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Chapter Eight

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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. – PowerPoint PPT presentation

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Title: 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.
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