1. Orally 
2. Rectal
3. Axillary
4. Temporal

• Infection #1
• Physical activity
• Warm external emperature
• Dehydration (loss of body fluid)

• Aging -- slow metabolism
• Decreased physical activity
• Cold external environment/temperature
• Certain drug
• Shock

• is a child or irrational
• breathe through the mouth
• unconscious

MEASURE AND RECORD TEMPERATURE 

When would the nurse aide take an axillary temperature ?

Do not use rectal thermometer if the patient has

• diarrhea 
• fecal impaction 
• combative behavior
• rectal bleeding
• hemorrhoids
• had rectal surgery
• recently had a heart attack
• recently had prostate surgery 
• a colostomy

• Glass clinical thermometer
• Electronic Thermometer
• Digital Thermometer
• Disposal Thermometer

• Start with 94º F (34º C)
• Each shorter line equals two-tenths (2/10 or 0.2) of 1 degree

3 minutes

• Lower the backrest of the bed, ask the pts to turn on his side
• put on gloves
• place a small amount of lubricant (water base)
• fold the top bedclothes back to expose the pts' anal area
• Separate the buttocks with one hand. 
• Insert the covered probe about 1 inch into the rectum
• Replace the bedclothes for privacy as soon as the thermometer is inserted.

The pressure of the blood felt against the wall of an artery as the heart alternately contracts (beats) and relaxes (rests).

Beats per minute 

[image]

1. Temporal  -  side of forehead
2. Carotid - neck
3. Apical -  apex of heart (#3 should be at apex of heart)
4. Brachial - inner elbow
5. Radial - wrist
6. Femoral - groin
7. Popliteal - behind knee
8. Posterior tibial
9. Dorsalis pedis - top of foot/between toe and..

MEASURE AND RECORD PULSE

[image]

At which of the locations shown in the above diagram would the nurse aide take a femoral pulse?

Location 5

The femoral artery is the large artery which emerges from the pelvis to nourish the lower extremity. It produces an obvious pulse which can be easily felt in the crease between the thigh and abdomen at about its middle.

MEASURE AND RECORD BLOOD PRESSURE

[image]

At which of the locations shown in the above diagram would the nurse aide place the stethoscope when taking a blood pressure reading?

Location 4

When measuring a resident's blood pressure, the diaphragm of the stethoscope is placed firmly over the brachial artery, which is located at the inner aspect of the elbow. The entire diaphragm must be in contact with the skin to obtain an accurate reading.

1. Rate or speed
2. Character

• Rhythm
• Volume or fullness

the volume you palpate. 

Wether it is weak, strong or thready

1. Normal
2. Bounding
3. Weak/Thready

• Regular-steady beat
• Irregular - inconsistent beat

• On the left side of the front of the chest
• Between the fifth and sixth ribs
• Just below the left nipple
• In wome, under the left breast

• Rate - number of respirations per minute
• Rhythm - regularity
• Symmetry - ability of the chest to expand equally as air enters each lung
• Volume - depth of respiration
• Character - terms used to describe the character of respirations include :

- Regular 
- Irregular
- Shallow
- Deep
- Labored (difficult)

Respiration should be reported :

• Accelerate if the rate is more than 25 per minute
• If the rate is less than 12 per minute, it is too slow

• Illness
• Emotions
• Elevated temperature
• Gender
• Age
• Exercise
• Position
• Drugs

• A bell or diaphragm
• Tubing that carries sounds to the listener
• Earpieces that direct the sounds into the listener's ears

• A Dial (Aneroid) gauge  a round Pressure gauge 
• Mercury

• Sex of patient
• Exercise
• Eating
• Stimulants (substances that speed up body function)
• Emotional stress, such as anger, fear
• Disease condition
• Hereditary
• Pain
• Obesity
• Age
• Condition of blood vessels
• Some drugs

Blood pressure is lowered by :

• Fasting
• Rest
• Depressants
• Weight loss
• Emotion
• Abnormal condition, such as hemorrhage (loss of blood)

A condition that means the person is likely to develop high 

blood pressure in the future

Prehypertension between 120/80 mm Hg and

139/89 mm Hg

• Has an intravenous feeding
• Is being treated for burns, fractures, or other injuries
• Has a dialysis access device
• Is on the same side as the patient's recent mastectomy (breast removal)
• Has pulse oximeter

• is paralyzed
• is the site of an intravenous infusion (IV)
• as a pulse oximeter on it
• Has impaired circulation
• Is the site of a dialysis access device
• is fractured
• is burned
• Is on the same side as a recent mastectomy or other surgical procedure site

• Temperature
• Blood Pressure
• Respiration 
• Pain

 Although height and weight are not part of the vital signs, but also commonly measured

                               Systolic             Diastolic

Hypotension               <100                <60

Normal                      <120                <80

Prehypertension          120-139           80-89

Stage I Hypertension   140-159           90-99

Stage II                     >160               >100