CNA Baseline Collecting and documenting vital signs and measuring weight

 CNA Baseline Collecting and documenting vital signs and measuring weight

    Additional Ratings

Description

Monitoring/Documenting Vital signs, pain level and patient measurements (weight, height, neck circumference)
Behavioral Criteria

Verify the identity of your patient, and explain that you are going to take their Vital Signs (Blood Pressure, pulse, temperature, oxygen saturation):

Blood Pressure:

    Position of  patient -sitting or lying down, Legs kept uncrossed and remain quiet  (no talking)
    Select the appropriate size cuff and apply it directly over the skin, above the elbow.
    Does not take  blood pressure on Restricted Extremity, over an intravenous line (IV), injured or painful extremity.
    Obtain reading from display and document Systolic, Diastolic and Mean Arterial Pressure (MAP) in Electronic Health Record (EHR)
    Notify nurse of abnormal reading

Pulse Oximetry:

    Ensure patient hand is clean (no nail polish or false nails)
    Place oximetry probe onto one of the patient's fingers
    Obtain reading from display and document in EHR
    Notify nurse of abnormal reading

Respiratory Rate:

    Observe the patient as they breathe, and count each rise and fall of the chest as one respiration. Count the breaths for one minute.
    Record the respiration rate in the EHR.
    Notify the nurseif patient is having any  difficulty with achieving regular deep breaths

Pulse:

    Obtain reading from display and document in EHR
    Notify nurse of abnormal reading

Temperature:

    Select appropriate placement for oral, axillary, or temporal to obtain temperature
    Obtain reading from display and document in EHR
    Notify nurse of abnormal reading

Pain  Level:  

    Obtain/document  stated pain level from patient
    Notify nurse of pain level

Weighing Patient:

Standing scale

    Check that scale reads zero to ensure accurate measurement.
    Assist patient onto the scale and remain close to the patient to prevent falls
    Have the patient  stand as still as possible for accuracy
    Obtain reading from display and document in the EHR
    Notify nurse if abnormal reading

Bed Scale

    Zero bed prior to weighing patient
    Weigh patient
    Obtain reading and document in the EHR

Measuring Neck Circumference

    Use paper measuring tape- place around patient's neck.  
    Record measurement in cm in EHR.

 

Evidence of Achievement

Direct observation of competency in all areas through patient care or simulation / case study; documentation in EHR accurate and complete
References

    Toolbox (Policy/Procedure)
        Specimen Collection Utilizing Soft Id System

    Mohammad, Y., et al. (2010). "Clinical use of pulse oximetry: Pocket reference 2010" [Online]. Accessed January 2021 via the Web at https://www.networks.nhs.uk/nhs-networks/south-east-coast-respiratory-programme/documents/OximetryPG.pdf

    The Joint Commission. (2021). Standard NPSG.07.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission

    World Health Organization. (2011). "Pulse oximetry training manual" [Online]. Accessed January 2021 via the Web at https://www.who.int/patientsafety/safesurgery/pulse_oximetry/who_ps_pulse_oxymetry_training_

    Hanlon, P. (2015). Patient monitoring: Oximetry enhances care. RT for Decision Makers in Respiratory Care, 28(2), 15–18.

    American Association of Critical-Care Nurses. (2016). "AACN practice alert: Obtaining accurate noninvasive blood pressure measurements in adults" [Online]. Accessed April 2020 via the Web at https://www.aacn.org/clinical-resources/practice-alerts/obtaining-accurate-noninvasive blood-pressure--measurements-in-adults

    Kallioinen, N., et al. (2017). Sources of inaccuracy in the measurement of adult patients’ resting blood pressure in clinical settings: A systematic review. Journal of Hypertension, 35, 421–441. [Online]. Accessed April 2020 via the Web at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5278896/

    Davie, A., & Amoore, J. (2010). Best practice in the measurement of body temperature. Nursing Standard, 24(42), 42–49.

    Geijer, H., et al. (2016).  Temperature measurements with a temporal scanner: Systematic review and meta-analysis. BMJ Open, 6(3), e009509. Accessed April 2020 via the Web at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4823400/

    Tipton, P. H., et al. (2012). Patient safety: Consider the accuracy of height and weight measurements. Nursing, 42(5), 50–52. Accessed April 2020 via the Web at https://journals.lww.com/nursing/Fulltext/2012/05000/Consider_the_accuracy_of_height and weight