Post on 28-Apr-2015
Guidelines
The nurse caring for the client is responsible for vital signs measurement.
Equipments should be functional and appropriate for the size and age of the client
Equipment should be selected based on the client’s condition and characteristics
Know the client’s medical history, therapies, and prescribed medications
Control or minimize environmental factors that may effect vital signs
Collaborate with the physician to decide the frequency of v/s assessment
Approach client in a calm, caring manner
Use an organized, systematic approach when taking v/s
The nurse verifies and communicates significant changes in v/s
Use v/s measurements to determine indicators for medication administration
Body temperature
>>The balance between the heat produced by the body and the heat lost from the body
2 types:
Core Temperature
surface temperature
methods of temperature taking
Oral
Take oral temperature 2-3 minutes
Wash the thermometer before use
Place thermometer under the tongue
•Contraindications to oral temperature
taking:
•Oral lesion or surgery•Cough•Nausea and vomiting•Very young children•Restless, disoriented•Seizure prone
RectalPosition: Sim’s position
Lubricate thermometer before insertion
Insert thermometer by 0.15-1.5 inches
Hold the thermometer in place for 2 mins
1.Provide privacy.2. Position 3.Apply disposable gloves.4. Squeeze liberal portion of lubricant.5. With non-dominant hand, separate client’s buttocks to expose the anus.6. Ask client to breathe slowly and relax.7. Gently insert thermometer into anus in direction of umbilicus.
8. If resistance is felt during insertion, withdraw thermometer immediately.9. Once positioned, leave thermometer in place10. Remove thermometer from anus.11. Wipe with antiseptic solution.12. Return thermometer to storageWipe client’s anal area with soft tissue to remove lubricant or feces and discard tissue13.Remove gloves and dispose.
Contraindications:
>Anal or rectal conditions or surgeries[hemorrhoids, hemorrhoidectomy]
>Diarrhea
Axillary
•Pat dry the axilla•Place the thermometer on the client’s axilla•Place the arm tightly across the chest to keep the thermometer in place for 9 minutes
Steps:1.Provide privacy2.Position4.Move clothing or gown away from shoulder and arm.5. Raise client’s arm away from torso. Insert thermometer into center of axilla. place arm across client’s chest.6. Hold thermometer in place.7. Remove from axilla.8. Return thermometer to storage.9. Perform hand hygiene
Pulse
-wave of blood created by contraction of the left ventricle of the heart.
Pulse sites:
over the temporal bone of the head ; superior and lateral to the eye
at the lateral aspect of the neck
at the left midclavicular line 5th intercostal space
Temporal
Carotid
Apical
Brachial
Radial
Femoralalong side of the inguinal ligament
on the thumb side of the inner aspect of the wrist
at the inner aspect of the upper arm (biceps muscles) or medially at the antecubital space
Posterior tibial
Popliteal
Pedal(dorsalis pedis)
at the back of the knee
at the dorsum of the foot
at the middle aspect of the ankle, behind the medial malleolus
assessment of pulse
Rate- The normal PR per min are as follows:Newborn to 1 mo.: 80-180 beats/min1yr: 80- 140 bpm2yrs: 80-130 bpm6yrs: 75-120 bpm10 yrs: 50-90 bpmAdult: 60-100 bpm
1.Perform hand hygiene2.Assess3.Position4.Place tips of first two fingers of hand over
groove along radial or thumb side of client’s inner wrist
5.Lightly compress6.Determine strength of pulse .7.After pulse can be palpated regularly, look at
the watch’s second hand and begin to count
Assessing respiration
•Rate – normal:16-20/min (adult)•Depth – observe the movement of the chest•may be normal, deep or shallow•rhythm – observe for regularity of exhalations and inhalations
Respiration
3 processes
Ventilation
Diffusion
Perfusion
quality or character – refers to the respiratory effort and sound of breathing•eupnea- normal respiration that is quiet, rhythmic, effortless•tachypnea- rapid respiration marked by quick, shallow breaths.•Bradypnea -slow breathing•Hyperventilation- prolonged and deep breaths . carbon dioxide is excessively exhaled.•Hypoventilation- slow shallow respiration.•Dyspnea- difficult and labored breathing.•Orthopnea- ability to breath only in upright position.
1.Position client.2.Place client’s arm in relaxed position across
abdomen or lower chest, or place nurse’s hand directly over client’s upper abdomen
3.Observe complete respiratory cycle.4.After cycle is observed, look at watch’s hand
and begin to count
Blood pressure
--Is a measure of the pressure exerted by the blood as it pulsates through the arteries
Systolic pressureDiastolic pressure
Pulse pressure
>normal: 30-40 mmHgP.P= S-D
Factors affecting BP:•Age•Exercise•Stress•Race•Obesity•Medications•Diurnal variations
> Ensure the client is rested>Allow 30 minutes to pass if the client had smoked or ingested caffeine before taking the BP>Use appropriate size of BP cuff>Position the patient in sitting or supine position>Apply BP cuff snugly, 1 inch above the antecubital space>Use the bell shaped diaphragm of the stethoscope since the BP is a low-frequency sound >Inflate deflate the cuff slowly, 2-3 mmHg at a time>Wait 1-2 mins before making further determinations
Assessing BP
Classification of blood pressure for adults
Category systolic, mmHg diastolic, mmHg
Hypotension < 90 < 60
Normal 90 – 120 and 60 – 80
Prehypertension 121 – 139 or 81 – 89
Stage 1 Hypertension 140 – 159 or 90 – 99
Stage 2 Hypertension ≥ 160 or ≥ 100
Steps:1. Detemine the best site for BP assessment2. Select appropriate cuff size3. Expose upper arm by removing restrictive clothing4. With client sitting or lying, position client’s fore arm, supported, with palm turned up at level of the heart.5. Palpate brachial artery.6. Position cuff 2.5 cm above site of brachial pulsation. Apply bladder of cuff above artery by centering arrows marked on cuff over artery.7. Place stethoscope earpieces in ears and be sure sounds are clear.
8. Palpate the brachial pulse again & place stethoscope lightly over this area. Position mercury gauge on the manometer at eye level.9. Adjust the screw above the bulb to tighten the valve on the air pump and make sure bulbs are not obstructed.9. Inflate the cuff by pumping the bulb to about 30 mmHg above the point at which radial pulse disappears.10. Deflate the cuff slowly---about 2mm/sec--- by turning the valve in the opposite direction while listening to the first Korotkoff’s sounds.
11. Record the 1st and last sounds.12. Deflate the cuff at least another 10mmHg to make sure you hear no more sounds. Then deflate completely.13. Document readings.