Taking the vital signs.docx

7/30/2019 Taking the vital signs.docx

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Taking the TEMPERATURE

1. Explain the procedure to the patient.2. Get the thermometer, disinfect from bulb to stem.3. Read the thermometer if in the level of 35C, if not shake the thermometer until it reaches to

35C.4. Instruct the patient to open mouth and place thermometer under the patients tongue then

instruct patient toclose mouth.

Taking the PULSE Rate

1. While waiting for the appropriate time, palpate radial artery and count pulse for 1 minute inthe proper.

Taking the RESPIRATORY Rate

1. Proceed to counting the pulse rate for 1 minute. Observing the proper technique, 1 hand stillholding unto the radial artery. Record both RR & PR.

Taking the BLOOD PRESSURE

1. Apply the BP cuff with arm hyper extended.2. Palpate brachial artery with left hand, put the stethoscope unto the ear with the earpiece the

patient3. Inflate cuff till pulsation disappears and add 30 mmHg4. Place diaphragm bell of stethoscope over brachial artery5. Release valve slowly, take systole, then diastole.6. Remove cuff and record BP.7. Remove Oral thermometer from the mouth8. Wipe thermometer from stem to bulb.9. Read the temperature and record.10.Disinfect thermometer properly.11.Record TRP and Graph properly.

Be familiar first with the Normal Vital Signs by Age:

VARIATIONS IN NORMAL VITAL SIGNS BY AGE

Age Oral

Temperature

In Degrees

Celsius

(Fahrenheit)

Pulse (Average

and Ranges)Respirations

(Average and

Ranges)

Blood Pressure

(mm Hg)

Newborns 36.8 (98.2)

axillary

130 (80 to 180) 35 (30 to 80) 73/55

1 year 36.8 (98.2)axillary

120 (80 to 140) 30 (20 to 40) 90/55

5 to 8 years 37 (98.6) 100 (75 to 120) 20 (15 to 25) 95/57

10 years 37 (98.6) 70 (50 to 90) 19 (15 to 25) 102/62

Teen 37 (98.6) 75 (50 to 90) 18 (15 to 25) 120/80

Adult 37 (98.6) 80 (60 to 100) 16 (12 to 20) 120/80


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Older adult

(more than 70years)

37 (98.6) 70 (60 to 100) 16 (15 to 20) Possible increase

diastolic

VITAL SIGNSProcedures Checklist

NAME:_____________________________YEAR

&SECTION:____________DATE:___________

Preparation Performed Remarks

Correctly Incorrectly Not

1. Assess:

A.) Temperature- Clinical signs of fever

- Clinical signs of hypothermia- Clients readiness for the procedure- Site most appropriate for

measurement

- Factors that may alter core bodytemperature

B.) Pulse- Clinical signs of cardiovascular

alteration, other than pulse rate,rhythm, or volume

- Factor that may alter pulse rate

C.) Respiration- Skin and mucus membrane color

- Position assumed for breathing

- Signs of cerebral anoxia

- Chest movement- Activity tolerance

- Chest pain

- DyspneaMedications affecting respiratory

rate.

D.) Blood Pressure

- Signs and symptoms ofhypertension

- Signs and symptoms of hypotension

- Factors affecting blood pressure.

2. Assemble equipment and Supply:- Thermometer

- Cotton balls with alcohol or alcohol

wipes


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- Tissue /wipes

- Watch with a second hand orindicator.

- Stethoscope

- Blood pressure cuff of the

appropriate size- Sphygmomanometer

Procedure

1. Identify the client properly andexplain what you are going to do, why

it is necessary, and how he can

cooperate.

2. Wash hand and observe otherappropriate infection control

procedure

3. Provide for client privacy.

4. Place the client in the appropriateposition

ASSESSING BODY TEMPERATURE (AXILLARY TEMPERATURE)

1. Wipe the armpit with tissue paper orask the client to do it if able

2. Wipe the thermometer from bulb to

stem with alcoholized cotton ball.

3. Place the thermometer on the clientsopposite side.

4. Wait for appropriate amount of time.

(While waiting for the time, the nurse

can now assess the other vital signs.)

5. Remove the thermometer and wipe

with the tissue if necessary.

6. Read the temperature.

7. Wipe the thermometer withalcoholized cotton ball from stem to

bulb. Return to container.

ASSESSING A PERIPHERAL PULSE (RADIAL PULSE)

1. Palpate and count the pulse. Place two

or three middle fingers lightly and

squarely over the pulse point.2. Count for one full minute and note thepulse rhythm and volume.

ASSESSING RESPIRATION

1. Place the clients arm across the chest

and observe the chest movementswhile supposedly taking radial pulse.

2. Count the respiratory rate for 1 full


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minute. An inhalation and an

exhalation is counted as onerespiration. Observe the depth,

rhythm, and character or respiration.

ASSESSING BLOOD PRESSURE

1. The elbow should be slightly fixedwith the palm of the hand facing up

and the forearm supported at heart

level.

2. Expose the upper arm

3. Wrap the deflated cuff evenly around

the upper arm. Locate the brachial

artery. Apply the center of the bladderdirectly over the artery.

4. For an adult, place the lower border of

the cuff appropriately 2.5 cm (1 inch)

above the antecubital space.5. If this is the clients initial

examination, perform a preliminary

palpatory determination of systolicpressure.

6. Palpate the brachial artery with

fingertips.

7. Close the valve on the pump byturning the knob clockwise.

8. Pump the cuff until you no longer feel

the brachial pulse. At that pressure,

the blood cannot flow through theartery. Note the pressure on the

sphygmomanometer at which pulse is

no longer felt.

9. Release the pressure completely in the

cuff, and wait for one to two minutes

before making further measurements.

10. Position the stethoscope appropriately

11. Clean the earpieces of the stethoscope

with alcohol.

12. Warm the amplifier by rubbing it with

the palm of your hand.

13. Insert the ear attachments of the

stethoscope in your ears so that they

tilt slightly forward.

14. Ensure that the stethoscope hands

freely from the ears to the diaphragm.

15. Place the bell of the amplifier of the


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stethoscope over the brachial pulse.

Hold the diaphragm with thumb andindex finger.

16. Auscultate the clients blood pressure.

17. Pump the cuff until the

sphygmomanometer reads 30 mm Hgabove the point where the brachial

pulse disappeared.

18. Release the valve of the cuff carefullyso that the pressure decreases at the

rate of 2-3 mm Hg per second.

19. As the pressure falls, identify the

mamometer reading at each of fivephases, if possible.

20. Deflate the cuff rapidly.

21. Wait one or two minutes before

making further determinations.22. Repeat the above steps once or twice

as necessary to confirm the accuracy

of the reading.

23. If this is the client initially

examination, repeat the procedure on

the clients other arm.

24. Remove the cuff.

25. Wipe the cuff with an approveddisinfectant.

26. Document in the clients record (TPR

Sheet):A.) The temperature in the client

record.

B.) The pulse rate and rhythmC.) The respiratory rate, depth, and

rhythm

Report pertinent assessment date

according to agency policy.

Taking the TEMPERATURE

1. Explain the procedure to the patient.

2. Get the thermometer, disinfect from bulb to stem.

3. Read the thermometer if in the level of 35C, if not shake the thermometer until it reaches to

35C.

4. Instruct the patient to open mouth and place thermometer under the patients tongue then instruct patient to close

mouth.

Taking the PULSE Rate


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5. While waiting for the appropriate time, palpate radial artery and count pulse for 1 minute in the

proper.

Taking the RESPIRATORY Rate

6. Proceed to counting the pulse rate for 1 minute. Observing the proper technique, 1 hand still holding unto the radial artery.

Record both RR & PR.

Taking the BLOOD PRESSURE

7. Apply the BP cuff with arm hyper extended.

8. Palpate brachial artery with left hand, put the stethoscope unto the ear with the earpiece the

patient

9. Inflate cuff till pulsation disappears and add 30 mmHg

10. Place diaphragm bell of stethoscope over brachial artery

11. Release valve slowly, take systole, then diastole.

12. Remove cuff and record BP.

13. Remove Oral thermometer from the mouth

14. Wipe thermometer from stem to bulb.

15. Read the temperature and record.

16. Disinfect thermometer properly.

17. Record TRP and Graph properly.

Taking the vital signs.docx

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