7.1. INTRODUCTION TO DEMONSTRATE REPORTING AND DOCUMENTATION OF CLIENT DATA
Learning Objectives
• Measure temperature, pulse, and respiration
• Measure weight and height
• Recognize normal and abnormal blood pressure readings
• Identify normal and abnormal vital signs
• Measure intake and output
• Document client data
• Prioritize the reporting of data
• Recognize signs of client discomfort
Nursing assistants collect and document client data such as vital signs, height, weight, intake, and output. While performing cares and collecting data, nursing assistants spend a lot of time with residents and may observe subtle changes in behavior, mood, mobility, and cognition, as well as signs of discomfort. They report these observations promptly to nurses to ensure safe, quality, holistic care. This chapter will discuss collection of this data, as well as prioritization of data that should be immediately reported to the nurse.
7.2. DOCUMENTING AND REPORTING DATA
Documentation is legally required for nursing assistants and other health care team members to record client observations and care provided in the medical record. Documentation is used to ensure continuity of care across shifts and among health care team members, to monitor standards of care for quality assurance activities, and to provide information for reimbursem*nt purposes by insurance companies and Medicare or Medicaid. Documentation may also be used for research purposes or, in some instances, for legal concerns in a court of law.[1]For these reasons, always document the care you provide and never document for someone else. Review Chapter 1, “Documenting and Reporting” for details on how observations should be recorded. The facility or employer should provide training on how to document according to their expectations and what should be included in the client’s record.
Charting by exception (CBE)is a common type of health care documentation indicating routine care and collection of data were completed. Notes are only written for abnormal findings or anything out of the ordinary. CBE is designed to keep documentation concise and reduce the amount of time required for documentation. CBE may include checklists and flowsheets as efficient means of documenting that standards of care have been provided. For example, nursing assistants may document activities of daily living (ADL) or vital signs on a flow sheet. See an example of an ADL flowsheet using the information in the following box. Keep in mind that documentation is reviewed and submitted by agencies for insurance reimbursem*nt, so it is imperative that charting is accurate and up-to-date.
See a PDF example of anADL flowchart.
In addition to documenting client cares and data collected, nursing assistants also report findings to the nurse. When observations are normal, they can be reported at routine times such as during shift change report. However, abnormal vital signs or significant changes in client status pertaining to breathing, circulation, cognition, pain, or falls should be immediately reported to the nurse for rapid assessment and intervention to ensure client health and safety.
Nursing assistants use critical thinking skills to determine what should be immediately reported to the nurse. If you are unsure about the significance of a finding, it is best to report it to the nurse and allow them to determine what is needed for the resident. It is never incorrect to report information to the nurse. However, waiting to report an important finding can negatively impact the client’s health, so use a cautious approach and report anything that seems out of the ordinary. As you gain experience, your critical thinking skills will grow and improve.
Throughout this textbook, observations are described that should be immediately reported. Review Chapter 3.2 (“Emergency Situations”) and Chapter 6.3 (“Pain”) for additional information. The “Normal Ranges for Vital Signs” section in this chapter can be used to determine when vital signs are out of range and should be reported to the nurse.
References
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This work is a derivative ofNursing FundamentalsbyOpen RNand is licensed underCC BY 4.0↵.
7.3. RECOGNIZING SIGNS OF CLIENT DISCOMFORT
While performing cares, obtaining vital signs, or collecting other data, the nursing assistant may notice subjective or objective signs of discomfort in the client.
Subjective signs of discomfort are what the person reports to you such as, “My stomach hurts,” or “I feel achy when I walk.” Subjective reports cannot be verified objectively and must be reported based on what the person communicates. For this reason, when documenting subjective data, write exactly what the client said in quotations. For example, a nursing assistant might document: The client stated, “My stomach hurts.”
Objective data are observable and verifiable. Nursing assistants may suspect a client is experiencing discomfort based on nonverbal signs, such as grimacing, guarding the injured body part, rocking, rubbing the area, or moaning. When a client is unable to verbally communicate, noticing objective signs of pain is integral for providing comfort measures and improving their quality of life. Review the Pain Assessment in Advanced Dementia (PAINAD) in Chapter 6 (“Pain”) that is used to observe and document objective signs of pain.
Review the concepts of objective and subjective data in the Chapter 1.5, “Guidelines for Reporting” subsection.
7.4. OBTAINING VITAL SIGNS
Vital signs are taken upon admission to a facility and then routinely (e.g., weekly in long-term care settings or every shift in inpatient care settings). They are also obtained when there is a change in client condition (e.g., a suspected infection), after a fall, or with some medication changes.
Vital signs are taken at regular intervals to establish a client’s baseline, evaluate trends, and determine if a client is experiencing a variance outside their normal range. Many factors can affect vital signs, including activity level, medications, recent intake, or age.
Vital signsinclude temperature recorded in Celsius or Fahrenheit, pulse, respiratory rate, blood pressure, and oxygen saturation using a pulse oximeter. Obtaining a pain rating is often considered a sixth vital sign. Read about pain ratings in the “Pain” section of Chapter 6.
See Figure 7.1[1]for an image of a nursing assistant obtaining vital signs. Obtaining vital signs may be delegated to a nursing assistant for stable patients, depending on the state’s scope of practice for nurse aides and agency policy and training.[2]
Figure 7.1
Obtaining Vital Signs
Temperature
Accurate temperature measurements provide information about a patient’s health status and guide clinical decisions made by the nurse. For example, an elevated temperature (referred to as a fever) can indicate the client is experiencing an infection. Body temperature is documented in degrees Celsius (ºC) or Fahrenheit (ºF).
There are several methods for measuring body temperature based on the client’s developmental age, cognitive functioning, level of consciousness, health status, and agency policy. Common methods of temperature measurement include oral, axillary, tympanic, rectal, and temporal routes. Each of these routes is further discussed in the following subsections, and Skills Checklists are provided later in the chapter.
When documenting a client’s temperature, it is important to document the route used to obtain the temperature because of normal variations in temperature in different locations of the body. For example, axillary temperature can be one degree or more lower than an oral temperature. See normal temperature ranges according to method in Table 7.5a in the “Normal Ranges for Vital Signs” section of this chapter.
Oral Temperature
Oral temperatureis taken in the mouth under the tongue. Normal oral temperature is 35.8 – 37.3ºC (96.4 – 99.1ºF). An oral thermometer is shown in Figure 7.2.[3]The device has blue coloring indicating its use as an oral or axillary thermometer, as opposed to a rectal thermometer that has red coloring. Oral temperature is reliable when it is obtained close to the sublingual artery at either side of the base of the tongue. Some factors can cause an inaccurate measurement using the oral route. For example, if the patient recently consumed a hot or cold food or beverage, chewed gum, or smoked prior to measurement, a falsely elevated or decreased reading may be obtained. Oral temperature should be taken 15 to 25 minutes following consumption of a hot or cold beverage or food or 5 minutes after chewing gum or smoking.[4]
Figure 7.2
Oral Thermometer
Axillary Temperature
Axillary temperatureis taken in the armpit. The axillary method is a minimally invasive way to measure temperature and is commonly used in children or in adults with impaired cognition who may not tolerate oral or tympanic routes. It uses the same electronic device as an oral thermometer (with blue coloring), but the probe is placed in the armpit. The axillary temperature can be as much as one degree lower than the oral temperature. See Figure 7.3.[5]for an image of a nursing assistant taking an axillary temperature.[6]
Figure 7.3
Axillary Temperature
Tympanic Temperature
Tympanic temperatureis taken using a device placed in the ear. It is more accurate than oral or axillary measurement because the tympanic membrane in the ear shares the same artery that perfuses the hypothalamus (the part of the brain that regulates the body’s temperature). The tympanic temperature is typically 0.3 – 0.6°C higher than an oral temperature. See Figure 7.4[7]of a tympanic thermometer. The tympanic method should not be used if the patient has a suspected ear infection.[8]
Figure 7.4
Tympanic Thermometer
Rectal Temperature
Rectal temperatureis taken in the rectum. It is the most accurate measurement method but is considered an invasive procedure. Some sources suggest its use only when other methods are not appropriate. However, when measuring infant temperature, it is considered a gold standard because of its accuracy. An adult requiring a rectal temperature should be placed in the Sims’ position. (SeeChapter 8for positioning techniques.) The rectal temperature is usually 1ºC higher than oral temperature. A rectal thermometer has red coloring where the probe attaches to the device to distinguish it from an oral/axillary thermometer.[9]See Figure 7.5[10]for an image of a rectal thermometer.
Figure 7.5
Rectal Thermometer
Temporal Temperature
Temporal temperatureis taken by using a device placed on the forehead. Temporal thermometers contain an infrared scanner that measures the heat on the surface of the skin resulting from blood moving through the temporal artery in the forehead. Temporal temperature is typically 0.5°F (0.3°C) to 1°F (0.6°C) lower than an oral temperature. It is a quick, noninvasive method, but accurate measurement is dependent on good contact with the skin and good placement on the forehead. See Figure 7.6[11]for an image of a temporal thermometer.
Figure 7.6
Temporal Thermometer
Pulse
Pulserefers to the pressure wave that expands and recoils arteries when the left ventricle of the heart contracts. It can be palpated at many points throughout the body as shown in Figure 7.7.[12]
Figure 7.7
Common Pulse Assessment Locations
Nursing assistants typically obtain the radial pulse because it is easily accessible. See Figure 7.8[13]for an image of a nursing assistant obtaining a radial pulse. To locate the radial pulse, ask the client to hold the palm of their hand upwards. Draw an imaginary line from the extended index finger of the resident past the wrist to the radial bone and then palpate the radial pulse just inside the radial bone. Use your index and third finger when palpating a pulse; never use the thumb because it has its own pulse, and you may inadvertently count your own heart rate rather than the heart rate of the client. When obtaining a pulse, the patient should be seated comfortably with their arms and legs uncrossed. If the patient is lying down, this may lower their heart rate so their position should be documented.
Figure 7.8
Radial Pulse
Pulse is measured in beats per minute. The normal adult pulse rate (heart rate) at rest is 60–100 beats per minute, with different ranges according to age.[14]See normal pulse ranges by age in Table 7.5b in the “Normal Ranges for Vital Signs” section of this chapter.
The pulse rate should be regular, meaning the frequency of the pulsation felt by your fingers is an even tempo with equal intervals between pulsations. However, heart conditions can cause irregularities in heart rate, called arrhythmias. When an irregular pulse is noted, it should be documented and reported to the nurse. It is considered best practice to assess a patient’s pulse for a full 60 seconds, especially if there is an irregularity to the rhythm.[15]
Respiration
Respirationrefers to a person’s breathing and the movement of air into and out of the lungs. Inspiration refers to the process causing air to enter the lungs, and expiration refers to the process causing air to leave the lungs. A respiratory cycle (i.e., measured as one breath for the respiratory rate) is one sequence of inspiration and expiration (i.e., the chest rises and falls once).[16]
The quality of a person’s breathing is normally relaxed and silent. However, loud breathing, nasal flaring, or the use of accessory muscles in the neck, chest, or ribs is a sign of breathing problems (referred to asrespiratory distress). People who are experiencing respiratory distress naturally assume atripod position, meaning they lean forward and place their arms or elbows on their knees or on a bedside table to help improve lung expansion. If a patient is demonstrating new signs of respiratory distress as you are obtaining their vital signs, immediately notify the nurse.[17]
Respirations normally have a regular rhythm in children and adults who are awake. A regular rhythm means that the frequency of the respiration follows an even tempo with equal intervals between each respiration. However, newborns and infants commonly exhibit an irregular respiratory rhythm.[18]
Normal respiratory rates vary based on age. The normal resting respiratory rate for adults is 12–20 breaths per minute, whereas infants younger than one year old normally have a respiratory rate of 30–60 breaths per minute.[19]See normal respiratory rate ranges by age in Table 7.5c in the “Normal Ranges for Vital Signs” section of this chapter.
When obtaining a respiratory rate, the most accurate measurement is obtained when the client is not aware you are watching their breathing; knowing they are being observed can unconsciously change their breathing pattern. For this reason, many nursing assistants count the client’s respirations while they appear to be taking their pulse. (This is one exception to the standard rule of explaining to the client what you will be doing.)
When counting respirations, it can be difficult to see a complete respiratory cycle. Respirations can be observed by looking at the client’s shoulders move up and down with each breath, the stomach or chest rising and falling, or the clothing around the ribs moving. You may have to ask the client to remain quiet while respirations are being observed because talking or moving changes the respiratory rate. Respirations are documented as the number of breaths per minute, with each cycle of inspiration and exhalation counting as one breath.
Blood Pressure
Blood pressureis the measurement of the force of blood against the walls of the arteries as the heart pumps blood through the body. It is reported as millimeters of mercury (mmHg). This pressure inside the arteries changes when the heart is contracting compared to when the heart is resting and filling with blood. For this reason, blood pressure is expressed as two numbers called systolic pressure and diastolic pressure (e.g., 120/80).Systolic blood pressure(the top number of the fraction) is the pressure in the arteries duringsystole(i.e., when the ventricles are contracting and causing the ejection of blood into the aorta and pulmonary arteries).Diastolic blood pressure(the bottom number of the fraction) is the resting pressure in the arteries duringdiastole(i.e., the phase between each contraction of the heart when the ventricles are filling with blood).[20]
Depending on your state’s scope of practice for nursing assistants and the training you receive at the facility where you work, you may be delegated the task of taking blood pressure with an automated cuff. Be aware of the client’s health status because there are circ*mstances when blood pressure should not be taken on a certain arm, such as an arm containing a fistula for dialysis, an intravenous (IV) line, or implanted birth control. If the person has had a mastectomy, blood pressure should not be taken on the arm on the side of the mastectomy.
When obtaining a blood pressure, allow the person to rest in place for a few minutes or an inaccurately high blood pressure may be obtained due to recent activity. Position the person in a seated position with their legs and arms uncrossed and the elbow of their arm at heart level supported by a table or your arm. Lying down or standing will change the blood pressure reading, so document if the client is standing, sitting, or lying down when the blood pressure is measured.
Raise the client’s sleeve or assist the client to remove their arm from their sleeve. Place the artery marker on the blood pressure cuff directly on the skin above the client’s brachial artery. To find the brachial artery, gently flex the arm and feel for the bicep muscle, which is the larger muscle of the upper arm. The brachial artery is located towards the inside of the base of the bicep muscle.
See the different sizes of blood pressure cuffs in Figure 7.9.[21]In adults, “regular” or “large” cuffs are typically used based on the size of the client’s upper arm.
Figure 7.9
Different Sizes of Blood Pressure Cuffs
It is vital to ensure the cuff fits appropriately on the person’s arm in order to obtain an accurate blood pressure measurement. An undersized cuff will cause an artificially high blood pressure reading, and an oversized cuff will produce an artificially low reading. When applying the cuff to the client’s arm, the end of the cuff should be within the indicated range margins on the cuff. See Figure 7.10[22]for an image of the range designated on the cuff.
Figure 7.10
Range Markings to Ensure Proper Cuff Size
After the cuff is in place, press the start button on the monitor. The cuff will automatically inflate to a specific pressure and then deflate at a rate of 2 mmHg per second. The monitor digitally displays the blood pressure reading when it is done. See Figure 7.11[23]for an image of an automatic blood pressure monitor. Abnormal blood pressure readings should be promptly reported to the nurse. See normal and abnormal blood pressure ranges in Table 7.5d in the “Normal Ranges for Vital Signs” section of this chapter.
Figure 7.11
Automatic Blood Pressure Monitor
Oxygen Saturation
Patient oxygenation status is assessed routinely using pulse oximetry.Oxygen saturation, also referred to as SpO2, is a client’s oxygenation status measured by a pulse oximeter. SpO2 estimates a person’s oxygenation level based on how much hemoglobin in their red blood cells is “saturated” with oxygen. The target range of SpO2 for an adult is 94-98%. For patients with chronic respiratory conditions, such as chronic obstructive pulmonary disease (COPD), their normal range for SpO2 is often lower (e.g., 88% to 92%).
Although SpO2 is an efficient, noninvasive method to assess a patient’s oxygenation status, it is an estimate and not always accurate. For example, severe anemia (i.e., decreased level of hemoglobin in the blood) or decreased peripheral circulation can cause an inaccurately low SpO2 level.[24]
A pulse oximeter includes a sensor that measures light absorption of hemoglobin to estimate oxygen saturation. See Figure 7.12[25]for an image of a pulse oximeter. The sensor can be attached to the patient using a variety of devices. For intermittent measurement of oxygen saturation, a spring-loaded clip is attached to a patient’s finger or toe. However, this clip is too large for use on newborns and young children, so the sensor is typically taped to a finger or toe. An earlobe clip is an alternative for patients who cannot tolerate the finger or toe clip or have a condition (such as vasoconstriction and poor peripheral perfusion) that can affect the results. Fingernail polish causes inaccurate measurement and should be removed from the nail of the finger being used for measurement.[26]
When documenting a client’s oxygen saturation level, it is vital to document if the client was receiving supplemental oxygen or if the reading was taken while they were breathing room air. If supplemental oxygen was being provided, the type of oxygenation device and the amount of oxygen being delivered should also be documented (e.g., “Oxygen saturation of 90% while receiving oxygen via nasal cannula at 2 Liters/minute”).
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7.5. NORMAL RANGES FOR VITAL SIGNS
Temperature
The average body temperature is 98.6º F (37º C), but normal body temperature can range between 97º F (36.1º C) to 99º F (37.2º C), depending on the activity level or the time of day. Older adults have lower body temperatures; a reading of 96º F (36º C) is not unusual. See Table 7.5a for average temperature ranges according to the measurement method. In general, notify the nurse for temperatures greater than 38º degrees C (100.4º degrees F) because this indicates a fever.
Table 7.5a
Normal Range of Temperatures According to Method[1],[2]
| Method | Average Range C | Average Range F |
|---|---|---|
| Oral | 35.8 – 37.3ºC | 96 – 99ºF |
| Axillary | 34.8 – 36.3ºC | 94.6 – 97.3ºF |
| Tympanic | 36.1 – 37.9ºC | 96.9 – 100.2ºF |
| Rectal | 36.8 – 38.2ºC | 98.2 – 100.7ºF |
| Temporal | 35.2 – 36.7ºC | 95.3 – 98ºF |
Pulse
Heart rate varies greatly from newborns to adults. In general, immediately report an adult’s pulse rate that is less than 60 or higher than 100 to the nurse. See Table 7.5b for normal heart rate ranges by age.
Table 7.5b
Normal Heart Rate Ranges by Age[3]
| Age Group | Heart Rate |
|---|---|
| Preterm | 120 – 180 |
| Newborn (0 to 1 month) | 100 – 160 |
| Infant (1 to 12 months) | 80 – 140 |
| Toddler (1 to 3 years) | 80 – 130 |
| Preschool (3 to 5 years) | 80 – 110 |
| School Age (6 to 12 years) | 70 – 100 |
| Adolescents (13 to 18 years) and Adults | 60 – 100 |
Respiration
Respiratory rate varies greatly from infants to adults. In general, report an adult’s respiratory rate immediately to the nurse if it is less than 12 or greater than 20. See normal respiratory rate ranges by age in Table 7.5c.
Table 7.5c
Respiratory Rate Ranges by Age[4]
| Age | Normal Range |
|---|---|
| Newborn to one month | 30 – 60 |
| One month to one year | 26 – 60 |
| 1-10 years of age | 14 – 50 |
| 11-18 years of age | 12 – 22 |
| Adult (ages 18 and older) | 12 – 20 |
Blood Pressure
Blood pressure (BP) is categorized into three ranges: low blood pressure (hypotension), normal blood pressure, and high blood pressure (hypertension (HTN)). In general, 120/80 mmHg is considered a normal adult blood pressure reading. See blood pressure ranges for adults for categories of hypotension, normal, and hypertension in Table 7.5d. Systolic and/or diastolic blood pressure readings outside the normal range should be immediately reported to the nurse.
Table 7.5d
Blood Pressure Ranges for Adults[5]
| Category | Systolic Reading | Diastolic Reading |
|---|---|---|
| Hypotension (low BP) | Less than 90 mmHg | Less than 60 mmHg |
| Normal | 91-129 mmHg | 61-89 mmHg |
| Hypertension (high BP) | 130 mmHg or higher | 90 mmHg or higher |
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7.6. MEASURING WEIGHT AND HEIGHT
Height and weight are documented upon admission to a facility as a baseline measurement and then taken routinely. Accurate weights are required for calculating medication dosages, ensuring adequate food and fluid intake, and monitoring chronic conditions such as heart failure (because weight gain is often the first indication of an impending problem).
If a resident requiresdaily weightsas documented in their care plan, their weight should be taken on the same scale at the same time every day, before any food or fluids are consumed, and while wearing a similar amount of clothing. The weight is documented, and weight changes of 3 pounds over 24 hours or 5 pounds within a week should be immediately reported to the nurse to address any possible complications. See the “Measuring Weight for Ambulatory Residents” Skills Checklist for measuring weight for more details.
If a resident is nonambulatory, the nursing assistant should weigh the wheelchair and any associated accessories (such as foot pedals or a chair cushion). After the resident is dressed and groomed, the nursing assistant should bring them to the scale, obtain the weight, and then subtract the weight of the chair and associated accessories. See Figure 7.13[1]for an image of weighing a resident on a wheelchair scale.
Figure 7.13
Wheelchair Scale. Used on the basis of Fair Use.
If a resident requires transfer with a full-body mechanical lift, some lifts have a scale function that can weigh the resident as they transfer from bed to wheelchair.
Height
Resident height is typically obtained on admission and documented in the medical record. Because height rarely changes, measurement is rarely repeated. See the “Measuring Height for Ambulatory Residents” Skills Checklist for measuring the height of an ambulatory person with a stadiometer. Figure 7.14[2]shows a person being measured with a stadiometer. If a resident is nonambulatory or unable to stand, their height can be measured with a tape measure while they are lying in bed. Height is recorded in inches or millimeters based on agency policy.
Figure 7.14
Measuring Height With a Stadiometer. Used on the basis of Fair Use.
Body Mass Index
Nursing assistants may be asked to obtain a height and weight to calculate a resident’s Body Mass Index (BMI).Body mass index (BMI)is a calculated measure of body fat based on a person’s height and weight. It is calculated by dividing weight in kilograms by the square of their height in meters. BMI is used to evaluate if an individual is underweight (BMI less than 18.5), normal (BMI 18.6-24.9), overweight (BMI over 25), or obese (BMI over 30). Elevated BMI measurements are associated with cardiovascular disease, type 2 diabetes, and other chronic diseases.[3]
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7.7. MEASURING INTAKE AND OUTPUT
Nursing aides assist with documenting clients’ intake and output.Intakerefers to the amount of fluids the client ingests, andoutputrefers to the amount of fluids that leave the body. Total intake should be nearly equal to total output every day, but some fluids, referred to as “insensible losses,” cannot be measured, such as fluids lost through the respiratory system, sweat, and stool. Therefore, urine is the most commonly measured output. Other fluids, like wound drainage in a drainage device, are also measured.
Fluids are typically documented as milliliters (mL). See the Chapter 5.7, “Documentation of Food and Fluids” subsection for review of converting ounces to mL and additional information on measuring intake and output.
Fluid intake is routinely documented with meal intake. Some clients with certain health conditions also have their output measured and documented every shift. Intake and output are then calculated over a 24-hour period and monitored by the nurse. A client’sintake and output (“I&O”)may be closely monitored by the nurse due to illness, a new medication, or a circulatory or urinary condition. See Figure 7.15[1]for an example of a 24-hour intake and output documentation record.
Figure 7.15
Sample Intake & Output Documentation Record
References
- 1.
"Intake and Output Record.PNG" byChippewa Valley Technical Collegeis licensed underCC BY 4.0↵.
7.8. SKILLS CHECKLIST: ORAL, TYMPANIC, AXILLARY, RECTAL AND TEMPORAL TEMPERATURES
- 1.
Gather Supplies: Thermometer; probe covers for oral, rectal, axillary, or tympanic thermometer. See Figure 7.16[1]at the end of this checklist for an image of various types of thermometers.
- 2.
Routine Pre-Procedure Steps:
Knock on the client’s door.
Perform hand hygiene.
Introduce yourself and identify the resident.
Maintain respectful, courteous, and professional communication at all times.
Provide for privacy.
Explain the procedure to the client.
- 3.
Procedure Steps:
Oral temperature
Remove the probe from the device.
Slide a probe cover (from the attached box) onto the oral thermometer without touching the probe cover with your hands.
Place the thermometer under the client’s tongue at either side of the base of the tongue.
Instruct the person to keep their mouth closed.
Leave the thermometer in place for as long as is indicated by the device manufacturer, usually indicated by a beep.
Read the digital display of the results.
Discard the probe cover in the garbage without touching the cover.
Place the probe back into the device.
- 4.
Tympanic temperature
Remove the tympanic thermometer from its holder.
Place a probe cover on the thermometer tip without touching the probe cover with your hands.
Ask the client to keep their head still.
For an adult or older child, gently pull the outer ear up and back to visualize the ear canal.
For an infant or child under age 3, gently pull the outer ear down.
Insert the probe just inside the ear canal.
Do not force the thermometer into the ear.
Hold the device in place until it beeps (within a few seconds after the temperature is measured).
Read the results displayed.
Discard the probe cover in the garbage without touching the cover.
Place the device back into the holder.
- 5.
Axillary temperature
Remove the probe from the device.
Place a probe cover (from the attached box) on the thermometer without touching the cover with your hands.
Ask the client to raise their arm or gently raise their arm for them.
With the probe facing towards the back of the resident, place the thermometer probe in the armpit on bare skin as high up into the axilla as possible.
Ask the patient to lower their arm or gently lower it for them.
Leave the device in place until it beeps, usually about 10–20 seconds.
Read the displayed results.
Discard the probe cover in the garbage without touching the cover.
Place the probe back into the device.
- 6.
Rectal temperature (Use the red probe)
Put on gloves.
- 7.
Position the patient:
For infants, place them in a supine position and raise their legs upwards toward their chest.
For older children and adults, assist them into a side lying position and explain the procedure.
Remove the probe from the device.
Place a probe cover (from the attached box) on the thermometer.
Lubricate the cover with a water-based lubricant.
Gently insert the probe 2–3 cm or less inside the anus, depending on the patient’s size.
Remove the probe when the device beeps.
Read the result.
Discard the probe cover in the trash can without touching it.
Cleanse the device as indicated by agency policy.
Remove gloves, turning them inside out and discard.
Perform hand hygiene.
- 8.
Temporal temperature
Remove eyeglasses from the client if they are worn.
Place the sensor on their forehead, ensuring good skin contact.
Slowly slide the thermometer across the forehead to the ear, maintaining contact with the skin at all times.
Stop when the sensor reaches the hairline and read the displayed result.
- 9.
Post-Procedure Steps:
Check for resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document temperature and report abnormal findings to the nurse.
Figure 7.16
Thermometers
View a YouTube video[2]of an instructor demonstration of obtaining a temperature:
View a YouTube video[3]of an instructor demonstration of obtaining a rectal temperature:
References
- 1.
"Thermometers"by Landon Cerny is licensed underCC BY 4.0↵.
- 2.
Chippewa Valley Technical College. (2022, December 3). Obtaining a Temperature. [Video]. YouTube. Video licensed underCC BY 4.0.https://youtu
.be/rZftX0z6aKo↵. - 3.
Chippewa Valley Technical College. (2023, January 5). Rectal Temperature. [Video]. YouTube. Video licensed underCC BY 4.0.https://youtu
.be/LKg2OS2D3rQ↵.
7.9. SKILLS CHECKLIST: PULSE
Pulse
- 1.
Gather Supplies: Watch or clock with a second hand
- 2.
Routine Pre-Procedure Steps:
Knock on the client’s door.
Perform hand hygiene.
Introduce yourself and identify the resident.
Maintain respectful, courteous, and professional communication at all times.
Provide for privacy.
Explain the procedure to the client.
- 3.
Procedure Steps:
Locate the radial pulse by placing the tips of your fingers on the side of the resident’s wrist.
Count the pulse for 60 seconds.
- 4.
Post-Procedure Steps:
Check on resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document pulse and report abnormal findings to the nurse.
View a YouTube video[1]of an instructor demonstration of obtaining a pulse:
References
- 1.
Chippewa Valley Technical College. (2022, December 3). Obtaining a Pulse. [Video]. YouTube. Video licensed underCC BY 4.0.https://youtu
.be/Q82Fn8pLDtg↵.
7.10. SKILLS CHECKLIST: RESPIRATIONS
- 1.
Gather Supplies: Watch or clock with a second hand
- 2.
Routine Pre-Procedure Steps:
Knock on the client’s door.
Perform hand hygiene.
Introduce yourself and identify the resident.
Maintain respectful, courteous, and professional communication at all times.
Provide for privacy.
Explain the procedure to the client.
- 3.
Procedure Steps:
Count respirations for 60 seconds.
- 4.
Post-Procedure Steps:
Check on resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document respiratory rate and report abnormal findings to the nurse.
View a YouTube video[1]of an instructor demonstration of obtaining respirations:
View a YouTube video[2]of an instructor demonstrating obtaining temperature, pulse, and respirationsin a sequential procedure:
References
- 1.
Chippewa Valley Technical College. (2022, December 3). Obtaining Respirations. [Video]. YouTube. Video licensed underCC BY 4.0.https://youtu
.be/yljzSZHqbq8↵. - 2.
Chippewa Valley Technical College. (2022, December 3). Obtaining Temperature, Pulse, and Respirations. [Video]. YouTube. Video licensed underCC BY 4.0.https://youtu
.be/_NRc4zEYrNI↵.
7.11. SKILLS CHECKLIST: MEASURING HEIGHT FOR AMBULATORY RESIDENTS
- 1.
Gather Supplies: Gait belt and stadiometer
- 2.
Routine Pre-Procedure Steps:
Knock on the client’s door.
Perform hand hygiene.
Introduce yourself and identify the resident.
Maintain respectful, courteous, and professional communication at all times.
Provide for privacy.
Explain the procedure to the client.
- 3.
Procedure Steps:
Put nonskid footwear on the resident.
Apply a gait belt if indicated on the care plan.
If the resident is in a wheelchair, assist the resident to the stadiometer and lock the brakes.
Assist the resident to stand and walk to the stadiometer.
Slowly turn the resident so their back is near the stadiometer and they are facing away from the supporting wall.
Instruct the resident to look forward and keep their chin up.
Gently lower the stadiometer arm to the top of the resident’s head.
Note the measurement.
Raise the stadiometer arm.
Assist the resident back to the wheelchair if used.
Remove the gait belt if it was applied.
Unlock the brakes if the resident is seated in a wheelchair.
- 4.
Post-Procedure Steps:
Check on resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document height and report abnormal findings to the nurse.
View a YouTube video[1]of an instructor demonstration of measuring height:
References
- 1.
Chippewa Valley Technical College. (2022, December 3). Measuring Height. [Video]. YouTube. Video licensed underCC BY 4.0.https://youtu
.be/T_h4uMnh3UA↵.
7.12. SKILLS CHECKLIST: MEASURING WEIGHT FOR AMBULATORY RESIDENTS
- 1.
Gather Supplies: Gait belt and scale
- 2.
Routine Pre-Procedure Steps:
Knock on the client’s door.
Perform hand hygiene.
Introduce yourself and identify the resident.
Maintain respectful, courteous, and professional communication at all times.
Provide for privacy.
Explain the procedure to the client.
- 3.
Procedure Steps:
Verify the resident is wearing nonskid footwear.
Balance (or zero) scale.
If the resident is in a wheelchair, apply the brakes.
Assist the resident to stand, using a gait belt as needed.
Walk the resident to the scale.
Assist the resident to step on the scale.
Check that the resident is centered on the scale.
Check that the resident has their arms at their side.
Ensure the resident is not holding on to anything that would alter the reading of the weight.
Adjust the weights until the scale is in balance or read analog scale.
Assist the resident back to a seated position.
Remove the gait belt if it was used.
Release the brakes if the resident is seated in a wheelchair.
- 4.
Post-Procedure Steps:
Check on resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document weight and report abnormal findings to the nurse.
View a YouTube video[1]of an instructor demonstration of measuring weight:
References
- 1.
Chippewa Valley Technical College. (2022, December 3). Measuring Weight. [Video]. YouTube. Video licensed underCC BY 4.0.https://youtu
.be/QnQoEwdcG1k↵.
7.13. LEARNING ACTIVITIES
VII. GLOSSARY
- Axillary temperature
Temperature taken in the armpit using the same device as when taking an oral temperature. It can be as much as one degree lower than the oral temperature.
- Blood pressure
The force of blood against the walls of the arteries as the heart pumps blood through the body reported in millimeters of mercury (mmHg). It is expressed as two numbers: systolic pressure and diastolic pressure.
- Body mass index (BMI)
A calculated measure of body fat based on a person’s height and weight.
- Charting by exception (CBE)
A common type of health care documentation where routine care is provided and notes are only written for abnormal findings or anything out of the ordinary. It is designed to keep documentation concise and reduce the amount of time required for documentation.
- Daily weights
Client weight taken at the same time every day, on the same scale, in similar clothing, and before any food or fluids are consumed.
- Diastole
The phase between each contraction of the heart when the ventricles are filling with blood.
- Diastolic blood pressure
Resting pressure within the arteries during diastole.
- Hypertension (HTN)
Elevated blood pressure.
- Hypotension
Low blood pressure.
- Insensible losses
Fluid loss that cannot be measured, such as fluids lost through the respiratory system, sweat, and stool.
- Intake and output (I&O)
Fluid intake and output measured and documented every shift.
- Oral temperature
Temperature taken in the mouth under the tongue.
- Output
Fluids that leave the body, including urine output that is measured.
- Oxygen saturation (SpO2)
Oxygenation status by a pulse oximeter based on how much of hemoglobin in red blood cells is “saturated” with oxygen.
- Pulse
The pressure wave that expands and recoils arteries when the left ventricle of the heart contracts. It can be palpated at many points throughout the body.
- Rectal temperature
Temperature taken in the rectum. It provides the most accurate temperature measurement but is considered an invasive procedure.
- Respirations
The movement of air into and out of the lungs. Inspiration refers to the process causing air to enter the lungs, and expiration refers to the process causing air to leave the lungs.
- Respiratory distress
Problems breathing.
- Systole
The phase of the heartbeat when the ventricles contract, causing the ejection of blood into the aorta and pulmonary arteries.
- Systolic blood pressure
The maximum pressure within the arteries during systole.
- Temporal temperature
Temperature taken by using a device placed on the forehead that measures the heat on the surface of the skin resulting from blood moving through the temporal artery in the forehead.
- Tripod position
A position that people experiencing respiratory distress naturally assume by leaning forward and placing their arms or elbows on their knees or on a bedside table to help improve lung expansion.
- Tympanic temperature
Temperature taken using a device placed in the ear. It is more accurate than oral or axillary measurement because the tympanic membrane in the ear shares the same artery that perfuses the hypothalamus (the part of the brain that regulates the body’s temperature).
- Vital signs
Vital signs include temperature recorded in Celsius or Fahrenheit, pulse, respiratory rate, blood pressure, and oxygen saturation using a pulse oximeter.
