VITAL SIGNS

A. Assessing Body Temperature

Preparation

1. Assess:

·0 Clinical signs of fever and hypothermia

·1 Client's readiness for the procedure

·2 Site most appropriate for measurement

·3 Factors that might alter core body temperature

2. Assemble euipment:

·4 Thermometer

·5 Cotton balls with alcohol

·6 Watch with second hand indicator

·7 Stethoscope and BP Apparatus/ Sphygmomanometer

·8 Tri-color pen

·9 6-inch ruler

Procedure

1. Introduce yourself, and verify the client's identity. Explain to the client what your going to do,
why it is necessary, and how the client can cooperate.

2. Perform hand hygiene, and observe other appropriate infection control procedures.

3. Provide for client privacy.

4. Place the client in the appropriate position

5. Place the thermometer

Apply a protective sheath or probe cover, if appropriate

Lubricate a rectal thermometer.

6. Wait for the appropriate amount of time.

Electronic and tympanic thermometers will indicate that the reading is complete via a light or
tone.

Check package instructions for length of time to wait for prior to reading chemical dot or tape
thermometers.

7. Remove the thermometer, and discard the cover or wipe with tissue, if necessary.

8. Read the temperature.

If the is obviously too high, too low, or inconsistent with the client's condition, recheck it with a
thermometer known to be functioning properly.

9. Wash the thermometer, if necessary, and return it to the storage location.

10. Document the temperature in the client record.

B. Assessing a Peripheral Pulse

Preparation

1. Assess:

·10 Clinical signs of cardiovascular alteration, other temperature or volume

·11 Factors that might alter pulse rate

2. Assemble equipment:

·12 Thermometer

·13 Cotton balls with alcohol

·14 Watch with second hand indicator

·15 Stethoscope and BP Apparatus/ Sphygmomanometer

·16 Tri-color pen

·17 6-inch ruler

Procedure

1. Introduce yourself, and verify the client's identity. Explain to the client what your going to do,
why it is necessary, and how the client can cooperate.

2. Perform hand hygiene, and observe other appropriate infection control procedures.
3. Provide for client privacy.

4. Select the pulse point.

5. Assist the client to a comfortable resting position.

6. Palpate and count the pulse. Place two or three middle fingertips lightly and squarely over the
pulse point.

7. Assess the pulse rhythm and volume.

8. Document the pulse rate, rhythm and volume, and your actions in the client record.

B. Assessing an Apical Pulse

Preparation

1. Assess:

·18 Clinical signs of cardiovascular alteration, other temperature or volume

·19 Factors that might alter pulse rate

2. Assemble equipment:

·20 Thermometer

·21 Cotton balls with alcohol

·22 Watch with second hand indicator

·23 Stethoscope and BP Apparatus/ Sphygmomanometer

·24 Tri-color pen

·25 6-inch ruler

Procedure

1. Introduce yourself, and verify the client's identity. Explain to the client what your going to do,
why it is necessary, and how the client can cooperate.

2. Perform hand hygiene, and observe other appropriate infection control procedures.

3. Provide for client privacy.

4. Position the client appropriately in a comfortable supine position or assist to a sitting position.
Expose the area of the chest over the apex of the heart.

5. Locate the apical pulse.

6. Auscultate and count heartbeats.

7. Assess the rhythm and the strength of the heartbeat.

Assess the rhythm of the heartbeat by noting the pattern of intervals between the beats.

Assess the strength (volume) of the heartbeat.

B. Assessing Apical-Radial Pulse

1. Assess.

·26 Clinical signs of cardiovascular alteration, other temperature or volume

·27 Factor taht may alter pulse rate

2. Assemble equipment:

·28 Thermometer

·29 Cotton balls with alcohol

·30 Watch with second hand indicator

·31 Stethoscope and BP Apparatus/ Sphygmomanometer

·32 Tri-color pen

·33 6-inch ruler

Procedure

1. Introduce yourself, and verify the client's identity. Explain to the client what your going to do,
why it is necessary, and how the client can cooperate.

2. Perform hand hygiene, and observe other appropriate infection control procedures.

3. Provide for client privacy.

4. Position the client appropriately.

5. Locate the apical and radial pulse sites.

6. Count the apical and radial pulse rates.

One-Nurse Technique

Assess the apical pulse for 60 seconds.

Assess the radial pulse for 60 seconds.

7. Document the apical and radial (AR) pulse rates, rhythm, volume, and any pulse deficit in the
client record. Also record related data.

C. Assessing Respirations

Preparation

1. Assess:

·34 Skin and mucous membrane color

·35 Positioned assumed for breathing

·36 Signs of cerebral anoxia

·37 Chest movements

·38 Activity tolerance

·39 Chest pain and dyspnea

2. Assemble equipment:

·40 Thermometer

·41 Cotton balls with alcohol

·42 Watch with second hand indicator

·43 Stethoscope and BP Apparatus/ Sphygmomanometer

·44 Tri-color pen

·45 6-inch ruler

Procedure
1. Introduce yourself, and verify the client's identity. Explain to the client what your going to do,
why it is necessary, and how the client can cooperate.

2. Perform hand hygiene, and observe other appropriate infection control procedures.

3. Provide for client privacy.

4. Observe or palpate and count the respiratory rate.

5. Observe the depth, rhythm, and character of respirations.

6. Document the repiratory rate, depth, rhythm, and character on the appropriate record.

D. Assesing Blood Pressure

Preparation

1. Assess:

·46 Signs and symptoms of hypertension and hypotension

·47 Factors affecting blood pressure

2. Assemble equipment:

·48 Thermometer

·49 Cotton balls with alcohol

·50 Watch with second hand indicator

·51 Stethoscope and BP Apparatus/ Sphygmomanometer

·52 Tri-color pen

·53 6-inch ruler

Procedure

1. Introduce yourself, and verify the client's identity. Explain to the client what your going to do,
why it is necessary, and how the client can cooperate.

2. Perform hand hygiene, and observe other appropriate infection control procedures.

3. Provide for client privacy.

4. Position the client appropriately.

5. Wrap the deflated cuff evenly around the upper arm. Locate the brachial artery. Apply the
center of the bladder directly over the artery.

6. If this is the client's initial examination, perform a preliminary palpatory determination of

systolic pressure.

7. Position the stethoscope appropriately.

8. Auscultate the client's blood pressure.

9. If this is the client's initial examination, repeat the procedure on the client's other arm.

Palpate the radial or brachial pulse site as the cuff pressure is released. The manometer reading
at the point where the pulse reappears represents a value betweeb auscultated systolic and
diastolic values.

Help the client to assume a prone position. If the client cannot assume this position, measure
the blood pressure hile the client is in a supine position with the knee slightly flexed. Slight
flexing of the knee will facilitate placing the stethoscope on the popliteal space.

Expose the thigh, taking care not to expose the client unduly.

10. Remove the cuff.

11. Wipe the cuff with an approved disinfectant.

12. Document and report pertinent assessment data according to agency policy.