CNA > Measurements and Vital Signs > Flashcards

Measurements and Vital Signs Flashcards

Explain the purpose and protocols associated with taking patient vital signs and measurements (45 cards)

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1
Q

What are the FOUR main vital signs?

A
  1. Temperature
  2. Pulse
  3. Respirations
  4. Blood pressure

The four main vital signs are Temperature, Pulse, Respirations, and Blood Pressure.

CNA Insight: These are the four most important measurements that tell you how the resident’s body is working. They are your first clue that something is wrong. You must take them accurately and report any changes.

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2
Q

How is body temperature measured?

A
  • Orally
  • Rectally
  • Axillary, tympanic (ear)

Body temperature is measured orally (mouth), rectally (rectum), axillary (armpit), or tympanic (ear).

CNA Insight: The rectal temperature is the most accurate, but the axillary (armpit) temperature is the least accurate. Always use the method ordered by the nurse or the plan of care. Remember that the rectal method is invasive, so you must ensure the resident’s privacy and comfort.

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3
Q

List TWO factors that can affect temperature readings.

A
  1. Activity level
  2. Time of day

Factors that can affect temperature readings are activity level and time of day.

CNA Insight: A resident’s temperature is usually lower in the morning and higher in the evening. If they just drank a hot or cold drink, you must wait 15 to 20 minutes before taking an oral temperature.

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4
Q

Fill in the blanks:

A normal oral temperature range is ____ to ____ °F.

A

97.6 to 99.6

Normal temperature varies by measurement site.

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5
Q

True or False:

Rectal temperature is usually lower than oral temperature.

A

False

Rectal temperature is usually about one degree higher than oral temperature. Always remember to note the site (oral, rectal, etc.) when you record the temperature.

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6
Q

Define:

Hypothermia

A

A body temperature below the normal range.

Hypothermia can be life-threatening if not treated.

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7
Q

Define:

Fever

A

A temperature above the normal range.

Fevers are usually caused by infection.

Some fevers resolve naturally, but high fevers need treatment.

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8
Q

Which vital sign measures the heart rate?

A

Pulse

Pulse measures the heart rate.

CNA Insight: The pulse tells you how fast the heart is beating. You are checking the number of times the heart pumps blood in one minute.

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9
Q

List TWO ways of taking pulse measurements.

A
  1. By palpating an artery.
  2. Using a stethoscope.

Pulse measurements can be taken by palpating an artery (feeling with your fingers) or using a stethoscope.

CNA Insight: Always use your first two fingers to feel the pulse. Never use your thumb, as your thumb has its own pulse.

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10
Q

Which pulse site is most commonly used?

A

The radial pulse (wrist).

This is the easiest pulse to find. You should press gently on the artery on the thumb side of the resident’s wrist.

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11
Q

What is the normal pulse range for adults?

A

60-100 beats per minute.

A pulse above or below this range may indicate a health issue.

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12
Q

How long should a pulse be counted?

A

For one full minute.

This ensures accuracy and detects irregularities.

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13
Q

Fill in the blank:

A pulse over 100 beats per minute is called _______.

A

Tachycardia

A pulse over 100 beats per minute is called Tachycardia.

CNA Insight: This means the heart is beating too fast. It can be caused by exercise, fever, fear, or blood loss. Report any significant changes to the nurse.

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14
Q

What is the most accurate way to measure pulse in infants?

A

Apical pulse (using a stethoscope).

Infants’ pulses are faster and harder to detect peripherally.

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15
Q

True or False:

A weak pulse is always normal.

A

False

A weak pulse can be a sign of a serious problem, like low blood pressure, shock, or blood loss. If the pulse is hard to feel, report it to the nurse immediately.

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16
Q

What does a rapid, thready pulse indicate?

A
  • Possible shock
  • Blood loss

Requires immediate medical attention.

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17
Q

Define:

Respiration Rate

A

The number of breaths taken per minute.

It includes one inhalation and one exhalation.

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18
Q

What is the normal adult respiratory rate?

A

12-20 breaths per minute.

A rate that is too fast or too slow means the resident is having trouble breathing. Report any rate outside this range.

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19
Q

How can respirations be measured discreetly?

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A

By observing chest movement while pretending to check the pulse.

Respirations can be measured discreetly by observing chest movement while pretending to check the pulse.

CNA Insight: If the resident knows you are counting their breaths, they may change the way they breathe. Count the pulse first, and then keep your fingers on the wrist while you count the respirations.

20
Q

List THREE factors that can increase respiration rate?

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A
  1. Fever
  2. Anxiety
  3. Pain

High respiratory rate may indicate distress or illness. If the resident is breathing fast, try to calm them down. If the fast breathing continues, report it, as it could be a sign of a serious infection or heart problem.

21
Q

What is considered a dangerously low respiratory rate?

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A

Below 10 breaths per minute.

A dangerously low respiratory rate is bradypnea (below 10 breaths per minute) which can indicate respiratory failure or drug overdose.

CNA Insight: This is a medical emergency. It means the resident is not getting enough oxygen. Apnea is the complete absence of breathing, which is a life-threatening emergency. You must call for the nurse immediately and be prepared to assist with emergency procedures.

22
Q

What does blood pressure measure?

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A

The force of blood against artery walls.

Blood pressure readings include systolic and diastolic values.

23
Q

What is a normal blood pressure range?

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A

90/60 to 120/80 mmHg

Consistently high readings indicate hypertension while low readings indicate hypotension.

24
Q

Fill in the blank:

The first number in a blood pressure reading is the ______ pressure.

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A

systolic

This is the pressure when the heart is contracting (pumping). Think of “S” for Squeeze. The second number is the diastolic pressure; the pressure of the blood against the walls when the heart relaxes.

25
List THREE signs of **low blood pressure**.
1. Dizziness 2. Fainting 3. Shock ## Footnote Low blood pressure can be due to medications, bleeding, infection, heart failure, or dehydration.
26
Which **position** is best for taking blood pressure?
**Seated** with feet flat on the floor. ## Footnote Ensures accurate readings and patient comfort.
27
What is **orthostatic** hypotension?
A drop in blood pressure **when standing up**. ## Footnote Common in elderly patients, leading to dizziness and falls. **CNA Insight**: This is a major cause of falls. You must always have the resident sit on the edge of the bed for a few minutes and ask about dizziness before standing up to prevent this.
28
What should be done **before measuring** blood pressure?
Allow the patient to **rest for five minutes**. ## Footnote Activity can temporarily raise blood pressure readings.
29
What should be **observed** when checking skin integrity?
* Color * Moisture * Temperature * Presence of wounds ## Footnote You should observe the color, moisture, temperature, and presence of wounds. Your daily skin check is vital. Remember that on darker skin, a pressure injury may look like a darker, purplish patch, not just redness.
30
What can cause **poor skin integrity**?
* Pressure ulcers * Friction * Shearing ## Footnote Shearing is when the skin stays in one place but the bone moves (like when a resident slides down in bed). Always lift, never drag, a resident to prevent shearing.
31
What is the purpose of a **weight measurement**?
To **monitor health status** and detect changes. ## Footnote Sudden weight loss or gain may indicate a health problem.
32
How **often** should **weight be measured** in a hospital?
As ordered by the physician. ## Footnote Daily weight is important for conditions like heart failure, renal failure, and malnutrition. **CNA Insight**: This could be daily, weekly, or monthly. You must know the schedule and ensure you weigh the resident on time.
33
How should weight be measured **accurately**?
Using the **same scale** at the **same time** of day. ## Footnote The best time is usually in the morning, after the resident has used the restroom and before they have eaten breakfast. This ensures the most accurate comparison. Heavy clothing should also be removed since extra weight from clothing can give inaccurate readings.
34
# Fill in the blank: Weight should be measured in \_\_\_\_\_\_ **units**.
pounds or kilograms ## Footnote The unit depends on facility standards.
35
How should a patient’s **height be measured**?
Standing **upright** against a measuring device. ## Footnote Height should be measured standing upright against a measuring device. **CNA Insight**: If a resident cannot stand, you must measure them while they are lying flat in bed using a tape measure. If this is not possible, you must use the height that was recorded on their admission. Always record the measurement accurately.
36
Which vital sign is affected by **dehydration**?
Blood pressure ## Footnote Dehydration can cause hypotension and dizziness.
37
How can **hydration status** be assessed?
**By checking**: * urine color * skin elasticity ## Footnote Hydration status can be assessed by checking urine color and skin elasticity. **CNA Insight**: **Dark urine** means the resident is dehydrated. A well-hydrated person’s urine is usually light yellow in color. **Skin elasticity** (turgor) is checked by gently pinching the skin—if it stays tented, they are dehydrated.
38
# True or False: Poor hydration can lead to confusion **in older adults**.
True ## Footnote Dehydration affects cognitive function, especially in seniors.
39
What factors can affect **circulation**?
* Blood pressure * Heart function * Activity level ## Footnote Poor circulation can lead to complications like swelling and ulcers. **CNA Insight**: Encourage the resident to move as much as they can. Even small movements help keep the blood flowing and the muscles strong.
40
How can **mobility** affect vital signs?
Inactivity can lead to **poor circulation** and **weak muscles**. ## Footnote Exercise promotes heart health and stable vital signs. Caregivers can assist patients with limited mobility through regular repositioning and assisting with transfers.
41
# Define: Auscultation
Listening to **internal body sounds** with a stethoscope. ## Footnote Used for heart, lung, and bowel sounds.
42
How can **stress** affect vital signs?
It can **raise** heart rate and blood pressure. ## Footnote Relaxation techniques help manage stress-related symptoms. If a resident is anxious or upset, their vital signs will be high. Try to calm them down and take the vital signs again after a few minutes of rest.
43
Why should vital signs be **recorded accurately**?
They **guide medical decisions** and treatment. ## Footnote Errors in recording can lead to incorrect care. The doctor uses your numbers to decide what medicine or treatment to give. A mistake in recording can lead to the wrong treatment, so never guess a reading.
44
What should be done if **vital signs** are **abnormal**?
* Recheck if necessary * Report immediately ## Footnote If you get a strange reading, recheck it once to ensure your equipment is working. If the reading is still abnormal, report it to the nurse immediately.
45
How should caregivers ensure **patient comfort** during vital sign checks?
1. Explain procedures 2. Maintain privacy 3. Be gentle ## Footnote Always tell the resident what you are doing. For example, say, "I'm going to check your pulse now." This reduces their anxiety and helps you get a more accurate reading.
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