Question

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It is the monthly time for the nursing assistant to take a resident's vital sign. The resident has a history of high blood pressure and is on an antihypertensive medication. The resident has been eating ice cream four or five times a day and requesting at least three for breakfast and two during the nighttime hours. The nursing assistant has been giving the resident food every time the resident requests it because the previous month the resident lost 12 pounds. 1. What factors does the nursing assistant need to consider regarding changes that can occur in a resident's vital signs? 2. Why is it important for the nursing assistant to report any changes in a resident's vital signs to the nurse immediately? 3. The nursing assistant took the resident's temperature orally and got a reading of 99.4°F. Does this need to be reported to the nurse immediately? Why or why not? 4. The nursing assistant took the resident's pulse and got a reading of 78, weak and irregular. Does this need to be reported to the nurse immediately? Why or why not? 5. The nursing assistant needs to take the resident's respirations. What qualities should the nursing assistant note when measuring the resident's respirations? 6. The nursing assistant needs to take the resident's blood pressure. What is the normal range for an adult's blood pressure that the nursing assistant must remember and what findings must be reported to the nurse immediately? 7. Why is it important for the nursing assistant to accurately measure a resident's weight?

Answer 1

1. Temperature, pulse, respiration, B.P, pain are considered as vital signs. Measuring vital signs of residents accurately is ultimate because changes in vital signs are the first indicator of any illness. The nursing assistant needs to consider some of the factors such as the resident's age, gender, lifestyle, anxiety, posture, hereditary, current medications before checking vital signs. These factors may show slight variation in vital signs.

2. It is important to report to the nurse immediately if any change in vital signs because changes in vital signs are the first indicator of any illness. It gives clues to the medical problem so that the nurse can take prior intervention to prevent serious illness.

3. The adult normal oral temperature is 97.6 to 99.6 degree F. So the resident oral temperature is normal and the nursing assistant does need to inform the nurse immediately.

4. Yes. the Nursing Assistant should report to the nurse immediately because the weak and irregular beat may indicate the arrhythmias. So the resident's has to be evaluated further by the nurse.

5. The nursing should count the number of times the chest raises for the full one minute. The normal respiration rate is 12 to 20 breath per min. The nursing assistant should also note the quality of respiration such as shallow, deep, shortness of breath should be reported to the nurses.

6. The normal adult blood pressure is 100 / 60 to 139/ 89 mm of Hg. The nursing assistant should report to the nurse if the systolic or diastolic BP is greater or lesser than the normal level. Because both hypotension or hypertension can lead to complications.

7. Measuring resident's weight is necessary to know the gain or loss in actual weight. Increase in weight indicates accumulation of fluid in the body which usually seen in cardiac and kidney problems. Unintentional loss of weight indicates a nutritional deficiency or symptoms of a chronic illness such as diabetes.