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.