brachial
   artery.
2. Place earpieces of stethoscope in ears.
3. Close the valve (clockwise) until it stops. Do
   not over-tighten it (Fig. 13-25)
4. Inflate cuff to 30 mm Hg above the point at which
   the pulse is last heard.

Fig. 13-25. Close the valve by turning it
clockwise until it stops.
78
Measuring and recording blood pressure (one-step
method)

1. Open the valve slightly with thumb and index
   finger. Deflate cuff slowly.
2. Watch gauge. Listen for sound of pulse.
3. Remember the reading at which the first clear
   pulse sound is heard. This is the systolic
   pressure.

79
Measuring and recording blood pressure (one-step
method)

• Continue listening for a change or muffling of
  pulse sound. The point of a change or the point
  the sound disappears is the diastolic pressure.
  Remember this reading.
• Open the valve. Deflate cuff completely. Remove
  cuff.

80
Measuring and recording blood pressure (one-step
method)

• Wipe diaphragm and earpieces of stethoscope with
  alcohol. Store equipment.
• Make resident comfortable. Remove privacy
  measures.
• Leave call light within residents reach.
• Wash your hands.
• Be courteous and respectful at all times.

81
Measuring and recording blood pressure (one-step
method)

1. Report any changes in the resident to the nurse.
   Document procedure using facility guidelines.
   Record both the systolic and diastolic pressures.

82
Measuring and recording blood pressure (two-step
method)

• Equipment sphygmomanometer and blood pressure
  cuff, stethoscope, watch with second hand,
  alcohol wipes, pen and paper
• Identify yourself by name. Identify the resident.
  Greet the resident by name.
• Wash your hands.

83
Measuring and recording blood pressure (two-step
method)

• Explain procedure to resident. Speak clearly,
  slowly, and directly. Maintain face-to-face
  contact whenever possible. Encourage resident to
  assist if possible.
• Provide for the residents privacy with a
  curtain, screen, or door.

84
Measuring and recording blood pressure (two-step
method)

1. Position residents arm with palm up. The arm
   should be level with the heart. Roll up long
   sleeves approximately five inches above the
   elbow.
2. With the valve open, squeeze the cuff. Make sure
   it is completely deflated.

85
Measuring and recording blood pressure (two-step
method)

1. Place blood pressure cuff snugly on residents
   upper arm. The center of the cuff is placed over
   the brachial artery (1-1½ inches above the elbow
   toward inside of elbow).
2. Locate the radial (wrist) pulse with fingertips.
3. Close the valve (clockwise) until it stops.
   Inflate cuff slowly, watching gauge.

86
Measuring and recording blood pressure (two-step
method)

• Stop inflating when you can no longer feel the
  pulse. Note the reading. The number is an
  estimate of the systolic pressure.
• Open the valve. Deflate cuff completely.
• Write down estimated systolic reading.

87
Measuring and recording blood pressure (two-step
method)

• Before using stethoscope, wipe diaphragm and
  earpieces of stethoscope with alcohol wipes.
• Locate brachial pulse with fingertips.

88
Measuring and recording blood pressure (two-step
method)

1. Place diaphragm of stethoscope over brachial
   artery.
2. Place earpieces of stethoscope in ears.
3. Close the valve (clockwise) until it stops. Do
   not over-tighten it (Fig. 13-26).

Fig. 13-26. Close the valve but do not
over-tighten it. Tight valves are too hard to
release.
89
Measuring and recording blood pressure (two-step
method)

1. Inflate cuff to 30 mm Hg above your estimated
   systolic pressure.
2. Open the valve slightly with thumb and index
   finger. Deflate cuff slowly.
3. Watch gauge. Listen for sound of pulse.
4. Remember the reading at which the first clear
   pulse sound is heard. This is the systolic
   pressure.

90
Measuring and recording blood pressure (two-step
method)

• Continue listening for a change or muffling of
  pulse sound. The point of a change or the point
  the sound disappears is the diastolic pressure.
  Remember this reading.
• Open the valve. Deflate cuff completely. Remove
  cuff.

91
Measuring and recording blood pressure (two-step
method)

• Wipe diaphragm and earpieces of stethoscope with
  alcohol. Store equipment.
• Make resident comfortable. Remove privacy
  measures.
• Leave call light within residents reach.
• Wash your hands.

92
Measuring and recording blood pressure (two-step
method)

1. Be courteous and respectful at all times.
2. Report any changes in the resident to the nurse.
   Document procedure using facility guidelines.
   Record systolic and diastolic pressures.

93

• 9. Describe guidelines for pain management
• Signs of pain
• Sweating
• Nausea
• Vomiting
• Tightening of the jaw
• Holding a body part tightly
• Frowning
• Grinding teeth, etc.